A rare case of perianal Buschke Lowenstein Tumour

Buschke-Lenstein tumour (BLT) also known as giant condyloma acuminatum, is a verrucous lesion of genitoanal region cause by human papilloma virus subtypes 6 and 11. It is a rare entity with less than 100 cases reported so far. Poor hygiene, promiscuity, chronic irritation are the risk factors identified. A 52 year old male presented with a large perianal condyloma. Extensive surgical excision was done. Patient is recurrence free 10months since surgery. This aggressive tumor can recur and undergo malignant transformation. We report the following case of perianal Buschke-Lenstein tumour for its rarity.


Introduction
Buschke-Lowenstein tumour (BLT) also known as giant condyloma acuminatum, is a rare entity with less than 100 cases reported so far. 1,2 It is a sexually transmitted disease caused by human papilloma virus (types 6 and 11) with an incidence of 0.1% in general population. 3 Clinically, they are slow growing, locally destructive, cauliflower-like tumours of the anogenital region with a benign appearance on histopathology. 4 It is characterized by invasive growth, high recurrence rate and malignant transformation. This verrucous carcinoma is seen in perianal region. It is a well-differentiated squamous cell carcinoma. Surgical excision is the treatment of choice. 5 We report a case of perianal giant condyloma acuminata.

Case Report
A 52 year old male patient, presented to us with a large perianal mass that originated 30 years ago and gradually enlarged over the last 15 years with involvement of surrounding areas ( Figure 1). The patient complained of pain, occasional bleeding and intolerable fetid odour from these lesions since 2 months. On detailed history, the patient admitted to indulging in high risk sexual behaviours such as intercourse with sex workers and homosexual activities. There was no history of constipation, perianal discharge or bleeding per rectum. Local examination revealed multiple, large, exophytic, variegated tumour mass with multilobulated surface distributed over the scrotum and perianal areas. The largest tumor mass measure 10x6cm. Bilateral inguinal lymphadenopathy was also noted. Screening for STDs was negative. Our differential diagnoses were Condyloma acuminate, Buschke Lowenstein tumour, Squamous Cell Carcinoma, Melanoacanthoma. Histopathological examination revealed diagnosis of BLT with hyperkeratosis, acanthosis, papillomatosis and koilocytosis. Stroma showed dense lymphocytic infiltrate ( Figure 2). No evidence of malignancy was noted. Wide radical surgical excision of the lesions was done followed by split skin grafting. A V-Y mucocutaneous Gracilis flap was placed ( Figure 3). No recurrence has been detected in the 10 months since surgery. Buschke-Lowenstein tumour (BLT) also known as giant condyloma acuminatum, is a verrucous lesion of genitoanal region cause by human papilloma virus subtypes 6 and 11. It is a rare entity with less than 100 cases reported so far. Poor hygiene, promiscuity, c hronic irritations are the risk factors identified. A 52 year old male presented with a large perianal condyloma. Extensive surgical excision was done. Patie nt is recurrence free 10months since surgery. This aggressive tumor can recur and undergo malignant transformation. We report the following case of perianal Buschke-Lowenstein tumour for its rarity. Keywords: buschke-lowenstein tumor, perianal ,condyloma acuminate IJBR (2014) 05 (08) www.ssjournals.com

Discussion
Buschke Lowenstein tumour (BLT) also known as giant condyloma acuminatum. It was first described by Buschke and Lowenstein in 1925. It is a rare, slow growing tumour. Although histopathologically benign, it is a clinically malignant disease. 5 The incidence is 0.1% in the general population with less than 100 reported cases. Male: Female ratio is 2.7:1. 3 It is associated with Human Papilloma Virus (HPV) 6 and 11.
The risk factors are chronic irritation, multiple sexual partners, poor personal hygiene and immunosuppression. 6 BLTs develop by overgrowth of condyloma acuminatum. The sites affected in males are penis (81-94%), anorectal (10-17%), urethra (5%) and in females vulval region (90%) is involved. It has a relatively slow but inexorable progression, penetrating underlying tissue. The tumor may grow in the anal canal, giving rise to fistulas. 7 Secondary infection and necrosis are common. The hallmark of BLT is a high rate of recurrence and malignant transformation. The risk of recur rence after excision is 60-66%. 2 Transformation into malignant tumours has been reported in 30-56% cases. Overall mortality is 20-30%. 8 Clinically the tumor mass enlarges, infiltrating adjacent structures. The lesion can present as small as 2cm to as large as 2 0cm. Huang et al have reported tumor size in various studies comparable to our case. 9 Histologically it differs from condyloma acuminata by deep penetration of adjacent tissues. However, distinction from verrucous carcinoma is difficult.
Wide, radical surgical excision is the treatment of choice. Compromise with radicality was reported to cause recurrences. Mul tiple fistulous tracts may require an additional temporary loop colostomy.
Though recurrences are more with medical management, those that have been used are topical trichloroacetic acid, 5-fluorouracil and podophyllin and imiquimod. Systemic immunotherapy with interferon-α showed response rate of 76% while systemic chemotherapy with 5-fluorouracil, cisplatin, methotrexate, mitomycin and bleomycin showed less satisfactory response. 8 Etretinate and photodynamic therapy have been used with some success. 2 Surgical modalities of treatment such as Mohs technique or abdominoperineal amputation maybe required to achieve complete resection. Radiotherapy and Cryotherapy have been tried but with limited success. Laser treatment with Carbondioxide and Nd:YAG can be used. 3 We report this case for its rarity of the condition and to highlight the importance of radical surgery in the treatment of Buschke Lowenstein tumour.

Conclusion
Buschke Lowenstein tumour is a rare verrucous growth affecting the perianal region. Early detection and aggressive treatment can prevent recurrence and malignant transformation.