Integration of Anal Dysplasia Screening into the Primary Care of Persons Living with HIV.

Anal dysplasia can lead to anal cancer, which affects persons living with HIV (PLWH) more than people in the general population. Screening for anal dysplasia is recommended to detect anal cancer at an early stage. The aim of our process improvement project was to improve compliance and consistency in implementing anal dysplasia screening for PLWH receiving care at a Ryan White facility covering 18 counties in western North Carolina. There were 291 PLWH screened for anal dysplasia during the 9-month data-gathering period. The compliance rate significantly increased from a preintervention rate of 31.3% to 57.5% (p < .001). There were 109 (37.5%) abnormal screening results. PLWH who had abnormal screening results were more likely to be White. Gender and age were not significantly associated with abnormal screening results. Anal dysplasia screening is a simple procedure to detect precursors to cancer that can be integrated into the primary care of PLWH.

Early closure of fistula using neo-adjuvant intra-arterial chemotherapy in locally advanced anal cancer.

BACKGROUND: Locally advanced anal cancer patients, especially with T4 disease and fistula, have a dismal prognosis. Neo-adjuvant intra-arterial chemotherapy before standard chemoradiation has been shown to be promising in this setting. AIMS: We are reporting results from a larger patient population. METHODS: From 2005 to 2015, 25 consecutive patients with locally advanced anal cancer, 18 of them fistulised, received intra-arterial chemotherapy. RESULTS: Twenty-two of 25 patients (88%) had T4N0-3 disease and 3 (12%) T3N3. An objective tumour response was observed in 24 of 25 patients (96%): 24 partial responses and 1 with stable disease. Fistulas' complete closure was observed in 15 of 18 patients (83.3%). Following intra-arterial chemotherapy, 23 patients underwent chemoradiation. Twenty-one of 25 patients (84%) had a complete remission 6 months after treatment completion. Amongst 22 patients followed for 3 or more years, 18 of them (81%) are colostomy free at 3 years. Five-year overall survival is 75%. Most frequent grade 3-4 toxicity of IAC was neutropenia (25%). CONCLUSIONS: Neo-adjuvant intra-arterial chemotherapy combined to chemoradiation resulted in a high rate of fistulas closure and long-term control of locally advanced anal cancer. This interesting approach in the treatment of fistulised anal cancer, needs a prospective study before being considered a new standard strategy.

Risk Factors for the presence of anal intraepithelial neoplasia in HIV+ men who have sex with men.

OBJECTIVE: Anal Intraepithelial Neoplasia (AIN) is present in the majority of HIV+ men who have sex with men (MSM) and routine AIN-screening is subject of discussion. In this study we analysed a wide range of potential risk factors for AIN in order to target screening programs. METHODS: We screened 311 HIV+ MSM by high resolution anoscopy, with biopsies of suspect lesions. HIV-parameters, previous sexual transmitted infections (STI's), anal pathology, sexual practices and substance use were analysed in relation to AIN by uni- and multivariable logistic regression. RESULTS: AIN (any grade) was found in 175/311 MSM (56%), high grade (HG)AIN in 30%. In the univariable analysis, years since HIV diagnosis, years of antiretroviral therapy (cART) and anal XTC use decreased AIN risk, while a history of anogenital warts and use of GHB (γ-hydroxybutyric acid) increased this risk. In the multivariable analysis three parameters remained significant: years of cART (OR=0.92 per year, p=0.003), anal XTC use (OR=0.10, p=0.002) and GHB use (OR=2.60, p=0.003). No parameters were significantly associated with HGAIN, but there was a trend towards increased risk with anal enema use prior to sex (>50 times ever; p=0.07) and with a history of AIN (p=0.06). CD4 count, STI's, anal pathology, smoking, number of sex partners and anal fisting were not associated with (HG)AIN. CONCLUSION: GHB use increases the risk for AIN, while duration of cART and anal XTC use are negatively correlated with AIN. Given the high prevalence of AIN in HIV+ MSM, these associations are not helpful to guide a screening program.

Infusing Swanson's Theory of caring into an advanced practice nursing model for an infectious diseases anal dysplasia clinic.

The incidence of anal cancer is increasing among HIV-infected men and women. The process of screening for anal dysplasia and the management of abnormal findings are currently and most often based on a medical model. The needs of these patients, however, go well beyond medical care. A more comprehensive and holistic approach to health care is, therefore, required. Given the scope of practice of advanced practice nurses who are involved in the diagnosis and treatment of patients with anal dysplasia, it is appropriate for them to assume leadership roles in addressing the needs of these patients. This article describes the application of a theory of caring to create an advanced practice nursing model of care for HIV-infected men and women in infectious diseases anal dysplasia clinics.

[Mucinous adenocarcinoma on chronic perianal fistula treated by neoadjuvant chemoradiotherapy and laparoscopy-assisted abdominoperineal amputation]. / Adenocarcinoma mucinoso en fístula perianal de largo tiempo de evolución tratado mediante QT-RT neoadyuvante y amputación abdominoperineal laparoscópica.

We present a male patient with a perianal fistula of 30 years' duration that had been treated on several occasions. The patient presented with mucoid anal adenocarcinoma. He was treated with preoperative neoadjuvant chemotherapy (5-FU and leucovorin) and external radiation therapy plus laparoscopy-assisted abdominoperineal amputation. Mucoid adenocarcinoma on chronic perianal fistula is an infrequent process. Late diagnosis is associated with a poor prognosis.

Anal carcinomas in HIV-positive patients: high-dose chemoradiotherapy is feasible in the era of highly active antiretroviral therapy.

BACKGROUND: Anal carcinoma, a common disease in HIV-positive patients, is usually treated with chemoradiotherapy. Generally tolerance was poor before the availability of highly active antiretroviral therapies. We report our experience of treating anal carcinoma in the era of new antiviral drugs. PATIENTS AND METHODS: Between 1997 and 2001, nine men on highly active antiretroviral therapies with good immune status before chemoradiotherapy received concomitant chemoradiotherapy consisting of 5-fluorouracil and cisplatinum, and high-dose radiotherapy (60-70 Gy) for anal carcinoma. Six cancers were Stage I, two were Stage II, and one was Stage III. CD4+ cell counts were <200/ml for four patients, between 200/ml and 500/ml for four, and >500/ml for one. RESULTS: All patients received the planned dose of radiation (> or = 60 Gy). The chemotherapy dose was reduced 25 percent in six patients. Overall treatment time was 58 days. Grade 3 hematologic or skin toxicity occurred in four patients. No association was observed between high-grade toxicity and CD4+ cell count. None of the patients developed opportunistic infections during follow-up. Eight patients were disease-free after a median follow-up of 33 months. Among them, four had no or minor anal function impairment at the last follow-up visit. One patient with T4N2 disease relapsed locally one year after treatment and underwent salvage abdominoperineal excision. CONCLUSION: High-dose chemoradiotherapy for anal carcinomas is feasible with low toxicity in HIV-positive patients treated with highly active antiretroviral therapies. Local control is similar to that obtained for HIV-negative patients.

[Perianal Bowen's disease: a case report and review of the literature]. / Perianal Bowen's disease: a case report and review of the literature.

Perianal Bowen's disease is a uncommon, slow growing, intraepidermal squamous-cell carcinoma (carcinoma in situ) of the anal region and may be a precursor to squamous carcinoma of the anus. It is associated with cervical and vulvar intraepithelial neoplasia and have human papillomavirus as a common cause. Both sexes and all races are affected, with the highest prevalence in patients aged 20 to 45 years. The symptoms of anal Bowen's disease are unspecific and the clinical findings are uncharacteristic and include pain, itching, bleeding and a disturbing lump. Biopsy and histopathologic examination is required for diagnosis and to distinguish other perianal dermatoses; thus an anogenital warts that fail to respond to conventional therapy, or change in appearance, warrant a biopsy and, where the technique is available, DNA typing to identify the viral pathogen. Infact the etiologic agent, the human papillomavirus (HPV), has been classified by DNA techniques into at least 42 types, of which 16 and 18 are considered to carry a high risk for cancer. The intraoperative findings is a lesion at the anocutaneous line: perianal or intra-anal tumor, erosion or ulceration as well as lichenoid lesion or hyperpigmentation. The disease has a proclivity for recurrence and there are many controversies concerning treatment that effectiveness remains uncertain and range from aggressive wide local excision with skin grafting when necessary to laser vaporization (argon or CO2), radiotherapy or a new immune response modifier (Imiquimod). We report a case of a 50-years-old woman with recurrence of Bowen's disease associated with vulvar HPV infection and review the literature.

Oral vitamin a therapy for a patient with a severely symptomatic postradiation anal ulceration: report of a case.

Squamous-cell carcinoma of the anus is an uncommon but treatable gastrointestinal malignancy. Radiation, in addition to chemotherapy, is widely accepted as the standard of care for treatment in most patients. However, significant anal complications, such as stricture, fistula, and ulceration, may result from radiation therapy. Some medical therapies have been used for radiation proctopathy, but treatments for radiation-induced anal injury other than surgical diversion are unknown. Vitamin A has been shown in laboratory studies to facilitate wound healing and prevent radiation-induced gastrointestinal damage. However, it has not been used clinically in patients with radiation enteritis, proctopathy, or anal ulceration. We report a case of a patient with human immunodeficiency virus infection who developed a symptomatic anal ulcer after receiving high-dose radiotherapy for anal squamous-cell carcinoma. We prescribed 8,000 IU of oral vitamin A twice daily and within seven weeks his anorectal symptoms and anal ulcer completely resolved. Vitamin A seems to be very effective in the treatment of radiation-induced anorectal damage, with little toxicity and expense.

Endoscopic transanal resection provides palliation equivalent to transabdominal resection in patients with metastatic rectal cancer.

Patients with metastatic rectal cancer precluding curative low anterior resection (LAR) or abdominoperineal resection (APR) can require palliation for impending obstruction. LAR or APR is frequently not optimal because of the associated operative morbidity. Lesser procedures such as diverting colostomy require patients to live with a permanent stoma. Endoscopic transanal resection (ETAR) has been used for excision of rectal lesions. To determine whether ETAR provides palliation equivalent to LAR or APR, we reviewed the outcomes of 49 patients with rectal adenocarcinoma and unresectable liver metastases who required palliative intervention between January 1989 and July 1996. Of these 49 patients, 24 underwent ETAR; the intraluminal tumor was resected using the urologic resectoscope to achieve a hemostatic, patent lumen. The outcomes of these patients were compared to those of the other 25 patients who had palliative LAR, APR, or a Hartmann procedure during the same period. The median distance of the tumors from the anal verge was similar (5 cm; range 1 to 15 cm). ETAR patients had a higher percentage of poorly differentiated tumors (35% vs. 6%, P = 0.034) and higher preoperative alkaline phosphatase values (478 +/- 75 mg/dl vs. 231 +/- 24 mg/dl; P < 0.015), suggesting more aggressive disease and greater hepatic tumor burden, respectively. Despite these differences, overall survival and time spent outside the hospital were similar in the two groups. The median number of debulking procedures required in the 24 ETAR patients was two (range 1 to 17). Resections in the 25 LAR/APR patients included LAR in 20, APR in two, and Hartmann procedures in three. There was a trend toward more stomas in the LAR/APR group (28% vs. 17%). More important, morbidity was significantly higher in the LAR/APR patients (24% vs. 4%; P = 0.049). In conclusion, ETAR is a safe alternative for the palliation of incurable rectal tumors. Compared to transabdominal resection, ETAR provides equivalent palliation as measured by survival and proportion of the patient's life spent outside the hospital, with a lower stoma rate and significantly less morbidity. Therefore, in select patients with metastatic rectal cancer, ETAR is an important palliative option.

Hamartoma quístico retrorrectal / Retrorectal cystic hamartoma

Se presenta el caso de un paciente de 38 años con historia de dolor perineal y con pruebas de diagnóstico preoperatorio sugestivas de tumoración quística retrorrectal. El paciente fue intervenido quirúrgicamente y el diagnóstico anatomopatológico fue de hamartoma quístico retrorrectal. Se discuten el diagnóstico y el tratamiento (AU)

Perianal extramammary Paget's disease associated with primary linitis plastica of the rectum: report of a case.

We report herein a case of perianal extramammary Paget's disease associated with primary linitis plastica of the rectum. An 82-year-old woman was admitted to our hospital for investigation and treatment of a perianal eczematous lesion. A skin biopsy of the lesion revealed perianal extramammary Paget's disease and a barium enema demonstrated diffuse narrowing with an irregular contour at the ampulla recti. Under a suspected diagnosis of linitis plastica of the rectum, an abdominoperineal resection was performed to resect both the rectal and perianal lesions with regional lymphadenectomy. Grossly, marked narrowing and wall thickness were observed at the lower rectum, and a histological diagnosis of signet ring cell carcinoma was confirmed. The perianal eczematous lesion revealed many atypical cells with clear cytoplasm, being Paget cells, throughout the entire epidermis. Sparse distributions of signet ring cells were also observed in the subcutaneous tissue beneath the perianal eczematous lesion. The pathogenesis of perianal extramammary Paget's disease in this patient was therefore considered to be an intraepidermal extension of primary linitis plastica of the rectum.

[A case of fistula-cancer response to arterial chemoembolization].

Arterial chemoembolization was performed three times preoperatively for cancer associated with fistula-in-ano for diminishing the postoperative surgical tissue defect of the perineum. Partial response of the tumor to this treatment was confirmed by computed tomography. A sixty-two-year-old male patient recognized a mass in the perineum one and a half years ago. He had suffered from fistula-in-ano for thirty years. The mass increased its size and formed a tumor in the bilateral buttocks (12 x 9 cm and 9 x 9 cm in diameter). Biopsy specimen showed a moderately differentiated adenocarcinoma. Angiography showed a hypervascular tumor stain. The main feeders to the tumor were the superior rectal artery and bilateral internal iliac artery. Arterial chemoembolization was performed three times through the right and left internal iliac artery with Gelfoam particle. Arterial infusion chemotherapy was added through inferior mesenteric artery and bilateral internal iliac artery with a total 120 mg of adriamycin and 1,500 mg of 5-FU simultaneously. The tumor decreased in size to 44% of the preoperative size by the treatment. A radical operation was performed following the preoperative treatment. Preoperative arterial chemoembolization for cancer associated fistula-in-ano was considered to be helpful for local control.

Pruritus ani. Causes and concerns.

PURPOSE: The aim of this study was to determine how frequently pruritus ani (PA) is a symptom secondary to benign or malignant colon and anorectal pathology. METHODS: One hundred nine patients with PA as the only presenting symptom were prospectively evaluated over a two-year period. All patients underwent anoscopy, rigid proctoscopy, and colonoscopy and were treated for PA. Patient data were entered into a computer data base and analyzed. RESULTS: The mean age was 52.1 years; males outnumbered females 2:1. The mean duration of symptoms was 6.1 weeks. Mean coffee intake was four cups per day. Forty-five percent of patients smoked and 45 percent drank alcohol daily. Thirty-five percent had an abnormal proctosigmoidoscopy or colonoscopy. Twenty-seven (25 percent) patients had primary pruritus and 82 (75 percent) patients had coexisting colon or anorectal pathology. The PA-associated neoplasia included rectal cancer (11 percent), anal cancer (6 percent), adenomatous polyps (4 percent), and colon cancer (2 percent). Hemorrhoids (20 percent) and anal fissures (12 percent) were the most common pruritus-related anorectal diseases. Among the 23 percent of patients with PA and neoplasia, pruritic symptoms were present longer compared with those with PA and anorectal disease < 0.001 and primary pruritus (P < 0.0001). All patients with primary PA were initially treated with dietary fibers, steroid cream, and drying agents. The recurrence rate for primary pruritus was twice that for anorectal disease (P < 0.0001). CONCLUSIONS: PA responds to treatment in 89 percent of patients, while 11 percent are refractory to treatment. Symptoms suggestive of pruritus ani, especially those of long duration, should alert the surgeon to the potential for proximal colon and anorectal neoplasia.

Total body hyperthermia in the treatment of Kaposi's sarcoma in an HIV positive patient.

The effect of prolonged exposure to heat on the HIV has had limited exploration. This is the report of a 33-year-old white man with positive tests for HIV and multiple lesions of Kaposi's Sarcoma. The patient was exposed to total body hyperthermia of 42 degrees C for two hours. Three months following hyperthermia the patient feels improved. The lesions of Kaposi's Sarcoma have markedly regressed, and the T4 lymphocyte count has risen from 5 per cc to 330 per cc. HIV cultures (blood) remain negative. These data would indicate this modality of therapy has altered the progression of disease in this patient.

Synchronous and metachronous colon lesions in squamous cell carcinoma of the anal canal.

The charts of 79 patients with a histologic diagnosis of squamous cell carcinoma of the anal canal were reviewed to determine the incidence of synchronous and/or metachronous colon lesions. Forty-six patients underwent an adequate preoperative evaluation of the colon and rectum. Ten patients underwent colonoscopy, 33 patients underwent a barium enema, and three patients underwent colonoscopy and a barium enema. In this group six adenomatous polyps and three hyperplastic polyps were discovered. An adenocarcinoma of the sigmoid colon was found in another patient six months prior to the diagnosis of a squamous cell carcinoma of the anal canal. Twenty-three patients had follow-up evaluation of the large bowel for metachronous lesions following treatment of the squamous cell carcinoma of the anal canal. Ten patients underwent colonoscopy, three patients had a barium enema, and ten autopsies were available for analysis. In this group metachronous lesions consisted of two adenomatous polyps and one hyperplastic polyp.