Combined surgery and chemoradiation as a treatment for the Buschke-Löwenstein tumour

Radiation Therapy in the Management of Extensive Giant Condyloma Acuminata With Rectal Involvement: A Case Report

Giant condyloma acuminata (GCA) is a rare, locally aggressive manifestation of human papillomavirus (HPV) infection, typically affecting the anorectal area. Patients with GCA often have a poor prognosis due to the high risk of malignant transformation. In this case report, we present a 39-year-old man with HIV who developed progressive and refractory anorectal GCA. Despite initially non-cancerous pathology results, there were concerns regarding a malignant component to the mass. Multidisciplinary discussions led to the decision to pursue definitive radiation therapy. This case report and review of the literature highlight the role of radiation in the management of GCA and the importance of a multidisciplinary approach in the treatment of complex cases.

A perianal conundrum and its management: Condyloma versus carcinoma

INTRODUCTION

Giant condyloma acuminatum is an uncommon sexually transmitted disease. It also goes by the name Buschke-Löwenstein tumor and develops in immunocompromised patients in the anogenital area [1]. It is caused by human papillomavirus infection, subtypes 6 and 11 [2]. It grows rapidly with the destruction of local tissues, and often recurs [3]. Giant condyloma acuminatum can mimic squamous cell carcinoma. The work has been reported in line with SCARE criteria [4].

PRESENTATION OF CASE

A 44-year-old gentleman had presented with an insidious growing painless mass in the perianal region with anal canal invasion of 2 years duration. Over the last 3 months, it was associated with a rapid increase in size along with an ulcer and bleeding. He was a renal transplant recipient, on immunosuppressive therapy. The dermatologist had referred him to the surgeon with a concern of malignancy. He underwent examination under anesthesia and an incisional biopsy. The pathologist reported it as condyloma acuminata. The dermatologist had tried a few sessions of cryotherapy without success and the fear of malignancy was still lurking. He underwent wide local excision of the tumor and reconstruction of the anocutaneous junction with an advancement flap. The pathologist had reported the lesion as a large verrucous lesion consistent with condyloma acuminata. Short-term follow-up showed good continence of the anal canal and no recurrence.

CONCLUSION

Giant condyloma acuminatum can mimic squamous cell carcinoma. So when in doubt and conservative treatment fails, surgical excision is a good option both for treatment and pathological confirmation.

Squamous Cell Carcinoma Arising from Perianal Buschke-Lowenstein Tumor (Giant Condyloma Acuminatum): Comprehensive Literature Review

PURPOSE

This study aims to provide an overview of the literature on carcinoma arising from giant perianal condyloma acuminatum.

METHODS

We present a new case of squamous cell carcinoma arising from giant perianal condyloma acuminatum. We also conducted a systematic search of the medical literature using PubMed, Medline, Google, and Google Scholar related to carcinoma arising from giant perianal condyloma acuminatum. The following search terms were used in various combinations: condyloma acuminatum, giant condyloma acuminatum, Buschke-Lowenstein tumor, squamous cell carcinoma, and verrucous carcinoma. The search included articles published before in the English language November 2020.

RESULTS

A total of 55 article concerning 97 patients with carcinoma (squamous cell carcinoma, verrucous carcinoma, basaloid cell carcinoma, carcinoma insitu) arising from giant perianal condyloma acuminatum meeting the aforementioned criteria were included. The patients were aged from 24 to 82 years (median: 49.6, IQR: 21); 20 were female (median age: 52.5, IQR: 20.5), and 75 were male (median age: 53, IQR: 17.5). The gender data of the remaining two patients could not be obtained. The histopathological features of tumors arising from giant condyloma acuminatum are as follows: squamous cell carcinoma (n = 56), squamous cell carcinoma in situ (n = 16), verrucous carcinoma (n = 19) and basaloid cell carcinoma (n = 1), squamous cell carcinoma + verrucous carcinoma (n = 1), squamous cell carcinoma + squamous cell carcinoma in situ (n = 1), squamous cell carcinoma + basaloid cell carcinoma (n = 1) and malignant behavior (n = 2).

CONCLUSION

Giant condyloma acuminatum is a rare variant of anogenital warts. It is known that this tumor, which is mostly thought to be benign, has a high potential for local recurrence and transformation into invasive cancer. Therefore, it is vital that the tumor is resected with clean surgical margins, even if it looks benign, and that aggressive treatment options are not avoided when necessary.

Clinicopathologic features of Buschke-Löwenstein tumor: a multi-institutional analysis of 38 cases

Buschke-Löwenstein tumor (BLT) is a rare sexually transmitted disease, mostly described in clinical literature as case reports or small series. Here, we investigated the clinicopathologic features of BLT in a total of 38 cases retrieved from multiple academic institutions. The average age was 47.6 ± 12.8 (mean ± SD) years old at diagnosis. The male to female ratio was 4.4:1. Common presenting symptoms were pain/discomfort, bleeding, mass lesion, and discharge. It was frequently linked to smoking and positive human immunodeficiency virus status. The tumor size and thickness were 8.5 ± 6.6 cm and 1.5 ± 1.3 cm, respectively. Histologically, 19 (50%) cases had an invasive squamous cell carcinoma component and were associated with high-risk human papillomavirus infection. There was no lymphovascular or perineural invasion, or nodal metastasis at initial diagnosis. BLTs with invasion had higher frequency of dyskeratosis, neutrophilic microabscesses, and abnormal mitoses, but lower frequency of pushing border compared with BLTs without invasion. All patients underwent wide excision, and some also received chemoradiation therapy. After a median follow-up of 23 months (range 1-207), the recurrence rate was 23.7% and disease-specific mortality was 2.6%. In summary, we presented the largest case series of BLT to date to characterize its unique clinicopathologic features. Our study indicated that certain histologic features such as dyskeratosis, neutrophilic microabscess, and abnormal mitosis in the non-invasive portion may be important clues on lesional biopsy to predict the presence of underlying invasive carcinoma.

Giant anorectal condyloma acuminatum of Buschke-Löwenstein presents difficult management decisions

Condyloma acuminata, or anogenital warts, caused by human papillomavirus are the most common sexually transmitted disease. In rare cases, the disease could progress to an extensive neoplasm called Buschke-Löwenstein tumor (BLT), also known as giant condyloma acuminatum. BLT differs from normal condyloma acuminata by presenting with locally invasive growth, lack of spontaneous resolution, tendency for recurrence after treatment and potential for malignant transformation. We examine a BLT case reaching large dimensions in the anorectal region treated with neoadjuvant chemoradiation therapy and surgical excision of residual lesions. Furthermore, continuous follow-up care can help identify and prevent recurrence or malignant transformation of the tumor.

Two Cases of Verrucous Carcinoma: Revisiting the Definition

Verrucous carcinoma (VC) is an uncommon, distinct type of well-differentiated squamous cell carcinoma. Here we present two cases of VC, one arising from the lower leg and the other from genital skin. Case 1, a female patient, aged 95 years, had a brownish verrucous plaque on her right lower leg. Histopathologically, epithelial tumor cells grew pushing the stroma, while the basement membrane was intact. No prominent cellular atypia or hyperchromatin was found. Case 2, a male patient, aged 53 years, had a verrucous plaque at the border between his scrotum and inner aspect of his thigh. A pathological diagnosis of VC was made using an excisional specimen. Making a definitive diagnosis of VC is challenging but crucial. Pathological diagnosis using a small specimen might cause underdiagnosis or overdiagnosis. To avoid this, pertinent pathological diagnosis using an ample specimen is required. We also revisited the definition of VC to precisely understand its nature.

[Buschke-Lowenstein tumors]

BACKGROUND

A giant condyloma acuminatum which shows destructive growth but lacking invasion is designated as a Buschke-Lowenstein tumor (BLT).

OBJECTIVES

Classification of the BLT and therapeutic guidelines are provided.

MATERIALS AND METHODS

A MEDLINE literature search from 2006-2016 was performed.

RESULTS

Induction through low-risk mucosotropic human papillomavirus (HPV) infection separates BLT from verrucous carcinoma. In the last 10 years, slightly more than 100 new cases have been described. Invasion as a true sign of malignancy was described in 12% of cases. HIV infection was observed in 14%. As invasion often occurs only focally and may only be detected after complete resection, BLT must be treated and considered as a low grade in situ epithelial cancer that evolves from condylomata acuminata. Diagnosis is confirmed by HPV detection and typical histology. CT scans are recommended to rule out deeper invasion. Organ preservation surgery remains the recommended therapy.

CONCLUSIONS

Buschke-Lowenstein tumors represent low grade epithelial in situ carcinomas which evolved from condylomata acuminata. Focal invasion is frequent but metastases occur only rarely. Organ preservation surgery is recommended.

Buschke-Löwenstein Tumour: Successful Treatment with Minimally Invasive Techniques

We report a case of an 80-year-old female who presented with a four-year history of a growing mass in the perianal area with pain and bleeding during defaecation. Clinical examination revealed a locally destructive, cauliflower-like, verrucous mass measuring 10 × 12 cm in diameter. Histologic findings revealed a moderate degree of dysplasia of the epithelium with koilocytosis atypia, acanthosis, and parakeratosis, features that are consistent with Buschke-Löwenstein tumour. Polymerase-chain-reaction assay for human papillomavirus (HPV) showed an infection with HPV type 11. Full-thickness excision of involved skin was undertaken by cryotherapy and electrocautery over five months. The entire wound was left open to heal by secondary intention. After 3 years of follow-up, the patient has not experienced a recurrence, with excellent functional results, but the cosmetic results were satisfactory. These minimally invasive techniques can be safer and more cost-effective than surgery and the General Practitioner can play a key role in diagnosis.

The giant condyloma (buschke-löwenstein tumor) in the immunocompromised patient

Since Buschke and Löwenstein first described the giant condyloma in 1925 (which subsequently was named Buschke-Löwenstein tumor), there have been scattered reports over the past 90 years describing presentation and different avenues of treatment for patients with this condition. It is well known that immunocompromised individuals are at an increased risk of anogenital disease caused by human papillomavirus (HPV). In this report, we present the management of two HIV positive patients with giant condylomas. Both patients presented with urinary outflow obstruction and sepsis. Though giant condylomas are a rare phenomenon, these two cases underscore the importance of early treatment intervention, especially in the immunocompromised patient.

Verrucous carcinoma arising in an extended giant condyloma acuminatum (Buschke-Löwenstein tumor): a case report and review of the literature

INTRODUCTION

Verrucous carcinoma of the external genitalia and perianal region is a rare variant of well-differentiated squamous cell carcinoma. It has been reported to have limited metastatic potential.

CASE PRESENTATION

We report the case of a 54 year-old Moroccan man who presented with locally advanced giant condyloma acuminatum (Buschke-Löwenstein tumor) after prolonged intervals of neglect (approximately 10 years). The disease covered his suprapubic, external genitalia and perianal region. It was locally aggressive with extensive tissue destruction. After a biopsy of the lesion, the diagnosis of verrucous carcinoma was confirmed. He initially received chemoradiotherapy, followed by extensive local excision, but he developed septic shock and died a few days later.

CONCLUSIONS

The purpose of this case report is to present a case of verrucous carcinoma arising in an extensive giant condyloma acuminatum (Buschke-Löwenstein tumor) and discuss the literature on its diagnosis and management.

Sexually transmitted and anorectal infectious diseases

Sexually transmitted diseases (STDs) are common and they can involve the anus and rectum in both men and women. In this article, the main bacterial and viral STDs that affect the anus and rectum are discussed, including their prevalence, presentation, and treatment.

Reconstructive surgery in anal giant condyloma: Report of two cases

INTRODUCTION

Giant anal condyloma also called Buschke–Löwenstein tumor is a rare sexually transmitted disease involving anogenital region with potential malignant degeneration into invasive squamous carcinoma. Complete surgical excision is the treatment of choice and often wide wounds are necessary to reach clear margins and prevent recurrence.

PRESENTATION OF CASE

The authors present two cases treated with an S-plasty rotating and a bilateral house advancement flap respectively with good functional result.

DISCUSSION

Giant anal condyloma also called Buschke–Löwenstein tumor is a large exophytic, cauliflower-like mass that is characterized by local aggressive behavior. Immunosuppression favors rapid growth of the condylomas and increases the risk of their malignant transformation. In limited lesions primary excision can be safely performed leaving wounds open to granulate while in more extensive lesions flap or skin graft coverage is preferable to decrease the length of recovery and minimize risk of severe anal stricture. Abdominoperineal resection should be performed for more extensive lesions with deep invasion, malignant transformation or tumor recurrence.

CONCLUSION

Giant anal condyloma also called Buschke–Löwenstein is a rare pathology with mainly sporadic single center experience reported in literature. Surgical complete excision remains the best treatment although elevate should be eventual recurrence. No sufficient data are available to recommend any medical treatment such as interferon, radiotherapy or chemotherapy.

Intra-abdominal localisation of a buschke-lowenstein tumour: case presentation and review of the literature

Giant condyloma acuminatum or Buschke-Lowenstein tumour is a very rare disease which usually is located in the genital, anorectal, and perianal regions. It is regarded as a type of verrucous carcinoma occurring on anogenital mucosal surfaces where it is locally invasive but displays a benign cytology. We describe a case of a 24-year-old woman with persisting condyloma acuminata progressing to a large intra-abdominal Buschke-Lowenstein tumour. To our knowledge such an advanced stage has only been reported once before. The severity and extent of the tumour both determine the treatment and patient outcome. Treatment was impeded by cachexia, an immunosuppressive state after kidney transplantation and difficulties in establishing a reliable diagnose. Interferon treatment was started which initially led to tumour reduction but was complicated by an interferon-induced pancreatitis, pneumonia, and fasciitis necroticans resulting in death. We present a literature overview on the treatment options for a Buschke-Lowenstein tumour, with emphasis on interferon therapy, with all the advantages and disadvantages.

Management of peri-anal giant condyloma acuminatum--a case report and literature review

Giant condyloma acuminatum (GCA), originally described by Buschke and Loewenstein in 1925 as a lesion of the penis, is more rarely seen in the anorectum and is characterized by clinical malignancy in the face of histologic benignity; however, malignant transformation to frankly invasive squamous-cell carcinoma has been described in about one-third of patients. In addition, malignant transformation has been reported in patients with "ordinary" condylomata acuminata. Human papillomavirus, known to cause condylomata acuminata, is also known to induce these tumors and was found in 96% of 63 cases reviewed in the last 10 years. These lesions have a propensity for recurrence and a likelihood of malignant transformation, and lead to significant mortality. Therefore, early and radical R0 excision, along with vigilant follow-up, provides the hope for cure. Conservative and/or multimodal therapy has been reported in a few cases, but its effect is not yet proved. The authors report one case of GCA; in addition, they reviewed the literature over the last 10 years and compared with previous reviews.

Giant Condyloma Acuminatum of the Anorectum: Successful Radical Surgery with Anal Reconstruction

Buschke-Löwenstein tumor, or giant condyloma acuminatum, is a relatively uncommon lesion of the anus with aggressive local invasive behavior which may present as a large warty tumor of the genital region with expansive and destructive growth. Many sporadic reports have been published suggesting various therapeutic strategies. We report a case of Buschke-Löwenstein tumor treated with conservative surgery followed by reconstructive procedures without a loop colostomy.

Wide local excision for Buschke-Löwenstein tumor or circumferential carcinoma in situ

PURPOSE

This study aimed to evaluate the outcome of patients with Buschke-Löwenstein tumor or circumferential anal carcinoma in situ who underwent wide local excision with flap or skin graft coverage of the wound.

METHODS

A retrospective review was conducted of all patients operated at Kaiser Permanente Los Angeles Medical Center during a 6-year period. Outcome measures included postoperative complications, functional results, recurrence rate, and re-intervention rate.

RESULTS

Of 152 patients operated for dysplastic anal lesions or tumors, 10 (7%) underwent wide local excision for Buschke-Löwenstein tumor or circumferential anal carcinoma in situ [men 70%, mean age 36 years]. Median duration of symptoms was 5 years. Eighty percent of patients had prior operations and 50% were positive for the human immunodeficiency virus. Mean size of the lesion was 41 cm(2). Microscopic margin positivity was noted in 60%. Wound was closed with house advancement flap in majority of patients. Only one patient had fecal diversion. Median length of stay was 2 days. Postoperative complications were noted in 50% of patients. Rate of transient postoperative incontinence was 30%. Recurrent disease was noted in 3 patients with the human immunodeficiency virus [median follow-up: 18 months]. All recurrences were treated with local fulguration or medication.

CONCLUSION

Wide local excision with flap or skin graft coverage is an option for patients with Buschke-Löwenstein tumor or circumferential anal carcinoma in situ. Close postoperative surveillance is advised due to the risk of recurrent disease, especially in patients with the human immunodeficiency virus.

Giant condyloma acuminatum of the scrotum in a man with AIDS: a case report

Introduction

Giant condyloma acuminatum, also called a Buschke-Löwenstein tumor, first described in 1925, is a slow-growing, locally aggressive, destructive tumor of the ano-genital region. Scrotal tumors are rare. Reports on giant condyloma acuminatum lesions in patients with HIV and AIDS are surprisingly even rarer.

Case presentation

In this report, we present the case of a 42-year-old African man with AIDS who was undergoing anti-retroviral therapy. He was found to have a giant condyloma acuminatum of the scrotum. Wide surgical excision and scrotal reconstruction with a pedicled anterolateral thigh flap was performed, significantly improving his quality of life.

Conclusion

Decision making regarding the goals of surgical intervention in the terminally ill is a complex process. The options include conservative medical palliation or palliative excision versus a curative excision that has the potential for significant morbidity. Wide surgical excision with local flap reconstruction significantly improved the quality of life of the patient described herein. The challenges presented by emerging or unusual presentations of surgical pathology secondary to HIV and AIDS in patients who are on anti-retroviral therapy provide an opportunity for research and the establishment of guidelines for the use of adjuvant chemotherapy in these patients.

Successful treatment of a large Buschke–Lowenstein tumour with chemo-radiotherapy

We report the case of a patient with a large Buschke–Lowenstein tumour which had previously recurred following local excision. A preferred treatment modality for this rare variant of human papillomavirus has not been clearly defined. Treatment with chemo-radiotherapy in this case resulted in complete resolution of the disease without the need for further surgical intervention.

Malignancies of the anal margin and perianal skin

Malignancies of the anal margin and perianal skin are relatively uncommon lesions, comprising 3 to 4% of all anorectal malignancies. Commonly included in this group of cancers are Bowen's disease (intraepithelial squamous cell cancer), perianal Paget's disease (intraepithelial adenocarcinoma), invasive squamous cell cancer, basal cell cancer, and malignant melanoma. Buschke-Lowenstein tumor, or giant condyloma acuminatum, is not always included because this lesion is technically benign, although it displays aggressive local invasive behavior that makes it difficult to manage. Complaints are usually nonspecific, such as itching or burning, bleeding, pain, drainage, or a mass. Proper diagnosis requires a high index of suspicion on the part of the surgeon. Innocent local irritations will resolve in a short time with appropriate therapy; those that persist must be biopsied for tissue diagnosis. Wide local excision is the mainstay of treatment for early stage tumors as it preserves continence and obtains adequate local control. Adjunct therapies have been utilized in more advanced or recurrent lesions, including radiotherapy, photodynamic therapy, and imiquimod. All have met with a fair amount of success in controlling local disease; however, the number of patients treated in each instance is small, making it difficult to design an evidence-based treatment strategy. Invasion and metastasis are relatively rare in this group of neoplasms; perianal Paget's disease has the highest risk of associated underlying neoplasm. The most important consideration in developing a treatment strategy is which strategy would achieve the best clinical result with the least morbidity to the patient.