DP17: Gluteal verrucous carcinoma arising within chronic hidradenitis suppurativa

Abstract

Gluteal verrucous carcinoma arising within chronic hidradenitis suppurativa D.S. Alsaadi, P. Balasubramaniam, E. Raweily and P.D. Yesudian Glan Clwyd Hospital, Bodelwyddan, UK and Wrexham Maelor Hospital, Wrexham, UK Verrucous carcinoma is a rare clinicopathological variant of low-grade, well-differentiated squamous cell carcinoma, predominantly arising in the oropharynx, palmoplantar or genital region. Variable clinical presentations have been described, with lesions often appearing exophytic and verrucous. It can pose diagnostic challenges as histological features are frequently bland, with minimal atypia, resembling verruca vulgaris or pseudoepitheliomatous hyperplasia. We report a case of multiple verrucous carcinomas arising within chronic gluteal hidradenitis suppurativa (HS) lesions. A 65-year-old Portuguese man with a recent diagnosis of bronchial squamous cell carcinoma was referred with a 1-year history of tender, keratotic nodules on his left buttock that raised concerns of cutaneous metastases. He had a 20-year history of HS confined to lesions on his left buttock, for which he had received no treatment. Examination revealed multiple discharging sinuses and nine hard nodular, keratotic lesions on his left buttock, extending into the perineum. He was commenced on clindamycin and rifampin, and referred urgently to plastic surgery for consideration of surgical management. Incisional biopsy from the largest, most symptomatic lesion showed a keratinizing squamoproliferative lesion with minimal squamous atypia and invasion of the dermis in a broad, smooth front, suggestive of pseudoepitheliomatous hyperplasia or well-differentiated verrucous carcinoma. Following specialist multidisciplinary team (MDT) clinicopathological correlation, the latter was favoured. He had complete radical excision of the left gluteal skin with split-skin graft reconstruction and has had no recurrence for more than a year. Histology demonstrated an exophytic keratotic surface with deep sinus tracts. Specialist MDT review confirmed completely excised verrucous carcinoma. Cases of verrucous carcinoma arising within burn scars and chronic neuropathic ulcers have been reported in the literature. While squamous cell carcinoma (SCC) complicating HS is well documented (most commonly affecting the gluteal region), verrucous carcinomas within chronic HS wounds is less well recognized. In one series of 13 patients with SCC arising within HS lesions, six were distinguished histologically as verrucous carcinomas, while in another series, only two of 52 cases were found to be verrucous carcinoma. Diagnostic challenges pertaining to the mild atypia seen on histology compared with SCC have been highlighted, as well as the potential need for multiple deep biopsies and clinicopathological correlation in the setting of atypical nonhealing HS lesions. Radical surgery is advised to minimize risk of aggressive local recurrence. Importantly, radiotherapy should be avoided as it carries a risk for anaplastic transformation into high-grade SCC; distinguishing verrucous carcinoma from well-differentiated SCC is therefore advisable.