Our returning guest editor today is Ali Abadi, DPM joined by esteemed colleague, Christopher LaRosa, DPM. Dr. Abadi graduated from Temple School of Podiatric Medicine in May 2009. He received his Masters Degree in Biochemistry and Molecular Biology from Georgetown University and BS in Biology form George Mason University, VA and is currently a resident in Virtua West Jersey Hospital. Dr. LaRosa has a poditary practice in Gibbsobor, NJ.

Ryan Fitzgerald, DPM PRESENT RI Associate Editor Hess Orthopedics & Sports Medicine Harrisonburg, Virginia

Case Presentation:
Verrucous Carcinoma

Verrucous carcinoma is an uncommon variant of squamous cell carcinoma.¹ Due to its high frequency in individuals who chew tobacco or use snuff orally, it is sometimes referred to as “snuff dipper’s cancer”. Most patients with verrucous carcinoma have a good prognosis. Local recurrence is not uncommon, but metastasis to distant parts of the body is rare.² Here we describe the case of a 64-year-old woman with a lesion on the plantar surface of her left foot.

Case Report:

Figure 1 Verrucous carcinoma lesion on the plantar aspect of the left foot.

A 64-year-old female presents to the wound healing centre with a severely painful lesion on the plantar surface of her left foot (Figs.1). Patient states that the lesion has increased in size over the past year and denies any previous trauma to the area. Patient also reports active bleeding and cellulitis for which she was admitted to the hospital and treated with IV antibiotics. Her past medical history was significant for insulin-dependent diabetes mellitus controlled with insulin (diagnosed 10 years ago), diabetic neuropathy of lower extremities, hypertension, osteomyelitis of right hallux, skin cancer, appendectomy, and partial right great toe amputation. Physical examination revealed intact pedal pulses and a well-demarcated tumor affecting the ball of the left foot. It consisted of a grey-brown exophytic and hyperkeratotic mass, discharging malodorous debris through several sinus tracts.

Plain radiographs reveal a moderate increase in soft tissue swelling around the lesion (Fig.2a, 2b). Radiographic studies are negative for stress fracture or other obvious osseous abnormalities. Previous magnetic resonance imaging did not indicate any bone involvement. Surgery is discussed and planned for removal of the lesion (fig.3).

Click on the images below for a larger view.
Figure 2a Lateral plain radiographs of the left foot is negative for stress fracture or other obvious osseous abnormalities.		Figure 2b Lateral plain radiographs of the left foot is negative for stress fracture or other obvious osseous abnormalities.

Laboratory examination included corpuscular blood count with differential count, white blood cell count, rheumatoid factor, C-reactive protein, erythrocyte and sedimentation rate, all of which are unremarkable. Hemoglobin A1c was 8.1 and she was positive for MRSA.

 

	Figure 3. post-operative picture of left foot, 6 cm X 4 cm lesion was completely excised.

The patient was taken to the operating room, where the lesion was completely excised and sent to the pathology laboratory (fig.3). The lesion measured 6 cm X 4 cm. The pathology report is consistent with verrucous squamous cell carcinoma.

Postoperatively, the patient is able to ambulate without pain. No recurrence has been noted as of this writing.

Discussion:

The term verrucous carcinoma was first coined in 1948 by Ackerman to signify a well-differentiated, slow-growing neoplasm with locally recurring but non-metastasizing behavior.³ It was first described in the oral cavity and later reported in other stratified squamous surfaces. The three major locations of verrucous carcinoma are the oral cavity, the anogenital region, and plantar surface of the foot also known as epithelioma cuniculatum.³

In 1954, Aird et al⁴ described for the first time in English-language medical literature a rare form of verrucous carcinoma on the plantar surface of the foot.

The tumor occurs predominantly on the soles, but may also appear on the palms or other areas of the body. The cardinal manifestation of this disease is a fungating, exophytic mass with numerous keratin-filled sinuses.³ Verrucous carcinoma of the foot usually appears as a warty tumor that may resemble verruca vulgaris.For that reason, many patients are initially treated with many topical medications without success.⁶

These lesions usually occur on the anterior weight-bearing area of the sole of the foot. Verrucous carcinoma is histologically characterized by blunt papillary projections of well-differentiated epithelium, supported by edematous, typically non-reactive stroma.⁵

The epithelium presents little atypia and is characterized by well-differentiated, lightly staining, and benign-appearing keratinocytes.⁵ Human papilloma virus type 1 through 4,6,11 and 18 have been implicated in the pathogenesis of verrucous carcinoma, however, their exact roles are subject to controversy.⁵ Excision is the treatment of choice due to local aggressiveness and infrequent metastasis.

The differential diagnosis is broad and includes verruca vulgaris, reactive epidermal hyperplasia, dermatofibroma, benign adnexal tumor, Pyogenic granuloma and hyperkeratotic basal cell epithelioma.^1,5

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References:

1. Ridge  JA, Glisson BS, Lango MN, et al. “Head and Neck Tumors” in Pazdur R, Wagman LD Cancer  Management: A Multidiciplinary Approach. 11 ed. 2008
2. Rapini, Roland P. ; Bolognia, Jean L ; Jorizzo, Joseph L , 2007. Dermatology : 2-Volume set. St. Louis:     Mosby. ISBN 1-4160-2999-0
3. Ho J, Diven DG, Butler PJ. Tyring SK. An ulcerating verrucous plaque on the foot. Arch Dermatol. 2000;136:550-1
4. Aird I, Johnson HD, Lennox B et al. Epithelioma cuniculatum: a variety of squamous carcinoma peculiar to the foot. Br J Surg 1954;42:245-50
5. Noel jc, Peny MO, Goldschmidt D. Verhest A, Heenen M, De Dobbeleer G. Human papillomavirus type I DNA in verrucous carcinoma of the leg. J Am Acad Dermatol 1993;29: 1036-8.
6. Halpern J, Harris S, Suarez V, Epithelioma cuniculatum: A case report.Foot Ankle surg.
   2009;15:114-6.

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