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The second article in this continuing medical education series discusses the clinical and histopathologic features of common premalignant and malignant lesions of the oral cavity. It is imperative for dermatologists to be able to appropriately recognize suspicious lesions, determine the need to obtain a biopsy specimen, counsel, and refer patients presenting with premalignant or malignant conditions. Given the higher rates of mortality and morbidity of oral mucosal malignancies because of late diagnosis, appropriate treatment with multidisciplinary care in a timely manner is essential to patients with these neoplasms.

Cutaneous verrucous carcinoma is a rare variant of low-grade squamous cell carcinoma. It usually involves distal extremities and is often misdiagnosed as giant warts. Multiple cutaneous verrucous carcinomas are rare in the English-language literature. We describe a 41-year-old man with multiple verrucous plaques on both feet and ankles, as well as the left thigh. Immunohistochemical study with proliferating cell nuclear antigen revealed positive staining of the basal and suprabasal layers. The patient's condition was successfully treated with systemic acitretin.

Large papillomatous lesions clinically resembling verrucous carcinoma may be caused by viruses other than human papillomavirus. We report a case of recurrent vegetations covering the entire vulva in a pregnant patient with common variable immunodeficiency. Herpes simplex virus was recovered from these lesions. The patient did not respond to intravenous acyclovir, but her lesions dramatically healed with two courses of intravenous foscarnet. Repeated biopsies may prove necessary in cases such as this to ensure proper diagnoses.

The Buschke-Loewenstein tumor is an anogenital tumor of characteristic clinical and histologic pattern best considered as a low-grade, well-differentiated squamous cell carcinoma. This remarkable neoplasm and its features are reviewed in detail, stressing salient advances in our understanding of it.

Cutaneous verrucous carcinoma is a low-grade and well-differentiated variant of squamous cell carcinoma. This rare neoplasm follows a seemingly indolent progression and exhibits a low metastatic potential. Photodynamic therapy relies on the selective intratumoral cell accumulation and photoactivation of a photosensitizer, leading to the generation of phototoxic compounds responsible for necrosis and apoptosis of the target cells. An 82-year-old man presenting with a large long-standing verrucous carcinoma on the leg was treated successfully by 6 photodynamic therapy sessions administered at weekly intervals using methyl-aminolevulinate and 57-J/cm 2 irradiations at 634-nm wavelength. The use of methyl-aminolevulinate–photodynamic therapy for treating cutaneous verrucous carcinoma had not been reported so far. It may represent a convenient therapeutic alternative in this setting.

Verrucous carcinoma is a distinctive form of low-grade squamous cell carcinoma. It typically involves the oral cavity, larynx, esophagus, and skin. Cutaneous lesions typically arise in the genitocrural area and plantar surface of the foot, with rare case reports of verrucous carcinoma arising elsewhere on the body. Human papillomaviruses, predominately types 6 and 11, have been associated with some case reports. We present a case of verrucous carcinoma arising on the scalp with negative human papillomavirus testing in a relatively young patient.

Background: We present 2 patients with verrucous carcinoma (VC) of the foot, a malignancy of unknown origin. Objective: Molecular studies from the VCs were undertaken to determine the presence, type, and physical state of human papillomavirus (HPV) as well as the expression levels of certain oncogenes and antioncogenes. Methods: Synthetic consensus and type-specific primers were used to determine the HPV type from both VCs via polymerase chain reaction (PCR). Verification of fragments was accomplished by means of specific isotope-labeled oligonucleotide probes. The physical state of HPV DNA was determined by two-dimensional gel electrophoresis. Quantitative oncogene and antioncogene expression studies were performed with the use of reverse transcriptase PCR. Results: HPV type 16 was identified in episomal and integrated forms in both tumors. Expression studies revealed increased messenger RNA levels of c- Ki-ras oncogene and the p53 antioncogene and decreased messenger RNA levels of the Rb antioncogene in both VCs. Conclusion: Episomal and integrated forms of HPV-16 DNA were found in VCs of the foot, along with alterations of c- Ki-ras , p53, and Rb genes. (J Am Acad Dermatol 2001;45:49-55.)

Squamous cell carcinoma of the penis is almost exclusively a lesion of uncircumcised older men. It represents about 1% of cancers in men in the United States and 11% to 12% of all cancers in men in countries where circumcision is not routinely practiced. Verrucous carcinoma is an uncommon variant that accounts for only 5% to 16% of all penile squamous cell carcinomas. We describe penile verrucous carcinoma in a 37-year-old white man who had been circumcised in infancy. To our knowledge this is the first case report of verrucous carcinoma in a circumcised man without any predisposing penile anatomic abnormalities.

Penile tumors, although not frequent, represent a difficult diagnostic and therapeutic challenge. Of the malignant penile neoplasms, the most frequent is penile carcinoma, which includes squamous cell carcinoma and its well-differentiated variant, verrucous carcinoma. Current concepts about classification, epidemiology, pathogenesis, histopathology, diagnosis, staging, prognosis, and treatment are presented.

Because the combination of interferon alfa and retinoids proved useful in the treatment of squamous cell carcinoma'"!! and ve has been said to respond to etretinate alone, 12 we used the combination therapy for both our patient's VC and her hyperkeratosis of the palms and sales. Unfortunately, it did not seem to affect her ve. To our knowledge this is the first patient observed with ve of the sale associated with hyperkeratosis of the palms and soles.13. 14 The factors that might lead to the development of ve at these sites are unclear. Results of our HPV typing were negative, but Results were negative for human papillomavirus (HPV) type 2.

The understanding of condylomata acuminata (genital warts) has been enhanced by the recent development of diagnostic methods. Forty-two types of human papillomavirus were identified up to 1985, and at least sixteen types were involved in genital warts. The incidence of genital warts is around 0.1% in the general population and more than 0.5% in young persons. The incidence is known to be increasing rapidly and exceeding the incidence of genital herpes. Females are more prone to be affected. The epidemiologic evidence supporting the relationship between genital warts and genital cancer is overwhelming. The evidence also speaks for a strong correlation between genital warts and verrucous carcinoma of the genitalia, bowenoid papulosis, and laryngeal papilloma. The person having genital warts may also have other cutaneous warts. This observation is compatible with the finding that types of human papillornavirus involved in other cutaneous warts were found in genital warts. In view of the newer and easier ways of diagnosing nonconspicuous condyloma acuminatum and the potential for malignant transformation of condyloma acuminatum, it is strongly recommended that patients should be followed up periodically for early detection of neoplasia.

A case of verrucous carcinoma occurring on the dorsolumbar region of the back is reported. Verrucous carcinoma, although usually appearing on three leading sites (pan-oral, genitogluteal, and plantar), can exceptionally arise anywhere on the skin surface. It is important to be aware of this fact for more accurate diagnosis and treatment.

In two cases of epithelioma cuniculatum, a rather rare form of verrucous carcinoma of the plantar surface of the foot, the lesions were excised by means of microscopically controlled surgery (Mohs' chemosurgery) with successful results, both clinically and cosmetically. Although the tumor is generally slow-growing and often mistaken for a plantar wart, it can cause extensive local destruction. Metastasis has been reported and may be related to anaplastic transformation caused by radiotherapy. In certain cases, amputation may possibly be avoided through the use of microscopically controlled surgery.

A 58-year-old man presented with a 4-year history of a slowly enlarging, hyperkeratotic plaque on his glans penis that was compatible with a clinical diagnosis of pseudoepitheliomatous, keratotic, micaceous balanitis. The lesion had been treated unsuccessfully on three occasions with superficial shave excisional biopsies. Complete surgical excision produced excellent cosmetic and functional results with no evidence of recurrence at 3- and 6-month follow-up. A diagnosis of verrucous carcinoma was made on histologic examination of the excised material. Pseudoepitheliomatous, keratotic, micaceous balanitis is a distinctive clinical entity that represents a histologic spectrum ranging from hypertrophic-hyperplastic penile dystrophy to verrucous carcinoma.

Genital tumors represent a special group requiring effective and curative treatment while functional and cosmetic demands require tissue sparing techniques. For these reasons, micrographic surgery is indicated. Over the past 5 years we have treated 24 such patients utilizing standard techniques for micrographic surgery. The patient population included twenty male and four female patients with ages ranging from 27 to 80 years. Histologically confirmed diagnoses included squamous cell carcinoma, Bowen's disease, verrucous carcinoma, basal cell carcinoma, Paget's disease, and leiomyosarcoma. These were located on the penis, scrotum, perineum, and buttocks. Seven of these patients were considered to have recurrent tumors. Preexisting conditions existed in 6 patients, including balantis xerotica obliterans, trauma, decubitus ulcer, and hidradenitis suppurativa. All surgery was performed under local anesthesia in the cutaneous surgery unit. Average pretreatment tumor size was 2.0 × 1.9 cm. Average postoperative defect size was 4.5 × 3.7 cm. Tumors were excised with an average of three stages and 18 sections. Most defects (65%) were allowed to heal by secondary intention, five (21%) were closed primarily, and three were referred for closure. After surgery five patients developed metastases in their regional lymphatic system. No patients developed local recurrence. Micrographic surgery is a most useful treatment modality in patients with genital tumors for control of local disease. However, patients with squamous cell carcinoma should be considered for elective regional lymph node biopsy and/or dissection in conjunction with micrographically controlled excision of the primary tumor.