Verrucous carcinoma of the vulva: About a case report

Abstract

Introduction: Verrucous carcinoma of the vulva is a rare lesion, mainly affecting postmenopausal women, this lesion is a distinct and particular entity in the classification of vulvar carcinomas and its progression is uncertain and unpredictable. It is characterized by its extensive exophytic growth without infiltration of the basement membrane. Case Report: We report a case of verrucous carcinoma of the vulva collected at the Mohamed VI cancer treatment center in Casablanca, we will discuss through a literature review, its therapeutic and evolutionary diagnostic modalities. Conclusion: Therefore, verrucous carcinoma is a rare entity and its evolution is mainly local, rarely metastatic. It is the indication for exclusive surgical treatment with wide excision without lymphadenectomy in principle. Radiation therapy provides no survival benefit. The prognosis is relatively good but burdened by local recurrences.

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Journal of Case Reports and Images in Obstetrics and Gynecology, Volume 9, Issue 1, 2023; Pages 49–52. ISSN: 2582-0249
J Case Rep Images Obstet Gynecol 2023;9(1):49–52.
www.ijcriog.com
El Abbassi et al. 49
CASE REPORT OPEN ACCESS
Verrucous carcinoma of the vulva: About a case report
Imane El Abbassi, S Tangara, D El Karoini, M Sakim, M Ennachit,
M Benhessou, M El Kerroumi
ABSTRACT
Introduction: Verrucous carcinoma of the vulva is a
rare lesion, mainly affecting postmenopausal women,
this lesion is a distinct and particular entity in the
classification of vulvar carcinomas and its progression
is uncertain and unpredictable. It is characterized by its
extensive exophytic growth without infiltration of the
basement membrane.
Case Report: We report a case of verrucous carcinoma
of the vulva collected at the Mohamed VI cancer treatment
center in Casablanca, we will discuss through a literature
review, its therapeutic and evolutionary diagnostic
modalities.
Conclusion: Therefore, verrucous carcinoma is a rare
entity and its evolution is mainly local, rarely metastatic.
It is the indication for exclusive surgical treatment with
wide excision without lymphadenectomy in principle.
Radiation therapy provides no survival benefit. The
prognosis is relatively good but burdened by local
recurrences.
Keywords: Verrucous carcinoma, Vulva, Vulvectomy
How to cite this article
El Abbassi I, Tangara S, El Karoini D, Sakim M,
Ennachit M, Benhessou M, El Kerroumi M. Verrucous
carcinoma of the vulva: About a case report. J Case
Rep Images Obstet Gynecol 2023;9(1):49–52.
Imane El Abbassi1, S Tangara1, D El Karoini1, M Sakim1, M
Ennachit1, M Benhessou1, M El Kerroumi1
Affiliation: 1Mohamed VI Center for the Treatment of Gyneco-
Mammary Cancers, CHU IBN Rochd, Casablanca, Morocco.
Corresponding Author: Imane El Abbassi, Mohamed VI Cent-
er for the Treatment of Gyneco-Mammary Cancers, CHU IBN
Rochd, Casablanca, Morocco; Email: imane.mammeri.im@
gmail.com
Received: 05 February 2023
Accepted: 21 March 2023
Published: 26 April 2023
Article ID: 100145Z08IA2023
*********
doi: 10.5348/100145Z08IA2023CR
INTRODUCTION
Vulvar cancers represent less than 5% of all female
genital cancers, and most often affect postmenopausal
women over the age of 60 [1]. Verrucous cancer is a
rare entity constituting less than 1% of vulvar cancers,
and is characterized by an exophytic appearance and
slow growth, rarely metastatic to the lymph nodes [2].
Indeed, it is a well-differentiated form of squamous cell
carcinoma linked to viral infection by HPV 6, having the
appearance of giant condyloma without invasion of the
basement membrane [3]. It has a mainly local evolution,
therefore represents the indication for exclusive surgical
treatment with local resection in a healthy zone without
systematic inguinal lymph node control [4, 5]. We report
a case of verrucous carcinoma of the vulva, treated at
the Mohamed VI cancer treatment center in Casablanca,
reflecting the diagnostic and therapeutic particularities of
this pathology.
CASE REPORT
We report the case of a 64-year-old patient, nulligest,
menopausal for 10 years, having a history as her sister
followed for breast cancer. She consulted for a whitish
vulvar lesion associated with vulvar itching evolving for
10 months before her admission, without associated
digestive or urinary signs. All evolving in a context of
conservation of the general state.
The clinical examination revealed a whitish exophytic
lesion of the vulva involving both the right labia minora
and the clitoris measuring 3×2.5 cm, the lymph node
areas were unharmed (Figure 1).
A vulvar biopsy was performed at this level, showing
a well-differentiated verrucous carcinoma. The pelvic
CASE REPORT PEER REVIEWED | OPEN ACCESS

Journal of Case Reports and Images in Obstetrics and Gynecology, Volume 9, Issue 1, 2023; Pages 49–52. ISSN: 2582-0249
J Case Rep Images Obstet Gynecol 2023;9(1):49–52.
www.ijcriog.com
El Abbassi et al. 50
A total vulvectomy alone without lymph node dissection
was performed. The anatomopathological result confirmed
the diagnosis of a verrucous squamous cell carcinoma with
healthy resection limits.
DISCUSSION
Verrucous carcinoma is a rare histological variety,
only 68 cases have been reported in the literature [6], is
characterized by diagnostic and prognostic particularities
that should be known to adapt the therapeutic attitude.
Indeed, it can occur in the vulva, the ear, nose, throat
(ENT) sphere, the penis, the scrotum, or the rectum [7].
Diagnosis, too, can be difficult to make. For this reason,
large biopsies should be performed to avoid misdiagnosis
and inadequate treatment [8].
Verrucous carcinomas exhibit several histological
diagnostic criteria such as a “pushed” tumor-dermis
interface with minimal stroma between the acanthotic
epithelium, minimal nuclear atypia, hyperkeratotic areas
on the surface of the tumor with little keratin formation at
inside the tumor and diffuse chronic inflammation of the
stroma [9]. It is locally invasive but rarely metastasizing,
usually affecting older postmenopausal women, which
is consistent with our study. However, its incidence is
currently increasing in young women [2, 10]. Indeed, it
is a well-differentiated form of squamous cell carcinoma
linked to viral infection by HPV 6, found in more than
50% of cases [3, 5], sometimes associated with polyviral
involvement, which explains the frequent association
of verrucous carcinoma of the vulva with intraepithelial
neoplasia and invasive carcinoma of the vulva [5, 11].
Its appearance is characterized by its significant
exophytic growth [12]: it is a budding lesion, cauliflower,
sometimes associated with a superficial ulceration. This
aspect can lead to the incorrect diagnosis of condyloma
acuminata or well-differentiated squamous cell carcinoma
[7, 13]. Thus, a biopsy that is too superficial and does not
include the underlying stroma may underestimate the lesion
giving an erroneous diagnosis of condyloma acuminata or
overestimate it giving a wrong diagnosis of squamous cell
carcinoma of another degree of differentiation [14].
It is therefore essential that the biopsy includes the
entire thickness of the lesion: the epithelium and a sufficient
quantity of chorion in order to avoid an inadequate
diagnosis and treatment [2, 5]. Microscopic examination
shows hyperplasia with hyperacanthosis, papillomatosis,
and sometimes surface hyperkeratosis. Cellular atypia and
mitosis are rare. Epithelial buds are branched but rounded
pushing back the underlying chorion. As for the basal
membrane, it is always respected [7, 15].
The treatment of verrucous carcinomas of the vulva
differs from that proposed for squamous cell carcinomas
[16]. However, although it is still a subject of discussion,
verrucous carcinoma of the vulva is the indication
for exclusive surgical treatment even in the event of
recurrence. Indeed, wide resection with a centimetric
Figure 1: Whitish exophytic lesion of the vulva involving both the
right labia minora and the clitoris measuring 3×2.5 cm.
ultrasound was without abnormality, a pelvic and inguinal
magnetic resonance image (MRI) was done highlighting
a tissue thickening of the right labia minora with an
intermediate signal on T2, in hypersignal intermediate
apparent diffusion coefficient (ADC) diffusion, enhanced
after injection of the phosphatidyl choline (PDC),
measuring 20×17×6 mm. Laterally this process comes
into contact with the large homolateral lip with loss of
the fibrous border of separation. It respects the ureteral
meatus (Figure 2).
Figure 2: Radiological appearance of the vulvar lesion.

Journal of Case Reports and Images in Obstetrics and Gynecology, Volume 9, Issue 1, 2023; Pages 49–52. ISSN: 2582-0249
J Case Rep Images Obstet Gynecol 2023;9(1):49–52.
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El Abbassi et al. 51
margin without dissection in principle is the reference
treatment because of its attenuated local malignancy [17].
However, the extension of the lesions can nevertheless
make the gesture dilapidating. Thus, dissection can only
be justified if the definitive examination revealed the
presence of a true invasive zone [3, 5], since it exposes to
the risk of complications such as lymphocele (40%), scar
infection (39%), lymphedema (28%), and suture disunity
(17%) [8]. Moreover, radiotherapy does not provide
any survival benefit. It can even induce post-radiation
anaplastic transformation with the appearance of lesions
with high metastatic potential [18].
The prognosis is relatively good in the event of wide
excision but is burdened by local recurrences and the
risk of appearance of secondary localizations in the event
of persistence of the etiological factors (atrophic lichen
sclerosis or HPV) [2, 4, 5]. This justifies clinical monitoring
every four months during the first year, every six months
for two years then every year with a clinical examination
of the vulva, perineum, and lymph node areas, possibly
supplemented by ultrasound, cytopuncture, and smear
screening [4].
CONCLUSION
Therefore, verrucous carcinoma is a rare entity, well-
differentiated histological form of squamous cell carcinoma
which is distinguished by its particular diagnostic,
therapeutic, and evolutionary modalities. Its treatment is
exclusively surgical based on wide excision without lymph
node dissection. The prognosis of these lesions is good but
burdened by local recurrences.
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Author Contributions
Imane El Abbassi – Conception of the work, Design of the
work, Acquisition of data, Analysis of data, Interpretation
of data, Drafting the work, Revising the work critically
for important intellectual content, Final approval of the
version to be published, Agree to be accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved
S Tangara – Conception of the work, Design of the work,
Acquisition of data, Analysis of data, Interpretation of
data, Drafting the work, Revising the work critically for
important intellectual content, Final approval of the
version to be published, Agree to be accountable for all
aspects of the work in ensuring that questions related

Journal of Case Reports and Images in Obstetrics and Gynecology, Volume 9, Issue 1, 2023; Pages 49–52. ISSN: 2582-0249
J Case Rep Images Obstet Gynecol 2023;9(1):49–52.
www.ijcriog.com
El Abbassi et al. 52
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved
D El Karoini – Conception of the work, Design of the
work, Acquisition of data, Analysis of data, Interpretation
of data, Drafting the work, Revising the work critically
for important intellectual content, Final approval of the
version to be published, Agree to be accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved
M Sakim – Conception of the work, Design of the work,
Acquisition of data, Analysis of data, Interpretation of
data, Drafting the work, Revising the work critically for
important intellectual content, Final approval of the
version to be published, Agree to be accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved
M Ennachit – Conception of the work, Design of the
work, Acquisition of data, Analysis of data, Interpretation
of data, Drafting the work, Revising the work critically
for important intellectual content, Final approval of the
version to be published, Agree to be accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved
M Benhessou – Conception of the work, Design of the
work, Acquisition of data, Analysis of data, Interpretation
of data, Drafting the work, Revising the work critically
for important intellectual content, Final approval of the
version to be published, Agree to be accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved
M El Kerroumi – Conception of the work, Design of the
work, Acquisition of data, Analysis of data, Interpretation
of data, Drafting the work, Revising the work critically
for important intellectual content, Final approval of the
version to be published, Agree to be accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved
Guarantor of Submission
The corresponding author is the guarantor of submission.
Source of Support
None.
Consent Statement
Written informed consent was obtained from the patient
for publication of this article.
Conflict of Interest
Authors declare no conflict of interest.
Data Availability
All relevant data are within the paper and its Supporting
Information files.
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