Stanford School of Medicine

Surgical Pathology Criteria

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Verrucous Carcinoma of the Anus


  • Cytologically bland squamous carcinoma characterized by blunt, pushing margins

Alternate/Historical names

  • Ackerman tumor
  • Buschke-Loewenstein tumor
  • Buschke-Löwenstein tumor (correct German spelling)
  • Giant condyloma acuminatum

Covered separately

Diagnostic Criteria

  • Cytologically bland
    • No more than mild dysplasia
    • Mitotic figures confined to basal layer unless inflamed
    • Orderly maturation
  • Invasion by blunt, pushing downward projections
    • No single cell or sharp jagged invasion
    • No vascular or perineural invasion
    • Locally destructive of underlying and adjacent tissues
    • May be difficult to appreciate microscopically
  • Surface exophytic growth
    • Acanthosis and papillomatosis
  • Does not metastasize
  • May involve perianal skin, anus and rectum
  • Frequent transformation to usual type squamous carcinoma
    • Defined by the presence of any of the following:
      • Moderate to severe cytologic dysplasia
      • Jagged invasion
      • Metastasis
    • Requires extensive sampling to exclude
    • Seen in 42% of reported cases
    • (Older reports of transformation of verrucous carcinoma following radiation therapy at various sites have not been supported by the recent literature)
Teri A Longacre MD
Robert V Rouse MD
Department of Pathology
Stanford University School of Medicine
Stanford CA 94305-5342

Original posting/updates : 10/7/10, 11/13/11

Supplemental studies


  • No studies of anal verrucous carcinoma reported

Genetic analysis

  • Human papilloma virus (HPV) can be demonstrated by PCR in some cases
    • Usually 6 and 11

Differential Diagnosis

    Verrucous Carcinoma vs. Pseudoepitheliomatous Hyperplasia

    • Verrucous carcinoma is characterized by blunt, destructive downward growth
      • This distinction is frequently not possible on histologic grounds alone
      • Frequently requires clinical correlation


    Verrucous Carcinoma of the Anus Usual Squamous Carcinoma of the Anus
    Only blunt pushing invasion Jagged invasion
    No more than mild dysplasia Usually significant dysplasia
    Mitotic figures confined to basal layer unless inflamed Mitotic figures may be present at all levels
    No vascular or perineural invasion May have vascular or perineural invasion
    Does not metastasize May metastasize
  • Note that usual squamous carcinoma can develop in verrucous carcinoma

    Verrucous Carcinoma of the Anus Condyloma Acuminatum
    Usually large Usually small
    Blunt destructive downward growth Superficial lesion, no destructive growth
    May develop fistulas and sinuses Does not produce fistulas or sinuses


    • Verrucous carcinoma with podophyllin effect should be distinguished from usual squamous cell carcinoma
      • Podophyllin does not produce:
        • Cytologic dysplasia
        • Disturbance of maturation
        • Dyskeratosis
      • Early podophyllin effects (≤48 hours post application)
        • Intra- and intercellular edema
        • Necrotic keratinocytes in lower half of epithelium
        • Numerous mitotic figures in lower half of epithelium
      • Changes resolving by 72 hours
        • Necrotic keratinocytes now in upper half of epithelium
        • Fewer mitotic figures
      • Changes entirely resolved by one week


    • Usually a large, slowly growing cauliflower-like lesion
    • Resistant to topical therapy
    • May develop fistulas and sinuses
    • Does not metastasize unless usual squamous carcinoma develops

    Grading / Staging / Report


    • Low grade by definition
    • If usual squamous carcinoma develops, it should be graded appropriately


    • Use TNM staging for anal carcinoma


    • Preferred terminology is verrucous carcinoma

    Classificatiion / Lists

    Anal Tumors and Neoplasms

    Extension from rectal lesions must be ruled out


    • Bosman FT, Carneiro F, Hruban RH, Thiese ND (Eds). WHO Classifiication of Tumors of the Digestive System, IARC, Lyon 2010
    • Longacre TA, Kong CS, Welton ML. Diagnostic problems in anal pathology. Adv Anat Pathol. 2008 Sep;15(5):263-78.
    • Bertram P, Treutner KH, Rübben A, Hauptmann S, Schumpelick V. Invasive squamous-cell carcinoma in giant anorectal condyloma (Buschke-Löwenstein tumor). Langenbecks Arch Chir. 1995;380(2):115-8.
    • Bogomoletz WV, Potet F, Molas G. Condylomata acuminata, giant condyloma acuminatum (Buschke-Loewenstein tumour) and verrucous squamous carcinoma of the perianal and anorectal region: a continuous precancerous spectrum? Histopathology. 1985 Nov;9(11):155-69.
    • Wade TR, Ackerman AB. The effects of resin of podophyllin on condyloma acuminatum. Am J Dermatopathol. 1984 Apr;6(2):109-22.


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