Verrucous carcinoma

A. Cardesa N. Zidar

Vocal Cord Keratosis Histopathology
Fig. 3.13 Verrucous carcinoma. A large lesion with abundant keratosis arranged in "church-spire" configuration. There is a broad, pushing border of infiltration.

Definition

Verrucous carcinoma (VC) is a non-metastasizing variant of well-differentiated squamous cell carcinoma (SCC) characterized by an exophytic, warty, slowly growing neoplasm with pushing margins.

ICD-O code 8051/3

Synonym

Ackerman tumour {12} Epidemiology

VC occurs predominantly in men in the 6th and 7th decades of life {1671}.

Etiology

VC has been related to tobacco smoking. Human Papillomavirus (HPV) genotypes 16 and 18, and rarely 6 and 11, have been identified in some, but not all, VC {250,289,777,1233,1283}.

Localization

Larynx is the second most common site of VC in the head and neck (after oral cavity) and accounts for 15-35% of all VC {1350} and 1-4% of all laryngeal carcinomas {777,1671,1956}. Most arise from the anterior true vocal cords, though it may occur in the supraglottis, subglottis, hypopharynx and trachea {1350,1671}

Clinical features

Hoarseness is the most common presenting symptom; other symptoms include airway obstruction, weight loss,

Fig. 3.12 Endoscopic view of a verrucous carcinoma. Wart-like, whitish outgrowth of the vocal cord.

dysphagia, and throat pain {1671,1956}. Enlarged lymph nodes are common and reactive rather than neoplastic {978}.

Macroscopy

VC presents as a sharply circumscribed, broad based exophytic warty tumour which is usually firm, and tan to white.

Histopathology

VC consists of thickened club-shaped papillae and blunt intrastromal invaginations of well-differentiated squamous epithelium with marked keratinization and thin fibrovascular cores. The squamous epithelium lacks cytologic criteria of malignancy, and by morphometry, the cells are larger than those seen in SCC {489}. Mitoses are rare, and observed in the basal layers. DNA synthesis (S-phase) is also limited primarily to the basal layers {737}. VC invades the stro-ma with a pushing, rather than infiltrating border. Dense lymphoplasmacytic host response is common. Intraepithelial microabscesses are seen, and the abundant keratin may evoke a foreign body reaction.

The surrounding mucosa shows progres sive transition from hyperplasia to VC. A downward dipping of epithelium often "cups" the VC periphery, and is the ideal site for deep biopsy {174,1192}. Hybrid tumours are VC containing foci of conventional SCC. The incidence of hybrid tumours in the larynx is approximately 10% {1956}. It is important to recognize this variant of VC, as it has the potential to metastasize {131,174}.

Differential diagnosis

The differential diagnosis of VC includes exophytic SCC, hybrid VC, papillary SCC, keratinizing squamous cell papillo-ma and verruca vulgaris. VC lacks cyto-logical atypia, this distinguishes it from exophytic SCC, hybrid VC and papillary SCC. The pushing margins of VC are smooth, in distinction to the irregular shaped invasive islands of SCC. Papillomas have thin, well-formed papillary fronds, with limited keratinization, as compared to the markedly keratinized papillae of VC. Verruca vulgaris of the larynx {722} characteristically contains layers of parakeratotic squamous cells with large keratohyaline granules, identical to their counterpart on the skin.

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