Buschke-Lowenstein tumor in a patient with decompensated cirrhosis.

Sir,

A 57-year-old Caucasian male presented with continuous oozing of blood from a large exophytic growth over the abdomen and penile shaft. The patient reported a slowly enlarging exophytic growth over his penis [Figure 1a] and abdomen [Figure 1b] for past 35 years. He never sought medical attention for these; however, for the past 2 weeks, he was continuously oozing blood from these growths, requiring him to change clothes and bed sheets several times a day. Past medical history was significant for end-stage liver disease from untreated hepatitis C. At presentation, his hemoglobin was 6.6 and INR 1.9. During the course of hospitalization, patient was transfused as needed with reversal of coagulopathy; however the bleeding continued. Biopsy from both abdominal and penile growth showed increased mitosis and atypia, causing push effect, but lacked basement membrane invasion, [Figure 2a and b] consistent with diagnosis of Buschke-Lowenstein tumor (BLT). Our patient failed radiotherapy and surgery was not an option because of decompensated cirrhosis with irreversible coagulopathy.

Figure 1

(a) Large, exophytic lesions over the penile shaft and scrotum; (b) Large, exophytic lesions on the abdomen

Figure 2

(a and b) Histopathology of lesions illustrates papillomatosis, acanthosis, and keratin pearls with increased mitosis and atypia

DISCUSSION

BLT is a slow-growing cauliflower-like lesion, caused by human papilloma virus types 6 and 11.[12] It is more common in males, with a male: female ratio of 2.7:1. The mean age of presentation is 44 years. It primarily affects the genital and anorectal regions. The most common presentation is a huge mass causing disfigurement. Others include fistulas, abscess, bleeding, weight loss, pruritus, and anemia. It represents a stage of intermediacy with common wart at one end and invasive squamous cell cancer (verrucous carcinoma) at the other. Histologically, it is similar to condyloma acuminatum, but, with a tendency to compress and displace the deeper tissues, without basement membrane disruption. Malignant transformation occurs in 40-60%[3] of cases with histological evidence of basement membrane invasion that is then termed as verrucous carcinoma. Although it lacks metastatic potential, its recurrence rate is 70%.[4]

Early radical surgery with wide excision margins remains the mainstay of treatment and offers a hope of cure.[5] Various case reports demonstrating successful treatment of BLT with other conservative modalities such as systemic chemotherapy, cryosurgery, podophyllin, topical 5-FU, intralesional bleomycin, 13-cis retinoic acid, imiquimod, CO2 laser surgery, and interferons[46] has been reported; but, for larger lesions, these modalities have shown limited efficacy, making early radical surgery with wide excision the treatment of choice.[56]

This patient was deemed to be a non-operative candidate because of underlying cirrhosis and irreversible coagulopathy. The patient received palliative radiation to the lesions, which was complicated by further bleeding, and was finally discharged to hospice care.