ANTICANCER RESEARCH 27: 4491-4494 (2007)
Verrucous Carcinoma of the Cervix: Detection of Carcinogenetic
Human Papillomavirus Types and their Role during Follow-up
ANTONIO FREGA1, ANKICA LUKIC1, FLAVIA NOBILI1, ANTONELLA PALAZZO1,
ROBERTO IACOVELLI1, DEBORAH FRENCH2 and MASSIMO MOSCARINI1
Departments of 1Gynecology, Perinatology and Childhealt, and
2Experimental Medicine and Pathology, University “Sapienza”, Rome, Italy
Abstract. Background: Verrucous carcinoma is a rare variant
of well-differentiated squamous cell carcinoma of the uterine
cervix. Infection with high-risk human papillomavirus (HPV)
is the main cause of intraepithelial and invasive neoplasias of
the female genital tract, but the aetiology of verrucous
carcinoma is still unknown. The aim of this study was to
evaluate the presence of HPV in verrucous carcinomas of the
cervix and to investigate the persistence and the role of high
risk HPV types in follow-up. Patients and Methods: Three
patients, with atypical cytologies, were observed. All the
patients underwent cytology and colposcopy followed by direct
biopsy. The Hybrid Capture II microplate method was used for
molecular detection of pre-surgical low- and high-risk HPV
types. HPV tests were performed during the follow-up,
annually. Results: The cytological findings revealed that
atypical squamous cells “cannot rule out high-grade lesion”
(ASC-H) in one case and high grade squamous intraepithelial
lesion (H-SIL) in two cases. The HPV test detected high risk
HPV types. Colposcopic findings showed cervical exophytic
lesions. The histology revealed a well-differentiated verrucous
carcinoma Ib stage, according to FIGO classification, in every
case. Following radical hysterectomy, the post-operative course
was uneventful. The mean follow-up time was 4.6 years. The
follow-up HPV tests of the H-SIL patients were consistently
negative as to cytological and colposcopical findings and no
relapse was observed. At one-year follow-up the ASC-H patient
who had shown postoperative histological features of
koilocytosis associated with CIN2 and VAIN 3 had a
persistence of high-risk HPV types with negative cytological and
colposcopical findings. The HPV test was positive for two years
and colposcopic and histological findings of VAIN degree 2
were revealed three years after surgery. Following vaginal laser
Correspondence to: Prof. Antonio Frega, Viale Ippocrate, 97-
00161, Rome, Italy. Tel/Fax:+396233295579, e-mail: a.frega@tin.it
Key Words: Verrucous carcinoma, high-risk human papillomavirus,
follow-up.
0250-7005/2007 $2.00+.40
CO2 vaporization the subsequently cytological and colposcopic
checks were negative as was molecular detection of HPV.
Conclusion: Follow-up colposcopy, cytology and molecular
detection of HPV is recommended in all verrucous carcinoma
patients since carcinogenic HPV DNA detection could
represent a valuable diagnostic tool as an adjunct to cytology,
for monitoring HPV infections with transforming potential.
Verrucous carcinoma, cervical lymphoma, cervical small cell
carcinoma, and sarcomas (1-3) are rare neoplasia of the
uterine cervix. Verrucous carcinoma is a rare variant of well-
differentiated squamous cell carcinoma that is often confused
with the more common condyloma acuminatum or papillary
type of squamous cell carcinoma and it has a tendency to
local invasion, without nodal or distant metastases.
Only 44 cases of cervical verrucous carcinoma have been
described in the world literature, the other typical
localizations are the vulva and vagina in the female genital
tract, the male penis and the oral cavity. It is a primarily a
tumour of the postmenopausal age and the involvement of
the vulva and the cervix seems to be more common than
involvement of the vagina. The patients with involvement of
the uterine cervix seem to be slightly younger than patients
with the tumour located in the vagina or in the vulva (4).
Infection with high-risk human papillomavirus (HPV) is
the main cause of cervical intraepithelial and invasive
neoplasias. HPV DNA has been detected in >90% of
cervical carcinomas, with the most common HPV types
identified as HPV 16, 18, 31, 33 and 45. Patients with
persistent infection with these HPV types have a clearly
enhanced risk of developing cervical carcinoma (5).
The aetiology of verrucous carcinoma of the female
genital tract is still unknown although it has been associated
with irritation and inflammation. Much evidence is
accumulating indicating HPV as either the causative agent
or a likely cofactor in the development of this lesion and it
has been detected in approximately 25% of cases (6, 7).
The objective of this study was to evaluate the presence
of HPV in verrucous carcinomas of the cervix and to
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 ANTICANCER RESEARCH 27: 4491-4494 (2007)
investigate the persistence of high-risk HPV types as a
predictor for the development of intraepithelial or invasive
lesions of the lower genital tract, as an adjunct to cytology
during the follow-up after treatment.
Patients and Methods
From 2001 to 2003, three patients, with atypical cytologies,
attended to the Department of Gynaecology, Perinatology and
Child Health, University of Rome “Sapienza”. A personal history
(age, parity, sexual habits, contraception, cigarette smoking, drug
and alcohol consumption,) and written consent were available for
every patient. All the patients underwent cytology and colposcopy
followed by direct biopsy from any area revealing the greatest
degree of abnormality. Preoperative cervical cytology specimens
were collected in all cases from the ectocervix and from a
cytobrush endocervical device. Cytological diagnosis was
formulated in agreement with the Bethesda System (8).
Colposcopy was performed by means of a Zeiss 50 T colposcope
(Carl Zeiss Inc. Oberkochen, Germany), using 5% acetic acid and
followed by Lugol test. Colposcopic findings were classified
according to the International Classification (9). The Hybrid
Capture II microplate method was used for molecular detection
of low (6, 11, 42, 43, 44) and high-risk (16, 18, 31, 33, 35, 39, 45,
51, 52, 56, 58, 59, 68). HPV types as described by the manufacturer
(Digene, Gaithersburg, MD, USA).
Trans-vaginal ultrasound tomography and pelvic contrast-
enhanced magnetic resonance imaging (MRI) were performed to
determine the regional extent of the tumour and for mapping nodal
disease. A chest X-ray was performed preoperatively to exclude
metastatic disease.
All the women with a histological diagnosis of verrucous
carcinoma underwent a type II Piver radical hysterectomy, with
bilateral salphingoophorectomy, upper vaginal third colpectomy
and pelvic lymphadenectomy. Definitive histology and tumour
staging according to the FIGO classification were obtained from
surgical specimens (10).
In the first year after surgical treatment all patients were
followed up at three-month intervals and subsequently six-month
intervals for two years and then annually. Cytological Pap smear
and colposcopy were carried out at the time of the follow-up
checks, a direct biopsy was obtained from any suspicious area. The
HPV tests were performed annually. Pelvic ultrasound tomography
was performed every six months and a chest X-ray every year.
Results
The median age of the patients at diagnosis was 48. 6 years
(range 45-55). Two patients had more than 2 full term
pregnancies and one patient was nulliparous. The median
age at first intercourse was 16. 6 years, the number of
lifetime sexual partners was more than 2 for all three
patients. In addition no patient declared condom use as a
contraceptive method. No patients were alcohol users, one
was a drug abuser and they were all cigarette smokers (more
than five cigarettes daily).
Cytological findings revealed atypical squamous cells
“cannot rule out high-grade lesion” (ASC-H) in one case
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and high grade squamous intraepithelial lesion (H-SIL) in
two cases. In all the patients the Hybrid Capture test
detected high risk HPV types.
Colposcopic findings showed cervical exophytic lesions
measuring approximatively 20 mm in two patients and 15
mm in the other one. The lesions appeared to be
characterized by a white thickened epithelium, with an
irregular cerebroid surface without defined borders, bloody,
with atypical vessels and necrotic areas. The histology
obtained by direct biopsy revealed a well differentiated
verrucous carcinoma in every case.
The trans-vaginal ultrasound tomography and pelvic
(MR) revealed neoformative processes with a diameter of
20 mm in two patients and 12 mm in the other one at the
isthmo-cervical region. No pathological involvement of
periuterine or adnexal and parameters structures was
described in any three patients. Moreover there was no
evidence of adenopathy, no free endoperitoneal fluid and
no distant disease at chest X-ray.
The post-operative course was uneventful and the three
patients did not require any type of additional treatment.
The post-operative tissues were examined macro- and
microscopically and the histology confirmed the bioptic
diagnosis of verrucous carcinoma.
Microscopic examination showed papillomatous tumours
with a well-differentiated stratified squamous epithelium
(Figure 1). The deeper layers were characterised by a
pronounced hyperkeratosis and parakeratosis with rare
mitotic figures.
There was no microscopic evidence of the spread of the
malignant tumours outside the cervix and no metastases to
the pelvic lymph nodes were observed. These histological
findings were suggestive of Ib stage, according to the FIGO
classification, in every case.
The patient with a preoperative cytological diagnosis of
ASC-H revealed histological features of koilocytosis
associated with cervical intraepithelial neoplasia grade 2
(CIN2) and vaginal intraepithelial neoplasia grade 3
(VAIN 3) coexisting with the verrucous carcinoma in the
surgical specimen.
The patients regularly attended all the follow-up and no
local recurrence or distant disease were reported. The mean
follow-up time was 4. 6 years (range 3-6 years).
In the women with a preoperative cytological diagnosis of
H-SIL, the one-year follow-up HPV test was negative as to
cytological and colposcopical findings. No relapse was
evident in these cases during follow-up.
The patient with a preoperative cytological diagnosis of
ASC-H, and postoperative histological features of
koilocytosis associated with CIN2 and VAIN 3 had a
persistence of high-risk HPV types with negative cytological
and colposcopical findings at one-year follow-up. The
remained HPV test positive for two years during the follow-
 Frega et al: Verrucous Carcinoma of the Cervix and Human Papillomavirus
Figure 1. Microscopic features of verrucous carcinoma: a) well-
differentiated verrucous squamous cell carcinoma, 1.2 cm wide, invading
the sub-epithelial stroma deep down to 3 mm; b) inflammatory infiltration;
c) stroma; d) normal native cervical squamous epithelium (E.E.10x).
up checks and colposcopic and histological findings of
VAIN degree 2 were revealed three years after Piver II
surgery. This patient underwent vaginal laser CO2
vaporization. Subsequently the cytological and colposcopic
and molecular detection of HPV gave negative results.
At the last follow-up check all cases revealed negative
HPV tests, cytological and colposcopical findings.
Discussion
The female genital tract is an uncommon location for
verrucous carcinoma. Its histological characteristics were
first described by Ackerman (11) as a slow-growing, locally
aggressive tumour of the oral cavity. Because of the rarity
of verrucous carcinoma, the histological diagnosis is usually
difficult since it must be differentiated from condylomata
acuminata, giant condyloma acuminatum (Buschke-
Loewenstein tumour) and invasive squamous cell carcinoma
(12, 13).
To distinguish this tumour from a benign condyloma,
findings regarding the central connective tissue support are
important. The fibrovascular cores of a verrucous carcinoma
are limited to the superficial part of the tumour, in contrast
to a benign condyloma, of which the fibrovascular cores
extend from a deep layer to the surface (14).
An adequate biopsy of a verrucous carcinoma must
show an equally well-differentiated bulbous rete-ridge
pattern at the base of the lesion. These findings distinguish
a verrucous carcinoma from a well-differentiated
squamous carcinoma, that forms much keratin superficially
but that might be relatively anaplastic and infiltrating in its
deeper layers.
According to the report of Pantanovitz all three cases in
this study showed a diagnostic cytology specimen although
the analysis of earlier published data about the utility of
cytological specimens obtained during colposcopy described
a negative value of this procedure (15).
The HPV has been related (16, 17) to the
development of squamous intraepithelial lesion of the
cervix (SIL), carcinoma in situ and invasive squamous
cell carcinoma, but the exact relation ship between
verrucous carcinoma and HPV types is unknown. Several
studies on HPV prevalence in verrucous carcinoma have
been performed using different methods for the
detection of HPV subtypes. Some case reports have
shown HPV in verrucous carcinoma of the vulva and of
the vagina, but several unsuccessful attempts to detect it
in cervical verrucous carcinoma have been described in
the literature (18-25).
In this report high-risk HPV types were detected in all
three cervical invasive lesions. The association between
HPV and this tumour could indicate that it is a causative
or cofactor-like substance in the development of verrucous
carcinoma.
Verrucous carcinoma has been described as a slow but
relentlessly expanding tumour which in advanced stages or
in recurrent lesions tends to be more aggressive (26).
Radical surgery is the main factor improving the overall and
disease free survival in these patients. Primary hysterectomy,
with or without adjuvant radiotherapy, has achieved a 50%
cure rate (27).
The multicentricity of pre-neoplastic intraepithelial
lesions as CIN and/or VAIN associated with verrucous
carcinoma, could be regarded as a surrogate marker for
viral persistence and a prerequisite for recurrence. High-
grade HPV or viral persistence has often been proposed as
positive predictor value in identifying progressive and
persistent lesions. A probable predictive value of HPV
DNA for the monitoring of patients previously treated for
verrucous carcinoma was observed in this study. Testing
HPV DNA could be a useful technique in the triage of
patients after surgery and it is necessary for determining
whether cases affected by high risk HPV represent
persistent or transient infections that will regress (28).
Follow-up colposcopy, cytology and molecular detection
of HPV is recommended in all patients previously treated
for malignant neoplasia. Even if cervical verrucous
carcinoma is considered a rare variant of well-differentiated
squamous cell carcinoma, the introduction of carcinogenic
HPV DNA detection could represent a valuable diagnostic
tool as an adjunct to cytology, for monitoring HPV
infections with transforming potential.
Acknowledgements
This work was partially supported by PRIN 2005 and Faculty
project 2005.
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 ANTICANCER RESEARCH 27: 4491-4494 (2007)
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Received July 26, 2007
Revised October 9, 2007
Accepted October 11, 2007