Keywords
Buschke–Loewenstein tumor - condyloma acuminate - malignant transformation - penis
The Buschke–Loewenstein tumor (BLT) is a sexually transmitted and very rare giant
condyloma acuminatum.[1]
[2] This lesion is usually a large cauliflower-like tumor affecting the anogenital region.[2]
[3] Although it is a benign tumor that develops slowly, it has destructive and local
aggressive features.[2]
[4] Also, it has a malignant differentiation potential which is mostly to the squamous
cell carcinoma.[3] Several treatment options have been described in the literature for BLT, but how
malignant transformation should be treated is controversial.[3]
[5] This article aims to present a very rare malignant transformation of a large penile
BLT case and its treatment.
Case
A 59-year-old male patient was admitted to our clinic with a lesion starting from
the penis and growing slowly for 8 years. The patient's human papillomavirus (HPV)
and human immunodeficiency virus (HIV) tests were negative and had no known disease.
Multiple biopsies were taken from the depressed and pink-red areas, which differed
from the lesion in appearance (red arrow shows malignant transformation area), all
of them were reported as the squamous cell carcinoma arising in the condyloma acuminatum
of Buschke and Loewenstein ([Fig. 1a]). There was no inguinal pathological lymphadenopathy. The lesion was extensively
excised with 1 cm intact surgical margin macroscopically ([Fig. 1b]). Areas other than the penile skin were repaired with split-thickness skin grafts,
while penile skin defect was repaired with scrotal cutaneous flaps elevated from the
scrotal skin to prevent the secondary contractions. Surgical borders were intact,
and histopathologic reports showed a malignant transformation on the giant condyloma.
The patient was followed for 6 years postoperatively and no recurrence was observed
([Fig. 1c]). Penile radix had no contracture and erectile function was normal.
Fig. 1 (a) Preoperative view of 15 × 15 cm condyloma accuminata. Red arrow shows the malignant
transformation area of this giant Buschke–Loewenstein tumor. (b) Intraoperative view of defect after the excision of tumor with 1 cm surgical margin.
(c) Postoperative 6th year view of the patient.
Discussion
BLT was described by Buschke and Loewenstein in 1925 as a giant condyloma acuminatum
case of penile BLT.[3]
[6] Condyloma acuminatum is known to have a local destructive effect without metastasis.[7] It rarely progresses into squamous cell carcinoma.[1]
[2] Whether a partially ulcerated, bleeding mass is determined, squamous cell carcinoma
differentiation of tumor may be suspected. Condyloma acuminata is associated with
HPV infection and malignant transformation is common in HIV-positive patients.[7] The case differs with the absence of HPV and HIV infection and the reason of very
rare malignant transformation.
In the literature, it is defined that BLT is commonly seen in the anogenital region.[8]
[9] Being settled in penis makes this case more special and rare.
The treatment options for condyloma acuminatum include cryosurgery, topical podophyllin,
or trichloroacetic acid; however, these treatments are much more convenient for small
lesions.[7] Because of being locally aggressive, destructive, and malignant transformation potency,
exact therapy is the surgical excision. However, if there is a malignant transformation
as in our case and to prevent the recurrences, excisions should be performed with
large surgical margins. Penile BLT has a specialty because wide resections of penile
skin are challenging to reconstruct. We did not prefer skin graft as the main reconstruction
method to prevent penile contracture and maintain the erectile function. For this
reason, we preferred local flaps elevated from the scrotum. Because of the benefit
of excess scrotal skin, the donor site of the scrotal flaps could be repaired primarily,
and donor site morbidity was reduced.
Since there is a possibility of malignant transformation, we recommend both radical
surgical excision of condylomas in this area without fear and reconstruction with
local flaps for penis and skin grafts for the suprapubic regions.
Conclusion
Condyloma acuminata is rarely accompanied by malignancies. Also, reconstruction and
management of this rare condition is crucial. A functional repair of a condyloma acuminata
defect was presented. We think that this work will contribute to the literature.
