Oral Carcinoma Arising Under Implant-Supported Prosthesis: Progression of Proliferative Verrucous Leukoplakia Initially Mimicking Lichen Planus.

Proliferative verrucous leukoplakia (PVL) is a non-homogenous type of oral leukoplakia, characterized by multifocal white plaques, propensity to recur after treatment, with strong tendency towards malignant transformation. Interestingly, some studies show that, at initial stages, PVL may resemble oral lichen planus (OLP), potentially leading to misdiagnosis. A 52-year-old woman, with a previous OLP diagnosis, was referred to our service for implant installation and follow-up of OLP lesions. After clinicopathological re-evaluation, a diagnosis of PVL (early stage) was made, and a maxillary full-arch implant-supported prosthesis supported by implants was installed. After 6 years of follow-up, the patient developed squamous cell carcinoma around the implants. The current case emphasizes that PVL patients with oral lesions suggesting peri-implantitis or peri-implant mucositis deserve a more meticulous investigation.

Classificatory updates in verrucous and cuniculatum carcinomas: Insights from the 5th edition of WHO-IARC head and neck tumor classification.

The International Agency for Research on Cancer (IARC) and World Health Organization (WHO) collaboratively produce the 'WHO Blue Books' essential tools standardizing the diagnostic process for human cancers. Regular updates in this classification accommodate emerging molecular discoveries, advances in immunohistochemical techniques, and evolving clinical insights. The 5th edition of the WHO/IARC classification of head and neck tumors refines the 'Oral Cavity and Mobile Tongue' chapter, including sections for non-neoplastic lesions, epithelial tumors, and tumors of uncertain histogenesis. Notably, the epithelial tumors section is rearranged by tumor behavior, starting with benign squamous papillomas and progressing through potentially malignant oral disorders to oral squamous cell carcinoma (OSCC). The section on OSCC reflects recent information on epidemiology, pathogenesis, and histological prognostic factors. Noteworthy is the specific categorization of verrucous carcinoma (VC) and carcinoma cuniculatum (CC), both associated with the oral cavity and distinct in clinical and histologic characteristics. This classification adjustment emphasizes the oral cavity as their predominant site in the head and neck. Designating specific sections for VC and CC aims to provide comprehensive insights into these unique subtypes, elucidating their clinical features, distinct histological characteristics, prevalence, significance, and clinical relevance. By categorizing these subtypes into specific sections, the 5th edition of the WHO classification aims to provide a more nuanced and detailed account, enhancing our understanding of these specific variants within the broader spectrum of head and neck tumors.

[Marjolin's ulcer associated with verrucous carcinoma in an immunocompromised patient]. / Úlcera de Marjolin asociada a carcinoma verrugoso en paciente inmunocomprometido.

Background: Marjolin's ulcer is the malignant degeneration of any chronic wound, with a latency period from tissue injury to variable malignant transformation that may occur up to 30 years later. Among the associated neoplasms, squamous cell carcinoma (SCC) is the predominant lineage in up to 71% of cases. The verrucous carcinoma variant has been estimated to have a low presentation, being described in the literature as 2% of all SCC and reported anecdotally in immunosuppressed patients, which justifies the objective of this publication. Clinical case: 65-year-old female patient with a history of being a carrier of human immunodeficiency virus (HIV) infection, who presented a verrucous carcinoma associated to a Marjolin ulcer secondary to herpes zoster and infection of soft tissues in the right leg, with a latency period of 10 years from the initial infectious process to histopathological confirmation. Conclusions: The finding of a verrucous carcinoma on a Marjolin ulcer has been little described in literature, with a lower incidence in the context of a patient with a history of being a carrier of HIV infection, finding 7 case reports, the oldest from 1998. For this reason, it is important to have diagnostic suspicion, to carry out an adequate study protocol and always making clinical-pathological correlation, in order to establish timely and individualized treatment.

Introducción: la úlcera de Marjolin es la degeneración maligna de cualquier herida crónica, con un periodo de latencia desde la lesión tisular a la transformación maligna variable que puede presentarse hasta 30 años después. De las neoplasias asociadas, el carcinoma espinocelular es la estirpe predominante hasta en 71% de los casos. La variante de carcinoma verrugoso se ha estimado con una presentación baja, pues ha sido descrito en la literatura como el 2% de todos los carcinomas espinocelulares y reportado de manera anecdótica en pacientes inmunosuprimidos, lo que justifica el objetivo de esta publicación. Caso clínico: mujer de 65 años con el antecedente de ser portadora de infección por virus de inmunodeficiencia humana (VIH), que presentó un carcinoma verrugoso asociado a una úlcera de Marjolin secundaria a herpes zóster e infección de tejidos blandos en pierna derecha, con un periodo de latencia de 10 años desde el proceso infeccioso inicial hasta la confirmación histopatológica. Conclusiones: el hallazgo de un carcinoma verrugoso asentado sobre una úlcera de Marjolin ha sido poco descrito en la literatura, con una menor incidencia en el contexto de un paciente con antecedente de ser portador de infección por VIH, ante lo cual encontramos 7 reportes de caso, el más antiguo de 1998. Por este motivo es importante contar con la sospecha diagnóstica, para poder hacer un protocolo de estudio adecuado y siempre haciendo correlación clínico-patológica, con la finalidad de instaurar un tratamiento oportuno e individualizado.

An unusual case of disseminated cryptococcosis in an immunocompetent host presenting with verrucous skin lesions.

Disseminated cryptococcosis, commonly linked to immunocompromised conditions like HIV infection, is exceedingly rare in immunocompetent individuals. This case report presents a rare case of disseminated cryptococcosis in an immunocompetent patient, who manifested with fever, weight loss, neurological manifestations, and distinct verrucous skin lesions. Mycological cultures and histopathological assessments were conducted, leading to the identification of Cryptococcus neoformans var. gattii within both lung and skin biopsies. This case highlights the significance of considering this yeast infection within immunocompetent individuals and the necessity for promptly initiating appropriate antifungal therapy to enhance patient outcomes.

Identification of Proteomic Biomarkers in Proliferative Verrucous Leukoplakia through Liquid Chromatography With Tandem Mass Spectrometry.

Proliferative verrucous leukoplakia (PVL) is an oral potentially malignant disorder associated with high risk of malignant transformation. Currently, there is no treatment available, and restrictive follow-up of patients is crucial for a better prognosis. Oral leukoplakia (OL) shares some clinical and microscopic features with PVL but exhibits different clinical manifestations and a lower rate of malignant transformation. This study aimed to investigate the proteomic profile of PVL in tissue and saliva samples to identify potential diagnostic biomarkers with therapeutic implications. Tissue and saliva samples obtained from patients with PVL were compared with those from patients with oral OL and controls. Label-free liquid chromatography with tandem mass spectrometry was employed, followed by qualitative and quantitative analyses, to identify differentially expressed proteins. Potential biomarkers were identified and further validated using immunohistochemistry. Staining intensity scan analyses were performed on tissue samples from patients with PVL, patients with OL, and controls from Brazil, Spain, and Finland. The study revealed differences in the immune system, cell cycle, DNA regulation, apoptosis pathways, and the whole proteome of PVL samples. In addition, liquid chromatography with tandem mass spectrometry analyses showed that calreticulin (CALR), receptor of activated protein C kinase 1 (RACK1), and 14-3-3 Tau-protein (YWHAQ) were highly expressed in PVL samples. Immunohistochemistry validation confirmed increased CARL expression in PVL compared with OL. Conversely, RACK1 and YWHA were highly expressed in oral potentially malignant disorder compared to the control group. Furthermore, significant differences in CALR and RACK1 expression were observed in the OL group when comparing samples with and without oral epithelial dysplasia, unlike the PVL. This research provides insights into the molecular mechanisms underlying these conditions and highlights potential targets for future diagnostic and therapeutic approaches.

Macrophages CD163+ and Factor XIIIa+ Provide a First-Line Defence against Proliferative Verrucous Leukoplakia Antigens.

This study aimed to evaluate the density of the dendritic cells (DCs) and macrophages in oral leukoplakia (OL) and proliferative verrucous leukoplakia (PVL) by immunohistochemical analysis. We analysed paraffined tissue samples of PVL (n = 27), OL (n = 20), and inflammatory fibrous hyperplasia (n = 20) as the control group using the immunomarkers for DCs (CD1a, CD207, CD83, CD208 and CD123) and macrophages (CD68, CD163, FXIIIa and CD209). A quantitative analysis of positive cells in the epithelial and subepithelial areas was determined. Our results showed a reduction in CD208+ cells in the subepithelial area of the OL and PVL compared to the control. Additionally, we found a higher density of FXIIIa+ and CD163+ cells in the subepithelial area in PVL compared to the OL and control. Four-way MANOVA revealed a relationship between increased CD123+ cell density in the subepithelial area of "high-risk" samples regardless of disease. Macrophages provide the first line of defence against PVL antigens, suggesting a distinct pattern of innate immune system activation in PVL compared to OL, which may contribute to the complexity and the high rate of malignant transformation in the PVL.

Prognostic outcomes of oral squamous cell carcinoma derived from proliferative verrucous leukoplakia: A systematic review.

OBJECTIVE: This study aimed to evaluate prognostic outcomes of PVL-derived oral squamous cell carcinomas (P-OSCC) based on recurrence, new primary tumour, metastasis and survival information. STUDY DESIGN: Five databases and grey literature were searched electronically with the following main keywords (proliferative verrucous leukoplakia, squamous cell carcinoma and malignant transformation) to answer the following review question: 'Are survival outcomes for P-OSCC worse?' based on the PECOS principle. The Joanna Briggs Institute Critical Appraisal tool was used to identify possible biases and assess the quality of each of the primary studies. RESULTS: A total of 21 articles met the inclusion criteria, and the results of this systematic review suggest that P-OSCC can recur and generate new primary tumours; however, metastases are rare. Thus, most patients remain alive for an average period of 5 years. CONCLUSION: Apparently, P-OSCC has better clinical prognostic characteristics than conventional OSCC. There is a lack of information on the main prognostic outcomes of P-OSCC; therefore, specific studies must be performed to achieve a better comparison between P-OSCC and conventional OSCC progression.

High density of CD8 T cell and immune imbalance of T lymphocytes subsets are associated with proliferative verrucous leukoplakia.

Oral leukoplakia (OL) and proliferative verrucous leukoplakia (PVL) are oral potentially malignant disorders (OPMDs) that microscopically show no or varying degrees of dysplasia. Even sharing clinical and microscopic aspects, PVL shows a more aggressive clinical behaviour, with a malignant transformation rate greater than 40%. Inflammatory infiltrate associated with dysplastic lesions may favour malignant transformation of OPMDs. This study aimed to evaluate the density of T cells and cytokines in dysplastic lesions from OL and PVL patients. Additionally, we evaluated whether soluble products produced in vitro by dysplastic keratinocytes are capable of modulating apoptosis rates and Th phenotype (Th1, Th2, Th17 and Treg) of peripheral blood mononuclear cells. The density of CD3, CD4 and CD8 T cells was assessed by immunohistochemistry. Cytokines and chemokines profile from frozen tissue samples were analysed using the LUMINEX system. Apoptosis rates and Th phenotype modulation were evaluated by flow cytometry. Our results showed an increase in the number of CD8 T cell in the subepithelial region from PVL dysplastic lesions in relation to OL samples. PVL showed increased levels of IL-5 and a decrease in IL-1ß and IFN-γ levels compared to OL. Soluble products of PVL and oral carcinoma cell cultures were able to reduce apoptosis rate and promote an imbalance of Th1/Th2 and Th17/Treg. The high-subepithelial density of CD8 T cells and immune imbalance of T lymphocytes subsets probably play an important role in the pathogenesis of PVL and may explain its more aggressive behaviour in relation to OL.

Carcinoma escamoso híbrido de la planta del pie / Squamous hybrid carcinoma of the sole of the foot

Resumen El carcinoma escamoso (CEC) es un tumor maligno de la epidermis y sus anexos. Es el segundo en frecuencia después del carcinoma basocelular y presenta distintas variantes clinicopatológicas. El subtipo carcinoma verrucoso (CV) es una variante poco frecuente de CEC con características histopatológicas y comportamiento específico. Ocasionalmente, se pueden observar componentes carcinomatosos de células escamosas convencionales en el CV, denominándose a esta entidad tumores "híbridos", los cuales representan el 20% de los casos observados. Reportamos el caso de un paciente varón de 72 años con una gran lesión exofítica que compromete 5to dedo y planta de pie derecho con diagnóstico de carcinoma escamoso híbrido. El objetivo de la presentación es mostrar una asociación infrecuente, haciendo énfasis en su seguimiento cercano ya que puede manifestar cambios en su comportamiento clínico diseminándose a los ganglios linfáticos regionales.

Abstract Squamous carcinoma (SCC) is a malignant tumor of the epidermis and its appendages. It is the second most common after basal cell carcinoma and has different clinicopathological variants. The verrucous carcinoma (VC) subtype is a rare variant of SCC with histopathological characteristics and specific behavior. Occasionally, carcinomatous components of conventional squamous cells can be observed in the VC, this entity being called "hybridized" tumors, which represent 20% of cases.We report the case of a 72-year-old male with a large exophytic lesion involving the 5th right toe and foot with a diagnosis of squamous hybrid carcinoma. The objective of the presentation is to show an infrequent association, emphasizing its close follow-up as it can modify its clinical behavior by spreading to regional lymphnodes.

Definitive Radiotherapy versus Surgery for the Treatment of Verrucous Carcinoma of the Larynx: A National Cancer Database Study

Abstract Introduction Traditionally, larger lesions of laryngeal verrucous carcinoma are treated with surgical excision, with definitive radiotherapy generally reserved for smaller lesions. However, data utilizing modern databases is limited. Objective The authors sought to assess, utilizing the National Cancer Database, whether overall survival for patients with laryngeal verrucous carcinoma was equivalent when treated with definitive radiotherapy versus definitive surgery. Methods A retrospective cohort study was conducted utilizing the National Cancer Database. All cases of laryngeal verrucous carcinoma within the National Cancer Database between 2006 and 2014 were reviewed. Patients with T1-T3 (American Joint Commission on Cancer 7th Edition) laryngeal verrucous carcinoma were included and stratified by treatment modality. Demographics, treatment, and survival data were analyzed. Results A total of 392 patients were included. Two hundred and fifty patients underwent surgery and 142 received radiotherapy. The two groups differed in age, transition of care, clinical T stage, and clinical stages. There was no significant difference in survival between T1-T3 lesions treated with surgery or radiotherapy (p =0.32). Age, comorbidities, insurance status, and clinical T stage impacted overall hazard on multivariate analysis (p <0.01). For patients treated with radiotherapy, age, insurance status, and clinical T stage were predictive of increased hazard. Conclusion Overall survival is equivalent for patients with clinical T1 and clinical T2 laryngeal verrucous carcinoma treated with primary radiotherapy versus primary surgery. Thus, radiotherapy should be considered as a non-inferior treatment modality for certain patients with laryngeal verrucous carcinoma.

Carcinoma verrucoso, una variante inusual de tumor laríngeo / Verrucous carcinoma, an unusual variant of laryngeal tumor

Introducción: El carcinoma verrucoso es una variante poco común de carcinoma escamoso bien diferenciado, que carece de rasgos citológicos de malignidad, tiene un crecimiento lento, es infiltrativo, pero no metastatiza. Objetivo: Identificar los aspectos clínico-histopatológicos y terapéuticos de una variante inusual de tumor laríngeo. Presentación del caso: Se reporta un nuevo caso de carcinoma verrucoso, paciente masculino de 78 años que se presentó en la consulta de Otorrinolaringología del Hospital Docente general "Enrique Cabrera" con disfonía. Se realizó laringoscopia indirecta y se detectó lesión exofítica sugestiva de neoplasia. Se tomaron tres biopsias, solo la última, fue de utilidad para diagnosticar un carcinoma verrucoso. Se trató con radiaciones y cirugía. El paciente presenta un intervalo libre de enfermedad después de ocho años de seguimiento. Conclusiones: Para el diagnóstico del carcinoma verrucoso es necesario biopsias profundas y la acuciosidad del patólogo para llegar al diagnóstico. Se hace énfasis en la importancia del trabajo en el contexto del grupo multidisciplinario(AU)

Introduction: Verrucous carcinoma is an uncommon variant of a well differentiated squamous carcinoma that lacks cytological features of malignancy and is often slow-growing, infiltrative, but not metastatic. Objective: To identify the clinical, histopathologic and therapeutic aspects of an unusual variant of laryngeal tumor. Case presentation: A 78-year-old male patient who attended the otorhinolaryngology consultation at "Enrique Cabrera" General Teaching Hospital with dysphonia is reported as a new case of Verrucous carcinoma. Indirect laryngoscopy was performed and an exophytic lesion suggestive of neoplasia was detected. Three biopsies were taken, but only the last one was useful to diagnose a Verrucous carcinoma. It was treated with radiation and surgery. The patient has a disease-free survival after eight years of follow-up. Conclusions: Deep biopsies performed by a skillful pathologist are necessary to reach the diagnosis of Verrucous carcinoma. Emphasis is placed on the importance of working in the context of a multidisciplinary team(AU)

Definitive Radiotherapy versus Surgery for the Treatment of Verrucous Carcinoma of the Larynx: A National Cancer Database Study.

Introduction Traditionally, larger lesions of laryngeal verrucous carcinoma are treated with surgical excision, with definitive radiotherapy generally reserved for smaller lesions. However, data utilizing modern databases is limited. Objective The authors sought to assess, utilizing the National Cancer Database, whether overall survival for patients with laryngeal verrucous carcinoma was equivalent when treated with definitive radiotherapy versus definitive surgery. Methods A retrospective cohort study was conducted utilizing the National Cancer Database. All cases of laryngeal verrucous carcinoma within the National Cancer Database between 2006 and 2014 were reviewed. Patients with T1-T3 (American Joint Commission on Cancer 7th Edition) laryngeal verrucous carcinoma were included and stratified by treatment modality. Demographics, treatment, and survival data were analyzed. Results A total of 392 patients were included. Two hundred and fifty patients underwent surgery and 142 received radiotherapy. The two groups differed in age, transition of care, clinical T stage, and clinical stages. There was no significant difference in survival between T1-T3 lesions treated with surgery or radiotherapy ( p = 0.32). Age, comorbidities, insurance status, and clinical T stage impacted overall hazard on multivariate analysis ( p < 0.01). For patients treated with radiotherapy, age, insurance status, and clinical T stage were predictive of increased hazard. Conclusion Overall survival is equivalent for patients with clinical T1 and clinical T2 laryngeal verrucous carcinoma treated with primary radiotherapy versus primary surgery. Thus, radiotherapy should be considered as a non-inferior treatment modality for certain patients with laryngeal verrucous carcinoma.

Hybrid Verrucous Carcinoma: A Wolf in Sheep's Clothing Case Report and Integrative Review of 280 Cases

ABSTRACT: Hybrid verrucous carcinoma (HVC) is defined as a rare neoplasm in which there is histopathological evidence of verrucous carcinoma and microscopic foci of squamous cell carcinoma, synchronously in the same site, affecting behavior and prognosis. This study aimed to present a new case of HVC in the mouth, and critically and comparatively analyze the cases reported in literature, to better understand the biological behavior and contribute to diagnostic precision. A review was performed using six databases, and the gray literature. Twenty-two articles were selected, with a total of 280 cases. The most frequent clinical appearance was verrucous carcinoma which included benign lesions. This implies that the potential for aggressive behavior can be detected microscopically, in the form of a ruptured basement membrane, which visualization can be facilitated by the use of some immunohistochemical markers discussed here. This is important for the diagnosis of HVC and adequate treatment. Hybrid verrucous carcinoma is what can be thought of as "a wolf in sheep's clothing." When analyzing cases with clinical suspicion of verrucous carcinoma microscopically, great attention is recommended, since they may be HVC and can recur, metastasize, and lead to death.

RESUMEN: El carcinoma verrugoso híbrido (CVH) se define como una neoplasia poco frecuente en la que existe evidencia histopatológica de carcinoma verrugoso y focos microscópicos de carcinoma de células escamosas, sincrónicamente en el mismo sitio, que afectan el comportamiento y el pronóstico. Este estudio tuvo como objetivo presentar un nuevo caso de CVH en la cavidad oral, y analizar crítica y comparativamente los casos reportados en la literatura, para comprender mejor el comportamiento biológico y contribuir a la precisión diagnóstica. Se realizó una revisión utilizando seis bases de datos y la literatura gris. Se seleccionaron veintidós artículos, con un total de 280 casos. La aparición clínica más frecuente fue el carcinoma verrugoso que incluyó lesiones benignas. Esto implica que el potencial de comportamiento agresivo puede detectarse microscópicamente, en forma de una membrana basal rota, cuya visualización puede ser facilitada por el uso de algunos marcadores inmunohistoquímicos discutidos aquí. Esto es importante para el diagnóstico de CVH y el tratamiento adecuado. El CVH es lo que se puede considerar como "un lobo con piel de oveja". Al analizar microscópicamente casos con sospecha clínica de carcinoma verrugoso, se recomienda una atención inmediata debido a que pueden ser CVH y pueden recurrir, metastatizar y conducir a la muerte.

Lesiones tumorales en región oral: carcinoma verrucoso y carcinoma oral de células escamosas. Reporte de un caso / Tumor lesions in the oral region: verrucous carcinoma and oral squamous cell carcinoma. A case report

El carcinoma oral de células escamosas representa un problema en la salud pública a nivel mundial. Siendo la neoplasia maligna más frecuente en la cavidad oral y uno de los diez cánceres más comunes en todo el mundo. El carcinoma verrucoso es una variante del carcinoma oral de células escamosas que presenta un alto grado de invasión local y baja posibilidad de extenderse. Además, representa del 2 al 12% de todos los carcinomas orales, con una tasa de supervivencia de 5 años. El presente artículo reporta el caso de un paciente masculino de 79 años, después de realizados los exámenes extra e intraoral, así como los complementarios, se observa un aumento de volumen en la porción anterior de la mandíbula, crateriforme irregular, doloroso a la palpación. Se diagnosticó carcinoma verrucoso involucrando a los órganos dentarios 3.3-4.3 y la mucosa circundante. El tratamiento consistió en la remoción quirúrgica completa, sin alteración o daño a las zonas circundantes, con seguimiento postoperatorio. El conocimiento de este tipo de patología puede orientar al odontólogo a la sospecha de diferentes lesiones cancerígenas, lo que permitirá prevenir complicaciones y así brindar la mejor opción de tratamiento a los pacientes afectados.

Oral squamous cell carcinoma represents a worldwide public health problem. Being the most common malignant neoplasm in the oral cavity and one of the ten most common cancers worldwide. Verrucous carcinoma is a variant of oral squamous cell carcinoma that has a high degree of local invasion and low possibility of spreading. In addition, it represents 2 to 12% of all oral carcinomas, with a 5-year survival rate. This article reports the case of a 79-year-old male patient, after performing the extra and intraoral exams, as well as the complementary ones, an increase in volume is observed in the anterior portion of the mandible, irregular crateriform, painful on palpation. Verrucous carcinoma was diagnosed involving teeth 3.3-4.3 and the surrounding mucosa in the oral cavity. The treatment consisted of complete surgical removal, without alteration or damage to the surrounding areas, with postoperative follow-up. Knowledge of this type of pathology can guide the dentist to the suspicion of different cancerous lesions, which will prevent complications and thus provide the best treatment option for affected patients.

Carcinoma de células escamosas de la lengua / Squamous cell carcinoma of the tongue

Las neoplasias de la lengua son los tumores más comunes de la cavidad bucal y la mayoría pertenecen a carcinomas de células escamosas. Presentamos dos casos de carcinomas de la lengua, correspondientes a un carcinoma escamoso moderadamente diferenciado y un carcinoma verrugoso, en mujeres de mediana edad con factores de riesgo oncogénicos. Estos tumores pueden tener diversos grados de diferenciación, los cuales determinan su pronóstico y tratamiento.

Tongue neoplasms are the most common in the oral cavity, and the majority correspond to squamous cell carcinomas. We present two cases of tongue carcinomas, corresponding to moderately differentiated squamous cell carcinoma and verrucous carcinoma, in middle-aged women with oncogenic risk factors.These tumors can have various degrees of differentiation, which determine their prognosis and treatment.

Squamous cell carcinoma with sarcomatous transformation of the penis.

Malignant tumors of the penis are rare, most of them being squamous cell carcinomas (SCCs). We report the case of a 75-year-old man with a large penile mass submitted to partial penectomy. The specimen showed an exophytic mass involving the glans, coronal sulcus, and prepuce. Microscopic examination showed a carcinoma with two distinct areas: a mixed SCC and a sarcomatoid carcinoma. The SCC component had areas of verrucous carcinoma and areas of classical invasive SCC. The tumor cells expressed p63 with the absence of p16 expression. Vimentin and p53 were positive in the sarcomatous component. The morphology and immunohistochemistry were compatible with mixed SCC (verrucous hybrid-sarcomatoid carcinoma). Additionally, the tumor cells also expressed 3 different clones of PDL1 (22C3, SP263, and SP142). Two months later, the patient presented local recurrence with multiple lymph nodes and lung metastases, dying 7 weeks later. Mixed tumors represent diagnostic challenges. The correct identification of adverse prognostic factors can be the first step to implement the treatment with a higher probability of success.