Successful treatment of recurrent buschke - Lowenstein tumor by radiation therapy and chemotherapy

Dear Editor: Giant condyloma acumintaum (GCA) or Buschke–Lowenstein tumor is a slow-growing, locally aggressive, cauliflower-like tumor of great size that usually arises in the perineal region. Buschke in 1896 and then Buschke and Lowenstein in 1925 described it as a carcinoma-like condyloma acuminatum in the penis. GCAwas found to occur in the anorectal region by Dawson et al. in 1965. GCA shares gross features with condyloma acuminatum and squamous cell carcinoma but can be differentiated based on unique histological features. Current management includes topical agents, definitive surgical excision, and neoadjuvant chemoradiotherapy. We report a case of recurrent GCA in a patient with two previous surgical excisions who was treated to complete regression with definitive radiation therapy and chemotherapy and is still disease-free after a 5-month follow-up. A 38-year-old heterosexual, HIV-negative and hepatitis C-negative male was consulted by our department with the finding of GCAwith conversion to verrucous carcinoma and well-differentiated squamous cell carcinoma. The patient first noticed a wart-like lesion in the perianal area 3 years prior to presentation, which continued to grow in size. The lesion was biopsied 1 year prior to presentation,which was positive for GCA. Surgical excision was done a month later, and the final pathology showed GCA, Buschke–Lowenstien type, with focal transformation to verrucous carcinoma. The mass recurred within 5 months, and repeat surgical excision was done. The pathology from the excision showed welldifferentiated squamous cell carcinoma with verrucous carcinoma and GCA. No adjuvant therapy was given. The mass recurred for a second time in 4 months, increasing in size and pain, which led the patient to the emergency room for the current presentation. At current presentation, the patient presented with worsening perineal pain associated with swelling of his right thigh and perineum, a 50-lb weight loss, dysuria, and erectile dysfunction. To start, Vancomycin and Zosyn were administered intravenously to the patient. Incision and drainage yielded white, malodorous fluid. Dermatologic exam showed a 12×10 cm cauliflower-like perineal mass at the scrotal bass involving the base of the penis without invasion into the urethra. Computed tomography (CT) of the pelvis showed a mass located in the midline of the perineum, involving the inferior aspect of the penis and ischiocavernosus on both sides. There were bilaterally enlarged inguinal and external iliac lymph nodes. No metastatic lesions were demonstrated on CT, X-ray, or ultrasound. Due to the patient’s multiple past surgical excisions and the extent of the tumor, surgical excision would have caused significant morbidity. As a result, chemotherapy and radiation therapy were prescribed to the patient. The patient was given radiation to the perineal tumor with a dose of 54 Gy in 30 fractions using a AP-PA technique, along with concurrent chemotherapy with Mitomycin and 5-fluorouracil (5-FU). The patient tolerated treatment well and demonstrated symptomatic improvement with complete regression of the tumor. The patient has remained free from recurrence at a follow-up of 6 months. W. Haque : E. Kelly : L. S. Carpenter (*) Department of Radiology, Section of Radiation Oncology, Baylor College of Medicine, One Baylor Plaza, BCM 620, Houston, Texas 77030, USA e-mail: scarpenter@sleh.com