Giant condyloma acuminatum of vulva treated by surgical excision and reconstruction of defect

Abstract

Giant condyloma acuminatum (GCA) is a rare sexually transmitted disease caused by Human papilloma virus (HPV) and characterised by invasive growth. Very few cases of GCA of vulva have been reported till now in the English literature [1–3]. We report a case of 34-year-old lady with GCA of vulva who was successfully treated by simple vulvectomy and reconstruction of the defect by ‘‘four-flap technique’’. A 34-year-old, married woman presented with complaints of growth on her vulva for the last 8 months. The patient was 6 months pregnant when she first noted the lesion and did not seek any medical help. Two months after her caesarean delivery, she underwent cryosurgery, but with no improvement. She denied any history of sexual promiscuity. On examination there was a 14 cm 9 10 cm 9 6 cm friable, foul smelling growth on her vulva involving both labia majora, extending anteriorly to mons pubis and posteriorly to perianal region (Fig. 1a). There were a few satellite lesions on labia minora and perianal region. Clitoris, urethra and external anal sphincter were not involved. Colposcopic, proctoscopic and oropharyngeal examinations were normal. The patient and her partner were screened negative for sexually transmitted diseases and high-risk HPV DNA. Incisional biopsy showed squamous cell papilloma with koilocytic changes and it was positive for HPV DNA type 6. A simple vulvectomy, achieving wide margins, was performed. Small lesions in perianal area and labia minora were also excised. Reconstruction of vulva was performed using ‘four flap technique’ (personal communication by Dr. Prakash V, Department of plastic surgery, Safdarjung Hospital, New Delhi). In this technique, four random pattern flaps in the dimension of 1:1 or 1:2 were raised adjacent to the defect and advanced medially to resurface the defect. This resulted in defect being transferred laterally, but this defect was smaller than the original defect and could be closed primarily (Fig. 1b). Final histopathology report confirmed the diagnosis of condyloma acuminatum with mild degree of dysplasia. Functional outcome was good with no sexual complaints. She remained free of recurrence at 12 months of follow-up (Fig. 1c). Many treatment strategies have been documented in the literature for management of GCA, but mainly in the form of case reports. Complete surgical excision with histologically clear margins, with or without adjuvants, is the mainstay of the treatment for GCA, including that of vulva [1, 3]. Other modalities include combined radiotherapy and chemotherapy, topical agents (e.g. podophyllin, 5-FU, imiquimod, bleomycin) and intralesional injections of interferons [4–6]. The skin defects created after excision of GCA in the peri-anal region can be managed with mesh skin grafting, flaps and even healing by secondary intention [1, 7–9]. Flaps have been shown to give better results for reconstruction of vulva [8, 9]. The additional advantage of our ‘four flap technique is that the scars do not extend over the perineum or thighs. In our patient, the postoperative period P. Mittal (&) R. Gupta R. Dewan S. Singhal J. Suri Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Delhi 110029, India e-mail: drpratima@hotmail.com