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 smoking
7. 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, respectively7,8. 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 excision2,3,5.
The application of topical podophyllin is helpful for ordinary condyloma acuminata. However, it does not effect in GCA5,9. 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 defect5,6. 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 patients4,6.
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.
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