Penis and scrotum - Condyloma acuminatum

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Penis and scrotum

Benign Tumors

Condyloma acuminatum

Editor: Antonio Cubilla, M.D. and Alcides Chaux, M.D. (See Reviewers page)

Revised: 23 February 2010, last major update - February 2010

Definition

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● Contagious HPV-related lesion with a clearly predilection for anogenital area

Terminology

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● Also known as genital wart

Epidemiology

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● Transmitted through skin to skin contact during oral, genital or anal sex

● Most commonly affects young males in teens and 20’s

● HPV is the most common sexually transmitted disease in US, but many HPV infections don’t lead to condyloma (NIAID Fact Sheet)

Sites

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● Most common sites (in decreasing frequency) are glans, foreskin, meatus and shaft

● Often near coronal sulcus and inner surface of foreskin

Etiology

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● Most frequently caused by HPV genotypes 6 and 11

● Other genotypes have been identified as well (16, 18, 30-32, 42-44 and 51-55)

● Related to verruca vulgaris (common wart)

Clinical features

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● Benign

● Small lesions detected with topic acetic acid

● Malignant transformation is a very rare event

Case reports

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● 46 year old HIV+ man with condyloma overgrowth caused by immune reconstitution inflammatory syndrome (Urology 2009;74:1013)

Treatment

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● Medical treatment includes imiquimod cream, 20% podophyllin antimitotic solution, 0.5% podofilox solution, 5% 5-FU cream and trichloroacetic acid (TCA)

● Also freezing, burning (electrocautery), CO2 laser (Eur J Dermatol 2008;18:153) or surgical excision (if large)

● Recurs but does not evolve into invasive cancer

Clinical images

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Cauliflower like Severe lesion Various images

lesion of foreskin

Large scrotal lesion

Gross description (Macroscopy)

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● Papillary, fungating, wart-like, often multiple lesions, 1 mm or larger

● Must section and examine lesion thoroughly to rule out verrucous carcinoma

Micro description (Histopathology)

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● Arborescent (tree-like, complex) “condylomatous” spiky papillae with prominent central fibrovascular cores

● Surface koilocytosis (koilocytes have hyperplastic epithelium with wrinkled hyperchromatic nuclei, perinuclear halos and frequent bi- and multinucleation)

● Sharply defined base without invasion

● Preservation of orderly maturation of epithelial cells

● T lymphocytes (CD4+) present

● May have reactive atypia but no evidence of invasion

● Variable acanthosis and hyperkeratosis

● Note: koilocytosis is not evident in some cases, but the histological pattern is otherwise characteristic

Micro images

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Low power shows acanthosis Hyperkeratosis and koilocytosis Parakeratosis and koilocytosis

and papillarity (site unknown)

Fig A: This early lesion has epithelial hyperplasia and is suggestive of fibroepithelial polyp or seborrheic keratosis

Fig B: Koilocytosis with focal perinuclear clearing and irregular nuclear membranes

Fig C: In situ hybridization for HPV 6/11

(site unspecified)

Podophyllin effect on more advanced tumor

Fig A: Verrucous tumor

Fig B: Prominent koilocytosis

Fig C: Areas of apparent atypia and increased mitotic activity

Scrotal lesion-low power

Cytology description

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● Cytopathologic detection of HPV infection in penile samples collected for liquid-based cytology is low (Cancer 2008;114:489)

Molecular / cytogenetics description

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● Lesions with HPV 6 and 11 by in situ hybridization usually have perinuclear halos and nuclear atypia

● Lesions with HPV DNA by PCR only may contain only a focally thickened granular layer associated with epithelial crevices (AJSP 1992;16:269)

Differential Diagnosis

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● Pearly penile plaques: HPV negative, hyperkeratosis but no koilocytosis, no significant inflammation

● Verruciform tumors (verrucous, papillary and warty carcinomas): invasion is evident

Additional references

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● Wikipedia

End of Penis and scrotum > Benign tumors > Condyloma acuminatum

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