The Buschke-Löwenstein tumor (BLT) is a rarity. It was first described in 1925 by Abraham Buschke and Ludwig Löwenstein (both dermatologists). Although being a benign disease, BLT is locally aggressive, and malignant transformation into a squamous cell carcinoma (SCC) is possible. BLT is associated with HPV infection, and its incidence in men is two to three times higher. It presents with a big cauliflower-like mass of the anus, perianal area, or genitalia.
Although benign, the Buschke-Löwenstein Tumor is locally aggressive, and malignant transformation is possible.
Treatment of the BLT can be challenging due to its size, local aggressiveness, and high recurrence rate. The best treatment strategy is still not well defined. However, complete excision with free margins (wide local excision) seems to be the first-line treatment. Chemotherapy, radiotherapy, or combined approaches (neoadjuvant therapy followed by surgery) are also possible. BLT has no lymph node involvement nor metastasis unless there is a malignant transformation into an SCC. BLT usually arises from the perianal skin. However, surgeons must know it can affect both the anal sphincter and the rectum. Because of that possible invasion, in some patients, radical surgery is only possible with abdominoperineal resection.
There are only a few cases reported in worldwide literature, making it difficult to make solid conclusions. That is the reason to report all rare cases. Recently, we published in BMJ Case Reports the case of a patient with a Buschke-Löwenstein Tumor with malignant transformation into an SCC treated with a two-staged surgery and radiotherapy.
A male patient resorted to the General Surgery consultation with Dr. Jaime Vilaça at Hospital da Luz Arrábida (Vila Nova de Gaia, Portugal) because of a 20cm perianal cauliflower-like tumor, with local pain and foul smell. Wide local excision aiming at R0 resection, and a diverting stoma was the first option. However, the presence of anal sphincter invasion precluded a radical resection preserving the rectum. In that setting, an abdominoperineal resection was necessary to obtain an R0 resection. Because pathology diagnosed a malignant transformation into an SCC, adjuvant radiotherapy was delivered. After several months of follow-up, the patient was doing fine.
Which factors make an R0 resection not possible? Which cases should we treat with an abdominoperineal resection? When should neoadjuvant therapy be delivered? How to treat a patient unfit for surgery? What to do in the presence of malignant transformation? For how long should the follow-up be?
BLT treatment is challenging.
We present you with an algorithm for BLT treatment.
After an extensive revision of several case reports and case series, we present the reader and the medical community with a decision algorithm. I believe this new tool will help clinicians offer BLT patients the best treatment strategy. All surgeons should know this algorithm, and should read and learn about this entity.
If it is rare, it exists. So, learn and share knowledge about it. That is the way of learning surgery.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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