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Intranasal Condyloma Acuminatum with Malignant Transformation

(A) Cauliflower-like lesion growing in the right nasal vestibule and occluding the naris; (B) papillary architecture with hyperkeratosis of the overlying squamous epithelium; (C) koilocytosis, which is characteristic of active viral replication; and (D) invasive carcinoma beyond the basement membrane (black arrow), consisting of irregular nests of hyperchromatic cells showing squamous differentiation and focal mitotic figures (black asterisks).

(A) Cauliflower-like lesion growing in the right nasal vestibule and occluding the naris; (B) papillary architecture with hyperkeratosis of the overlying squamous epithelium; (C) koilocytosis, which is characteristic of active viral replication; and (D) invasive carcinoma beyond the basement membrane (black arrow), consisting of irregular nests of hyperchromatic cells showing squamous differentiation and focal mitotic figures (black asterisks).

A 48-year-old man with a growing mass in the right naris and epistaxis for 6 months visited our department in August 2016. He had a history of diabetes mellitus and psoriasis. We observed a cauliflower-like lesion in the right nasal vestibule (Figure A), extending to the septum and nasal floor. Nasopharyngoscopy revealed that the nasopharynx, oropharynx, hypopharynx, and larynx were free of lesions. The pathological diagnosis was condyloma acuminatum. HC2 high-risk human papillomavirus DNA testing (Hybrid Capture II; Qiagen, Hilden, Germany) of the specimen indicated negative results for high-risk human papillomavirus infection. The patient acknowledged that he had previously experienced penile condyloma acuminatum, which was cured.

In the microscopic examination, low magnification revealed a papillary (villous) architecture with hyperkeratosis (Figure B), whereas high-magnification epithelium revealed vacuolization (koilocytosis), which was characteristic of human papillomavirus infection (Figure C). Focal invasive squamous cell carcinoma was noted (Figure D). Invasive growth was manifested by the interruption of the basement membrane and growth of tumor islands in the subepithelial stroma. Because adequate safe margins were not achieved, re-excision or adjuvant radiotherapy was recommended. However, the patient was lost to follow-up for 3 months, and he then returned to receive radiotherapy for local recurrence.

The most common pathogens for condyloma acuminatum are human papillomavirus types 6 and 11, and rarely, types 16 and 18. Subtypes 6 and 11 are “low-risk human papillomavirus” that cause condyloma acuminatum on or around the genitals, anus, mouth, or throat. Subtypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68 are associated with malignant transformation.1

The classical histopathological features of condyloma acuminatum include broad reticulated acanthosis, hyperkeratosis, and koilocytosis, which is the histological gold standard for diagnosis.2

According to the literature, most condyloma acuminatum malignant transformations occur in the anogenital regions, and up to 90% of cases are associated with human papillomavirus types 16 and 18.3 Another condyloma acuminatum-associated low-grade malignancy is termed “giant condyloma acuminatum” and occurs in the anogenital region. This disease is thought to be verrucous carcinoma and is highly related to human papillomavirus types 6 and 11. Abscess formation and fistulas are common in this condition.4

Immunosuppression, coexisting human immunodeficiency virus infection, irritant effects of anal sex, and unhygienic conditions play a role in malignant transformation. As observed in the present case, diabetes mellitus can lead to an immunocompromised state, and psoriasis involves the dysregulation of T cell function.4 Both conditions may contribute to malignant transformation. The patient did not consent to being tested for human immunodeficiency virus.

The most reliable treatment method is radical excision in the anogenital area. Radiotherapy can be applied either alone or with chemotherapy in cases of recurrence or unresectable lesions. However, no current data about the malignant transformation of condyloma acuminatum in the nasal area are available, and the epidemiology and treatment protocols are unclear.

In conclusion, condyloma acuminatum rarely presents in the nasal cavity, and the associated malignant transformation has not yet been reported in the literature. Immunocompromised states may be a contributor to this process, and more intensive surveillance is required if frequent recurrence is observed. Due to the limited number of cases, a comprehensive consensus for treatment should be obtained in the future.

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-Tengchin Wang, MD, Chiehjen Wu, MD

This article originally appeared in the November 2017 issue of The American Journal of Medicine.

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