Surgical excision for giant condyloma acuminatum (Buschke–Löwenstein tumor): A case report

Abstract

Giant condyloma acuminatum (Buschke–Löwenstein tumor; BLT) is a rare HPV-associated disease characterized by progressive proliferation, high recurrence rates (60–70%), and potential for malignant transformation to squamous cell carcinoma. Although histologically benign, aggressive local behavior and involvement of functionally critical anatomical structures present substantial therapeutic challenges. This report describes the successful function-preserving surgical management of extensive treatment-refractory BLT. A 69-year-old woman with a history of malignant lymphoma and diabetes mellitus developed vulvar condyloma that was resistant to sequential imiquimod therapy, cryotherapy, and laser ablation. The lesion progressively enlarged to 15 × 9.5 × 2.5 cm, encompassing the entire vulva and perianal area. Clinical examination and imaging confirmed the absence of urethral and rectal mucosal invasion. Preoperative imiquimod was administered to the urethral meatus, vaginal introitus, and perianal area for 4 weeks to control microscopic disease at functionally critical sites. Surgical resection prioritized function preservation: ≥1 cm margin at the periphery, while mucosal boundaries were approached closely at critical sites. Residual rough mucosal areas underwent bipolar cauterization. Primary closure was achieved without the need for flap reconstruction. Mild postoperative wound dehiscence without infection resolved with conservative management, permitting secondary healing. Five months postoperatively, complete epithelialization was achieved with no recurrence, preserved urinary and bowel function, and the absence of vaginal symptoms. This case demonstrates that combining preoperative imiquimod, function-prioritizing surgical margins, local ablation, and tolerance of secondary healing can achieve oncologic control while maintaining quality of life in extensive BLT. Long-term surveillance remains essential.

Highlights

• •Giant condyloma acuminatum (Buschke–Löwenstein tumor; BLT), though benign, risks recurrence and malignant transformation.
• •Massive BLT extending to the urethral meatus, vaginal introitus, and perianal area resisted multiple conservative treatments.
• •Multidisciplinary treatment with neoadjuvant topical imiquimod and function-prioritized conservative surgery was effective.
• •Tolerating secondary intention healing for wound dehiscence achieved good epithelialization without functional impairment.
• •Individualized BLT strategies with preoperative drug therapy balance functional preservation and oncological control.

1. Introduction

Condyloma acuminatum is a verrucous lesion caused by low-risk human papillomavirus (HPV) types 6 and 11 [1]. While most cases remain localized and amenable to conservative management, rare progressive cases develop into giant lesions that extend across the vulvar, perineal, and perianal regions. The giant condylomas present substantial clinical challenges owing to their size, anatomical location, and biological behavior [2]. Although histologically benign, these lesions demonstrate aggressive local growth with recurrence rates of 60–70% and carry the risk of malignant transformation to squamous cell carcinoma [3]. The subset exhibiting locally destructive characteristics was first described by Buschke and Löwenstein in 1925 and termed Buschke–Löwenstein tumor (BLT) [4].

Wide surgical excision with adequate margins remains the first-line treatment for giant condyloma [5], [6]. However, lesions involving the urethral meatus, vaginal wall, or anal canal present substantial therapeutic dilemmas: achieving adequate surgical margins risks considerable functional compromise, including potential urinary or fecal diversion [7], [8]. Reports specifically addressing conservative surgical approaches combined with local ablative techniques and their short-term outcomes remain limited, particularly regarding female patients.

This report presents an extensive vulvar BLT development after malignant lymphoma treatment in a patient with diabetes who was refractory to multiple therapies. Through a multidisciplinary approach incorporating preoperative imiquimod therapy, function-preserving resection margins, local ablation, and secondary healing acceptance, favorable short-term outcomes were achieved.

2. Case Presentation

A 69-year-old woman (gravida 2, para 2, menopausal age 52 years) with a history of malignant lymphoma (chemotherapy completed at age 66 years 11 months, currently in remission) and diabetes mellitus developed vulvar pruritus and discomfort at age 67 years 5 months following new HPV exposure. A biopsy confirmed condyloma acuminatum. She had not received HPV vaccination. Despite treatments with topical imiquimod (Beselna®), liquid nitrogen therapy, and CO₂ laser therapy, the treatment-refractory lesion enlarged. By the age of 69, extensive involvement of the labia minora, labia majora, clitoris, and perianal area prompted referral.

Examination revealed a body mass index of 15.8 with normal nutritional parameters (serum protein 6.9 g/dL, albumin 4.5 g/dL). A papillary tumor measuring 15 × 9.5 × 2.5 cm was observed, extending throughout the vulva to the perianal area (Fig. 1A). MRI showed no deep invasion. Cystoscopy revealed a papillary tumor near the external urethral meatus without bladder involvement, and urine cytology revealed koilocytes, suggesting an HPV infection. Colorectal examination confirmed the absence of invasion beyond the dentate line. Additionally, a gynecological examination revealed no vaginal wall invasion, and cervical cytology revealed NILM.

Fig. 1.

Clinical and pathological findings of giant condyloma acuminatum (Buschke–Löwenstein tumor).

A: Gross clinical appearance of a giant verrucous mass with papillary proliferation extending from the vulva to the perianal region. The lesion occupied the entire vulvar area and demonstrated a cauliflower-like nodular proliferation.

B: Internal gross view of the tumor. Red arrow: external urethral meatus; blue arrow: vaginal introitus.

Pathological Findings.

C: Macroscopic view of the resected specimen showing a large exophytic cauliflower-like tumor. The cross-sectional view shows a verrucous proliferation without invasion of the deep stroma.

D: Low-power histological view showing prominent papillary proliferation with epidermal thickening (acanthosis) and hyperkeratosis.

E: High-power histological view of koilocytosis. In situ hybridization using the RNAscope™ method detected positive signals for low-risk HPV (red). Numerous positive signals were observed within epithelial cell nuclei, suggesting active viral replication.

Clinical and pathological findings confirmed the diagnosis of Buschke–Löwenstein tumor. Given the resistance to treatment and progressive enlargement, surgical excision was performed. As the lesion spared the urethra and rectum with preservation of the urethral meatus and anus deemed feasible, preoperative imiquimod cream was applied to the external urethral meatus, vaginal introitus, and perianal canal for four weeks to control microscopic disease at functionally critical sites (Fig. 1B). Objective tumor reduction assessment proved difficult, given the massive size of the tumor.

Resection margins incorporated ≥1 cm peripherally, prioritizing function preservation medially to spare the external urethral meatus, vaginal wall, and anus. Near the urethral meatus and vaginal introitus, the resection was extended to the mucosal boundary to maintain function (Fig. 1C). The initially planned bilateral gracilis flap reconstruction proved unnecessary as skin advancement permitted primary closure. During closure, the perineal body was reinforced with the vaginal introital and anal-side mucosa sutured vertically to prevent stenotic scar contractures.

Post-resection, the rough mucosal surfaces around the vaginal introitus and urethral meatus were subjected to bipolar cauterization to address potential microscopic residual disease. Microscopic tumor positivity at the medial margins was anticipated, given the function-preservation priority. Intraoperative blood loss totaled 750 mL, with hemoglobin declining from a preoperative value of 9.3 g/dL to 6.0 g/dL intraoperatively, necessitating transfusion of four units of packed red blood cells.

Histologically, the stratified squamous epithelium showed outward papillary proliferation with superficial koilocytosis (Fig. 1D). RNAscope™ in situ hybridization confirmed low-risk HPV positivity. The absence of significant cellular atypia or invasive proliferation established the final diagnosis of giant condyloma acuminatum (Buschke–Löwenstein tumor) (Fig. 1E).

Postoperatively, the mild wound dehiscence without infection responded to conservative management with favorable granulation. Postoperative topical imiquimod was omitted because of the dehiscence. The patient was discharged on postoperative day 30. Nearly complete epithelialization was achieved at two months (Fig. 2). No local recurrence was confirmed at five-month follow-up. No urethral stenosis or voiding dysfunction occurred, and anal function was preserved without stenosis. No symptoms of vaginitis or dryness due to labial loss were observed.

Fig. 2.

Postoperative wound healing.

POD 0 (Postoperative Day 0): The perineal body between the vagina and anus was sutured with circumferential sutures placed around the vagina and anus to prevent stenosis.

POD 2: Mild wound dehiscence without signs of infection or early granulation tissue formation was observed.

POD 13: Granulation tissue formation progressed with a decrease in exudate. Wound dehiscence was observed between the vagina and anus.

1 Month: Wound contraction advances with progressive epithelialization.

2 Months: Wound healing further progresses with nearly complete epithelialization achieved.

3 Months: Stable scar formation.

3. Discussion

This case exemplifies the effective multidisciplinary management of extensive treatment-refractory vulvar BLT using a comprehensive approach combining preoperative imiquimod therapy, function-prioritizing surgical resection, local ablation techniques, and acceptance of secondary healing. Five months postoperatively, the patient remained recurrence-free with preserved organ function and an excellent quality of life.

BLT typically emerges in immunocompromised states and exhibits aggressive local behavior with high recurrence rates and an inherent risk of malignant transformation. A focused narrative review of female BLT surgical treatments reported between 2014 and 2024 was conducted. Among the 10 surgically managed cases identified, the mean patient age at onset was relatively young at 30.3 years, with substantial proportions demonstrating immunocompromised backgrounds including HIV infection, autoimmune disease states, pregnancy-associated immunomodulation, or diabetes mellitus (Table 1) [[3], [7], [9], [10], [11], [12], [13]]. The patient's malignant lymphoma was in documented complete remission at the time of BLT diagnosis, suggesting that concurrent diabetes mellitus and late-age HPV exposure likely contributed significantly to tumor development. In HIV-infected populations, BLT demonstrates a notably rapid progression to invasive squamous cell carcinoma, with disease severity correlating directly with CD4-positive T-lymphocyte counts [1]; however, this pattern was not applicable to the present case.

Table 1.

Review of surgical interventions for Buschke–Löwenstein tumor (BLT) in female patients.

Year	Author	Age	Patient Characteristics	Tumor Localization and size	Surgical Technique and Reconstruction	Outcome and Follow-up
2014	Atkinson et al. [9] Patient A	29	HIV positive (CD4 250 cells/μL), Sepsis	Bilateral labia majora and mons pubis; 1875 g	Radical excision; Primary closure (interrupted sutures)	No complications. No recurrence at 6 months.
2014	Atkinson et al. [9] Patient B	24	HIV positive (CD4 190 cells/μL)	Right vulva and mons pubis 2010 g.	Surgical excision; Primary closure (interrupted sutures)	Dehiscence (3 cm, re-sutured); No significant recurrence at 6 months (minor perianal warts excised).
2016	Petrini et al. [3]	16	History of drug and alcohol abuse	Vulvo-perianal; Length 15 cm, Thickness 7 cm.	Wide local excision with radiofrequency; Secondary intention healing	No complications. No recurrence at 12 months.
2016	Rachman & Hasan [10]	42	SLE (immunosuppressed)	Vulva and anus; Size NR	Surgical excision	No complications. Cervical recurrence at 1 month
2019	Gungor Ugurlucan et al. [11] Case 1	22	Type 1 Diabetes Mellitus, Smoker	Mons pubis to anal mucosa; Size NR	Partial skinning vulvectomy. Primary closure (single mattress sutures)	Dehiscence (conservative management); No recurrence at 1 year.
2019	Gungor Ugurlucan et al. [11] Case 2	20	Sexually active	Lower perineum to intergluteal cleft; Size NR	Sharp surgical excision; drain placement in gluteal incisions	No complications. No recurrence at 1 year.
2019	Cui et al. [12]	17	Pregnant (34 weeks)	Perineal and perianal; 5 cm × 3.8 cm, 13 cm × 6 cm	En bloc excision using an electric scalpel (performed 2 weeks post-Cesarean section). Primary closure	HPV-11 confirmed; Long-term outcome NR
2022	Boda et al. [13] Case 6	34	HIV positive for 23 years (CD4 750 cells/mm3), Smoker	Vulva, suprapubic area, and buttocks; Giant mass, Size NR	Pelvectomy with nephrostomy; localized radiotherapy	Malignant transformation to poorly differentiated SCC (T4N2MxV0L1); HPV 6, 11, 16, 18, 39, and 53 positive. Long-term outcome NR
2022	Boda et al. [13] Case 7	75	NR	Vulvar area; Size NR	Radiosurgical excision followed by pelvectomy with nephrostomy and radiotherapy	Malignant transformation to moderately differentiated SCC; HPV 6, 16, and 18 positive. Long-term outcome NR
2024	Ajagbe et al. [7] Case 3	24	Mild intellectual disability	Labia, introitus, extending to anal region; Size NR	Surgical excision; Secondary intention healing	No complications. (No specific recurrence reported in follow-up period). No recurrence was observed at 8 months.
2025	Present case	69	History of Malignant Lymphoma (post-chemotherapy status), Diabetes Mellitus.	Vulvo-perianal (involving clitoris/urethra) 15 × 9.5 × 2.5 cm	Wide local excision (1 cm margin); Primary closure (simple interrupted sutures)	Intraoperative hemorrhage (750 mL), Dehiscence (conservative management); No recurrence at 5 months

Abbreviations: SLE: Systemic Lupus Erythematosus; NR: Not Reported; HIV: Human Immunodeficiency Virus; DM: Diabetes Mellitus; HPV: Human Papillomavirus; CS: Cesarean Section; Ant: Anterior; Post: Posterior; SCC: Squamous Cell Carcinoma.

Histopathologically, BLT characteristically demonstrates papillary proliferation of well-differentiated stratified squamous epithelium, prominent superficial koilocytosis indicating HPV cytopathic effect, marked acanthosis with a thickened spinous layer, and frequently exhibits a pushing pattern of deep tissue invasion rather than infiltrative growth [14]. The present case predominantly showed extensive superficial tumor extension without obvious deep pushing invasion, though RNAscope™ molecular analysis confirmed robust active replication of low-risk HPV, supporting characteristic BLT molecular pathology. The molecular mechanism involves HPV E6 and E7 viral oncoproteins, which cause p53 tumor suppressor dysfunction and drive abnormal epithelial cell proliferation [14].

Surgical excision with adequate margins remains the first-line treatment for BLT [15]. When conservative therapeutic approaches prove ineffective, as in this case, timely surgical intervention becomes imperative to prevent progressive anatomical disruption and to mitigate the risk of malignant transformation [7]. Standard oncologic principles recommend achieving surgical margins of ≥1 cm to minimize recurrence risk [16], yet achieving such margins near the vulva, urethral meatus, vaginal introitus, and anal canal directly conflicts with functional preservation. Preoperative imiquimod therapy was introduced with concentrated application to the mucosal boundary regions, targeting macroscopically undetectable microscopic disease extensions. Although massive tumor dimensions precluded reliable objective assessment of tumor reduction, the intraoperative approach of resecting the mucosal boundaries followed by bipolar electrocoagulation provided multimodal addressing of potential microscopic residual disease. The documented absence of disease recurrence at five months provides encouraging preliminary evidence, although a longer follow-up is necessary. The indication for colostomy exists when the tumor invades the anal sphincter complex or mucosa proximal to the dentate line [7], [17]. Successful avoidance of colostomy greatly benefits quality of life.

The reconstruction strategy considerations included high BLT recurrence rates and a probable microscopic positive margin status, favoring simple primary closure over complex flap reconstruction. The vulvar perianal region represents a contaminated surgical field with an elevated risk of wound dehiscence, particularly under tension closure. The patient developed postoperative wound dehiscence without infectious complications and achieved excellent epithelialization through managed secondary intention healing. Secondary healing management in immunosuppressed populations, when not accompanied by an infection, is a reasonable, effective, and safe option. An additional theoretical consideration involves HPV biology. Viral proliferation requires intact normal stratified squamous epithelium as a cellular substrate, suggesting that fibrous scar tissue formed during secondary healing may function as a structural barrier that mechanically suppresses subsequent HPV re-proliferation [5].

However, the limitations of this study warrant further investigation. Despite BLT representing a disease characterized by high long-term recurrence rates, the 5-month postoperative follow-up proved inadequate for a comprehensive recurrence risk evaluation. Additionally, an objective assessment of preoperative imiquimod therapy tumor reduction was precluded by the massive, irregular lesion configuration. Rigorous long-term surveillance, including the systematic evaluation of HPV-related lesions at other sites, remains essential.

For extensive conservative treatment-refractory BLT, multidisciplinary therapeutic approaches combining preoperative imiquimod therapy, function-prioritizing surgical resection, local ablative techniques, and the acceptance of secondary healing can achieve curative resection while maintaining organ function and the patient's quality of life. Female BLT frequently occurs in immunocompromised patients, necessitating individualized treatment planning and flexible adaptive management strategies.

Contributors

Akari Hirakawa, Sayuri Miyoshi and Ryusuke Murakami contributed to patient care, conception of the case report, acquiring and interpreting the data, undertaking the literature review and drafting the manuscript.

Itaru Tsuge contributed to patient care and revising the article critically for important intellectual content.

Ryota Nakagawa and Masahito Hoki contributed to patient care and drafting the manuscript.

Yukiko Okada, Yosuke Kawamura, Takuto Shimamura, Takuma Oosuga, Taito Miyamoto, Rin Mizuno, Masumi Sunada, Mana Taki and Koji Yamanoi contributed to acquiring and interpreting the data, drafting the manuscript and revising the article critically for important intellectual content.

Masaki Mandai contributed to revising the article critically for important intellectual content.

All authors approved the final submitted manuscript.

Patient consent

Written informed consent was obtained from the patient for publication of the case report and accompanying images.

Provenance and peer review

This article was not commissioned and was peer reviewed.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work the authors used Claude (Anthropic) and Editage AI in order to assist with language editing. After using these tools, the authors reviewed and edited the output as needed and take full responsibility for the content of the published article.

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or non-profit sectors.

Declaration of competing interest

The authors declare that they have no competing interest regarding the publication of this case report.