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Figure 31 (See color insert) (A) Paget's disease: the lesions are red and velvety, with white patches. (B) The typical large Paget cells contain abundant pale cytoplasm and are seen at the dermal-epidermal junction, as well as percolating up the epithelium.

Table sí Extramammary Paget's Disease

Diagnosis

Symptoms

Clinical appearance

Differential diagnosis

Therapy

Extramammary Pruritus, Paget's burning, disease bleeding

Red velvety lesions with white plaques

Melanoma (histologically), Paget's disease of urothelial or anorectal origin

Wide excision for noninvasive disease benignity to the clinician. These lesions are associated with HPV type 6 and 11 (62). There is often reactive induration of tissue adjacent to a verrucous carcinoma, as well as reactive lymphadenopathy, which may raise the clinical suspicion of metastatic disease (63). Pathological diagnosis may be difficult, as superficial biopsies may not

Figure 32 Squamous cell carcinoma of the vulva. (A) This is an example of an exophytic lesion. (B) (See color insert) This is an example of an endophytic lesion. (C) Typical appearance of squamous cell carcinoma, non-HPV-related type. Irregular tumor nests are invading the stroma, which is exhibiting a desmoplastic reaction. (D) In the non-HPV-related tumors, the lesions are often well differentiated and exhibit keratin pearls as demonstrated here. Abbreviation: HPV, human papilloma virus.

Figure 32 Squamous cell carcinoma of the vulva. (A) This is an example of an exophytic lesion. (B) (See color insert) This is an example of an endophytic lesion. (C) Typical appearance of squamous cell carcinoma, non-HPV-related type. Irregular tumor nests are invading the stroma, which is exhibiting a desmoplastic reaction. (D) In the non-HPV-related tumors, the lesions are often well differentiated and exhibit keratin pearls as demonstrated here. Abbreviation: HPV, human papilloma virus.

Table 32 Squamous Cell Carcinoma

Clinical

Diagnosis Symptoms appearance Differential diagnosis Therapy

Invasive None when Ulcerating or Basal cell carcinoma, Usually radical surgery, squamous cell carci-

small.

Pruritus and bleeding when large exophytic lesion keratoacanthoma, sexually transmitted diseases if ulcerative with possible adjuvant radiation therapy. Cryosurgery to the primary lesion has been reported in advanced disease noma

Figure 33 Verrucous carcinoma. (A) Lesions grossly appear large and warty. (B) Low-power view demonstrating the warty architecture. (C) Lesions show minimal atypia, and there may be human papilloma virus cytopathic changes. (D) These lesions exhibit a "pushing" border, in contrast to the invasive border seen in usual squamous cell carcinoma.

Figure 33 Verrucous carcinoma. (A) Lesions grossly appear large and warty. (B) Low-power view demonstrating the warty architecture. (C) Lesions show minimal atypia, and there may be human papilloma virus cytopathic changes. (D) These lesions exhibit a "pushing" border, in contrast to the invasive border seen in usual squamous cell carcinoma.

Table 33 Verrucous Carcinoma

		Clinical	Differential
Diagnosis	Symptoms	appearance	diagnosis	Therapy
Verrucous	Mass, pruritus	Large exophytic	Condyloma acuminatum,	Wide local
carcinoma		warty mass	squamous cell carcinoma	excision

include the deeper portions needed to histologically document invasion. The overall histology is similar to that of condyloma acuminatum, with minimal atypia, and possible koilocytosis, but verrucous carcinomas have a pushing invasive front. These lesions rarely metastasize. Radiation therapy has been reported to induce anaplastic change (Table 33) (59).

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