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harbor anogenital HPV without showing any symp-
toms (3).
The disfiguring and unpleasant presentation of
anogenital warts was recognized in the ancient world.
Today it is known that the warts develop due to the bio-
logical expression of sexually transmitted HPVs exhibit-
ing a preferential trophism for the anogenital mucosa (3).
All papillomaviruses consist of 55 nm, non-enveloped
virions with a double-stranded DNA genome of approx-
imately 8000 base pairs within an icosahedral capsid (2).
HPV represents a large family of at least 100 genetic
related types. Various types, identified by different num-
bers in concordance with their chronological order of
discovery, are specifically responsible for a variety of
human warts (3). HPVs are described in three groups,
named as the “low”, “intermediate” and “high” risk
groups (2). Almost 30 HPV types are able to infect the
anogenital area. Classical “condylomas” are benign
lesions caused by so-called “low-risk” HPV genotypes,
with HPV 6 and 11 found in more than 90% of cases.
However, condyloma patients can be infected simultane-
ously with multiple HPV types, including various onco-
genic “high-risk” types (HPV 16, 18, 31, 33, 35, 39, 45,
Acta Chir Belg, 2009, 109, 612-616
A Surgical Approach to Anogenital Buschke Loewenstein Tumours
(Giant Condyloma Acuminata)
E. Balik, T. Eren, D. Bugra
Istanbul University, Istanbul Faculty of Medicine, Department of General Surgery.
Key words. Condyloma acuminata ; anal surgery.
Abstract. Background : Condyloma acuminata are anogenital warts caused by human papillomavirus (HPV). Neglected
giant peri-anal condyloma acuminata (Buschke Loewenstein Tumours) require major surgical procedures. This report
reflects our experience concerning the aggressive surgical approach to this rarely presented type of condyloma acumi-
nata.
Methods : The medical records of five patients, who had been surgically treated following the diagnosis of giant peri-
anal condyloma acuminata between April, 1996 and September, 2003 were reviewed and evaluated retrospectively. Full
thickness tumour and skin excisions were performed followed by delayed split thickness skin graftings in all patients.
Results : Five patients (3 men, 2 women) who suffered from giant condyloma acuminata lesions obliterating the anal
canal were evaluated. The mean age was 36.5 years (range : 24-52). All patients underwent total surgical excisions. The
wounds were left open for secondary healing, and following a mean time period of 35 days, split thickness skin graft-
ings were performed. The histopathologic examinations of the specimens of these five patients did not reveal any malig-
nant transformations. No recurrences were detected at the end of a mean follow-up period of 22 months and all patients
were considered to be disease-free at the end of their long-term 5-year follow-up periods.
Conclusions : Peri-anal condyloma acuminatum is usually a benign disease, but may grow locally to an excessive extent,
developing into a Buschke Loewenstein Tumour, and may cause serious peri-anal hygiene problems. Even though the
incidence of malignant transformation is rare, there is always a risk of this complication occurring. Transmission of the
disease to other sexual partners is another point of concern. Therefore, this disease must be treated aggressively with
total surgical excision. The results of our surgical treatment methods are satisfactory.
Introduction
Human papillomavirus (HPV) causes papillomas (warts)
on the skin, respiratory mucosal surfaces (laryngeal and
oral papillomas) and condyloma acuminata (anogenital
warts) (1). Condyloma acuminata (anogenital warts) is a
common sexually transmitted disease. The prevalence of
genital HPV infection in the general population has been
difficult to estimate and is not well established, but
approximately one percent of the sexually active popula-
tion is believed to have genital warts. With the advent of
new diagnostic modalities such as polymerase chain
reaction (PCR), Southern blot, and dot blot, the detection
of HPV-DNA has been made easier (2). The majority of
new condyloma patients are 15-30 years old and both
sexes are equally affected (3). BAUER and colleagues
found that 46% of sexually active women receiving
routine annual gynaecological examinations at a college
health service were detected to be HPV-DNA positive
using PCR (4). It is known that overt anogenital warts
afflict at least 0.5-1.0% of 15 to 25-year-old sexually
active people, which reveals that the overt lesions
constitute only the “tip of the iceberg” as most people
etc.) which are strongly associated with anogenital intra-
epithelial neoplasia and with anogenital cancer (3).
Condyloma acuminata are usually identified by their
pathologic appearance. Lesions can be flat, sessile,
pedunculated or exophytic. Giant condyloma acuminata
(GCA), or Buschke Loewenstein Tumours (BLT), of the
anorectum are rare but may show a potentially fatal
course. Approximately 50% of squamous cell carcino-
mas of the outer genitals and of the anal canal are patho-
genetically related to the persistence and progression of
high-risk HPV-induced lesions (3). Condyloma acumi-
nata has been linked to the human papilloma virus and
has distinct histologic features. Controversy exists as to
the nature, epidemiology, pathologic nature and the man-
agement of the tumour. Despite recent modifications in
sexual behavior, anal and peri-anal condyloma acumina-
ta continues to be seen with increasing frequency.
Giant condyloma acuminata (GCA) or BLT is a rare
disease that commonly affects the genitalia. It was origi-
nally described in 1896 by Buschke and was further elab-
orated as a separate entity in, 1925 by Buschke and
Loewenstein. Reports of a BLT affecting the anorectal
and perineal regions are sporadic. The first reported case
was described by Dawson in, 1965. There is a limited
number of reports and studies in the literature. In our
paper, we also present a limited number of cases diag-
nosed with BLT (GCA).
The treatment of anogenital HPV infections remains a
major challenge. There are different modalities present
for this purpose, including surgical / ablative (excision,
electrodesiccation, loop electricosurgical excision
procedure, laser ablation and cryotherapy), immuno -
modulatory (imiquimod, interferon a, interferon band
interferon g) and chemotherapeutic (trichloracetic acid,
podophyllin, podophyllotoxin and 5-flourouracil)
approaches (2). Our report concentrates on the entity of
giant genital warts in the perineal / peri-anal regions and
the efficacy of a surgical approach in terms of perform-
ing total excisions for the treatment of these conditions.
Methods
Five patients diagnosed with giant condyloma acumina-
ta (GCA-BLT) of the peri-anal region were treated surgi-
cally between April, 1996 and September, 2003 at the
Istanbul University, Istanbul Faculty of Medicine,
Department of General Surgery. Retrospective analysis
was performed to evaluate the data of these 5 patients,
including gender, age, location of the lesions, associated
diseases, surgical treatment, length of time until the
achievement of complete healing, early and late term
complications and recurrence rates. Approval for this
study was obtained from the Ethics Committee of
Istanbul University, Istanbul Faculty of Medicine.
Anogenital buschke Loewenstein Tumours 613
Radical total surgical excisions under general anaes-
thesia were performed on all patients. Patients were
operated on in either the lithotomy, jack-knife or prone
positions. The operative technique was based on the
complete excision of the entire diseased skin and subcu-
taneous fatty tissue down to the deep fascia. All excisions
were performed by cold scalpel and / or electrocautery.
Secure or healthy margins were obtained by resecting the
lesions together with approximately 2 cm of healthy
skin. Healing was facilitated by reconstructive surgery
performed after at least three weeks following the initial
operation. The wounds of all patients were left open for
secondary healing and, following a mean time period of
a 35 days, split thickness skin graftings were performed
(Figs. 1-5). No diverting colostomies were necessary.
Fig. 1
Giant peri-anal Buschke Loewenstein Tumour
Fig. 2
Total surgical excision
614 E. Balik et al.
The patients were examined weekly during office vis-
its following their discharge from the hospital until com-
plete wound healing was achieved and office visits for
control examinations were continued monthly for the
first six months thereafter. The mean follow-up period
was 22 months.
The diagnosis of condyloma acuminata was based on
clinical features and in all cases was confirmed by patho-
logic examinations of the resected tissues. All specimens
were evaluated at the Department of Pathology of
Istanbul University, Istanbul Faculty of Medicine.
Results
All five patients (3 men, 2 women) were diagnosed as
having giant condyloma acuminata (GCA-BLT) obliter-
ating the anal canal. The mean age of the study group
was calculated to be 36.5 (range : 24-52) years.
The most common symptoms and signs at presenta-
tion were complaints of impairment in peri-anal hygiene,
defecational disorders and the feeling of a peri-anal
mass. The mean duration of the patients complaints was
7 years (range : 4-18). Two of these patients described
themselves as having had a continuous homosexual life-
style in their past. Meanwhile, all five patients were
detected as being negative for HBsAg, Anti-HCV and
Anti-HIV.
No evidence of anodermal invasion was observed in
any of these patients. No surgical complications were
met in terms of early or late postoperative complications
following the surgical interventions.
The histopathologic examinations of the specimens of
these five patients did not reveal any malignant transfor-
mations.
No evidence of recurrence was detected at the end of
a mean follow-up period of 22 months. Finally, all
patients were considered to be disease-free at the end of
their long-term 5-year follow-up periods.
Discussion
It is an agreed fact that the traditional goals of therapy for
sexually transmitted diseases, eradication of infection,
elimination of symptoms, prevention of long-term seque-
lae and the interruption of transmission may not be com-
pletely applicable to genital warts at this time (2).
Unfortunately, the incidence of condyloma acuminata
is not decreasing, despite the serious modifications in
sexual practices across the United States. More recently,
health officials have estimated that 1,000,000 Americans
make contact with genital and peri-anal warts and,
Fig. 3
Complete secondary healing in the postoperative 4th week
Fig. 5
Skin graft wound in its healing process
Fig. 4
Split thickness skin grafting
furthermore, two-thirds of their sexual partners subse-
quently make contact with the disease every year (5, 6,
7). It should also be taken into consideration that these
numbers will have a tendency to increase in the future.
There is still no data for the incidence and epidemiology
of condyloma acuminata in our country. However, there
seems to be a trend towards younger ages at presentation
and towards a male predominance for giant condyloma
acuminata of the anorectum (5, 6, 8, 9).
The treatment goals are focused on eliminating pyhsi-
cal and psychosocial stressors associated with genital
warts. Condylomata are often disfiguring and disrupt the
patients sex life as they can cause itching, burning, pain,
and postcoital bleeding.
Giant condyloma acuminatum (GCA) has been linked
to the human papilloma virus (HPV) and has distinct
histopathologic features. Historically, various treatment
modalities have been put into practice including chemo -
therapy (trichloracetic acid, podophyllin, podophyllo -
toxin and 5-flourouracil), immunotherapy (imiquimod,
interferon a, interferon band interferon g), electrodesic-
cation, loop electricosurgical excision procedure, laser
ablation, cryotherapy, wide local excision, abdomino -
pelvic resection and the frequent addition of neo-
adjuvant and / or adjuvant systemic chemotherapy and
radiation therapy. Despite the variability of the treatment
methods, recurrence is unfortunately a common result of
this disease during follow-up.
There are a number of different modalities that have
been introduced for the treatment of the disease. Current
therapies, with the exception of interferon and
imiquimod, focus on destruction of the visible lesion
with an emphasis on providing patient comfort and
decreasing the spread of disease (2). As stated earlier,
these methods have been limited by high recurrence
rates. It has been reported in multiple studies that recur-
rences are detected in 25-70% of patients during follow-
up. Immunomodulating agents address viral load and are
focused on eradication of the underlying cause of the vis-
ible lesion. Interferon has been limited in its success,
secondary to cost, toxicity, and the inability for patient
self-application. Imiquimod offers self-application and
tolerable local effects with acceptable recurrence
rates (2).
The roles of radiation therapy and chemotherapy in
treating gigantic lesions are uncertain. Some authors sug-
gest that the sole use of these modalities leads to poor
outcome. Furthermore, the question whether there could
be any effect from radiation therapy in transforming
these benign lesions into cancer has been raised by
several authors (7, 10, 11, 12).
In their report of two surgically treated extensive
perineal Buschke Loewenstein Tumour (BLT) cases,
Tytherlaeigh MG et al, stated that pre-operative
chemoradiation was found to be useful in the manage-
Anogenital buschke Loewenstein Tumours 615
ment of histologically proven BLT (13). However, one of
these patients died because of recurrent disease and the
other patient was reported to be disease-free following
abdominoperineal resection (13), which is a far too radi-
cal and destructive surgical procedure in our opinion. In
accordance with the treatment modalities in our study,
PARISE P. et al. (14), and RENZI A. et al. (15), reported
cases of BLT successfully treated by total excisional sur-
gery, also revealing that there was no evidence to support
the need for destructive surgery or chemo- and radiother-
apy.
The infective agent of anogenital condyloma acumi-
nata is the human papilloma virus (HPV), a DNA
popavirus, which has over 100 identified genotypes, with
more than 30 being responsible for genital warts.
However, anogenital HPV is associated with a spectrum
of anal pathologies including asymptomatic infection,
benign warts, dysplasia and invasive anal squamous cell
carcinoma (16, 17, 18). Further evidence for the associa-
tion of condyloma and anal squamous cell cancer was
given by DNA studies that identified the HPV genome
within the samples of anal squamous cell carcinoma (17,
18, 19, 20). From another point of view, if HPV of the
types 16 or 18 is demonstrated in condylomata lesions,
malignant degeneration should be considered and histo-
logical examination is essential to differentiate it from
squamous cell carcinoma (21).
The foci of invasive cancer within GCA specimens are
of uncertain significance, nor do they seem to correlate
with the recurrence rates, or the prognosis. Local inva-
sion and local recurrence are the major causes of morbid-
ity for this disease. BLT (GCA) is accepted as being a
locally destructive tumour that does not infiltrate or
cause metastases (22). Complete excision is the pre-
ferred initial therapy when feasible (9, 18, 19, 20, 23).
Total surgical excisions were carried out in all of our
patients.
In summary, perineal / peri-anal condyloma acumina-
ta is usually a benign disease, but may grow locally to a
wide extent and cause serious peri-anal hygiene prob-
lems. Malignant transformation may occur. There is a
large variety of medical treatment methods, however,
which are quite ineffective for GCA (BLT) in the per-
ineal / peri-anal regions, with high recurrence rates.
Therefore, from the surgeon’s point of view, this disease
must be treated aggressively with total surgical excision.
DETOMA G. et al. reported three cases of peri-anal GCA
treated by radical local excision and reconstruction by S-
plasty grafts, without performing loop colostomy (24). In
our study we also present a series of five cases treated
with total surgical excision and delayed reconstructive
surgery, without the creation of any stomas.
High recurrence rates are observed in patients whose
lesions have persisted for a long time. The endo-anal loca-
tion of lesions is also another risk for recur
rence (25).
616 E. Balik et al.
The management of those patients with recurrence can
also be achieved successfully via radical surgery.
However, in our study group of five patients, no endo-
anal lesions were observed, no recurrences were met, and
all patients were seen to be disease-free at the end of
their long-term follow-up periods of 5 years.
Conclusions
Peri-anal condyloma acuminatum is usually a benign
disease, but may grow locally to an excessive extent,
developing into a Buschke Loewenstein Tumour (BLT),
and may cause serious peri-anal hygiene problems. Even
though the incidence of malignant transformation is rare,
there is always a risk for this complication to take place.
Transmission of the disease to other sexual partners is
another point of concern. Anogenital BLTs are giant
lesions that are difficult to control by conservative and /
or medical treatment methods. Surgical intervention
seems to be the most effective therapeutic method for
these entities in order to eliminate the lesions and their
negative effects on the patient’s life comfort and also to
prevent the probable future recurrence of the disease.
Therefore, this disease must be treated aggressively with
total surgical excision. The results of our surgical treat-
ment methods are satisfactory. We conclude that
increased numbers of future studies are still necessary to
define the nature and the best treatment method for this
rare disease.
References
1. SINAL S. H., WOODS C. R. Human papillomavirus infections of the
genital and respiratory tracts in young children. Semin Pediatr
Infect Dis, 2005, 16 (4) : 306-316.
2. WRIGHT J. Jr, HINES J. Condyloma acuminata : treatment strategies
for the primary care provider. Primary Care Update for OB/GYNS,
2000, 7(1) : 35-39.
3. LONGSTAFF E., VON KROGH G. Condyloma eradication : self-thera-
py with 0.15-0.5% podophyllotoxin versus 20-25% podophyllin
preparations – an integrated safety assessment. Regul Toxicol
Pharmacol, 2001, 33 (2) : 117-137.
4. BAUER H. M., TING Y., GREER C. E., et al. Genital HPV infection in
female university students as determined by a PCR-based method.
JAMA, 1991, 265 : 472-477.
5. BOGOMOLETZ W. V., POTET F., MOLAS G. Condyloma acuminata,
giant condyloma acuminatum (Buschke Loewenstein Tumour) and
verrucous squamous carcinoma of the perineal and anorectal
region : a continous precancerous spectrum ? Histopathology,
1985, 9(11) : 1155-1169.
6. BAIRD P. J., ELLIOTT P., STENING M., KORDA A. Giant condyloma
acuminatum of the vulva and anal canal. Aust N ZJ Obstet
Gynaecol, 1979, 19 : 119-122.
7. WILTZ O. H., TORREGROSA M., WILTZ O. Autogenous vaccine : the
best therapy for perineal condyloma acuminata ? Dis Colon
Rectum, 1995, 38 : 838-841.
8. CREASMAN C., HAAS P. A., FOX T. A. Jr, BALAZS M. Malignant
transformation of anorectal giant condyloma acuminatum
(Buschke-Lowenstein Tumour). Dis Colon Rectum, 1989, 32 :
481-487.
9. BILLI NGHAM R. C ondyloma acuminata. In : MAZ IER W. P.,
LEVIEN D. H. (eds.). Surgery of the colon, rectum and anus.
Philadelphia : WB Saunders, 1995 : 315.
10. SHAH I. C., HERTZ R. E. Giant condyloma acuminatum of the
anorectum : a report of two cases. Dis Colon Rectum, 1972, 15 :
207-210.
11. SCHWARTZ R. A. , NYCH AY S. G., LYONS M., SCIALE S C. W.,
LAMBERT W. C. Buschke-Lowenstein Tumour : verrucous carcino-
ma of the anogenitalia. Cutis, 1991, 47 : 263-266.
12. TROMBETTA L. J., PLACE R. J. Giant condyloma acuminatum of the
anorectum : trends in epidemiology and management : a report of
a case and review of the literature. Dis Colon Rectum, 2001, 44 :
1878-1886.
13. TYTHERLEIGH M. G., BIRTLE A. J., COHEN C. E., GLYNNE-JONES R.,
LIVINGSTONE J., GILBERT J. Combined surgery and chemoradiation
as a treatment for the Buschke-Löwenstein Tumour. Surgeon,
2006, 4(6) : 378-383.
14. PARISE P., SARZO G., FI NCO C., MARINO F., SAVA STANO S.,
MERIGLIANO S. Giant condyloma acuminatum of the anorectum
(Buschke-Lowenstein Tumour) : a case report of conservative
surgery. Chir Ital, 2004, 56 (1) : 157-61.
15. RENZI A., BRUSCIANO L., GIORDANO P., ROSSETTI G., IZZO D., DEL
GENIO A. Buschke-Löwenstein Tumour. Successful treatment by
surgical electrocautery excision alone : a case report. Chir Ital,
2004, 56 (2) : 297-300.
16. MESTROVIC T., CAVCIC J., MARTINAC P. et al. Reconstruction of skin
defects after radical excision of anorectal giant condyloma acumi-
natum : 6 cases. J Eur Acad Dermatol Venereol, 2003, 17 : 541-
545.
17. HYACINTHE M., KARL R., COPPOLA D. et al. Squamous-cell carcino-
ma of the pelvis in a giant condyloma acuminatum : the use of neo-
adjuvant chemoradiation and surgical resection : a report of a case.
Dis Colon Rectum, 1998, 41 : 1450-1453.
18. SOBHANI I., VUAGNAT A., WALKER F. et al. Prevalence of high grade
dysplasia and cancer in the anal canal in human papillomavirus-
infected individuals. Gastro-enterology, 2001, 120 : 857-866.
19. METCALF A. M., DEAN T. Risk of dyplasia in anal condyloma.
Surgery, 1995, 118 : 724-426.
20. THOMPSON J. P. S., GRACE R. H. The treatment of perianal and anal
condyloma acuminata : a new operative technique. J R Soc Med,
1978, 71 : 180-185.
21. GREIF C., BAUER A., WIGGER-ALBERTI W., ELSNER P. Giant condylo-
ma acuminata (Buschke-Löwenstein Tumour). Dtsch Med
Wochenschr, 1999, 124 (33) : 962-964.
22. JONGEN J., REH M., BOCK J. U., RABENHORST G. Perianal precancer-
ous conditions (Bowen’s disease, Paget’s disease, Carcinoma in
situ, Buschke-Lowenstein Tumour). Kongressbd Dtsch Ges Chir
Kongr, 2001, 118 : 79-86.
23. KAPLAN I. W. Condyloma acuminata. New Orleans Med Surg J,
1942, 94 : 388-390.
24. DETOMA G., CAVA LLARO G., BITONTI A., POLISTE NA A.,
ONESTI M. G., SCUDERI N. Surgical management of perianal giant
condyloma acuminatum (Buschke-Löwenstein Tumour) : a report
of three cases. Eur Surg Res, 2006, 38 (4) : 418-422.
25. CARROZZA P. M., MERLANI G. M., BURG G., HAFNER J. CO2laser sur-
gery for extensive, cauliflower-like anogenital condyloma acumi-
nata : a retrospective long-term study on 19 HIV-positive and 45
HIV-negative men. Dermatology, 2002, 205 (3) : 255-259.
E. Balik, M.D.
Istanbul University, Istanbul Faculty of Medicine
Department of General Surgery
GSM : +90 532 204 40 00
E-mail : emrebalik@yahoo.com
