Abstract
Condyloma acuminatum is a human papillomavirus (HPV)-induced disease. It is usually transmitted sexually, and it frequently occurs in the anogenital area. A finding of condyloma acuminatum in the oral cavity is rare. Besides HPV, other risk factors for oral condyloma include chewing betel quid and smoking. We report the case of a 52-year-old man who presented with a 2 × 2-cm verrucous white patch on his buccal mucosa. He was habituated to both betel quid and cigarette smoking. A biopsy of the lesion identified it as a verrucous hyperplasia of the squamous epithelium with HPV-related koilocytic changes. The lesion was excised, and further histopathology identified it as condyloma acuminatum. The patient was disease-free 9 months postoperatively. The possibility of condyloma acuminatum should be considered in the differential diagnosis of an oral white lesion. The most common treatments are surgical excision, cryosurgery, electrocautery, and laser excision. There is no known role for antiviral therapy.
Introduction
Condyloma acuminatum is common in the anogenital skin and mucosa. It is rarely described in the oral cavity. 1 Oral condyloma was first documented by Heidingsfeld 2 in 1901, and the first case indexed in PubMed was reported by Knapp and Uohara 3 in 1967. Its most common locations are the upper and lower lip, labial and buccal mucosa, soft palate, and the dorsum of the tongue. 4 Patients whose sexual partners have genital condyloma have a higher incidence of oral condyloma, which suggests that the oral form may be related to sexual practices that facilitate transmission of human papillomavirus (HPV).5,6
We report a new case of oral condyloma acuminatum, one that was not associated with anogenital condyloma or any other HPV-induced lesions.
Case report
A 52-year-man presented to our surgical oncology outpatient clinic with a 3 -month history of a white patch on his buccal mucosa and intolerance to spices. For 27 years, he had been a betel quid chewer and cigarette smoker, but the onset of his symptoms led him to discontinue these practices. However, after he stopped, the lesion did not regress.
On examination, a 2 × 2-cm white, raised patch was present on the buccal mucosa; the mass extended up to the oral commissure (figure 1). No other lesion or cervical adenopathy was noted. The patient was provisionally diagnosed with leukoplakia. However, a subsequent punch biopsy revealed verrucous hyperplasia of the squamous epithelium with HPV-related acanthosis and koilocytic atypia.
The lesion on the buccal mucosa is seen at presentation.
The patient underwent cold-knife excision of the lesion. Histopathology of the excised specimen was similar to that of the biopsy specimen, as the lesion showed a condylomatous pattern (figure 2). No areas of dysplasia or malignant transformation were identified. Postoperatively, the patient remained free of symptoms and disease at the 9-month follow-up.
Photomicrographs of the excised specimen under low (A) and high (B) power show the hyperplasia of the squamous epithelium with HPV-related acanthosis and koilocytic atypia.
Discussion
Condyloma acuminatum is caused by HPV that is usually transmitted through sexual or skin-to-skin contact. More than 60 subtypes of HPV have been identified; the difference among them is their amino acid sequences. Viruses are shed from macro- and microscopic lesions, so clinicians should take care to protect themselves when examining an infected patient.
Patients with uncomplicated condyloma are usually asymptomatic. Their lesions appear as pedunculated, soft papules that measure approximately 2 to 3 mm in diameter.
Condyloma acuminatum has been specifically linked to the HPV DNA genotypes 6 and 11; more than 75% of patients with oral condyloma are positive for HPV DNA.7,8 The exact mode of HPV transmission in oral condyloma is not known, although it is suspected to occur through orogenital, oroanal, and hand-to-mouth autotransmission. About 50% of patients who participate in orogenital sex with a partner who has genital high-risk HPV infection develop HPV-induced oral lesions, including condyloma. 1 Nonsexual modes of transmission include contact with contaminated surfaces, self-inoculation from genital lesions, and perinatal transmission from mother to newborn. The autotransmission route has been identified by cytologic detection of identical HPV types in both the oral cavity and anogenital area in patients who are affected by both.9–11
Oral condylomas have also been reported to occur in patients who have genital warts or whose sexual partner has genital warts. Reported infection rates of sexual partners range from 25 to 65%. 12
The average incubation period for external genital warts is 2 to 3 months (range: 1 to 8). 13 Subclinical HPV infection can persist without the development of macroscopic lesions. 4
The diagnosis of these lesions can be based on the typical appearance of soft, pink nodules that coalesce into cauliflower-like masses. They may appear as either a single lesion or multiple masses. These lesions are mostly distinct, although our patient's lesion clinically resembled an ulcerative leukoplakia.
Histologically, these lesions are characterized by hyperplasia, slight parakeratosis, and the presence of numerous koilocytes. 14 Their treatment is by surgical excision, cryosurgery, electrocautery, photodynamic therapy, Mohs microsurgery, or laser excision.15,16
Since condyloma acuminatum lesions tend to recur, patients usually require ongoing follow-up and further treatment. Antiviral therapy has no documented role in this infection. Topical application of podophyllotoxin, imiquimod, trichloroacetic acid, and catechin has been tried, but its exact role in preventing recurrence is not known. HPV vaccination may be tried for prevention, but its efficacy also remains unproven.
In conclusion, awareness of the possibility that an oral cavity lesion may represent condyloma acuminatum is important because this lesion is associated with oncogenic HPV genotypes. Patients with suspected oral condyloma acuminatum and their sexual partners should undergo a thorough anogenital examination.