Giant Condylomata Acuminata of Buschke and Lowenstein

First described by Buschke and Löwenstein in 1925, the giant condyloma of Buschke and Löwenstein (GCBL) is a slow-growing, locally destructive verrucous plaque that typically appears on the penis but may occur elsewhere in the anogenital region. It most commonly is considered to be a regional variant of verrucous carcinoma, together with oral florid papillomatosis and epithelioma cuniculatum.

Related eMedicine articles of possible interest include the following:

• Squamous Cell Carcinoma
• Human Papillomavirus
• Warts, Genital

GCBL is slow growing, highly destructive to contiguous tissue, and seldom metastasizes. Most commonly located on the glans penis, GCBL can be found on any anogenital mucosal surface, including the vulva, vagina, rectum, scrotum, and bladder.¹ Co-localization with human papillomavirus (HPV) types 6 and 11 occasionally HPV types 16 and 18; and, on one occasion, HPV 54 has been shown. The E6 protein of HPV-6 and HPV-11 binds p53 tumor suppressor protein less efficiently than that of HPV-16 and HPV-18 but, theoretically, could lead to accelerated degradation of the p53 protein. The E6 protein also inhibits p53 transcription.

Alternatively, a mutation may occur in the p53 protein, leading to clonal proliferation. Several reports have shown some overexpression of p53 in genital warts and squamous cell carcinomas (SCCs), but one study concluded that despite the overexpression, p53 mutations were not present.³ Other implicated agents are chronic chemical exposure, chronic irritation, and poor hygiene.

GCBL is rare. Estimates of incidence show that GCBL accounts for 5-24% of penile cancers, which, in turn, are 0.3-0.5% of male malignancies. Another review assessed that verrucous carcinoma accounted for approximately 50% of all low-grade SCCs of the penis. GCBL located outside the penis is much more infrequent. Fewer than 50 cases of perianal tumors and only 20-30 cases of vulvar or bladder GCBL have been reported. The bladder lesions have been associated with schistosomiasis (ie, Schistosoma haematobium).

SCC of the penis is much more common elsewhere in the world compared with the United States. No specific data are available in the English literature regarding international incidence.

If untreated, GCBL can be locally very destructive, extending into the pelvic organs and bony structures. Even with treatment, morbidity rates can be high because recurrences are very common with all treatment modalities. One case report noted recurrent lesions in the ischial tuberosities that required pelvic exenteration. Malignant transformation is reported in 30-56% of patients.

No racial predilection is reported.

Most cases of GCBL occur in males on the glans penis. This condition is more common in males who are uncircumcised. The male-to-female ratio is 3.5:1.

Two thirds of cases of GCBL occur in persons younger than 50 years. It is rarely reported in children. A recent trend toward a younger reported age at presentation is recognized.

GCBL typically starts on the prepuce as a keratotic plaque and slowly expands into a cauliflowerlike mass, as large as 15 cm. The lesion may ulcerate or form a penile horn and typically is associated with a foul odor. Expansion to the corpus cavernosum and urethra may occur, with subsequent fistulation. Regional lymphadenopathy is common, primarily due to secondary infection, not metastases. Similar slow progression is noted on perianal lesions. Presenting symptoms of perirectal GCBL include perianal mass (47%), fistula or abscess (32%), and bleeding (18%).

Chronic phimosis and poor penile hygiene have been postulated as inciting or contributing events. This may account for the higher incidence in males who are uncircumcised. Populations with a higher incidence of circumcision have a lower rate of GCBL. In general, newborn circumcision has been estimated to be 99.9% effective in eliminating cancer of the penis. Chronic irritation, produced by a perianal fistula and ulcerative colitis, has been implicated as a causative factor. Immunosuppression secondary to HIV disease or due to immunosuppressive medication may be a predisposing factor. Other risk factors for GCBL are low socioeconomic status, drug abuse, use of oral contraceptives, presence of other sexually transmitted diseases, diabetes, smoking, and, possibly, pregnancy,⁴ which may be associated with an impaired immune response.