Case Report
Verrucous carcinoma of the breast: a rare skin malignancy
Paul Nimrod Firaza, MD
1st year, Surgery Resident
Jose R. Reyes Memorial Medical Center
Sta Cruz, Manila
Abstract
Verrucous carcinoma (VC) is a well-differentiated squamous cell carcinoma, which is locally aggressive, exopphytic, low-grade, and slow-growing malignancy with a low metastatic potential. Verrucous carcinoma typically involves the oral cavity, larynx, genitalia, skin, and esophagus and is rarely seen in the breast. Early diagnosis, and histological confirmation of this breast carcinoma, is essential to prevent unnecessarily mutilating surgery. Here, we report a case of a 74-year old female with an exophytic breast mass and a review of literature on the new developments on managing verrucous carcinoma especially on areas where tissue preservation is of importance.
Introduction
Verrucous carcinoma is a rare tumor, well known for being distinct from both squamous papilloma and squamous cell carcinoma, and intermediate between them in its behavior. Human papilloma virus infection has been implicated in the etiology of both verrucous carcinoma and the viral wart, with subtypes 11, 16 and 18 having been previously demonstrated in cutaneous lesions. (1,2) VC of the skin can occur in any skin sites, can transform into less differentiated squamous cell carcinoma, and may be associated with squamous cell carcinoma in situ. (3) Verrucous carcinoma is difficult to diagnose on biopsy, due to the lack of cytological features of malignancy. Histologically, the tumors were composed of squamous epithelial cells with minimal cellular atypia arranged in a verrucous pattern. (3) Microscopic features are similar to those of a viral wart but in a large biopsy or excisional specimen; it can be differentiated by its characteristic ‘pushing’ endophytic invasive margin (Figure 2). (1)
Case presentation
A 74-year old female, with a 1-year history of slowly enlarging exophytic, irregularly shaped, cauliflower-like mass (Figure 1) on the left lower quadrant aspect of the left breast with no noted lymph nodes in the axilla. There were no associated symptoms of nipple discharge, skin discoloration, weight loss, anorexia and fever. However, patient noted occasional breast pain and pruritus on the area of the lesion. The patient then underwent two-incision biopsy on separate occasions revealing Verruca Vulgaris and Squamous Cell Carcinoma. The latter diagnosis prompted the patient to underwent Sentinel Lymph Node biopsy; Wide Excision with Frozen Section proceeded to Mastectomy Left, completion lymphadenectomy. The microscopic sections of the mass showing solid sheets of tumor cells exhibiting a characteristic pushing effect with bulbous invasions to the stroma. Individual cell shows mild pleomorphism with vesicular nuclei and prominent nucleoli with few mitotic figures and keratin pearls also noted. Diagnosis of the tumor revealed Verrucous carcinoma, skin with invasion of superficial dermis. The nipple, areola complex, lymphovascular spaces, sentinel lymph node, and 13/13 axillary
lymph nodes were found to be negative for malignant cell. There was an adequate margin of resection with a sentinel lymph node frozen section biopsy revealing benign findings. The patient was discharged recovered and was remaining well during clinical follow-up.
Discussion
Verrucous carcinoma (VC) was first described by Ackerman in 1948, affecting the oral cavity as a low-grade tumor that generally is considered a clinicopathologic variant of squamous cell carcinoma. In 1954, Aird et al described a cutaneous type as verrucous carcinoma (carcinoma cuniculatum) because of its characteristic cryptlike spaces on histologic appearance. (3,4,5) In a recent review by Kubik and Rhatigan, most authors consider carcinoma cuniculatum and verrucous carcinoma to be synonymous which shows a lack of clear conceptual distinction between these two entities may cause diagnostic confusion leading to further delay in an already difficult diagnosis. (6)
Figure 1. Pre-operative Picture
Verrucous carcinoma typically involves the oral cavity, larynx, genitalia, skin, and esophagus. It is a slowly growing and locally destructive tumor, which manifests as a verrucous, exophytic, or endophytic mass that typically develops at sites of chronic irritation and inflammation. It enlarges slowly but may be locally destructive by penetrating deeply into the skin, fascia, and even bone, but it has a low metastatic potential. (7)
The diagnostic of choice for demonstrating the exact location and extent of the verrucous carcinoma (VC) tumor for preoperative staging and surgical planning is Computed tomography or magnetic resonance imaging.
The treatment of choice for cutaneous verrucous carcinomas is surgical excision and Mohs micrographic surgery (MMS). (8) Excision with conventional margins of 4mm of healthy tissue (9) is most valuable in the treatment of small (T1) verrucous carcinomas of the trunk and extremities and in areas in which tissue sparing is not essential with cure rates reaching up to 95-99%. Standard excision with permanent conventional
Figure 2.Solid sheets of tumor cells exhibiting characteristic pushing effect with bulbous invasion to the stroma.
sections is a highly effective treatment for many verrucous carcinomas. The depth of the excision should include the subcutaneous fat because even small verrucous carcinomas may extend into the subcutaneous fat. Excision with an arbitrary margin may present a subclinical positive margin, especially in extensive tumors with inflammatory changes, requiring further surgery resulting to more healthy tissue being excised than is necessary. (9)
Mohs Micrographic Surgery (MMS) is the procedure of choice usually done by dermatologic surgeon for verrucous carcinoma for which tissue preservation is needed. The main advantage of MMS over simple excision is the ability to examine all excision margins (deep and lateral) and to carefully map residual foci of invasive carcinoma. MMS provides a cure rate for verrucous carcinoma of 94-100% and has been of particular value in curing verrucous carcinoma with perineural invasion. MMS is performed routinely in an outpatient setting with the patient under local anesthesia. (9)
There are other modalities offered for managing verrucous carcinoma such as Cryosurgery, curettage and electrodesiccation, radiation therapy topical or systemic chemotherapy (bleomycin, 5-fluorouracil, cisplatin, methotrexate), carbon-dioxide laser, intralesional interferon alfa, imiquimod, and photodynamic therapy. (9)
Verrucous carcinoma (VC) is usually cured with appropriate therapy. Mostly cases of verrucous carcinomas rarely have an aggressive course as their clinical outcome. However, recurrence of cutaneous carcinoma with clear surgical margins has been reported. In addition, patients are at risk for developing additional verrucous carcinoma and squamous cell carcinoma and should be evaluated with skin examinations at 3- to 12-month intervals. Several preventive measures can be advised to patients especially with chronic skin inflammation or trauma to prevent these problems from developing malignancies within them. Patients are usually advised regarding the importance of hygiene that may help prevent inflammatory conditions that predispose patients to verrucous carcinoma. (9)
References:
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4. Ackerman LV. Verrucous carcinoma of the oral cavity. Surgery. Apr 1948;23(4):670-8.
5. Aird I, Johnson HD, Lennox B, Stansfeld AG. Epithelioma cuniculatum: a variety of squamous carcinoma peculiar to the foot. Br J Surg. Nov 1954;42(173):245-50.
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7. Abbas MA. Wide local excision for Buschke-Löwenstein tumor or circumferential carcinoma in situ. Tech Coloproctol. Sep 2011;15(3):313-8.
8. Hagiwara H, Kanazawa T, Ishikawa K, et al. Invasive verrucous carcinoma: a temporal bone histopathology report. Auris Nasus Larynx. Apr 2000;27(2):179-83.
9. Bassam, Zeina et.al. Dermatologic manifestations of verrucous carcinoma.http://emedicine.medscape.com/article/1101695-overview (viewed last November 8, 2012)