Can a perianal condyloma reach the pelvis?

Description

A 42-year-old MSM black male was admitted due to vigorous perianal bleeding. Physical examination revealed a 14×8 cm exophytic erythematous perianal tumour with a moist verrucous surface (figure 1, right). The lesion had its origin on the right anal verge, extending over 3 cm on the anal canal, as seen by anuscopy. There was no loco-regional lymphadenopathy upon palpation. Laboratory data revealed microcytic anaemia (Hg 3.9 g/dl) and pelvic MRI showed abnormalities on the external anal sphincter, right isquiorectal fossa fat and thickening of perianal skin. On histopathology, there was a papillomatous epithelial proliferation with viral cytopathic effect and no signs of atypia, in keeping with condyloma acuminatum (figure 2). Patient’s history was remarkable for a 4-year HIV-1 positive serology (current viral load <50 copies/ml and CD4+ count 123 cells/mm³), diabetes mellitus and chronic renal disease. He was on highly active antiretroviral therapy, insulinotherapy and dialysis. He had had a sexually transmitted diseases appointment 2 years before (figure 1, left) and refused surgical treatment. In face of the presumptive diagnosis of Buschke–Löwenstein tumour, a wide local surgical excision was planned. The patient unexpectedly died during the anaesthetic induction. Buschke–Löwenstein tumour or giant condyloma acuminatum is considered a verrucous carcinoma, being locally invasive, but rarely capable of metastatic disease. It is an uncommon tumour of the anorectum, associated with the human papillomavirus types 6/11. Though foci of squamous cell carcinoma are commonly found, its histology may look remarkably benign; thus, the lack of a wider sample does not allow to rule out a malignant transformation in this case. Radical surgery can be curative, but recurrences are frequent.1 ,2

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Figure 1

Patient’s perianal lesion on a sexually transmitted diseases appointment in 2009 and on admission, 2011.

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Figure 2

Buschke–Lowenstein tumour sample on microscopy (H&E). Notice the parakeratosis, granular vacuolisation and hyperkeratosis with a thick stratum corneum in the specimen analysed; these features generally characterise the benign BL tumours and support the differential diagnosis from ordinary warts.