TECHNICAL NOTES
Circumferential Anal Giant Condyloma Acuminatum: A New Surgical Approach Angelo Guttadauro, M.D. • Marco Chiarelli, M.D. • Daniele Macchini, M.D. Silvia Frassani, M.D. • Matteo Maternini, M.D. • Aimone Bertolini, M.D. Francesco Gabrielli, M.D. Istituti Clinici Zucchi, Università degli Studi Milano-Bicocca, Milan, Italy
INTRODUCTION: Perianal giant condyloma acuminatum is a rare clinical condition related to human papillomavirus infection and characterized by a circumferential, exophytic, cauliflower-like mass with an irregular warty surface localized in the anal region. TECHNIQUE: A circular incision with a diathermocoagulator was performed on macroscopically healthy skin, 1 cm from the margin of the lesion. The dermis was divided from the subcutaneous tissue. This way, a mucocutaneous cylinder including the whole lesion was obtained. A median radial incision was carried out to open the cylinder at its front. A progressive circumferential section on healthy mucosa (≈1 cm above the margin of the lesion) by means of a radiofrequency dissector allowed for the complete removal of the mass. The healthy mucosa of the anal canal was pulled out by Allis forceps and was sutured to the external margin of the internal sphincter with single layer of Vicryl (polyglactin 910) 2-0 sutures. RESULTS: Two months after surgery, no findings of anal stenosis or mucosal ectropion were reported. At the 1-year follow-up there was no recurrence of condylomatosis in any of the 3 cases. CONCLUSIONS: Our procedure seems simpler to perform when compared with other techniques and reduces hospital stay and complications such as anal stenosis and mucosal ectropion. KEY WORDS: Buschke-Löwenstein tumor; Circular incision; Giant condyloma acuminatum.
T
he incidence of anogenital warts has increased in the past decades and is, to date, the most common sexually transmitted disease in Western countries.1 Condylomata acuminata are correlated with low-risk human papillomavirus (HPV) type 6 and 11 infection, whereas high-risk HPV type 16 is frequently present in anogenital malignant lesions.2–4 Perianal giant condyloma acuminatum (GCA) is a rare clinical condition related to HPV infection and characterized by a circumferential, exophytic, cauliflower-like mass with an irregular warty surface localized in the anal region. This clinical condition was first described in 1925 by Buschke and Löwenstein as a lesion of the penis. In 1963, Knoblich and Failing5 reported a case of GCA localized in the anal region. Some authors consider the Buschke-Löwenstein tumor as a clinical manifestation of the verrucous carcinoma,4 but the majority of authors prefer to classify it as an extensive form of condyloma acuminatum with a high potential for malignant transformation.2,6 Currently, Buschke-Löwenstein tumor is synonymous with GCA. GCA is not a malignant lesion by histologic criteria but often shows a propensity to compress or infiltrate adjacent tissues and harbor tumor foci.6 An attractive hypothesis suggests that, on the analysis of their clinical and histopathologic characteristics, condylomata acuminata, GCA (the Buschke-Löwenstein tumor), and verrucous squamous carcinoma may represent a continuous precancerous spectrum.7 As of now, the treatment of choice for the GCA is local excision.6,8 Three patients were reported as successfully treated with a new surgical approach.
PATIENTS AND METHODS Financial Disclosure: None reported. Correspondence: Matteo Maternini, M.D., Istituti Clinici Zucchi, Università degli Studi Milano-Bicocca, Milan, Italy. E-mail: [email protected] Dis Colon Rectum 2015; 58: e49–e52 DOI: 10.1097/DCR.0000000000000339 © The ASCRS 2015 Diseases of the Colon & Rectum Volume 58: 4 (2015)
The patients we treated showed a cauliflower lesion defined by a grape-like conglomerate merging into cribrous areas. The lesion has a hard, rubbery consistency and is free from adhesions with the underlying planes. All of the above are consistent with a giant condyloma. A previous outpatient anoscopy was performed to rule out anal canal and rectal condylomatosis above the dentate line. e49
e50
Guttadauro et al: A More Simple Approach to GCA
Figure 1. A circular incision with diathermocoagulator is performed on macroscopically healthy skin, 1 cm from the lesion margin.
The bowel preparation consisted of 2 enemas 1 day before surgery. Informed consent was obtained for surgical treatment and handling of personal data. The operation was performed under spinal anaesthesia; intravenous metronidazole and ceftriaxone were given prophylactically. The patient was placed in the high lithotomy position. A circular incision with a diathermocoagulator was performed on macroscopically healthy skin, 1 cm from the margin of the lesion (Fig. 1). The dermis was divided from the subcutaneous tissue. A gentle submucosal dissection was then performed in the anal canal as far as healthy mucosa was encountered, taking care to preserve the internal sphincter. In this way, a mucocutaneous cylinder including the whole lesion was obtained. A median radial incision was carried out to open the cylinder at its front. A progressive circumferential section on healthy mucosa (≈1 cm above the margin of the lesion) by means of a radiofrequency dissector allowed for the complete removal of the mass (Fig. 2A). In our experience, using a radiofrequency apparatus yields better results in terms of hemostasis and faster healing of surgical wounds with less lateral heat diffusion. The healthy mucosa of the anal canal was pulled out by Allis forceps and was sutured to the external margin
of the internal sphincter with single layer of Vicryl (polyglactin 910) 2-0 sutures (Fig. 2B). The remaining perianal wound was left to second intention healing. Patients were discharged on the second postoperative day, with a recommendation for oral pain medication (ketorolac, 10 mg twice a day for 4 days), oral laxatives (lactulose, 2 teaspoons per day), a fiber-rich diet, and daily sitz baths with diluted chloramines. The patients underwent weekly outpatient examinations for 6 weeks. Home dilation was prescribed twice per week for 6 weeks, 15 days after surgery. Follow-up was scheduled at 2 months and at 1 year after the surgery.
RESULTS Histology confirmed each patient as having diffuse anoperineal condylomatosis without malignant degeneration. The early postoperative period was uneventful in all 3 patients: no bleeding, wound infection, or anal incontinence was reported (Fig. 3A). Hospital stay was 2 days for all 3 patients. Complete healing occurred in 40 days. Two months from surgery, no findings of anal stenosis or mucosal ectropion were
Figure 2. A, A progressive circumferential section on healthy mucosa (≈1 cm above the lesion margin) by means of a radiofrequency dissector allows the complete removal of the mass. B, The anal canal healthy mucosa is pulled out by Ellis forceps and is sutured to the external margin of the internal sphincter with single layer of Vicryl 2-0 sutures.
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Diseases of the Colon & Rectum Volume 58: 4 (2015)
Figure 3. A, The early postoperative course was regular in all 3 patients: no bleeding, wound infection, or anal incontinence was found. B, After 2 months, no cases of anal stenosis or mucosal ectropion were registered.
reported (Fig. 3B). At the 1-year follow-up, there was no recurrence of condylomatosis in any patient.
DISCUSSION Sexual intercourse is the primary route of diffusion for interpersonal transmission of anogenital condylomatosis.9 A high prevalence of anal warts is found in men who have sex with men, particularly in HIV-positive patients.10 In these patients, condylomata occur with larger size, grow more rapidly, and show a higher incidence of recurrence and dysplasia compared with that of the general population.11 Patients affected by GCA present longstanding symptoms: the particular method of transmission and the localization of the lesions often induce them to undergo a physical examination very late in the course of the disease. Currently the correlation between perianal GCA and risks factors for anal condylomatosis (HIV infection and homosexual orientation) is not clearly defined because of the paucity of data found in literature. In our series, no patient turned out to be HIV positive, and only 1 admitted to have anal receptive intercourse. Medical treatment of anogenital warts is characterized by a recurrence rate of 20% to 30%, whereas surgical treatment has clearance rates close to 100%.12 The therapeutic indication depends on the size of condylomata: small lesions can be successfully treated with local chemical agents, whereas extensive lesions require surgery.12,13 Medical treatment includes topical compounds containing podophyllotoxin and imiquimod.12 Electrocoagulation with a diathermocoagulator or liquid nitrogen cryotherapy may be used in case of localized anal warts.13 GCA localized in the anorectal region is typically a large perianal circumferential mass characterized by potential malignant transformation and high recurrence rates.6,8 A wide surgical excision with 1-cm macroscopically negative margins is presently considered the most appropriate treatment for this type of lesion.14,15
The incidence of malignant transformation of GCA is very high and varies from 30% to 56%.6,16 Consequently, radical surgical excision that allows complete histologic examination is mandatory for these patients: any additional therapies will be scheduled in relation to the presence of tumor, infiltration of surrounding tissues, or involvement of resection margins. GCAs are associated with a very high recurrence rate that can reach 65%6,16; excisional surgery with 1-cm disease-free margins seems to guarantee the lowest rate of recurrence.13,14 Furthermore, patient immune status seems to play a decisive role: in HIV-positive patients, the incidence of recurrent condylomata after surgery is significantly higher than in the HIV-negative population.17 In our series, the absence of recurrence at 1 year in all of the patients may be related to both radical surgery and complete patient immunocompetence. A large anodermal resection exposes the patients to a risk of postoperative stenosis, and many authors suggest different types of plastic reconstructive surgery to cover the skin defect and to prevent second-intention healing.13,18 The kind of reconstruction after excision is debated. Different techniques have been proposed, including mesh-skin grafts, Whitehead technique, rotational S-flaps, advancement flaps, and V-Y flaps.13,14,18,19 Nevertheless, this kind of surgery is characterized by a prolonged hospital stay and not negligible rates of complication, including hematoma, wound infection, and suture dehiscence.20 The absence of warts above the dentate line is a requirement to perform our technique. The fixing of the anal mucosa to the internal sphincter aims to place the dentate line in its natural position, avoiding its upward displacement with a consequent high risk of complications. A mucocutaneous suture, which is not easy to perform after a wide perianal excision, is avoided to prevent mucosal ectropion. Although anal stricture after surgery for diffuse condylomatosis seems to be uncommon,20 the choice of leav-
e52
ing the perianal wound to second-intention healing could lead to postoperative stenosis. To minimize this complication we recommend regular evacuations and home dilations twice a week; indeed, frequent postoperative examinations are needed. According to our initial experience, the proposed surgical approach seems to combine technical simplicity, rapid discharge, and low complication rates.
CONCLUSION Surgical circumferential excision by radiofrequency dissector followed by suture of the anal mucosa to the inferior margin of the internal sphincter might be a valid therapy for GCA. In our experience, although it is limited because of the rarity of such lesions, we had no findings of stenosis or recurrence. Our procedure seems simpler to perform and reduces hospital stay and complications. Therefore, we think it is a valid option for treating these patients. A larger number of patients is desirable to confirm our results in the future. REFERENCES 1. Patel H, Wagner M, Singhal P, Kothari S. Systematic review of the incidence and prevalence of genital warts. BMC Infect Dis. 2013;13:39. 2. Gormley RH, Kovarik CL. Dermatologic manifestations of HPV in HIV-infected individuals. Curr HIV/AIDS Rep. 2009;6:130–138. 3. Tachezy R, Jirasek T, Salakova M, et al. Human papillomavirus infection and tumours of the anal canal: correlation of histology, PCR detection in paraffin sections and serology. APMIS. 2007;115:195–203. 4. Nebesio CL, Mirowski GW, Chuang TY. Human papillomavirus: clinical significance and malignant potential. Int J Dermatol. 2001;40:373–379. 5. Knoblich R, Failing JF Jr. Giant condyloma acuminatum (Buschke-Löwenstein tumor) of the rectum. Am J Clin Pathol. 1967;48:389–395. 6. Chu QD, Vezeridis MP, Libbey NP, Wanebo HJ. Giant condyloma acuminatum (Buschke-Lowenstein tumor) of the anorectal and perianal regions: analysis of 42 cases. Dis Colon Rectum. 1994;37:950–957.
Guttadauro et al: A More Simple Approach to GCA
7. Bogomoletz WV, Potet F, Molas G. Condylomata acuminata, giant condyloma acuminatum (Buschke-Loewenstein tumour) and verrucous squamous carcinoma of the perianal and anorectal region: a continuous precancerous spectrum? Histopathology. 1985;9:1155–1169. 8. Trombetta LJ, Place RJ. Giant condyloma acuminatum of the anorectum: trends in epidemiology and management–report of a case and review of the literature. Dis Colon Rectum. 2001;44:1878–1886. 9. Burchell AN, Winer RL, de Sanjosé S, Franco EL. Chapter 6: epidemiology and transmission dynamics of genital HPV infection. Vaccine. 2006;24(suppl 3):52–61. 10. Palefsky JM, Holly EA, Ralston ML, Jay N. Prevalence and risk factors for human papillomavirus infection of the anal canal in human immunodeficiency virus (HIV)-positive and HIVnegative homosexual men. J Infect Dis. 1998;177:361–367. 11. Manzione CR, Nadal SR, Calore EE. Postoperative follow-up of anal condylomata acuminata in HIV-positive patients. Dis Colon Rectum. 2003;46:1358–1365. 12. Lacey CJ, Woodhall SC, Wikstrom A, Ross J. 2012 European guideline for the management of anogenital warts. J Eur Acad Dermatol Venereol. 2013;27:e263–e270. 13. Tripoli M, Cordova A, Maggì F, Moschella F. Giant condylomata (Buschke-Löwenstein tumours): our case load in surgical treatment and review of the current therapies. Eur Rev Med Pharmacol Sci. 2012;16:747–751. 14. Abbas MA. Wide local excision for Buschke-Löwenstein tumor or circumferential carcinoma in situ. Tech Coloproctol. 2011;15:313–318. 15. Sarzo G, Del Mistro A, Mistro A, et al. Extensive anal condylomatosis: prognosis in relation to viral and host factors. Colorectal Dis. 2010;12(7 online):e128–e134. 16. Creasman C, Haas PA, Fox TA Jr, Balazs M. Malignant transformation of anorectal giant condyloma acuminatum (BuschkeLoewenstein tumor). Dis Colon Rectum. 1989;32:481–487. 17. de la Fuente SG, Ludwig KA, Mantyh CR. Preoperative immune status determines anal condyloma recurrence after surgical excision. Dis Colon Rectum. 2003;46:367–373. 18. De Toma G, Cavallaro G, Bitonti A, Polistena A, Onesti MG, Scuderi N. Surgical management of perianal giant condyloma acuminatum (Buschke-Löwenstein tumor): report of three cases. Eur Surg Res. 2006;38:418–422. 19. Uribe N, Millan M, Flores J, Asencio F, Díaz F, Del Castillo JR. Excision and V-Y plasty reconstruction for giant condyloma acuminatum. Tech Coloproctol. 2004;8:99–101. 20. Klaristenfeld D, Israelit S, Beart RW, Ault G, Kaiser AM. Surgical excision of extensive anal condylomata not associated with risk of anal stenosis. Int J Colorectal Dis. 2008;23:853–856.
Circumferential Anal Giant Condyloma Acuminatum: A New Surgical Approach Angelo Guttadauro, M.D. • Marco Chiarelli, M.D. • Daniele Macchini, M.D. Silvia Frassani, M.D. • Matteo Maternini, M.D. • Aimone Bertolini, M.D. Francesco Gabrielli, M.D. Istituti Clinici Zucchi, Università degli Studi Milano-Bicocca, Milan, Italy
INTRODUCTION: Perianal giant condyloma acuminatum is a rare clinical condition related to human papillomavirus infection and characterized by a circumferential, exophytic, cauliflower-like mass with an irregular warty surface localized in the anal region. TECHNIQUE: A circular incision with a diathermocoagulator was performed on macroscopically healthy skin, 1 cm from the margin of the lesion. The dermis was divided from the subcutaneous tissue. This way, a mucocutaneous cylinder including the whole lesion was obtained. A median radial incision was carried out to open the cylinder at its front. A progressive circumferential section on healthy mucosa (≈1 cm above the margin of the lesion) by means of a radiofrequency dissector allowed for the complete removal of the mass. The healthy mucosa of the anal canal was pulled out by Allis forceps and was sutured to the external margin of the internal sphincter with single layer of Vicryl (polyglactin 910) 2-0 sutures. RESULTS: Two months after surgery, no findings of anal stenosis or mucosal ectropion were reported. At the 1-year follow-up there was no recurrence of condylomatosis in any of the 3 cases. CONCLUSIONS: Our procedure seems simpler to perform when compared with other techniques and reduces hospital stay and complications such as anal stenosis and mucosal ectropion. KEY WORDS: Buschke-Löwenstein tumor; Circular incision; Giant condyloma acuminatum.
T
he incidence of anogenital warts has increased in the past decades and is, to date, the most common sexually transmitted disease in Western countries.1 Condylomata acuminata are correlated with low-risk human papillomavirus (HPV) type 6 and 11 infection, whereas high-risk HPV type 16 is frequently present in anogenital malignant lesions.2–4 Perianal giant condyloma acuminatum (GCA) is a rare clinical condition related to HPV infection and characterized by a circumferential, exophytic, cauliflower-like mass with an irregular warty surface localized in the anal region. This clinical condition was first described in 1925 by Buschke and Löwenstein as a lesion of the penis. In 1963, Knoblich and Failing5 reported a case of GCA localized in the anal region. Some authors consider the Buschke-Löwenstein tumor as a clinical manifestation of the verrucous carcinoma,4 but the majority of authors prefer to classify it as an extensive form of condyloma acuminatum with a high potential for malignant transformation.2,6 Currently, Buschke-Löwenstein tumor is synonymous with GCA. GCA is not a malignant lesion by histologic criteria but often shows a propensity to compress or infiltrate adjacent tissues and harbor tumor foci.6 An attractive hypothesis suggests that, on the analysis of their clinical and histopathologic characteristics, condylomata acuminata, GCA (the Buschke-Löwenstein tumor), and verrucous squamous carcinoma may represent a continuous precancerous spectrum.7 As of now, the treatment of choice for the GCA is local excision.6,8 Three patients were reported as successfully treated with a new surgical approach.
PATIENTS AND METHODS Financial Disclosure: None reported. Correspondence: Matteo Maternini, M.D., Istituti Clinici Zucchi, Università degli Studi Milano-Bicocca, Milan, Italy. E-mail: [email protected] Dis Colon Rectum 2015; 58: e49–e52 DOI: 10.1097/DCR.0000000000000339 © The ASCRS 2015 Diseases of the Colon & Rectum Volume 58: 4 (2015)
The patients we treated showed a cauliflower lesion defined by a grape-like conglomerate merging into cribrous areas. The lesion has a hard, rubbery consistency and is free from adhesions with the underlying planes. All of the above are consistent with a giant condyloma. A previous outpatient anoscopy was performed to rule out anal canal and rectal condylomatosis above the dentate line. e49
e50
Guttadauro et al: A More Simple Approach to GCA
Figure 1. A circular incision with diathermocoagulator is performed on macroscopically healthy skin, 1 cm from the lesion margin.
The bowel preparation consisted of 2 enemas 1 day before surgery. Informed consent was obtained for surgical treatment and handling of personal data. The operation was performed under spinal anaesthesia; intravenous metronidazole and ceftriaxone were given prophylactically. The patient was placed in the high lithotomy position. A circular incision with a diathermocoagulator was performed on macroscopically healthy skin, 1 cm from the margin of the lesion (Fig. 1). The dermis was divided from the subcutaneous tissue. A gentle submucosal dissection was then performed in the anal canal as far as healthy mucosa was encountered, taking care to preserve the internal sphincter. In this way, a mucocutaneous cylinder including the whole lesion was obtained. A median radial incision was carried out to open the cylinder at its front. A progressive circumferential section on healthy mucosa (≈1 cm above the margin of the lesion) by means of a radiofrequency dissector allowed for the complete removal of the mass (Fig. 2A). In our experience, using a radiofrequency apparatus yields better results in terms of hemostasis and faster healing of surgical wounds with less lateral heat diffusion. The healthy mucosa of the anal canal was pulled out by Allis forceps and was sutured to the external margin
of the internal sphincter with single layer of Vicryl (polyglactin 910) 2-0 sutures (Fig. 2B). The remaining perianal wound was left to second intention healing. Patients were discharged on the second postoperative day, with a recommendation for oral pain medication (ketorolac, 10 mg twice a day for 4 days), oral laxatives (lactulose, 2 teaspoons per day), a fiber-rich diet, and daily sitz baths with diluted chloramines. The patients underwent weekly outpatient examinations for 6 weeks. Home dilation was prescribed twice per week for 6 weeks, 15 days after surgery. Follow-up was scheduled at 2 months and at 1 year after the surgery.
RESULTS Histology confirmed each patient as having diffuse anoperineal condylomatosis without malignant degeneration. The early postoperative period was uneventful in all 3 patients: no bleeding, wound infection, or anal incontinence was reported (Fig. 3A). Hospital stay was 2 days for all 3 patients. Complete healing occurred in 40 days. Two months from surgery, no findings of anal stenosis or mucosal ectropion were
Figure 2. A, A progressive circumferential section on healthy mucosa (≈1 cm above the lesion margin) by means of a radiofrequency dissector allows the complete removal of the mass. B, The anal canal healthy mucosa is pulled out by Ellis forceps and is sutured to the external margin of the internal sphincter with single layer of Vicryl 2-0 sutures.
e51
Diseases of the Colon & Rectum Volume 58: 4 (2015)
Figure 3. A, The early postoperative course was regular in all 3 patients: no bleeding, wound infection, or anal incontinence was found. B, After 2 months, no cases of anal stenosis or mucosal ectropion were registered.
reported (Fig. 3B). At the 1-year follow-up, there was no recurrence of condylomatosis in any patient.
DISCUSSION Sexual intercourse is the primary route of diffusion for interpersonal transmission of anogenital condylomatosis.9 A high prevalence of anal warts is found in men who have sex with men, particularly in HIV-positive patients.10 In these patients, condylomata occur with larger size, grow more rapidly, and show a higher incidence of recurrence and dysplasia compared with that of the general population.11 Patients affected by GCA present longstanding symptoms: the particular method of transmission and the localization of the lesions often induce them to undergo a physical examination very late in the course of the disease. Currently the correlation between perianal GCA and risks factors for anal condylomatosis (HIV infection and homosexual orientation) is not clearly defined because of the paucity of data found in literature. In our series, no patient turned out to be HIV positive, and only 1 admitted to have anal receptive intercourse. Medical treatment of anogenital warts is characterized by a recurrence rate of 20% to 30%, whereas surgical treatment has clearance rates close to 100%.12 The therapeutic indication depends on the size of condylomata: small lesions can be successfully treated with local chemical agents, whereas extensive lesions require surgery.12,13 Medical treatment includes topical compounds containing podophyllotoxin and imiquimod.12 Electrocoagulation with a diathermocoagulator or liquid nitrogen cryotherapy may be used in case of localized anal warts.13 GCA localized in the anorectal region is typically a large perianal circumferential mass characterized by potential malignant transformation and high recurrence rates.6,8 A wide surgical excision with 1-cm macroscopically negative margins is presently considered the most appropriate treatment for this type of lesion.14,15
The incidence of malignant transformation of GCA is very high and varies from 30% to 56%.6,16 Consequently, radical surgical excision that allows complete histologic examination is mandatory for these patients: any additional therapies will be scheduled in relation to the presence of tumor, infiltration of surrounding tissues, or involvement of resection margins. GCAs are associated with a very high recurrence rate that can reach 65%6,16; excisional surgery with 1-cm disease-free margins seems to guarantee the lowest rate of recurrence.13,14 Furthermore, patient immune status seems to play a decisive role: in HIV-positive patients, the incidence of recurrent condylomata after surgery is significantly higher than in the HIV-negative population.17 In our series, the absence of recurrence at 1 year in all of the patients may be related to both radical surgery and complete patient immunocompetence. A large anodermal resection exposes the patients to a risk of postoperative stenosis, and many authors suggest different types of plastic reconstructive surgery to cover the skin defect and to prevent second-intention healing.13,18 The kind of reconstruction after excision is debated. Different techniques have been proposed, including mesh-skin grafts, Whitehead technique, rotational S-flaps, advancement flaps, and V-Y flaps.13,14,18,19 Nevertheless, this kind of surgery is characterized by a prolonged hospital stay and not negligible rates of complication, including hematoma, wound infection, and suture dehiscence.20 The absence of warts above the dentate line is a requirement to perform our technique. The fixing of the anal mucosa to the internal sphincter aims to place the dentate line in its natural position, avoiding its upward displacement with a consequent high risk of complications. A mucocutaneous suture, which is not easy to perform after a wide perianal excision, is avoided to prevent mucosal ectropion. Although anal stricture after surgery for diffuse condylomatosis seems to be uncommon,20 the choice of leav-
e52
ing the perianal wound to second-intention healing could lead to postoperative stenosis. To minimize this complication we recommend regular evacuations and home dilations twice a week; indeed, frequent postoperative examinations are needed. According to our initial experience, the proposed surgical approach seems to combine technical simplicity, rapid discharge, and low complication rates.
CONCLUSION Surgical circumferential excision by radiofrequency dissector followed by suture of the anal mucosa to the inferior margin of the internal sphincter might be a valid therapy for GCA. In our experience, although it is limited because of the rarity of such lesions, we had no findings of stenosis or recurrence. Our procedure seems simpler to perform and reduces hospital stay and complications. Therefore, we think it is a valid option for treating these patients. A larger number of patients is desirable to confirm our results in the future. REFERENCES 1. Patel H, Wagner M, Singhal P, Kothari S. Systematic review of the incidence and prevalence of genital warts. BMC Infect Dis. 2013;13:39. 2. Gormley RH, Kovarik CL. Dermatologic manifestations of HPV in HIV-infected individuals. Curr HIV/AIDS Rep. 2009;6:130–138. 3. Tachezy R, Jirasek T, Salakova M, et al. Human papillomavirus infection and tumours of the anal canal: correlation of histology, PCR detection in paraffin sections and serology. APMIS. 2007;115:195–203. 4. Nebesio CL, Mirowski GW, Chuang TY. Human papillomavirus: clinical significance and malignant potential. Int J Dermatol. 2001;40:373–379. 5. Knoblich R, Failing JF Jr. Giant condyloma acuminatum (Buschke-Löwenstein tumor) of the rectum. Am J Clin Pathol. 1967;48:389–395. 6. Chu QD, Vezeridis MP, Libbey NP, Wanebo HJ. Giant condyloma acuminatum (Buschke-Lowenstein tumor) of the anorectal and perianal regions: analysis of 42 cases. Dis Colon Rectum. 1994;37:950–957.
Guttadauro et al: A More Simple Approach to GCA
7. Bogomoletz WV, Potet F, Molas G. Condylomata acuminata, giant condyloma acuminatum (Buschke-Loewenstein tumour) and verrucous squamous carcinoma of the perianal and anorectal region: a continuous precancerous spectrum? Histopathology. 1985;9:1155–1169. 8. Trombetta LJ, Place RJ. Giant condyloma acuminatum of the anorectum: trends in epidemiology and management–report of a case and review of the literature. Dis Colon Rectum. 2001;44:1878–1886. 9. Burchell AN, Winer RL, de Sanjosé S, Franco EL. Chapter 6: epidemiology and transmission dynamics of genital HPV infection. Vaccine. 2006;24(suppl 3):52–61. 10. Palefsky JM, Holly EA, Ralston ML, Jay N. Prevalence and risk factors for human papillomavirus infection of the anal canal in human immunodeficiency virus (HIV)-positive and HIVnegative homosexual men. J Infect Dis. 1998;177:361–367. 11. Manzione CR, Nadal SR, Calore EE. Postoperative follow-up of anal condylomata acuminata in HIV-positive patients. Dis Colon Rectum. 2003;46:1358–1365. 12. Lacey CJ, Woodhall SC, Wikstrom A, Ross J. 2012 European guideline for the management of anogenital warts. J Eur Acad Dermatol Venereol. 2013;27:e263–e270. 13. Tripoli M, Cordova A, Maggì F, Moschella F. Giant condylomata (Buschke-Löwenstein tumours): our case load in surgical treatment and review of the current therapies. Eur Rev Med Pharmacol Sci. 2012;16:747–751. 14. Abbas MA. Wide local excision for Buschke-Löwenstein tumor or circumferential carcinoma in situ. Tech Coloproctol. 2011;15:313–318. 15. Sarzo G, Del Mistro A, Mistro A, et al. Extensive anal condylomatosis: prognosis in relation to viral and host factors. Colorectal Dis. 2010;12(7 online):e128–e134. 16. Creasman C, Haas PA, Fox TA Jr, Balazs M. Malignant transformation of anorectal giant condyloma acuminatum (BuschkeLoewenstein tumor). Dis Colon Rectum. 1989;32:481–487. 17. de la Fuente SG, Ludwig KA, Mantyh CR. Preoperative immune status determines anal condyloma recurrence after surgical excision. Dis Colon Rectum. 2003;46:367–373. 18. De Toma G, Cavallaro G, Bitonti A, Polistena A, Onesti MG, Scuderi N. Surgical management of perianal giant condyloma acuminatum (Buschke-Löwenstein tumor): report of three cases. Eur Surg Res. 2006;38:418–422. 19. Uribe N, Millan M, Flores J, Asencio F, Díaz F, Del Castillo JR. Excision and V-Y plasty reconstruction for giant condyloma acuminatum. Tech Coloproctol. 2004;8:99–101. 20. Klaristenfeld D, Israelit S, Beart RW, Ault G, Kaiser AM. Surgical excision of extensive anal condylomata not associated with risk of anal stenosis. Int J Colorectal Dis. 2008;23:853–856.
