Case Report - (2022) Volume 6, Issue 6
Received: 27-May-2022, Manuscript No. cmcr-22-70450;
Editor assigned: 28-May-2022, Pre QC No. P-70450;
Reviewed: 06-Jun-2022, QC No. Q-70450;
Revised: 15-Jun-2022, Manuscript No. R-70450;
Published:
25-Jun-2022
, DOI: 10.37421/2684-4915.2022.6.213
Citation: Cheikhna, F. Zahra, A. Benzzine, F. Haddad and F.Z. Elrhaussi, et al. "Buschke-Löwenstein Tumour with Anorectal Location in Immunocompetent Patients." Clin Med Case Rep 6 (2022): 213.
Copyright: © 2022 Cheikhna FZ, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Buschke lowenstein tumor (BLT) or giant condylomas acuminata (GCA) is relatively rare. It is caused by papillomavirus, and in particular by HPV serotypes 6, 11. It most commonly occurs in immunocompromised males. It is characterized by the frequency of recurrence and the risk of malignant transformation and the treatment remains essentially surgical.
We report the case of twelve patients treated for anorectal TBL, eleven of whom were immunocompetent. Based on this study and a review of the literature, we will describe this condition's epidemiological, therapeutic and evolutionary aspects. The originality of this study lies in the fact that this pathology has been diagnosed in immunocompetent patients.
Buschke-Löwenstein tumor • Anorectal location • Immunocompetent patients
Buschke-Lowenstein tumor (TBL) or giant condyloma acuminata, is a rare clinical entity, of viral origin, transmitted mainly by sexual means [1]. Its first description dates back to 1896. It was in 1925 that Buschke and Löwenstein made it a characterized entity [2]. The frequency is currently estimated at 0.1% of the general population. Degeneration affects only 8-25% of TBLs [3]. It is a proliferation of pseudo-epitheliomatous aspect which evolves towards extension on the surface and in depth or even malignant degeneration. Its treatment remains essentially surgical.
The aim of this work is to describe the epidemiological, therapeutic and evolutionary aspects of this condition.
We report a retrospective and descriptive study of twelve patients who were treated for anorectal TBL, over a period of 9 years, from January 2011 to December 2019. These patients underwent a proctologic examination, an assessment of sexually transmitted infections then surgical treatment followed by an anatomopathologic study of the operating specimen. Statistical analyses were performed using Excel software.
This study involved twelve patients. The average age was 47 years with extremes ranging from 22 to 60 years. We noted a male predominance, eight patients being male and four female, the sex ratio being 2. Only one patient was followed for HIV infection.
The eleven immunocompetent patients had no particular pathological history (In particular no diabetes, no chronic diseases and no corticosteroid therapy).
A large papillomatous tumour was found in all our patients. The size varies between 5 and 17 cm. The genital organs were invaded in 25% of the patients. In addition, we objectified intracanal involvement in 16.6% of all patients.
All of our patients have undergone surgical treatment. Eleven patients underwent wide excision of the lesions and one patient underwent palliative resection of the TBL which was invading the sphincter system. Electrocoagulation has been indicated for intracanal lesions.
All lesions were diagnosed as giant condyloma acuminata and low-grade dysplasias were found in 1 case.
The evolution was good in nine patients with a complete remission maintained. A patient who presented a local recurrence of the lesions underwent surgical revision and the pathological examination was in favor of a giant condyloma acuminata then the evolution was good with complete remission. Two cases of anal stenosis have been reported in patients who had intraductal extension treated by electrocoagulation and who were in complete remission, these patients received treatment by anal dilation using candles.
Buschke and Lowenstein in 1925 were the first to describe the bulkiness of giant condyloma acuminata and the term Buschke and Lowenstein tumor was thus born [2].
TBL is a relatively rare condition and always preceded by condyloma acuminata. Its frequency is estimated at 0.1% of the general population [4-6]. The diagnosis is most often made in adults. The vast majority are infected during the first sexual intercourse [7]. The average age of our patients is 47, which reflects their young age. There is a male predominance, 8 patients being male and 4 female, the sex ratio being 2. Risk of occurrence in men aged 18 to 44 [8,9]. Immunosuppression, chronic inflammation, poor hygiene and HIV infection appear to be risk factors for this condition [10-12]. Human Papilloma Virus (HPV) infection is widely implicated in the development of TBL and essentially low oncogenic risk genotypes (especially 6 and 11) [13]. Most immunocompetent patients clear the virus, in some it persists in a quiescent state in the deeper layers of the epidermis. The contraceptive pill, intercurrent infections, parity and smoking promote this persistence. Immunosuppression can reactivate the virus and inhibit its clearance [14]. The preponderant place of this disease in proctology consultation has recently been confirmed for the HIV population. In our study, 11 patients were immunocompetent and only 1 patient was followed for HIV, which does not agree with the data in the literature which dictate that this pathology is more frequent in the immudepressed, in particular patients infected with the human immunodeficiency virus [HIV].
TBL is most often located in the external genitalia and mainly in the penis. The anorectal localization remains less frequent but it is not uncommon. In our series, the localization at the level of the anal margin is constant. The genital organs were invaded in 25% of the patients. In addition, we objectified intracanal involvement in 16.6% of all patients.
Clinically, CAG most often begins as small rounded or threadlike lesions that are pinkish or of normal skin color. The duration of the transformation is variable, ranging from a few months to several years. In the state phase, we observe a large tumor (which can exceed 10 cm on the long axis) (Figure 1) papillomatous, irregular, with a surface bristling with digitations, budding, cauliflower-shaped, often whitish or yellowish in color, often presenting superficial ulcerations and added infectious lesions [15,16], its extension can be towards the scrotum or the vulva, the intergluteal groove, the buttocks, or even the rectum and the pelvis. On the surface it can give rise to an enormous tumor of about ten centimeters. In depth, the tumor evolves by destroying and pushing back neighboring structures without infiltrating them [4,11,17,18]. A large papillomatous tumor was found in all our patients. The size varies between 5 and 17 cm.
Figure 1. Large papillomatous tumor.
Histologically, it is a perfectly limited squamous tumor, characterized by considerable epithelial hyperplasia, sometimes pseudo-epitheliomatous, hyperacanthosis, hyperpapillomatosis and koilocytes which are pathognomonic markers of HPV infection, however their presence does not is not constant. The basal membrane remains intact, which proves the benignity of the tumor despite its malignant behavior [5,18,19].
The search for other sexually transmitted infections is systematic (HIV, chlamydia trachomatis, syphilis) [5,11]. In our series, all the patients benefited from an assessment of sexually transmitted infections, no case of association with HIV was reported except for a single patient who was followed for HIV.
The treatment appears to be uncodified and no strategy is available at the moment. Surgery remains the gold standard in the treatment of TBL. Complete excision avoids the recurrences that characterize the evolution of this tumour. Although the histology of the tumor is in favor of benignity, the excision must be early, large, carrying the entire surface and deep tumor and allowing histological analysis in search of degeneration [2,5]. In perianal locations, excision with preservation of the sphincter and reconstruction is carried out as often as possible, but more serious interventions such as amputation of the rectum or abdominoperineal amputations are sometimes necessary [17] .
All of our patients have undergone surgical treatment. Eleven patients underwent wide excision of the lesions and one patient underwent palliative resection of the TBL which was invading the sphincter system. Electrocoagulation has been indicated for intracanal lesions.
All lesions were diagnosed as giant condyloma acuminata and low-grade dysplasias were found in 1 case.
The evolution was favorable in nine patients with complete remission. A patient who presented a local recurrence of the lesions underwent surgical revision, the pathological examination was in favor of a giant condyloma acuminata then the evolution was favorable with complete remission. The two cases of anal stenosis that have been reported in patients who had benefited from coagulation for intraductal extension and who were in complete remission were treated by anal dilatation using candles.
This study reports twelve cases of BLT tumour, including eleven cases in immunocompetent patients. This suggests that this pathology can be found even in immunocompetent patients.
Buschke-Lowenstein tumor (or giant condyloma acuminata) is a rare tumor requiring early and extensive surgical treatment with regular post-surgical, clinical and histological monitoring. Its prevention is imperative based on the treatment of condyloma acuminata and the fight against sexually transmitted diseases.
No conflicts of interest.
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