Giant Condylomata Acuminata of Buschke and Lowenstein Treatment & Management

  • Author: Catharine Lisa Kauffman, MD, FACP; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 26, 2012
 

Medical Care

The treatment of choice for GCBL is wide surgical excision. Surgery alone has resulted in a disease-free status in 45.5% of patients.[8]

In addition, oral and topical chemotherapeutic modalities have been used with mixed success as adjuvants to surgery or as treatment for recurrences. Topical therapy alone, such as with 5-fluorouracil,[9] podophyllin, or interferon (IFN), are generally insufficient to control disease or prevent progression of the giant lesions. One case report noted that intralesional bleomycin in the wound bed of an incompletely resected tumor was effective, with no recurrence at 2 years. Topical cidofovir gel 1.5% used for several months produced clinical improvement, even in cases refractory to conventional treatment.[10, 11]

The postulated viral origin of these tumors has led to the use of IFN with moderate success. One case of vaginal GCBL responded to 6 months of IFN 2-alfa, with apparent complete resolution. Although topical IFN lacked clinical efficacy, intralesional administration[12] has produced complete responses in 47-62% of cases; however, the recurrence rate is 40%. Large lesions may be candidates for systemic IFN. A deeply infiltrating giant condyloma acuminatum experienced a major response after 9 months of continuous IFN administration at 10 MU thrice weekly, although no change in the tumor could be observed in the first several months.

Imiquimod was effective in combination with carbon dioxide laser ablation in a patient unable to tolerate surgery, whose tumor was positive for HPV-6.[13]

Traditional systemic antitumor agents have also been used. One report described the use of bleomycin, cisplatin, methotrexate, and leucovorin in a patient with recurrence after multiple surgeries for GCBL.[14] An autopsy 1 year later showed no evidence of active disease. A separate report noted tumor shrinkage with mitomycin-C and 5-fluorouracil combined with fractionated radiotherapy; unfortunately, this patient manifested pulmonary metastases.[15] Etretinate and photodynamic therapy with intravenous porphyrins have been used with some success in vaginal GCBL.

Radiation therapy remains controversial. Extensive evidence supports anaplastic transformation in oral/plantar verrucous carcinoma, but data in GCBL are mixed. While some studies show evidence of new aggressive behavior after radiation therapy, more than a few case reports document resolution of small tumors after radiation.[16] One review recommended the avoidance of radiation if possible; but, if necessary, the use of a large dose of radiation to minimize chances of further mutation may be effective in a candidate who is a poor surgical risk.[15] To support this view, one report describes successful treatment of a recurrent tumor with radiation at 4500 cGy in 25 fractions; the patient remained disease free when reevaluated at 20 months.

Bulky tumors have been shrunk with preoperative chemoradiation, followed by radical surgery, in some instances followed by reconstructive surgery. One regimen that lead to a complete response consists of mitomycin C and 5-fluorouracil administered concomitantly with radiation therapy 50.4 Gy to the tumor bed and prophylactic irradiation of the regional nodes.

Autologous vaccination with a preparation of condyloma cells was well tolerated clinically and produced good responses in an initial and recurrent giant condyloma acuminata. After more than 1 year of follow-up in this series, recurrence rates with various treatments were 50% for excision alone and bichloracetic acid, 85% for podophyllin and IFN alfa, and only 4.6% after excision and vaccination. Mean follow-up was 13 months (range, 6-23 mo).[17]

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Surgical Care

Surgical excision is the treatment of choice. Its main advantage is the ability to histologically examine the entire specimen to ensure clear margins and to evaluate for foci of SCC. As a drawback, it typically requires at least a partial penectomy, but one series successfully used glansectomy only, with excellent functional and therapeutic results.[18, 19] Mohs surgery appears to be the most efficacious surgical treatment, allowing specimen examination and sparing most of the tissue.

Recurrences of giant condyloma acuminatum can be successfully addressed with radical surgery. The cure rate with radical surgery reportedly is 61%, versus only 25% with chemoradiotherapy with or without local excision. Some authors recommend radical electrocautery surgical resection whenever possible.[20]

Resection with the carbon dioxide laser has also been effective, with the advantage of permitting a bloodless field, and it has been used effectively in a pregnant patient. Carbon dioxide and argon lasers are used for relapsing cases or as an alternative first-line therapy[21] .

Cryosurgery has been effective in several case reports, primarily on small lesions, with normal anatomy resulting after tumor resolution. Close monitoring is required because destruction of the entire tumor cannot be ensured.

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Contributor Information and Disclosures
Author

Catharine Lisa Kauffman, MD, FACP  Georgetown Dermatology and Georgetown Dermpath

Catharine Lisa Kauffman, MD, FACP is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Royal Society of Medicine, Society for Investigative Dermatology, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Doru Traian Alexandrescu, MD  Assistant Professor of Medicine, Georgetown University

Doru Traian Alexandrescu, MD is a member of the following medical societies: American Association for Cancer Research, American Cancer Society, American College of Physicians, American Medical Association, American Society for Blood and Marrow Transplantation, American Society of Clinical Oncology, American Society of Hematology, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Specialty Editor Board

Mark W Cobb, MD  Consulting Staff, WNC Dermatological Associates

Mark W Cobb, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Society of Dermatopathology

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Christopher Norwood, MD, and Mary K. Mather, MD, to the development and writing of this article.

References

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Giant condylomata acuminata of Buschke and Löwenstein of the perianal region, consisting of a slow-growing, ulcerated, cauliflowerlike mass.
 
 
 
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