Ki-67 Staining as a Tool to Differentiate Verrucous Carcinoma from

Condyloma Acuminatum on Skin Biopsy

Willy Sandhika

Department of Anatomic Pathology Universitas Airlangga Surabaya, Indonesia

Keywords: Ki-67 Staining, Verrucous Carcinoma, Condyloma Acuminatum.

Abstract: Verrucous carcinoma is a variant of well differentiated squamous cell carcinoma that slowly growing and

rarely metastasize. It grows as polypoid mass with verrucous surface. Macroscopically can produce exophytic

appearance that mimic condyloma acuminatum. On skin biopsy specimen that usually tiny tissue, the

microscopic appearance can be similar with condyloma acuminatum because it composed of well

differentiated squamous epithelial cells. Ki-67 staining can label proliferating cell even they are not in mitotic

state. Verrucous carcinoma has high proliferation index while condyloma acuminatum has low index. This

study want to prove whether Ki-67 staining can serve as reliable marker to differentiated verrucous carcinoma

from condyloma acuminatum. Sixteen case are retrieve from archive of Pathologic Department Dr, Soetomo

Hospital consist eight case verrucous carcinoma and condyloma acuminatum respectively.

Immunohistochemical staining with antibody Ki-67 was performed on each case. Squamous epithelial cells

that stain positive were count from each case, and the results were statistically compare between verrucous

carcinoma and condyloma acuminatum. The result of this study shows significant difference in number of Ki-

67 positive cells in verrucous carcinoma compare to condyloma acuminatum. There is also different in

squamous cell layer that expressed Ki-67. It is concluded that Ki-67 staining is a reliable tool that can

differentiate verrucous carcinoma from condyloma acuminatum on skin biopsy specimen.

1 INTRODUCTION

Verrucous carcinoma is a variant of well

differentiated squamous cell carcinoma. It is grow

exophytic with verrucous surface. Unlike squamous

cell carcinoma, it grows slowly with no metastatic

potential and behave as low grade malignancy.

Verrucous carcinoma can arise in anogenital region

and should be distinguished from condyloma

acuminatum (Liu, G., Li, Q., Shang, X., Qi, Z., Han,

C., Wang, Y., Xue, F., 2016). Verrucous carcinoma at

anogenital region can give clinical features

mimicking giant condyloma acuminatum which is

benign proliferative lesion caused by human

papilloma virus (HPV). On microscopic examination,

both disease can give similar features such as

acanthosis with papillomatosis with minimal nuclear

atypia. On the other hand, warty squamous cell

carcinoma can arise in giant condyloma acuminatum

making it more complicated. Therefore, it takes a

reliable test to differentiate verrucous carcinoma from

condyloma acuminatum especially in giant form

(Bambao, C., Nofech-Mozes, S., Shier, M., 2010).

Ki-67 protein are expressed in all proliferating

cells. Since the nature of malignancy is uncontrolled

excessive proliferation, examination of tumor tissue

with Ki-67 theoretically can be used as reliable tool

to detect malignant transformation in condyloma

acuminatum (Li, L. T., Jiang, G., Chen, Q., Zheng, J.

N, 2015). The aims of this study was to prove whether

Ki-67 stain can distinguish verrucous carcinoma from

condyloma acuminatum.

2 METHODS

Blok paraffin from verrucous carcinoma and

condyloma acuminatum each eight case (totally

sixteen case) were retrieved from archive of

Pathology department Dr. Soetomo Hospital

Surabaya. These paraffin blocks were sliced 6 m

thick and were placed in object glass to perform

immunohistochemistry stain with Ki-67 antibody.

Microscopic analysis were made by light microscope

to count Ki-67 positive cells. Only squamous cells

Sandhika, W.

Ki-67 Staining as a Tool to Differentiate Verrucous Carcinoma from Condyloma Acuminatum on Skin Biopsy.

DOI: 10.5220/0008156102990301

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 299-301

ISBN: 978-989-758-494-7

299

that expressed Ki-67 protein were count as positive.

The number of positive cells were count in area

40.000 m

using microscopic graticulae at 400 times

magnification. The number of squamous epithelia

cells that expressed Ki-67 protein were tabulated and

statistically analyzed to assessed is there significance

difference in number from verrucous carcinoma

compare to condyloma acuminatum.

3 RESULTS

Figure 1: Expression of Ki-67 protein in verrucous

carcinoma specimen. Ki-67 were expressed in all layer of

squamous epithelia cells. (Ki-67 immunohistochemistry

staining 400X magnification).

Figure 2: Expression of Ki-67 protein in condyloma

acuminatum specimen. Ki-67 were expressed mainly at

basal layer of squamous epithelia cells, only few scattered

cell in spinous layer expressed Ki-67. (Ki-67

immunohistochemistry staining, 400X magnification).

On microscopic examination there is significant

difference in Ki-67 positive cell from verrucous

carcinoma (56,75±9,00) compare to condyloma

acuminatum (22,25±4,40) (p=0.000). At cut off value

40 cells per 40.000 m

area, Ki-67 staining can

differentiate all case of verrucous carcinoma from

condyloma acuminatum which means 100 percent of

accuracy.

The pattern of Ki-67 positive cells were also differ

on verrucous carcinoma compare to condyloma

acuminatum. On verrucous carcinoma, Ki-67 were

expressed in all layer of squamous epithelia (figure 1)

while in condyloma acuminatum, the Ki-67 were

expressed only in basal layer (figure 2).

4 DISCUSSION

Ki-67 protein were expressed in proliferating cells.

Ki-67 protein can be detected within the nucleus of

proliferating cells during all active phases of the cell

cycle i.e. G

, S, G

and mitosis, but it is not expressed

in resting cells G

. Therefore it an excellent marker

for determining proliferative activity (Scholzen, T.,

Gerdes, J., 2000). Assessment of Ki-67 positive cell

can give different result from mitotic count since Ki-

67 were expressed in all proliferation cycle. Ki-67

index has been used for evaluating prognostic test for

disease progression in several cancer (Jonat W. and

Arnold N, 2011). In skin tumor, Ki-67 evaluation can

be used as a marker indentify a malignant process.

Leblebici has performed immunohistochemical

staining with Ki-67 on keratoacanthoma compare

with squamous cell carcinoma. It gives 81%

sensitivity and 100% specificity in detecting

malignant squamous cell from benign squamous

epithelial cells (Leblebici, C., Pasaoglu, E., Kelten,

C., Darakci, S., Dursun, N., 2017).

This study give different result in number of Ki-

67 positive cells as well as the pattern of Ki-67

positive cells. In verrucous carcinoma, the number

squamous epithelial that expressed Ki-67 is larger

significantly compare to that in condyloma

acuminatum. As it was count on 40.000 m area, the

verrucous carcinoma always have more than 40 Ki-

67 positive cells while squamous epithelia in

condyloma acuminatum consistently give less than 40

positive cells. It means 100 percent of accuracy.

There is also difference in staining pattern of

squamous cells that express Ki-67 protein. In

condyloma acuminatum, cells that express Ki-67

mostly on basal layer. Only a few scattered cells in

upper layer express Ki-67 whereas in verrucous

carcinoma, squamous cells from all layer express Ki-

67 protein.

Distinguishing condyloma acuminatum from

verrucous carcinoma are not always give clear-cut

criteria, since giant condyloma acuminatum can give

similar feature both macroscopic and microscopically

with verrucous carcinoma. Condyloma acuminatum

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usually behave as benign proliferative lesion with no

malignant potential but in a few circumstances it can

undergo malignant transformation. Papapanagiotou

has reported malignant transformation of giant

condyloma at perianal area (Papapanagiotou, I.K.,

Migklis, K., Ioannidou, G., Xesfyngi, D., Kalles, V.,

Mariolis-Sapsakos, T., Terzakis, E., 2017). The

coexistence of condyloma with verrucous carcinoma

make it more complicated in diagnosis since the

benign process can contain focus of some malignant

cells making malignant marker was strongly required

for benign looking cases (ErmanVlahovic, M., Vlahovic,

J., Mrcela, M., Hrgovic, Z., 2017).

Sometimes microscopic examination with

hematoxylin-eosin staining cannot detect malignant

transformation. Huang has reported a giant

condyloma acuminatum with benign microscopic

feature give recurrent lesion with malignant feature

(Huang SM, Leung WH and Chen BF, 2007).

Therefore it need an additional staining to detect

microscopic malignancy that involve a few epithelial

cells.

Ki-67 protein which expressed in proliferating

cells has been used to determine tumor grade in many

cancer has potential ability to differentiate

malignancy from benign process and also useful for

detection focus of malignant transformation that arise

in benign lesion (Jonat W. and Arnold N, 2011).

5 CONCLUSION

Ki-67 staining is useful tool for differentiate

verrucous carcinoma from condyloma acuminatum

with 100 percent accuracy.

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