Heterogeneous Tumors of Mixed Histology

About 10-24% of all penile carcinomas show mixed features9,11 and are composed of two (or very rarely three) morphologically distinctive SCC subtypes. One of the components should represent at least 20% of the tumor mass. The gross aspect is variegated but mixtures of growth pattern are common. When the tumor is composed of low- and highgrade areas it is not unusual that the former presents a verruciform or superficial spreading pattern while the latter depicts a vertical growth pattern. The most frequent mixed tumor is warty-basaloid carcinoma, representing about one-half of all mixed SCC.)9

Fig. 3.16 Warty-basaloid carcinoma. Infiltrative tumor nests composed of a mixed population of neoplastic cells with koilocytes located at the center and basaloid cells at the periphery

This variant can show three different patterns of growth: (1) exophytic superficial ver-ruciform areas corresponding to warty carcinoma and deeply infiltrative tumor nests corresponding to basaloid carcinoma; (2) deeply infiltrative non-verruciform tumor with mixed morphology: warty areas in the periphery and basaloid areas in the center of tumor nests (Fig. 3.16); and (3) exophytic tumor composed of mixed papillae with basaloid areas at the bottom and warty areas at the superficial layers. In all cases, neoplastic cells morphologically correspond to those previously described in the corresponding sections. Caution should be taken especially for not confusing warty-basaloid carcinomas with pure warty carcinomas since the metastatic rate of the former is expected to be higher than the latter. Considering the potential impact on prognosis any proportion of basaloid areas observed in an otherwise warty carcinoma should be recorded and the tumor classified as warty-basaloid carcinoma. In addition, typical condylomas can be found in association with warty-basaloid carcinomas in about one-half of all cases.11

Another mixed tumor, which represents about one-quarter of all mixed tumors, is hybrid verrucous carcinoma, which has been discussed previously (see Fig. 3.11). The association of usual SCC with other subtypes is rare although mixtures of the former with papillary, warty, and basaloid carcinomas have been reported.11 Another subtype that can present with a mixed morphology is sarcomatoid SCC in which areas of other subtypes are frequently found, usually as a minor component. These tumors should always be classified as sarcomatoid carcinomas, even if the other subtype represents more than 20% of the tumor mass, as treatment and outcome will depend only on the presence of sarcomatoid areas. Finally, therapeutic planning and prognosis should consider the highest histological grade, maximum level of anatomical infiltration, and presence of perineural/vascular invasion, regardless of tumor subtypes and the proportions found.

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