• Some cases may be associated with viral warts (plantar lesions)
• Verrucous carcinoma (VC) may arise in setting of longstanding lichen sclerosus (genital tumors)
Macroscopic
• Exophytic papillary tumor
• Broad and pushing base
• Deep burrowing pattern is hallmark of carcinoma cuniculatum (VC variant)
Microscopic
• Acanthotic papillae
• Slender fibrovascular cores
• Prominent (orange) keratin craters between papillae
• Lack of koilocytosis
• Extremely well differentiated
• Epithelium of papillae and keratin predominate over fibrovascular core
• Pushing, club-shaped base
• Higher grade areas &/or infiltrative borders are not features of pure VC
Raises possibility of hybrid (mixed) VC
Top Differential Diagnoses
• Carcinoma cuniculatum (VC variant)
• Mixed/hybrid VC with foci of SCC of usual type
• Condyloma acuminatum/giant condyloma
• Warty (condylomatous) SCC
• Papillary carcinoma (SCC variant)
Multicentric Verrucous Carcinoma Clinical image shows 2 separate verrucous carcinomas (VCs) (one on the right and the other on the left ) affecting the foreskin of a patient with chronic lichen sclerosus (LS) .
Partial Penectomy Cut Section Cut section of a partial penectomy specimen shows a verruciform tumor with sharp bulbous base confined to the lamina propria. Note the papillomatous and spiky surface.
Verrucous Carcinoma and Lichen Sclerosus Histologic section illustrates a VC confined to the lamina propria arising in a background of LS .
Verrucous Carcinoma Well-differentiated tumor with a well-defined stromal-tumor interface shows papillomatosis, acanthosis, and hyperkeratosis.
TERMINOLOGY
Abbreviations
• Verrucous carcinoma (VC)
• Squamous cell carcinoma (SCC)
Synonyms
• Buschke-Loewenstein tumor
Confusing term that has been used in reference to different papillary/verrucous squamous lesions, including VC
We recommend abandoning this term
• Ackerman tumor (oral florid papillomatosis)
Older term
Definitions
• Usually human papillomavirus (HPV)-unrelated variant of SCC with papillary surface and bulbous deep borders
• Very well differentiated
ETIOLOGY/PATHOGENESIS
Unknown Pathogenesis
• Most VC are unrelated to HPV
• p53 may play role in its pathogenesis
• Cutaneous lesions may be related to scarring and chronic inflammation
• Anogenital cases may be associated with
Phimosis
Lichen sclerosus (LS)
Lichen simplex chronicus
• Oral VC (Ackerman tumor) may be related to tobacco chewing
• Cutaneous (particularly plantar) lesions may arise within preexisting warts
• Rare cases of anogenital and cutaneous VCs may be associated with low- or high-risk HPV
CLINICAL ISSUES
Epidemiology
• Incidence
Rare
• Age
6th-7th decade
Site
• Originally described by Lauren Ackerman in oral cavity
• May also affect anogenital area and skin (sole of foot, finger, nail bed, scalp, wrist, buttocks, etc.)
Penile tumors are more frequent on foreskin
Presentation
• Exophytic white-gray neoplasm
• Unicentric tumors are more frequent than multicentric ones
• Anogenital lesions often arise in background of longstanding LS
Treatment
• Surgical
Prognosis
• Pure VCs have excellent prognosis
Tumors may recur but almost never metastasize
• Hybrid/mixed VCs have worse prognosis than pure VC
Behavior relates to least differentiated component
• There are sporadic reports of sarcomatoid/anaplastic transformation after radiation therapy
MACROSCOPIC
General Features
• Exophytic white-gray neoplasms with papillary, sometimes spiky surface
• Cut sections reveal broad base between tumor and stroma
• Tumors may invade deep dermis and deeper structures
• Irregular jagged borders or foci of necrosis are not features of pure VC
Size
• 1-5 cm in diameter
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and the other on the left 
) affecting the foreskin of a patient with chronic lichen sclerosus (LS) 
.
confined to the lamina propria. Note the papillomatous and spiky surface.
confined to the lamina propria arising in a background of LS 
.
