Buschke-Löwenstein tumor with squamous cell carcinoma treated with chemo-radiation therapy and local surgical excision: report of three cases.

Treatment of anorectal Buschke-Löwenstein tumor (BLT) with squamous cell carcinoma (SCC) transformation is not univocal given the rarity of the disease. BLT is characterized by its large size and tendency to infiltrate into underlying tissues. Malignant transformation can occur and it is important to identify the presence of neoplastic foci to decide the proper treatment. Our aim was to assess the effectiveness of neo-adjuvant chemo-radiation therapy (CRT) and local excision in order to avoid abdomino-perineal resection (APR). Three cases of anorectal BLT with SCC transformation are presented. All patients were HIV positive and treated with antiretroviral drugs. They underwent preoperative endoanal ultrasound, biopsies, total body tomography and anal brushing. Treatment consisted of neo-adjuvant chemo-radiation therapy (45 Gy to the pelvis plus a boost with 14.40 Gy to the primary tumor for a total of 59.40 Gy, and mitomycin-C in bolus on the first day, plus 5-fluorouracil by continuous infusion in the first and in the sixth week) and subsequent local surgical excision. During the follow-up, patients were subjected to the same preoperative diagnostic investigations and high resolution anoscopy. All patients showed a complete regression of the lesion after CRT and were treated by local surgical excision, thus avoiding permanent colostomy. In conclusion neo-adjuvant chemo-radiation therapy with local surgical excision could be considered an effective therapy in the treatment of anorectal BLT with SCC transformation to avoid APR.

Perineal reconstruction with local flaps: technique and results.

BACKGROUND: Wide excision of perineal lesions, often including the entire anal canal, may be necessary for benign and malignant conditions. Closure of these large defects is challenging, especially when continence is a goal. The aim of this study was to assess our experience with local flap closure of large perineal defects. METHODS: From 1994 to 2009, 20 patients underwent wide perineal and/or anal canal excisions and reconstruction using local flaps. Mean age was 45 years (range 20-65 years), 13 were male, and 8 (40 %) were immunocompromised. Primary indications included anal or perineal squamous cell carcinoma-(n = 12), Buschke-Lowenstein tumor (n = 3), and anal intraepithelial neoplasia (n = 3), hidradenitis, stenosis, ectropion, and traumatic cloaca repair (n = 1 each). Primary procedures included wide local excision of large neoplastic lesions-(n = 15) (mean size 10 cm, range 5-18 cm), abdominoperineal resection (APR) (n = 2), perineoplasty with sphincteroplasty-(n = 1), and others-(n = 2). All were reconstructed with bilateral local flaps (V-Y 18, S 2). Thirteen had complete excision of the anal canal to the anorectal ring preserving the sphincters. Six (30 %) had ostomies; 2 with APR and 4 temporary. RESULTS: There were no perioperative deaths. Mean hospital stay was 4.2 days. Follow-up averaged 35 months (range 3-87 months) in survivors. Five patients died during follow-up; 2 of complications of acquired immune deficiency syndrome (AIDS) and 3 of cancer (2 treated palliatively). Wound dehiscence occurred in 6 (30 %) patients: in 3 cases, this was minor dehiscence and healed quickly; in 3 cases, it was major dehiscence and occurred in the 2 radiation/APR patients and in one patient with advanced AIDS. Radiation was the only significant risk factor (P < .05). Twelve of 14 eligible patients with long-term follow-up and an intact anal canal are fully continent, and 2 are partially continent (1 traumatic cloaca; 1 the same as before surgery). CONCLUSION: Local flap reconstruction of the perineum and anal canal is an excellent method of managing large perineal defects. Most heal primarily, even in immunocompromised patients, and continence may be preserved. Local flaps should be avoided in irradiated patients.