Giant condyloma acuminatum (GCA), also known as Buschke- Löwenstein tumor (BLT) that occurs mostly in the ano-genital region and is sexually transmitted. It was first described by Buschke and Löwenstein in penile area as a carcinoma without microscopic invasion findings¹. GCA is an indolent cauliflower-like tumor, but unlike simple condyloma, it is locally aggressive and destructive². In spite of its histologically benign appearance, it may behave malignantly. Some authors consider that GCA is an intermediate lesion between verrucous carcinoma and condyloma acuminatum. GCA has a risk for transformation into an aggressive squamous cell carcinoma^2-4. Surgery is the primary treatment choice^2,3,5 but a high rate of local recurrence exists after excision (about 50-60% )⁶. Herein, we present a GCA which was successfully treated without recurrence by surgical excision with a four year follow-up period.

We present in this report a 55 years old married male with giant condyloma located at the involving penis, scrotum, perineum, and inguinal region. The initial small mass developed as a giant cauliflower like tumor in 22 years since the patient had not received any treatment. He had also two satellite lesions on the anterior face of both thigh regions.

Clinically the appearance of the lesion was a large, cauliflower-like, yellow and white papillomatous tumor with irregular surface (Figure 1). The clinical presentation of this particular case was as an invasive, fungating, itching, malodorous, "heaped up," warty lesion. The lesion was complicated by a few deep fissures discharging blood and pus.

Figure 1: Cauliflower-like verrucous giant tumor is extending to the pubic area from penoscrotal area.

The results of serological tests for human immunodeficiency virus (HIV) and syphilis of the patient and his spouse were negative. Cervical smear controls of his wife revealed usual cytopathological features.

An extensive surgical excision was performed. All involved skin was excised by electrocautery with macroscopically clear margins (Figure 2). The entire wound was repaired with the split thickness graft taken from the anterıor thigh face. The smaller satellite on thigh was also similarly excised. The result of histopathological examination was giant condyloma acuminatum with medium-grade dysplasia.

Figure 2: Aspect after the wide excision of giant tumor.

He was discharged from the hospital without any complication on the sixth postoperative day. No adjuvant treatment was given. He was healthy without any evidence of tumor four years after surgery operation (Figure 3). In the personal interview, patient expressed his satisfaction about sexual intercourse after the treatment.

Figure 3: Twelve months post-resection the split thickness graft of scrotum, penis and pubic is shown.

The predisposing factors for the giant condyloma acuminatum are as follows: chronic genital infections, immunosuppression (HIV or chemotherapy), pregnancy, diabetes, poor socioeconomic status, lack of hygiene, chronic alcoholism and smoking⁷. The same factors are also the risk factors in malignant transformation of GCA. Our patient did only have alcoholism and smoking from these risk factors.

Human papilloma virus (HPV), most commonly types 6 and 11, play an important role in the etiology of GCA. HPV type 6 and type 11 were found in 66% and 33% of the cases of GCA, respectively^7,8. In our patient we could not perform human papilloma virus (HPV) deoxyribonucleic acid (DNA) analysis.

In a situation as lymph node or tumor basis enlargement or bleeding and ulceration, the clinician should suspect about malignancy transformation. Lymph node dissection is indicated only if malignant transformation is suspected⁴. In our patient, he sometimes had bleeding complaints but no malignancy was diagnosed in histological analysis.

Although, intra-lesion/topical chemotherapy, radio chemotherapy, photodynamic therapy and carbon dioxide laser therapy have been used before, we think that the mainstay of therapy, as we performed in our patient, is the total wide excision^2,3,5.

The application of topical podophyllin is helpful for ordinary condyloma acuminata. However, it does not effect in GCA^5,9. Likewise, the application of topical 5-fluororacil has a poor outcome in GCA¹⁰. Radiotherapy may be indicated when excision could not performed or in the case of recurrence or incomplete excision as a complement surgery².

Although recurrence rates of the surgical excision has been reported about 50%, it is still accepted the primary treatment of GCA⁶. However, in the literature there are a few case reports as large as our case that a complete surgical excision were done and no recurrence were seen in a long follow-up period. We consider the reason of this such as incomplete excision, because generally the general surgeons or urologist performs these operations and they focused to closure of the defect^5,6. Therefore, excision must be wide and preferentially should be made by the Mohs technique and if there is a big defect, a consultation of plastic surgery should be requested. Recurrence after an incomplete excision is a frequent complication. No recurrence was observed in our case in a 4 years follow-up period.

Defects which occur after the excision of the GCA, were left open and allowed to heal by secondary intention or could be repaired with skin graft or flaps². After the repair of the penis with skin grafts, there might be complaints of erection due to the graft contraction. Our patient did not have such complaints. To prevent such complication, the graft has to be as thick as possible to be applied totally and should be supported by a massage with oil creams.

The differential diagnosis should be made with keratotic pseudoepitheliomatous balanitis, Bowen's disease (its dyskeratotic condylomatous form) and verrucous carcinoma. Distinction between verrucous carcinoma and GCA is difficult. Some authors consider these lesions to be similar⁴. However, GCA rarely presents with malign histologic features such as infiltration of the basement membrane, frequent mitotic index, angioinvasion or lymphatic metastases which represent the main difference with verrucous carcinoma. However verrucous carcinoma and GCA can coexist in 30% of patients^4,6.

Giant condyloma acuminatum, which is a viral infection, bears the potential of contamination. Therefore we suggest that the surgical team should use anti-viral gloves and protective glasses to prevent conjunctival contamination and anti-infection mask against the vapor coming out of the cautery used against bleeding.

Giant condyloma acuminatum is a very rare sexually transmitted disease, characterized by recurrence and invasive growth after treatment, with potential malignant transformation. Excision is mandatory even in very small condilomas to prevent GCA to evolve in greater size. We suggest that wide perineal excision by controllıng the histopathological margins is the best surgical choice with long term post-treatment clinical monitoring. The effect of adjuvant radio- chemotherapy is not clearly reported yet.