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PURPOSE: The purpose of this study was to analyze the postoperative follow-up of HIV-positive patients with anal condylomata acuminata, associating recurrence to the AIDS status. METHODS: Ninety-seven male, homosexual patients with anal condylomata were submitted to surgical treatment from August 1992 to December 1997. Specimens were obtained for histologic investigation of Ki-67 cell proliferation marker and for polymerase chain reaction to define the human papillomavirus type. The patients were advised to return weekly during the first month, and monthly up to the sixth month, to evaluate recurrence. Patients with high-grade anal intraepithelial neoplasia remain in follow-up. RESULTS: Histology revealed low-grade anal intraepithelial neoplasia in 81.44 percent of patients and high-grade lesions in 18.56 percent. The results showed that high-grade lesions were not more frequent in late-stage AIDS patients. Ki-67 expression, a cell proliferation marker, was greater in high-grade than in low-grade anal intraepithelial neoplasia, but had no association with AIDS status. Nononcogenic human papillomavirus 6 and 11 were the commonest types. Comparing papillomavirus types and anal intraepithelial grade, we noticed that both oncogenic and nononcogenic types were responsible for high-grade lesions. All patients healed and 51 (52.6 percent) had recurrence up to the sixth month. AIDS status and papillomavirus type were not associated with recurrence. However, high-grade anal intraepithelial neoplasia patients had more recurrence than those with low-grade lesions. Topical treatment failed in 20 patients (41.6 percent), and these were submitted to new surgical treatment. All of them were in the late stage of AIDS. Three who had high-grade lesions in the first operation had low-grade lesions in specimens from the second surgery. The same histologic pattern was observed in 17 patients who had low-grade lesions in warts removed in the first operation. Other patients with high-grade lesions had no recurrence or evolution to invasive carcinoma from five to ten years of follow-up. CONCLUSION: High-grade anal intraepithelial neoplasia and late-stage AIDS are risk factors for recurrence of anal condylomata.

PURPOSE: Human papillomavirus causes anogenital squamous intraepithelial lesions, warts, and cancer. Treatment of squamous intraepithelial lesions to prevent cancer often requires extensive surgery. We tested a human papillomavirus-specific immunotherapy, HspE7, as a potential alternative. METHODS: HspE7 was constructed by fusing heat shock protein Hsp65 from bacille Calmette-Guerin to E7 protein from human papillomavirus-16. Improvement in pathologic diagnosis of patients with persistent high-grade squamous intraepithelial lesions was studied in an open-label trial (HspE7 500 μg monthly ×3). Anogenital warts were not a trial parameter, but a retrospective review of the medical records of the first 22 patients enrolled at one site was undertaken to estimate the quality and frequency of responses of anogenital warts. Patients with warts by physical examination at baseline were scored at 24 weeks as to the percent reduction in wart size. RESULTS: Fourteen of the 22 patients had warts at baseline. At Week 24, 3 of the 14 patients had complete resolution of their warts, and 10 had warts reduced in size an estimated 70 to 95 percent. The remaining patient’s warts increased in size. The reduction in size in most patients greatly diminished the procedure necessary for complete ablation. No serious or severe adverse events were related to HspE7. CONCLUSIONS: A retrospective review of patients’ medical records suggests that HspE7 may be broadly active in anogenital warts. This activity crosses multiple human papillomavirus types. The warts improved substantially but usually did not totally disappear within six months. Patient follow-up continues. A new randomized, placebo-controlled trial is underway to evaluate these findings.

PURPOSE: The incidence of anogenital squamous-cell carcinoma was observed to have increased since the beginning of the human immunodeficiency virus infection epidemic among male homosexuals, both with acquired immunodeficiency syndrome and without acquired immunodeficiency syndrome. It seems that immunosuppression is the most important risk factor for the progression of anogenital lesions, recurrences of anal condyloma, and development of anal carcinoma, in particular in acquired immunodeficiency syndrome. High-grade anal intraepithelial neoplasia was predominantly observed in the human immunodeficiency virus-positive men. We have also observed a high rate of recurrences of anal lesions in cases of high-grade anal intraepithelial neoplasia. However, there are many cases of recurrences of low-grade anal intraepithelial neoplasia that cannot be predicted by routine histologic studies. By using immunohistochemical methods, we studied the expression of Ki-67 in epithelial cells of low-grade anal intraepithelial neoplasia of patients with acquired immunodeficiency syndrome to try to predict recurrence of these lesions. METHODS: Anal biopsies of 38 patients were studied retrospectively. Of these patients, 14 had no recurrences (Group 1), and 24 patients had recurrence of the anal lesions before one year of follow-up (Group 2). RESULTS: The median percentage of Ki-67-positive cells in Group 1 was 6.3±7.03 and in Group 2 was 24.1±16,72. The difference between Groups 1 and 2 was statistically significant (P

PURPOSE: Condyloma acuminata are anogenital warts caused by a human papillomavirus. Human papillomavirus is a tissue-specific, site-specific, double-stranded DNA virus, which is capable of inducing high-grade genital intraepithelial neoplasia and malignancy. The incidence of anogenital warts in the pediatric age group is rising, and sexual abuse has been implicated as a potential cause. METHODS: Accumulated data from separate questionnaires sent to practicing colorectal surgeons who are members of The American Society of Colon and Rectal Surgeons and fellows in colon and rectal training programs have been analyzed. RESULTS: Thirty percent of those polled responded to our survey. Of the respondents, 93 percent see less than two pediatric cases per year. Seventy-two percent stated that tissue specimens would be sent routinely for histopathologic identification. Although 73 percent of surgeons consider anogenital warts a potentially sexually transmitted disease, only 26 percent reported screening for other sexually transmitted diseases. A diagnostic and therapeutic protocol is followed by 19 percent of respondents. Patient follow-up varied from six months (43 percent) to lifelong examinations (3 percent). Sixty-four percent of respondents agreed that a diagnostic and therapeutic protocol based on current knowledge would be beneficial. CONCLUSION: We conclude that colon and rectal surgeons have a low exposure to anogenital warts in infants and children. Furthermore, we believe that a diagnostic and therapeutic protocol based on the current literature would be helpful.

PURPOSE: This study was undertaken to review the literature regarding the current therapy for recurrent and extensive anal warts. METHODS: The available treatments for condyloma acuminatum are reviewed with particular regard to their efficacy for recurrent or extensive anal lesions. Topical agents, surgical methods, and the use of interferon are discussed. Treatment of anal warts in the immunocompromised patient is also addressed. CONCLUSIONS: Although small lesions may be responsive to repeated applications of topical agents, more extensive lesions require surgical or combination treatment. Intralesional interferon may be a useful adjunct to surgical methods to decrease recurrence.

PURPOSE: Treatment of perianal condyloma acuminata is frustrating because most treatment options are fraught with high recurrence rates and patient discomfort. We propose that surgical excision followed by vaccination with an autogenous condyloma acuminata vaccine is the most effective therapy available in primary and recurrent perianal condyloma acuminata. METHODS: Eighty-three patients with perianal condyloma acuminata were treated from 1985 to 1992. Treatment was divided for patients as follows: surgical excision, 20; bichloroacetic acid, 10; podophyllin and interferon A, 5; excision followed by autogenous condyloma acuminata vaccination twice weekly using 0.1 ml subcutaneously for three weeks increasing to 1.0 ml subcutaneously for seven weeks, 43. Syphilis was diagnosed in seven patients; two were human immunovirus-positive. All but three patients were male. Of those patients treated with the vaccination protocol, 25 had primary and 18 had recurrent disease. RESULTS: Recurrence rates were: excision alone and bichloroacetic acid, 50 percent; podophyllin and interferon A, 85 percent; whereas only 4.6 percent recurred when treated with excision and vaccination. Mean follow-up was 13 (range, 6–23) months. All patients treated with the vaccination protocol tolerated the full course of therapy. CONCLUSION: We believe that excision of perianal condyloma acuminata followed by autogenous condyloma acuminata vaccination for approximately ten weeks is the most effective and definitive treatment option and, moreover, should be considered in all patients with perianal condyloma acuminata.

A case of squamous-cell carcinoma arising in association with perianal condyloma acuminatum was studied by light microscopy. The eight previously reported cases of malignant transformation of perianal and anorectal condylomata acuminatum are reviewed and the salient features described. Light microscopic examination of the case reported here demonstrated several foci of subtle and abrupt transition from condyloma acuminatum to epithelial dysplasia and to carcinoma in situ with focal frank invasion. This study further substantiates the existence of malignant transformation of condyloma acuminatum, particularly in perianal skin.

A new case of Goltz's syndrome, focal dermal hypoplasia, is documented. The literature is reviewed. The composite individuality warrants considering Golt'z syndrome a separate syndrome in the ectodermal dysplasias. Caution against diagnosing "condyloma-like" lesions occurring in ectodermally dysplastic patients as condyloma acuminatum is urged. Neoplastic transformation and the tendency to recurrence after surgical exicision of the cutaneous angiofibromas pose a difficult problem in surgical management.

Perianal condyloma is usually a benign disease, but may become locally aggressive; carcinomatous change may occur. This disease could be potentially malignant, and if malignant transformation occurs the treatment should include abdominoperineal resection. Perianal condylomas in association with anal fistula show malignant behavior; should such malignant behavior develop in perianal condyloma, the disease should be treated aggressively with excision and immunotherapy. Abdominoperineal resection may be necessary.

Giant condyloma acuminatum, originally described by Buschke and Loewenstein in 1925 as a lesion of the penis, is more rarely seen in the anorectum and is characterized by clinical malignancy in the face of histologic benignity; however, malignant transformation to frankly invasive squamous-cell carcinoma has been described. Malignant transformation has been reported in 15 patients with "ordinary" condylomata acuminata as well. Twenty giant condylomata acuminata have been previously reported, six of which (30 percent) went on to develop squamous-cell carcinoma. The authors report eight cases of giant condylomata acuminata with invasive squamous-cell carcinoma developing in four patients. Light and electron microscopic methods were used to verify the diagnosis of squamous-cell carcinoma and/or giant condyloma acuminatum in our cases. Human papillomavirus (HPV), known to cause condylomata acuminata, is also known to induce these tumors. The authors support the hypothesis that giant condyloma acuminatum represents an intermediate lesion in a pathologic continuum from condyloma acuminatum to squamous-cell carcinoma. These lesions have a propensity for recurrence, likelihood of malignant transformation, and significant mortality. Therefore, early and radical local excision, and in cases of recurrence, invasion, or malignant transformation, abdominoperineal resection, along with vigilant follow-up, provides the only current hope for cure.

Giant condyloma acuminatum (Buschke-Loewenstein tumor) is distinguished from condyloma acuminatum by its invasive nature and the formation of multiple fistulous tracts. The Buschke-Loewenstein tumor usually occurs on the penis, but four patients with anorectal giant condylomas have been reported in medical literature. This is a report of a patient in whom a squamous-cell carcinoma developed within a perianal giant condyloma; he received satisfactory palliative treatment by abdominoperineal resection and subsequent local treatment.

Perianal Bowen’s disease is a rare disease, diagnosed on the basis of suspicion and histologic examination. Although in gross appearance the lesion can mimic other anorectal conditions, such as condyloma acuminatum, psoriasis, neurodermatitis, leukoplakia, extramammary Paget’s disease, moniliasis, and seborrheic dermatitis, the histologic picture is distinctive and characteristic. A careful search must be made for other malignancies, as they may occur in 40 per cent of these patients. The treatment of choice is complete excision, with multiple histologic sections, reserving radical surgery for invasion and metastasis. Careful long-term follow up is imperative, as there is a strong possibility of recurrence.