Letters to the Editor

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.

DISCUSSION BLT is a slow-growing cauliflower-like lesion, caused by human papilloma virus types 6 and 11.[1,2] 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, CO 2 laser surgery, and interferons[4,6] has been reported; but, for larger lesions, these modalities have shown limited efficacy, making early radical surgery with wide excision the treatment of choice.[5,6]




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

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.

F. N. U. Shailesh, Nitin Relia, Naga Venkata K. Pothineni, Abhishek Agarwal Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA Address for correspondence: Dr. F. N. U. Shailesh, Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, Arkansas 72205, USA. E-mail: [email protected]




Trottier H, Burchell AN. Epidemiology of mucosal human papillomavirus infection and associated diseases. Public Health Genomics 2009;12:291-307. Aubin F, Prétet JL, Jacquard AC, Saunier M, Carcopino X, Jaroud F, et al. EDiTH Study Group. Human papillomavirus genotype distribution in external acuminata condylomata: A large French national study (EDiTH IV). Clin Infect Dis 2008;47:610-5. Papiu HS, Dumnici A, Olariu T, Onita M, Hornung E, Goldis D, et al. Perianal giant condyloma acuminatum (Buschke-Löwenstein tumor). Case report and review of the literature. Chirurgia (Bucur) 2011;106:535-9. Indian Dermatology Online Journal - 2014 - Volume 5 - Supplement Issue 1

Letters to the Editor 4. 5.


Jablonska S. Traditional therapies for the treatment of condylomata acuminata (genital warts). Australas J Dermatol 1998;39 Suppl 1:S2-4. Gholam P, Enk A, Hartschuh W. Successful surgical management of giant condyloma acuminatum (Buschke-Löwenstein tumor) in the genitoanal region: A case report and evaluation of current therapies. Dermatology 2009;218:56-9. Radovanovic Z, Radovanovic D, Semnic R, Nikin Z, Petrovic T, Kukic B. Highly aggressive Buschke-löwenstein tumor of the perineal region with fatal outcome. Indian J Dermatol Venereol Leprol 2012;78:648-50.

Indian Dermatology Online Journal - 2014 - Volume 5 - Supplement Issue 1

Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.144540


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Buschke-Lowenstein tumor in a patient with decompensated cirrhosis.

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