Chemoradiotherapy with and without deep regional hyperthermia for squamous cell carcinoma of the anus.

PURPOSE: To compare results after chemoradiotherapy with and without deep regional hyperthermia in patients with anal cancer. METHODS: Between 2000 and 2015, a total of 112 consecutive patients with UICC stage I-IV anal cancer received chemoradiotherapy with 5­fluororuracil and mitomycin C (CRT). In case of insufficient tumor response 4-6 weeks after chemoradiotherapy, patients received an interstitial pulsed-dose-rate brachytherapy boost. Additionally, 50/112 patients received hyperthermia treatments (HCRT). RESULTS: Median follow-up was 41 (2-165) months. After 5 years follow-up, overall (95.8 vs. 74.5%, P = 0.045), disease-free (89.1 vs. 70.4%, P = 0.027), local recurrence-free (97.7 vs. 78.7%, P = 0.006), and colostomy-free survival rates (87.7 vs. 69.0%, P = 0.016) were better for the HCRT group. Disease-specific, regional failure-free, and distant metastasis-free survival rates showed no significant differences. The adjusted hazard ratios for death were 0.25 (95% CI, 0.07 to 0.92; P = 0.036) and for local recurrence 0.14 (95% CI, 0.02 to 1.09; P = 0.06), respectively. Grades 3-4 early toxicities were comparable with the exception of hematotoxicity, which was higher in the HCRT group (66 vs. 43%, P = 0.032). Incidences of late side effects were similar with the exception of a higher telangiectasia rate in the HCRT group (38.0 vs. 16.1%, P = 0.009). CONCLUSION: Additional regional hyperthermia improved overall survival, local control, and colostomy rates. Its potential beneficial role has to be confirmed in a prospective randomized setting. Therefore, the HyCAN trial has already been established by our group and is currently recruiting patients (Clinicaltrials.gov identifier: NCT02369939).

The differential diagnosis and interdisciplinary treatment of anal carcinoma.

BACKGROUND: Anal carcinoma accounts for 2-4% of all cases of colorectal and anorectal carcinoma. Its peak incidence is from age 58 to age 64; women are affected somewhat more commonly than men. Its incidence has risen markedly in the past three decades. METHODS: This article is based on a selective review of the literature, including the guidelines of the National Comprehensive Cancer Network and the European Society of Medical Oncology. RESULTS: Anal carcinoma is often an incidental finding. About 85% of newly diagnosed cases are associated with an HPV infection with strain 16, 18, or 33. Radiochemotherapy with 5-fluorouracil and mitomycin C is the treatment of choice. The 5-year survival rate is 80-90%. Primary surgery with curative intent is indicated only for well-differentiated carcinoma of the anal margin (T1, N0). 10-30% of patients now undergo radical resection. The utility of endosonography and positron emission tomography for staging is debated and needs further study. CONCLUSION: The treatment of patients with anal carcinoma requires a specialized multidisciplinary approach in accordance with the current evidence-based guidelines. The potential role of prophylactic vaccination against oncogenic types of HPV in the prevention of anal carcinoma merits further investigation.

Contrast enhanced sonography of the gallbladder: a tool in the diagnosis of cholecystitis?

RATIONALE AND OBJECTIVES: To evaluate if contrast enhanced sonography (CES) can help to detect gallbladder inflammation and differentiate between acute and chronic cholecystitis. MATERIALS AND METHODS: Thirty-three patients with clinical suspicion of acute cholecystitis were examined with CES before cholecystectomy. Thirty patients with no history of gallbladder disease served as control. CES was performed using 2.5 mL SonoVue. A small mechanical index was chosen (0.1). The enhancement pattern of the gallbladder was ranked in a three-point scale: no enhancement, low enhancement and strong enhancement. 28/33 patients underwent surgery. Sonographic findings were compared to histological results. RESULTS: In 16/20 cases with histological proven acute cholecystitis, the gallbladder wall showed a strong enhancement. Low enhancement was found in four patients with acute and in six patients with chronic cholecystitis. The gallbladder wall of two patients with chronic inflammation and all patients (30/30) of the control group showed no enhancement. CONCLUSION: CES is a feasible tool for detecting gallbladder inflammation. Differentiating between acute and chronic cholecystitis seems to be possible.

Collagen foil (TissuFoil E) reduces the formation of adhesions when using polypropylene mesh for the repair of experimental abdominal wall defects.

BACKGROUND AND AIMS: Polypropylene meshes (PPMs) are routinely used in the treatment of incisional hernias to achieve a tension-free closure of the abdominal wall. Severe adhesions are a common cause of intestinal obstruction, or even intestinal fistulas. Using a porcine model, we investigated whether applying a collagen foil (CF) to the undersurface of a PPM will reduce adhesion formation. METHODS: In ten domestic pigs (20-25 kg), a median laparotomy was performed. In each animal the abdominal wall was reconstructed using three types of closure: simple closure by a running suture (control), PPM only, and PPM covered with CF (PPM-CF). After 6 weeks, the abdominal wall with adherent tissue was resected en bloc for macroscopic (quality and quantity of adhesion formation) and histological work-up. RESULTS: The PPM-CF showed significantly less severe (1.9 vs 3.0 according to a scoring system), and also less extended (23.8 vs 55.9% total coverage of the mesh), adhesions to the resected abdominal wall. Histological examination revealed fewer and less severe inflammatory reactions, necrosis, and foreign body reactions for the mesh and CF (PPM-CF). CONCLUSION: To combine meshes with the anti-adhesion properties of a CF may be another option to achieve more physiological and more tolerable prosthetic materials.

Treatment of ingrown toenails using a new conservative method: a prospective study comparing brace treatment with Emmert's procedure.

Ingrown toenails cause incapacitation and pain for the patient and lost time from work. Many different conservative and surgical treatment methods have been described. European chiropodists and podologists have long treated ingrown toenails with orthonyxia, which consists of implantation of a small metal brace or plate onto the dorsum of the nail. To determine whether orthonyxia is an acceptable alternative to surgery, we compared the VHO-Osthold brace (VHO-Osthold-Spange GmbH, Deisenhofen, Germany), a new method of orthonyxia, with Emmert's procedure, a standard surgical method that is virtually identical to the Winograd-type procedure, in a prospective study of 41 patients (21 in the brace group and 20 in the Emmert procedure group). Pain due to treatment was significantly lower in the brace group than in the Emmert procedure group, and patients in the brace group could wear regular shoes again without appreciable pain much earlier than those in the Emmert procedure group. In the brace group, there were four recurrences, and one patient was still receiving treatment at the end of follow-up; in the Emmert procedure group, there were three recurrences. None of the patients in the brace group had to take time off from work, whereas in the Emmert procedure group, working patients were off from work for an average of 14.7 days. Brace treatment proved to be a good conservative alternative to operative procedures.

Tumor site predicts outcome after radiochemotherapy in squamous-cell carcinoma of the anal region: long-term results of 101 patients.

PURPOSE: This study was designed to assess the long-term results following radiochemotherapy in patients with anal squamous-cell carcinoma and to evaluate the impact of tumor location on response, survival, and colostomy-free survival. PATIENTS AND METHODS: Between 1985 and 2001, a total of 101 patients with anal carcinoma were registered for curative treatment, of whom 77 had involvement of the anal canal alone, 10 cases had extension into the perianal skin, and 14 patients had pure anal margin tumors. Small tumors of the anal margin were not included since they were treated by surgical excision only. Among the 101 patients were 74 women and 27 men with a median age of 62 (range, 26-84) years. T categories (International Union against Cancer) were T1 (15), T2 (36), T3 (34), and T4 (16). Seventy-one patients had no evidence of nodal disease, whereas 30 presented with involved regional nodes. Radiation treatment was directed to the primary tumor region and to the inguinal, perirectal, and internal iliac nodes using a three-field to four-field box technique with 10MV photons up to a total dose of 5040 cGy. Lesions greater than 5 cm received an additional boost by interstitial or external radiation depending on circumferential extension of the residual tumor. All patients were scheduled for simultaneous chemotherapy with two cycles of 5-fluorouracil at a dose of 1000 mg/m (2)/day as 120 hours of continuous intravenous infusion on Days 1 to 5 and 29 to 33 and mitomycin C at 10 mg/m (2)/day on Days 1 and 29. Median follow-up time was was 7.5 (range, 1-16) years. RESULTS: Overall survival and colostomy-free survival rates for patients with anal canal cancer were 75 percent and 87 percent at five years, respectively. Patients with anal margin cancer had a less favorable outcome with five-year-overall and colostomy-free survival rates of 54 percent and 69 percent, respectively. After correction for imbalance between anal canal and anal margin tumors, i.e., exclusion of T1 tumors of the anal canal, difference in overall survival remained significant (73 percent vs. 54 percent, P = 0.01). Following multivariate analysis, tumor location (anal canal vs. anal margin, P = 0.02), age (P = 0.003), and dose intensity of chemotherapy (< or =75 percent vs. >75 percent, P = 0.03) remained independent significant factors for overall survival. Initial tumor response at six weeks (P = 0.03) was predictive for colostomy-free survival. CONCLUSIONS: With colostomy-free survival rates around 85 percent, long-term treatment results for anal canal carcinoma have reached a satisfactory level. However, patients with larger lesions of the perianal skin are at high risk for locoregional recurrence and possible treatment intensification in this subgroup seems desirable.