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Verrucous carcinoma of the anus

Case contributed by Dr Fahad Dilawez Rathore
Diagnosis certain

Presentation

Perianal mass.

Patient Data

Age: 65 years
Gender: Male

The large cauliflower-shaped superficial component of the mass extends over an area measuring up to 11.3 cm in the perineum, from the perianal region, extending posteriorly within the natal cleft on both sides (more on the left than the right). There is extension through the anal orifice to the anal canal, extending over approximately 2.5 cm.

The disease appears largely confined to the skin and superficial subcutaneous structures. Some stranding is noted through underlying buttock fat on the right side. On the left side, near the postero-superior margin of the mass, there may be some infiltration of disease up to 10 mm into buttock fat, associated with some disorganised vessels.

There is no lymph node enlargement seen on either side of the pelvis. The remaining pelvic structures appear unremarkable.

A subarticular cyst and subchondral sclerosis at the right hip joint noted, consistent with osteoarthritis was the left hip joint remains unremarkable. 

Case Discussion

A rare malignant complication of anorectal genital warts is verrucous carcinoma of the anus, also known as giant condyloma acuminatum or Buschke-Löwenstein tumour (BLT). This is a type of squamous cell carcinoma.

Genital warts are caused by Human Papilloma Virus infection (HPV). HPV is globally the most common Sexually Transmitted Infection (STI) affecting up to 13% of the human population. Although 40 strains of HPV are known to affect the anorectal regions, strains 6 and 11 most commonly cause genital warts. Strains 16 and 18 are high risk for developing malignancy. Surgery is the mainstay for warts which have undergone malignant transformation but have not metastasised. If malignant disease has metastasised palliative systemic chemoradiotherapy can be given. Rates of recurrence are high, especially for those warts which have undergone malignant transformation as getting clear resection margins is difficult 1.

 

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