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Anus and Perianus: Condyloma Acuminatum

Definition

  • Human papilloma virus associated superficial papillary lesion of anal and perianal zone

Alternate/Historical names

  • Anal wart

Covered separately

Diagnostic Criteria

  • Superficial lesion of squamous mucosa
    • No invasion
  • Acanthosis with papillomatosis
    • Variable hyperkeratosis
    • Superficial parakeratosis usually present
    • May have focal accentuation of the granular layer
  • Superficial koilocytosis
    • Perinuclear clearing
    • Hyperchromatic “raisinoid” nuclei
      • Irregular nuclear membrane
      • May be binucleate
  • Orderly maturation
    • Mitotic figures basal unless inflamed
    • Dyskeratosis may be present
  • Dysplasia usually low grade (LSIL)
    • Occasional cases with high grade dysplasia (HSIL)
    • Occasional cases with invasive squamous carcinoma
    • Thorough sampling required to exclude these findings
Teri A Longacre MD
Robert V Rouse MD
Department of Pathology
Stanford University School of Medicine
Stanford CA 94305-5342

Original posting/updates : 10/7/10

Supplemental studies

Immunohistochemistry

  • Staining for p16 is a useful surrogate for the presence of high risk HPV
    • Most condylomas have low risk HPV
    • Significance of demonstration of high risk HPV in an otherwise unremarkable condyloma is unclear

Genetic analysis

  • Human papilloma virus (HPV) can be demonstrated by PCR
    • Usually 6 and 11

Differential Diagnosis

Condyloma Acuminatum Non-specific Squamous Hyperplasia
Koilocytes at least focally present No koilocytes
Prominent parakeratosis Parakeratosis unusual

 

Condyloma Acuminatum Fibroepithelial Polyp
Koilocytes at least focally present No Koilocytes
Prominent parakeratosis Parakeratosis unusual
Lacks central stromal component Central stromal component, frequently with atypical stromal cells

 

Verrucous Carcinoma of the Anus Condyloma Acuminatum
Usually large Usually small
Blunt destructive downward growth Superficial lesion, no destructive growth
May develop fistulas and sinuses Does not produce fistulas or sinuses

 

  • Condyloma with podophyllin effect should be distinguished from HSIL
    • Podophyllin does not produce:
      • Cytologic dysplasia
      • Disturbance of maturation
      • Dyskeratosis
    • Early podophyllin effects (≤48 hours post application)
      • Intra- and intercellular edema
      • Necrotic keratinocytes in lower half of epithelium
      • Numerous mitotic figures in lower half of epithelium
    • Changes resolving by 72 hours
      • Necrotic keratinocytes now in upper half of epithelium
      • Fewer mitotic figures
    • Changes entirely resolved by one week

 

Differential diagnosis related to the presence of HSIL in a condyloma is covered under Anal Dysplasia

Clinical

  • Benign, unless complicated by the presence of carcinoma

    • Grading / Staging / Report

    Grading

    • The usual condyloma demonstrates low grade squamous intra-epithelial lesion (LSIL)
      • Koilocytes are, by definition, at least LSIL
    • High grade squamous intra-epithelial lesion (HSIL) may also be seen
    Low grade squamous intra-epithelial lesion (LSIL) High grade squamous intra-epithelial lesion (HSIL)
    Low nucleus/cytoplasmic (NC) ratio NC ratio ≥ 1
    Orderly maturation Disorderly maturation
    Atypical cells confined to superficial layer Atypical cells at all layers
    Mitotic figures confined to basal layers unless inflamed Mitotic figures at all levels
    No atypical mitotic figures Atypical mitotic figures may be seen

    Staging

    • Not applicable

    Report

    • Should address in some way the question of level of dysplasia, for example:
      • Condyloma acuminatum (LSIL), or
      • Condyloma acuminatum, no evidence of high grade dysplasia

    Classification / Lists

    Anal Tumors and Neoplasms

    Extension from rectal lesions must be ruled out

    Bibliography

    • Hamilton SR, Aaltonen LA eds. Pathology and genetics of tumours of the digestive system. World Health Organization classification of tumours, Vol. 2. Lyon: IARC Press 2000.
    • Longacre TA, Kong CS, Welton ML. Diagnostic problems in anus pathology. Adv Anat Pathol. 2008 Sep;15(5):263-78.
    • Wade TR, Ackerman AB. The effects of resin of podophyllin on condyloma acuminatum. Am J Dermatopathol. 1984 Apr;6(2):109-22.
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