Giant Condyloma of Buschke-Lowenstein: An Atypical Case

Joseph K. Kim, MD; Gabriel S. Levi, MD; David L. Carr-Locke, MD

Disclosures

January 05, 2012

Discussion

GCBL, which was once a gross discovery, has been studied at the molecular level. The pathogenesis is not definitive, but scientists speculate that GCBL alters cell proliferation control at both the genetic and protein synthesis level. Human papillomavirus (HPV) may cause point mutations or deletions in chromosome 17p. HPV proteins may also cause proteolytic degradation of the tumor suppressor gene p53. Another postulated mechanism is the binding of HPV E7 protein to the retinoblastoma gene, which normally restricts proliferation of the basal epithelium.[2]

GCBL is usually not metastatic or highly aggressive. Rather, it is usually histologically innocuous and can be excised locally. This case of GCBL demonstrates an uncommon case of aggressiveness as evidenced by MRI. GCBL is more prevalent in the male population (2.7:1) and the average age at detection is 43.9 years.[3] Sexual orientation was not found to be correlated with development of GCBL. Our patient did not fit the typical demographic profile for developing an extensive case of GCBL.

Pathologically, the gross specimen was as expected for GCBL. In fact, histology also confirmed that the epithelial extensions were pushing into the underlying stroma without invasion. Surprisingly, this GCBL appeared to be metastatic radiologically, with enlarged mesorectal lymph nodes and invasion through the mesorectal fascia. Perhaps this is why classification of this entity has seen numerous changes. The ambiguous classification and identification leads to a division in solidifying treatment modalities. A textbook GCBL is treated with local excision. However, for the patient described above, many would treat the patient as if he had metastatic squamous cell carcinoma of the anus.[4]

Perhaps we are now seeing premature and more aggressive variants of GCBL due to better detection modalities. Additionally, perhaps histologically benign GCBL should be evaluated and treated as a completely distinct entity from the locally aggressive form seen in this patient.

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