Sandbox: Verrucous carcinoma
Synonyms and keywords: Ackerman tumor; Verrucous carcinoma of the skin

# Overview
Verrucous carcinoma (also known as "Snuff dipper's cancer") is rare subtype of squamous cell carcinoma.  Common causes of verrucous carcinoma, include: tobacco chewing, or use snuff orally. Patients with oral verrucous carcinoma may be at greater risk of a second oral squamous cell carcinoma. Verrucous carcinoma may occur in various head and neck locations, as well as in the genitalia. The oral cavity is the most common site of this tumor. Verrucous carcinoma is most commonly seen among male patients between 50 to 80 years, and the median age at diagnosis is 67 years. The diagnosic criteria for verrucous carcinoma is biopsy and surgical excision must provide adequate specimens including the full thickness of the tumors and adjacent uninvolved mucosa for correct diagnosis.

# Historical Perspective
- Verrucous carcinoma was first discovered by Lauren V. Ackerman, an American physician in 1948.

# Classification
- Verrucous carcinoma may be classified into 5 subtypes:
- Epithelioma cuniculatum (Ackerman tumor, carcinoma cuniculatum)
- BuschkeLowenstein tumor (giant condyloma)
- Oral florid papillomatosis
- Subungual keratoacanthoma
- Gottron's carcinoid papillomatosis

# Pathophysiology
- Verrucous carcinoma is characterized as a well-differentiated squamous cell carcinoma with minimal metastatic potential.
- The pathogenesis of verrucous carcinoma is not fully understood.
- Different locations of verrucous carcinoma, include:
- Gingiva
- Buccal mucosa
- Alveolar mucosa
- Hard palate
- Floor of the mouth
- Larynx
- Esophagus
- Penis
- Vagina
- Scrotum
- There are no genetic mutations associated with the development of verrucous carcinoma.
- On gross pathology, characteristic findings of verrucous carcinoma include:
- Cauliflower-like, exophytic mass
- On microscopic histopathological analysis, characteristic findings of verrucous carcinoma include:
- Exophytic growth
- Well-differentiated
- "Glassy" appearance
- Pushing border - described "elephant feet"

# Causes
- Common causes of verrucous carcinoma, include:
- Use snuff orally
- Tobacco chewing
- Chewing betel nuts (Taiwan)
- Alcohol consumption

# Differentiating  Verrucous Carcinoma from Other Diseases
- Verrucous carcinoma must be differentiated from other diseases that cause leukoplakic patches, such as:
- Keratoacanthoma
- Giant verruca vulgaris
- Nongenital warts
- Pyoderma vegetans

# Epidemiology and Demographics
- Verrucous carcinoma is very uncommon

## Age
- Verrucous carcinoma is more commonly observed among patients aged 50 to 80 years old.
- Verrucous carcinoma is more commonly observed among middle-aged and elderly adults.

## Gender
- Males are more commonly affected with verrucous carcinoma than females.

## Race
- Verrucous carcinoma usually affects individuals of the Asian race.

# Risk Factors
- The most common risk factor in the development of verrucous carcinoma is human papillomavirus (HPV) infection. Other factors, such as schistosomiasis infections, are related to bladder verrucous carcinoma.

# Natural History, Complications and Prognosis
- The majority of patients with verrucous carcinoma remain asymptomatic for years.
- Early clinical features include translucent patches with erythematous base, and pruritus.
- If left untreated, patients with verrucous carcinoma may progress to develop malignant transformation.
- Common complications of verrucous carcinoma, include:
- Metastasis
- Prognosis is generally good, and the 5-survival rate of patients with verrucous carcinoma is approximately 75-80%.

# Diagnosis

## Symptoms
- Verrucous carcinoma is usually asymptomatic.
- Symptoms of verrucous carcinoma may include the following:
- Painful lymphadenopathy
- Non-healing scar
- Pruritus

## Physical Examination
- Patients with verrucous carcinoma usually appear malnourished.
- Physical examination may be remarkable for:
- Slow growing, diffuse, exophytic lesion
- Leukoplakic patches
- Enlarged regional lymph nodes.
- Painful multiple rugae-like folds and deep clefts.

### Gallery
- Verrucous carcinoma. Adapted from Dermatology Atlas.
- Verrucous carcinoma. Adapted from Dermatology Atlas.

## Laboratory Findings
- There are no specific laboratory findings associated with verrucous carcinoma.

## Imaging Findings
- There are no specific imaging findings for verrucous carcinoma.

# Treatment

## Medical Therapy
- The mainstay of therapy for verrucous carcinoma, may include:
- Bleomycin
- 5-fluorouracil
- Cisplatin
- Methotrexate

## Surgery
- Surgery is the mainstay of therapy for verrucous carcinoma.
- Complete surgical excision (Mohs surgery) is the most common approach to the treatment of verrucous carcinoma.

## Prevention
- Primary preventive measures available for verrucous carcinoma, include:
- Avoid chewing tabacco
- Once diagnosed and successfully treated, patients with verrucous carcinoma are followed-up every 3, or 12 months.
- Follow-up testing, include: regular skin examinations.