Löwenstein-Buschke: Clinicopathologic Analysis of 78 Cases of Large and Giant Condyloma Acuminata of the Anus

Abstract

Objective: The nature and clinicopathologic associations of Löwenstein-Buschke disease are unclear.

Materials and methods: 78 anal condylomatous lesions (≥2 cm) were analyzed. Cases were classified based on size as "medium-large"(2-5 cm, n=59), "large" (5-10 cm, n=13) and "giant" ( > 10 cm, n=6).

Results: Patients were predominantly males (male/female=70/8). The mean age was 38 years (range:20-66). Two distinct lining types were recognized: 1) Epidermal type, typically lacking overt koilocytotic change, with associated invasive carcinoma in 8%; 2) Mucosal type, often manifesting koilocytotic change, with associated invasive carcinoma in 21%. Three types of high-grade dysplasia were discerned: 1) Basaloid, 8/9 showing high-grade dysplasia/carcinoma in-situ but non-invasive lesions; 2) Keratinizing, innocuous-appearing, but 5/6 was associated with invasion; 3) Giant cell, showing scattered individual bizarre cells, with 3/5 showing invasive carcinoma. Overall, invasion was found in 14% of the cases. The bulbous, broad-based destructive pattern characterizing verrucous carcinomas of the upper aerodigestive tract was not observed. A statistically significant trend existed between the incidence of invasion and size: 8.5% for medium-large, 23% for large, and 50% for giant (p=0.02). There was no discernable trend in the depth of invasion relative to condyloma size.

Conclusions: Our findings suggest that Löwenstein-Buschke lesions are mega versions of conventional condyloma. Being verrucoid, large and minimally invasive, they can be conceptually regarded as a form of verrucous carcinoma, but they do not display the histologic characteristics of verrucous carcinoma defined in the aerodigestive tract. They exhibit two types of linings: the mucosal type that often shows koilocytotic changes, and the epidermal type that can be difficult to recognize in biopsies. These lesions may be associated with invasive carcinoma, albeit limited in amount.

Figure 1

The endoscopic examination of anal condyloma reveals a polypoid, cauliflower-shaped lesion.

Figure 2

The two distinct subsets of condyloma: A) Epidermal, harboring a distinct granular layer, stratum corneum, and decreased glycogen in the cells. If observed in isolation at high-power, this type could be indistinguishable from normal epidermis (H&E; x200). B) Mucosal, with an inconspicuous stratum corneum and prominent koilocytic changes (H&E; x200).

Figure 3

A-B) Basaloid type of dysplasia, showing expansion of basal or parabasal-like cells towards the upper layers of the mucosa with readily identifiable mitoses. (H&E; x40&200). C) Giant-cell type dysplasia, characterized by large pleomorphic nuclei (H&E; x400). D) Dyskeratotic dysplasia, characterized by keratinizing nests (H&E; x40).

Figure 4

A) Condyloma acuminata with focal microinvasion (H&E; x200). B) Condyloma acuminata with high-grade dysplasia and focal microinvasion highlighted by a cuff of chronic inflammation (H&E; x200). C-D) Condyloma acuminata with invasive squamous cell carcinoma [...] arising in keratinizing type of dysplasia (H&E; x100 & x200).