Deep Learning and High-Resolution Anoscopy: Development of an Interoperable Algorithm for the Detection and Differentiation of Anal Squamous Cell Carcinoma Precursors-A Multicentric Study.

High-resolution anoscopy (HRA) plays a central role in the detection and treatment of precursors of anal squamous cell carcinoma (ASCC). Artificial intelligence (AI) algorithms have shown high levels of efficiency in detecting and differentiating HSIL from low-grade squamous intraepithelial lesions (LSIL) in HRA images. Our aim was to develop a deep learning system for the automatic detection and differentiation of HSIL versus LSIL using HRA images from both conventional and digital proctoscopes. A convolutional neural network (CNN) was developed based on 151 HRA exams performed at two volume centers using conventional and digital HRA systems. A total of 57,822 images were included, 28,874 images containing HSIL and 28,948 LSIL. Partial subanalyses were performed to evaluate the performance of the CNN in the subset of images acetic acid and lugol iodine staining and after treatment of the anal canal. The overall accuracy of the CNN in distinguishing HSIL from LSIL during the testing stage was 94.6%. The algorithm had an overall sensitivity and specificity of 93.6% and 95.7%, respectively (AUC 0.97). For staining with acetic acid, HSIL was differentiated from LSIL with an overall accuracy of 96.4%, while for lugol and after therapeutic manipulation, these values were 96.6% and 99.3%, respectively. The introduction of AI algorithms to HRA may enhance the early diagnosis of ASCC precursors, and this system was shown to perform adequately across conventional and digital HRA interfaces.

Comparison between anal cytology, high-resolution anoscopy and HPV DNA genotyping by polymerase chain reaction in the post-treatment follow-up of condylomata acuminata.

AIM: to evaluate the presence of subclinical HPV-induced anal lesions with anal cytology, High-Resolution Anoscopy (HRA) and HPV genotyping by polymerase chain reaction (PCR) in the follow-up of treated condylomata acuminata (CA). METHODS: seventy-nine male patients were included. One month after anal CA eradication, the patients underwent brush samples collection for anal cytology and PCR, and HRA with biopsy of acetowhite lesions. These methods were compared within all patients and between groups, according to Human Immunodeficiency Virus (HIV) infection status: HIV-negative; HIV-positive with TCD4 count above and below 350 cells/mm3. RESULTS: the most frequent HPV types were 6 and 16. HPV DNA was isolated in 92%. HIV infection was associated with a higher number of oncogenic HPV types (p=0.038). All patients with negative PCR had negative HRA and cytology. There were no differences in cytological, HRA or histopathological findings between groups. CONCLUSION: the association of the findings of cytopathology, HRA and genotyping of HPV refined the diagnosis of HPV-induced lesions. The degree of immunodeficiency was not associated with increase in remnant HPV-induced anal lesions.

[Undetected surgical glove perforation during emergency procedures]. / Perfurações não detectadas de luvas em procedimentos de urgência.

OBJECTIVE: Gloves are the most important barriers that protect hospital personnel and patients. Unfortunately, glove perforation rates reach up to 78% in high risk procedures. The purpose of this prospective study was to evaluate the glove perforation rate in emergency procedures carried out in the Emergency Service of 'Santa Casa de São Paulo', School of Medicine. METHODS: The study analyzed all gloves used in the emergency room during a 2 months period. Gloves were tested immediately after the surgical procedure using the approved standardized water leak method. RESULTS: A total of 252 surgical gloves used by residents in 42 surgical procedures and 2361 gloves used in emergency procedures were tested for the presence of punctures by the water insuflation method. Forty one (16.3%) of the gloves tested showed at least one puncture, 18 (33%) in traumatic emergencies. The overall perforation rate in the emergency room was 7,3%. CONCLUSION: We concluded that the incidence of punctures in gloves during surgical procedures was high, and occurred mostly with surgeons.

Comparative study between amputation of the rectum in the classic Lloyd-Davies position and in ventral decubitus. / Estudo comparativo entre a amputação de reto na posição clássica de Lloyd-Davies e em decúbito ventral.

OBJECTIVE: to evaluate the benefits and disadvantages of the ventral decubitus position compared with that of Lloyd-Davies in patients submitted to abdominoperineal amputation of the rectum. METHODS: we conducted a retrospective study of 56 patients submitted to abdominoperineal amputation of the rectum due to distal rectal and anal canal neoplasms, treated at the Central Hospital of the Santa Casa de Misericórdia in São Paulo between 2008 and 2017. RESULTS: patients' mean age was 63.08 years, 48.2% of them women and 51.8%, men. Adenocarcinoma was the histological type, in 94.6% of cases, and squamous cell carcinoma, in 5.4%. The position of Lloyd-Davies was adopted in 66.1% of the procedures, and the ventral position, in 33.9%. At the time of surgery, four patients had synchronous metastases: hepatic (one case), pulmonary (one case) and simultaneous liver and lung (two cases). Neoadjuvant treatment was performed in 85.7% of the patients. Late postoperative complications occurred in 13 patients operated in the classic position and in one patient operated on in the ventral decubitus position. The overall survival time for the group operated in the classic position was on average 45.7 months, while in the group operated on in the ventral decubitus position it was 15.5 months. CONCLUSION: the ventral position group presented less need for intraoperative intravenous volume infusion and fewer postoperative complications, whereas the Lloyd-Davies group had better surgical and anesthetic times. Relapse, disease-free time, and overall survival should be evaluated at a longer follow-up time.

OBJETIVO: avaliar benefícios e desvantagens do posicionamento em decúbito ventral em relação ao de Lloyd-Davies, de pacientes submetidos à amputação abdominoperineal de reto. MÉTODOS: estudo retrospectivo de 56 pacientes submetidos à amputação abdominoperineal de reto por neoplasias de reto distal e de canal anal, tratados no Hospital Central da Santa Casa de Misericórdia de São Paulo entre 2008 e 2017. RESULTADOS: a média de idade dos pacientes foi de 63,08 anos, sendo 48,2% deles mulheres e 51,8%, homens. Adenocarcinoma foi o tipo histológico em 94,6% dos casos e carcinoma espinocelular em 5,4%. A posição de Lloyd-Davies foi a adotada em 66,1% das cirurgias e a posição ventral em 33,9%. No momento da cirurgia quatro pacientes apresentavam metástases sincrônicas: hepática (um caso), pulmonar (um caso) e hepática e pulmonar simultâneas (dois casos). Tratamento neoadjuvante foi realizado em 85,7% dos pacientes. Complicações pós-operatórias tardias ocorreram em 13 pacientes operados na posição clássica e em um paciente operado em decúbito ventral. O tempo de sobrevida global para o grupo operado na posição clássica foi, em média, de 45,7 meses, enquanto que no grupo operado em decúbito ventral foi de 15,5 meses. CONCLUSÃO: o grupo da posição ventral apresentou menor necessidade de infusão de volume intravenoso intraoperatório e menos complicações pós-cirúrgicas tardias, enquanto que o grupo Lloyd-Davies obteve melhores tempos cirúrgicos e anestésicos. Recidiva, tempo livre de doença e sobrevida global devem ser avaliados em um tempo maior de seguimento.

Comparative analysis of anal colposcopy with histology in the follow-up of patients under treatment for anal condyloma

Objectives: To compare morphological abnormalities on anal colposcopy against histology to determine anal high-grade squamous intraepithelial lesions (HSILs). Methods: This is a retrospective data assessment of HIV-negative and HIV-positive patients undergoing outpatient follow-up. The sample comprised 54 patients presenting acetowhite lesions on anal colposcopy. Acetowhite lesions were classified according to their morphology into punctation, verrucous, mosaic, ulcerated, or hypervascularized, and biopsies of these specimens were classified as anal HSIL, low-grade squamous intraepithelial lesion (LSIL), or normal. The data were analyzed using SPSS forWindows version 13.0 (SPSS Inc., Chicago, IL, USA). The results were analyzed using the nonparametric Mann-Whitney test, the Fisher exact test and the chi-squared parametric test. A 95% confidence interval (CI) was used and a level of significance <5% was adopted for all statistical tests. Results Fifty-four patients (50 males, 80% HIV+) with biopsied acetowhite lesions were assessed. There were 31 punctation lesions, 1 classified as HSIL (3.2%; 95%CI: 0- 40.0), 17 verrucous lesions, 3 HSIL (17.7%; 95%CI: 0-10.7), and 1 ulcerated, classified as HSIL (100%), and 4 mosaic and 1 atypical vessel lesion, all classified as LSIL. The results showed no association of presence of anal HSIL with positivity for HIV infection or with counts above or below 500/µl in HIV+patients. Statistical analysis was performed using the Mann-Whitney nonparametric test, the Fisher exact test, and the chi-squared parametric test. Conclusion: The comparison of morphological findings on anal colposcopy against histology revealed no morphological pattern suggesting anal HSIL. (AU)

Porokeratosis ptychotropica: a rare manifestation with typical histological exam.

Porokeratosis is a disorder of epidermal keratinization characterized clinically by a distinctive ridge-like border, and histologically by cornoid lamellae. The known clinical variants of porokeratosis are: classic porokeratosis of Mibelli, disseminated superficial (actinic) porokeratosis (DSAP), porokeratosis palmaris et plantaris disseminata, linear porokeratosis and punctate porokeratosis. In 1995, a seventh form was described as porokeratosis ptychotropica: a verrucous form resembling psoriasis involving the gluteal cleft presenting on the histological exam multiple cornoid lamellae. There are very few reports in the literature of this clinical variant. The present study describes the case of a healthy male presenting gluteal hyperkeratotic plaques for 22 years. He had been to several dermatologists, none of them had achieved a definitive diagnosis. We present a typical clinical presentation and its dermoscopy findings, in addition to histological examination that confirmed the diagnosis.

Impact of neoadjuvant therapy in downstaging of lower rectal adenocarcinoma and the role of pelvic magnetic resonance in staging.

OBJECTIVE: to evaluate the effect of neoadjuvant therapy on the stage (TNM) of patients with rectal adenocarcinoma and validate the use of MRI as a method of determining locoregional stage. METHODS: we conducted a retrospective study of 157 patients with lower rectum adenocarcinoma, whom we divided into two groups: Group 1, 81 patients (52%) who had undergone surgical treatment initially, with the purpose to analyze the accuracy of locoregional staging by pelvic magnetic resonance imaging throug the comparison of radiological findings with pathological ones; Group 2, 76 patients (48%), who had been submitted to neoadjuvant therapy (chemotherapy and radiation) prior to definitive surgical treatment, so as to evaluate its effects on the stage by comparing clinical and radiological findings with pathology. RESULTS: In group 1, the accuracy of determining tumor depth (T) and lymph node involvement (N) was 91.4% and 82.7%, respectively. In group 2, neoadjuvant therapy decreased the T stage, N stage and TNM stage in 51.3%, 21% and 48.4% of cases, respectively. CONCLUSION: neoadjuvant therapy in patients with rectal adenocarcinoma is effective in decreasing disease stage, and pelvic magnetic resonance imaging is effective for locoregional staging. OBJETIVO: avaliar o efeito da terapia neoadjuvante, nos pacientes portadores de adenocarcinoma de reto, sobre o estádio (TNM) e validar o emprego da ressonância magnética como método de determinação do estádio locorregional. MÉTODOS: estudo retrospectivo de 157 pacientes com diagnóstico de adenocarcinoma de reto baixo, que foram divididos em dois grupos: Grupo 1, 81 pacientes (52%), submetidos ao tratamento cirúrgico de princípio, cuja finalidade foi analisar a acurácia da determinação do estádio locorregional pela ressonância magnética da pelve, através da comparação entre os achados radiológicos e os achados anatomopatológicos; Grupo 2, 76 pacientes (48%), encaminhados à terapia neoadjuvante (quimioterapia e radioterapia), antes do tratamento cirúrgico definitivo, com o intuito de avaliar seus efeitos sobre o estádio, através da comparação dos achados clínico-radiológicos com os anatomopatológicos. RESULTADOS: no grupo 1, a acurácia da determinação da profundidade da lesão (T) e do comprometimento linfonodal (N), foram de 91,4% e 82,7%, respectivamente. No grupo 2, a terapia neoadjuvante diminuiu o estádio T, estádio N e o estádio TNM em 51,3%, 21% e 48,4% dos casos, respectivamente. CONCLUSÃO: a terapia neoadjuvante nos pacientes com adenocarcinoma de reto é efetiva na diminuição do estádio e a ressonância magnética da pelve é eficaz na determinação do estádio locorregional.

Scenario of elective colorectal oncology surgeries during the COVID-19 pandemic / Cenário das cirurgias colorretais oncológicas eletivas em meio à pandemia de COVID-19

The COVID-19 pandemic has changed the world health scenario, causing numerous problems related to the overload of services. In this scenario, the approach to oncological diseases becomes a challenge, considering the risk of progression of cancer disease and death due to delay in diagnosis and treatment. Faced with this exceptional situation, coloproctology services have been forced to change their routine to adapt to the new reality, considering risks and benefits in the conduct of these patients. Thus, the experience of the coloproctology service at the Santa Casa de São Paulo, São Paulo, state of São Paulo, Brazil, during the beginning of the COVID-19 pandemic is described, evaluating the possibility of maintaining elective oncological surgeries through selection by directed anamnesis. Method: Retrospective cohort study with prospective collection comparing colorectal surgery for cancer before and during the pandemic from December 2019 to July 2020. Results: In total, 81 patients were included. During the pandemic, 41 patients were operated on with 2 perioperative contaminations by COVID-19. Both length of stay and complications were not different between groups. Conclusion: Since there was no increase in COVID-19 morbidity and mortality in elective oncology surgeries with patients screened for guided anamnesis, it is worth considering this method for maintaining surgical procedures even in the event of apandemic. (AU)

A pandemia do COVID-19 modificou o cenário mundial da saúde, ocasionando inúmeros problemas relacionados à sobrecarga dos serviços. Neste contexto, a abordagem das doenças oncológicas se tornou um desafio, tendo em vista que o atraso no diagnóstico e no tratamento oncológico resulta emmaior risco de progressão de doença e óbito. Frente a esta situação excepcional, os serviços de coloproctologia foram obrigados a mudar a rotina, considerando riscos e benefícios na condução dos pacientes. Assim, descreve-se a experiência do serviço de coloproctologia da Santa Casa de São Paulo, São Paulo, SP, Brasil, durante o início da pandemia de COVID-19, avaliando a possibilidade de manutenção das cirurgias eletivas oncológicas através da seleção por anamnese dirigida. Método: Coorte retrospectiva com coleta prospectiva comparando cirurgias colorretais oncológicas realizadas de dezembro de 2019 a julho de 20202, comparando casos operados antes e durante a pandemia. Resultados: No total, 81 pacientes foram incluídos. Durante a pandemia, 41 pacientes foram operados, com duas contaminações perioperatórias por COVID-19. Nem o tempo de internação nem as complicações foram diferentes entre os grupos. Conclusão: Uma vez que não houve aumento da morbimortalidade por COVID-19 nas cirurgias oncológicas eletivas com pacientes triados por anamnese dirigida, vale considerar este método para a manutenção dos procedimentos cirúrgicos mesmo em vigência da pandemia. (AU)

Tumor de Buschke-Lowenstein perianal: relato de dois casos tratados com podofilina em vaselina sólida 25% / Perianal Buschke-Lowenstein tumor: report of two cases treated with 25% podophyllin ointment

O tumor de Buschke-Lowenstein (TBL) é variante extremamente rara do condiloma acuminado que, apesar de manifestar-se clinicamente por lesões de grandes proporções, apresenta comportamento biológico e características histológicas benignas. Existem diversas abordagens terapêuticas disponíveis, muitas delas apoiando-se em abordagens cirúrgicas extensas e mutilantes. Apresentamos dois casos de pacientes com TBL tratados com podofilina tópica, cujas respostas terapêuticas foram extremamente favoráveis em ambos os casos.

Buschke-Lowenstein tumor (BLT) is an extremely rare variant of condylomata acuminata that despite being clinically presented by large lesions, presents a benign biological behavior and histological characteristics. There are a number of therapeutic approaches available, many of which rely on extensive and mutilating surgical procedures. We present two cases of patients with BLT treated with topical podophyllin whose therapeutic responses were extremely favorable in both cases.

Analyzing the prevalence of proctological diseases in HIV-positive and -negative patients / Análise da prevalência de doenças proctológicas em pacientes HIV positivo e negativo

ABSTRACT Objective: To compare proctological diseases in HIV-positive and -negative patients. Method: Prospective study conducted in the proctology outpatient clinic at Instituto de Infectologia Emílio Ribas from 2013 through 2019. All of them underwent anamnesis and proctological examination and were divided into two groups (HIV+ and HIV−). The groups were then compared with regard to age, sex, diagnosis, and whether or not there was any indication for surgery. Results: 485 HIV + patients (41.9%) (Group I) and 672 HIV− (58.1%) (Group II). The mean age in Group I was 42.8 years, and 404 (83.3%) of the patients were males. In Group II, the mean age was 48.3 years, and 396 (59%) patients were females. In comparing the groups, a statistically significant difference was found regarding sex, age, and diagnosis. The incidence of hemorrhoid and anal skin tags was higher in group II and that of condyloma acuminata was higher in in Group I (p < 0.001). In Group I, condyloma acuminata was more prevalent, but in those with CD4 levels above 500 cells/mm3, the diagnoses were more similar to those in the population without HIV. Conclusions: Proctological diseases were found to be similar but have different incidences. The incidences of diseases in HIV− and + patients tend to approach each other as CD4 level increases.

RESUMO Objetivo: Comparar as doenças proctológicas nos pacientes HIV positivos e negativos. Método: Estudo prospectivo realizado no ambulatório de proctologia do Instituto de Infectologia Emílio Ribas de 2013 a 2019. Todos foram submetidos a anamnese e exame proctológico, e divididos em dois grupos (HIV+ e HIV−) sendo comparados em relação a idade, sexo, diagnóstico e se havia ou não indicação cirúrgica. Resultados: 485 pacientes HIV+ (41.9%) (Grupo I) e 672 HIV negativos (58.1%) (Grupo II). A média de idade do Grupo I foi 42.8 anos sendo 404 (83.3%) do masculino. No grupo II, a média de idade foi de 48.3 anos, sendo 396 (59%) do sexo feminino. Comparando os grupos, houve diferença estatisticamente significante em relação ao sexo, idade e diagnóstico. Houve maior incidência de hemorróida e plicoma no Grupo II e condilomas acuminados no Grupo I (p < 0.001). No Grupo I, o condiloma acuminado foi mais prevalente, porém naqueles com CD4 acima de 500 células/mm3, os diagnósticos se aproximaram da população sem HIV. Conclusão: As doenças proctológicas foram semelhantes, com incidências diferentes. A incidências das doenças de pacientes HIV− e + tendem a se aproximar na medida que o nível do CD4 aumenta.

Comparison between anal cytology, high-resolution anoscopy and HPV DNA genotyping by polymerase chain reaction in the post-treatment follow-up of condylomata acuminata / Comparação entre citologia anal, colposcopia anal e genotipagem do HPV por reação em cadeia da polimerase no seguimento pós-operatório de condiloma acuminado

ABSTRACT Aim: to evaluate the presence of subclinical HPV-induced anal lesions with anal cytology, High-Resolution Anoscopy (HRA) and HPV genotyping by polymerase chain reaction (PCR) in the follow-up of treated condylomata acuminata (CA). Methods: seventy-nine male patients were included. One month after anal CA eradication, the patients underwent brush samples collection for anal cytology and PCR, and HRA with biopsy of acetowhite lesions. These methods were compared within all patients and between groups, according to Human Immunodeficiency Virus (HIV) infection status: HIV-negative; HIV-positive with TCD4 count above and below 350 cells/mm3. Results: the most frequent HPV types were 6 and 16. HPV DNA was isolated in 92%. HIV infection was associated with a higher number of oncogenic HPV types (p=0.038). All patients with negative PCR had negative HRA and cytology. There were no differences in cytological, HRA or histopathological findings between groups. Conclusion: the association of the findings of cytopathology, HRA and genotyping of HPV refined the diagnosis of HPV-induced lesions. The degree of immunodeficiency was not associated with increase in remnant HPV-induced anal lesions.

RESUMO Objetivo: avaliar a presença de lesões anais subclínicas HPV-induzidas com citologia anal, colposcopia anal e genotipagem de HPV por reação em cadeia da polimerase (PCR) no seguimento de condilomas anais tratados. Método: foram incluídos 79 pacientes do sexo masculino. Após um mês da erradicação de lesões condilomatosas anais, os participantes voltaram em consulta para coleta de amostras com escova para citologia anal e PCR, e colposcopia anal com biópsia de lesões acetobrancas. Os métodos de detecção das lesões foram comparados entre os pacientes e entre grupos, de acordo com o status de infecção pelo vírus da imunodeficiência humana (HIV): HIV-negativo; HIV-positivo com TCD4 acima ou abaixo de 350 células/mm3. Resultados: os tipos de HPV mais frequentes foram 6 e 16. Infecção pelo HIV foi associada a maior número de tipos de HPV oncogênicos (p=0,038). Todos os pacientes com PCR negativo apresentaram colposcopia e citologia negativos. Não houve diferença nos achados citológico, colposcópico ou histopatológico entre grupos. Conclusão: a associação dos achados citopatológico, colposcópico e PCR melhorou a acurácia do diagnóstico de lesões anais HPV-induzidas. O grau de imunodeficiência não foi associado a maior frequência de lesões anais HPV-induzidas remanescentes.

Local control of human papillomavirus infection after anal condylomata acuminata eradication.

OBJECTIVE: To verify whether the eradication of anal condylomata acuminata was effective for local control of HPV infection using anal colposcopy and anal brush cytology. METHODS: We evaluated 147 patients treated for anal margin and/or anal canal condyloma, with 108 HIV-positive and 39 HIV-negative individuals. The average age for males was 40 years for HIV-positive and 27.5 for HIV-negative. In females, the mean age was 37.5 years for HIV-positive and 31.5 for HIV-negative. RESULTS: Twenty-four patients (16.3%) had normal cytology and anal colposcopy, 16 (10.9%) normal cytology and altered anal colposcopy, 52 (35.4%) normal anal colposcopy and altered cytology, and 55 (37.4%) had altered cytology and anal colposcopy. CONCLUSION: the eradication of clinical lesions failed to locally control HPV infection.

Uso do imiquimode para tratamento da doença de Paget extramamária: série de quatro casos / Imiquimod use for the treatment of extramammary Paget disease: series of four cases

Introdução: A doença de Paget extramamária é constituída por adenocarcinoma da pele em áreas de glândulas apócrinas. Trata-se de neoplasia rara cujo tratamento cirúrgico aparenta resultados satisfatórios. Devido às altas taxas de recorrência, entretanto, as cirurgias são potencialmente mutilantes. O imiquimode é imunoestimulador tópico utilizado no tratamento de verrugas anogenitais e carcinomas in situ. Seu uso tem sido descrito na literatura científica para terapia da doença de Paget extramamária com resultados satisfatórios. Objetivo: Descrever a evolução de quatro casos de doença de Paget extramamária tratados com imiquimode, para avaliação da evolução e resposta terapêutica. Métodos: Foi realizado estudo retrospectivo em serviço de dermatologia da cidade de São Paulo com revisão de prontuários de todos os pacientes com diagnóstico de doença de Paget extramamária e tratados com imiquimode de janeiro de 2011 a julho de 2018. Resultados: Foram incluídos quatro pacientes, três com lesão vulvar e um com lesão em bolsa escrotal. Duas mulheres evoluíram com resolução total da doença, uma não apresentou alteração, e o homem evolui com regressão de 70% da lesão, sendo submetido à exérese cirúrgica de área consideravelmente menor do que a da lesão inicial. Conclusões: O imiquimode se apresenta como método terapêutico válido no tratamento da doença de Paget extramamária.

Introduction: Extramammary Paget disease consists of a cutaneous adenocarcinoma in areas of apocrine glands. It is a rare neoplasia, and its surgical treatment yields satisfactory results. However, due to the high recurrence rates, surgeries are potentially disfiguring. Imiquimod is a topical immune-stimulant used for the treatment of anogenital warts and in situ carcinomas. Its use has been described in the scientific literature for the treatment of Extramammary Paget disease with satisfactory results. Objective: Describe the course of four cases of Extramammary Paget disease treated with imiquimod, to evaluate evolution and therapeutic response. Methods: A retrospective study was performed in a service of dermatology in the city of São Paulo, with the review of medical records of all patients diagnosed with Extramammary Paget disease and treated with imiquimod from January 2011 to July 2018. Results: Four patients were included, three with vulvar lesion and one with scrotal lesion. Two women presented completed resolution of the disease, one did not respond and the man progressed with 70% regression of the lesion, having undergone surgical excision of a considerably smaller area than the initial lesion. Conclusions: Imiquimod presents as a valid therapeutic modality for the treatment of Extramammary Paget disease.

Estudo comparativo entre a amputação de reto na posição clássica de Lloyd-Davies e em decúbito ventral / Comparative study between amputation of the rectum in the classic Lloyd-Davies position and in ventral decubitus

RESUMO Objetivo: avaliar benefícios e desvantagens do posicionamento em decúbito ventral em relação ao de Lloyd-Davies, de pacientes submetidos à amputação abdominoperineal de reto. Métodos: estudo retrospectivo de 56 pacientes submetidos à amputação abdominoperineal de reto por neoplasias de reto distal e de canal anal, tratados no Hospital Central da Santa Casa de Misericórdia de São Paulo entre 2008 e 2017. Resultados: a média de idade dos pacientes foi de 63,08 anos, sendo 48,2% deles mulheres e 51,8%, homens. Adenocarcinoma foi o tipo histológico em 94,6% dos casos e carcinoma espinocelular em 5,4%. A posição de Lloyd-Davies foi a adotada em 66,1% das cirurgias e a posição ventral em 33,9%. No momento da cirurgia quatro pacientes apresentavam metástases sincrônicas: hepática (um caso), pulmonar (um caso) e hepática e pulmonar simultâneas (dois casos). Tratamento neoadjuvante foi realizado em 85,7% dos pacientes. Complicações pós-operatórias tardias ocorreram em 13 pacientes operados na posição clássica e em um paciente operado em decúbito ventral. O tempo de sobrevida global para o grupo operado na posição clássica foi, em média, de 45,7 meses, enquanto que no grupo operado em decúbito ventral foi de 15,5 meses. Conclusão: o grupo da posição ventral apresentou menor necessidade de infusão de volume intravenoso intraoperatório e menos complicações pós-cirúrgicas tardias, enquanto que o grupo Lloyd-Davies obteve melhores tempos cirúrgicos e anestésicos. Recidiva, tempo livre de doença e sobrevida global devem ser avaliados em um tempo maior de seguimento.

ABSTRACT Objective: to evaluate the benefits and disadvantages of the ventral decubitus position compared with that of Lloyd-Davies in patients submitted to abdominoperineal amputation of the rectum. Methods: we conducted a retrospective study of 56 patients submitted to abdominoperineal amputation of the rectum due to distal rectal and anal canal neoplasms, treated at the Central Hospital of the Santa Casa de Misericórdia in São Paulo between 2008 and 2017. Results: patients' mean age was 63.08 years, 48.2% of them women and 51.8%, men. Adenocarcinoma was the histological type, in 94.6% of cases, and squamous cell carcinoma, in 5.4%. The position of Lloyd-Davies was adopted in 66.1% of the procedures, and the ventral position, in 33.9%. At the time of surgery, four patients had synchronous metastases: hepatic (one case), pulmonary (one case) and simultaneous liver and lung (two cases). Neoadjuvant treatment was performed in 85.7% of the patients. Late postoperative complications occurred in 13 patients operated in the classic position and in one patient operated on in the ventral decubitus position. The overall survival time for the group operated in the classic position was on average 45.7 months, while in the group operated on in the ventral decubitus position it was 15.5 months. Conclusion: the ventral position group presented less need for intraoperative intravenous volume infusion and fewer postoperative complications, whereas the Lloyd-Davies group had better surgical and anesthetic times. Relapse, disease-free time, and overall survival should be evaluated at a longer follow-up time.

Condilomas anogenitais em crianças: análise descritiva de 20 casos / Anogenital condylomas in children: descriptive analysis of 20 cases

Introdução: A ocorrência de verruga anogenital em crianças é relativamente infrequente, porém gera angústias para a família e para o médico diante da possível associação com abuso sexual. Objetivo: Demonstrar casos de verruga anogenital em crianças e opções terapêuticas utilizadas. Métodos: Estudo retrospectivo descritivo de verrugas anogenitais em menores de 12 anos de idade, com média de idade de quatro anos, atendidos entre 2011 e 2015, em ambulatório público de doenças sexualmente transmissíveis na cidade de São Paulo. Resultados: Demonstramos 20 casos, sendo 12 crianças do sexo feminino e oito do sexo masculino. A localização preferencial das lesões foi em região perianal (70%), e 30% das crianças apresentavam verruga extragenital. O tratamento de escolha em 65% dos casos foi com medicamentos tópicos (podofilina e imiquimode). O tempo máximo para a cura foi de 20 semanas. Conclusões: O condiloma anogenital foi mais frequente em meninas, a média de idade foi de quatro anos, a localização mais acometida foi a região perianal e apresentou boa resposta terapêutica com o tratamento tópico de escolha.

Introduction: The occurrence of anogenital warts in children is relatively rare, however it generates distress for the family and the physician regarding the possible association with sexual abuse. Objective: To demonstrate cases of anogenital wart in children and the therapeutic options used. Methods: Retrospective descriptive study of anogenital warts in children under 12 years of age, with a mean age of 4 years, treated between 2011 and 2015, in a sexually transmitted diseases public outpatient clinic in the Brazilian Southeast city of São Paulo. Results: The authors demonstrated 20 cases ­ of which 12 were female and 8 were male. The preferred location for the lesions was the perianal region (70%), with 30% of the children presenting extragenital warts. The treatment of choice in 65% of cases was the application of topical medication (podophyllin and imiquimod). The longest time to cure was 20 weeks. Conclusions: Anogenital condyloma was more frequent in girls, the mean age was 4 years, and the most affected site was the perianal region. The lesions had good therapeutic response with the application of the topical treatment of choice.

Submucosal lipoma simulating a malignant tumor of the left colon: a case report / Lipoma submucoso simulando tumor maligno de cólon esquerdo: relato de caso

Intestinal lipomas can occur anywhere in the gastrointestinal tract, and these tumors are more frequent in the colon. By being largely asymptomatic, colonic lipomas are usually found incidentally, as findings in colonoscopy examinations, in association with biopsy. Endoscopic or surgical resection is the therapeutic option, depending on the size of the tumor, its location, and the presence or absence of symptoms. In this study, we present a case of a 59-year old woman, with a descending colon lipoma histologically diagnosed only after surgical resection of the lesion. The approach was adopted according to the patient's clinical picture (intestinal bleeding, vomiting and weight loss), in addition to the occlusion of 80% of the colonic lumen observed in a colonoscopy.

Os lipomas intestinais podem ocorrer em qualquer parte do trato gastrointestinal, sendo mais frequente no cólon. Por serem em grande parte assintomáticos, os lipomas colônicos são usualmente encontrados acidentalmente como achados de exame de colonoscopia associada à biópsia. Como opções de tratamento, há a ressecção endoscópica ou cirúrgica, a depender do tamanho do tumor, sua localização e presença (ou não) de sintomas. Nesse relato, é apresentado um caso de uma mulher de 59 anos com lipoma de cólon descendente, diagnosticado histologicamente apenas após ressecção cirúrgica da lesão. A conduta foi adotada pelo quadro clínico de enterorragia, vômitos e perda ponderal, além da oclusão de 80% da luz do cólon observada em exame de colonoscopia.

Porokeratosis ptychotropica: a rare manifestation with typical histological exam

Abstract: Porokeratosis is a disorder of epidermal keratinization characterized clinically by a distinctive ridge-like border, and histologically by cornoid lamellae. The known clinical variants of porokeratosis are: classic porokeratosis of Mibelli, disseminated superficial (actinic) porokeratosis (DSAP), porokeratosis palmaris et plantaris disseminata, linear porokeratosis and punctate porokeratosis. In 1995, a seventh form was described as porokeratosis ptychotropica: a verrucous form resembling psoriasis involving the gluteal cleft presenting on the histological exam multiple cornoid lamellae. There are very few reports in the literature of this clinical variant. The present study describes the case of a healthy male presenting gluteal hyperkeratotic plaques for 22 years. He had been to several dermatologists, none of them had achieved a definitive diagnosis. We present a typical clinical presentation and its dermoscopy findings, in addition to histological examination that confirmed the diagnosis.

Impact of neoadjuvant therapy in downstaging of lower rectal adenocarcinoma and the role of pelvic magnetic resonance in staging / Impacto da terapia neoadjuvante na diminuição do estádio no adenocarcinoma de reto baixo: papel da ressonância magnética da pelve na determinação do estádio

ABSTRACT Objective: to evaluate the effect of neoadjuvant therapy on the stage (TNM) of patients with rectal adenocarcinoma and validate the use of MRI as a method of determining locoregional stage. Methods: we conducted a retrospective study of 157 patients with lower rectum adenocarcinoma, whom we divided into two groups: Group 1, 81 patients (52%) who had undergone surgical treatment initially, with the purpose to analyze the accuracy of locoregional staging by pelvic magnetic resonance imaging throug the comparison of radiological findings with pathological ones; Group 2, 76 patients (48%), who had been submitted to neoadjuvant therapy (chemotherapy and radiation) prior to definitive surgical treatment, so as to evaluate its effects on the stage by comparing clinical and radiological findings with pathology. Results: In group 1, the accuracy of determining tumor depth (T) and lymph node involvement (N) was 91.4% and 82.7%, respectively. In group 2, neoadjuvant therapy decreased the T stage, N stage and TNM stage in 51.3%, 21% and 48.4% of cases, respectively. Conclusion: neoadjuvant therapy in patients with rectal adenocarcinoma is effective in decreasing disease stage, and pelvic magnetic resonance imaging is effective for locoregional staging.

RESUMO Objetivo: avaliar o efeito da terapia neoadjuvante, nos pacientes portadores de adenocarcinoma de reto, sobre o estádio (TNM) e validar o emprego da ressonância magnética como método de determinação do estádio locorregional. Métodos: estudo retrospectivo de 157 pacientes com diagnóstico de adenocarcinoma de reto baixo, que foram divididos em dois grupos: Grupo 1, 81 pacientes (52%), submetidos ao tratamento cirúrgico de princípio, cuja finalidade foi analisar a acurácia da determinação do estádio locorregional pela ressonância magnética da pelve, através da comparação entre os achados radiológicos e os achados anatomopatológicos; Grupo 2, 76 pacientes (48%), encaminhados à terapia neoadjuvante (quimioterapia e radioterapia), antes do tratamento cirúrgico definitivo, com o intuito de avaliar seus efeitos sobre o estádio, através da comparação dos achados clínico-radiológicos com os anatomopatológicos. Resultados: no grupo 1, a acurácia da determinação da profundidade da lesão (T) e do comprometimento linfonodal (N), foram de 91,4% e 82,7%, respectivamente. No grupo 2, a terapia neoadjuvante diminuiu o estádio T, estádio N e o estádio TNM em 51,3%, 21% e 48,4% dos casos, respectivamente. Conclusão: a terapia neoadjuvante nos pacientes com adenocarcinoma de reto é efetiva na diminuição do estádio e a ressonância magnética da pelve é eficaz na determinação do estádio locorregional.

Local control of human papillomavirus infection after anal condylomata acuminata eradication / Controle local da infecção perianal pelo papilomavirus humano após a erradicação dos condilomas acuminados

OBJECTIVE: To verify whether the eradication of anal condylomata acuminata was effective for local control of HPV infection using anal colposcopy and anal brush cytology. METHODS: We evaluated 147 patients treated for anal margin and/or anal canal condyloma, with 108 HIV-positive and 39 HIV-negative individuals. The average age for males was 40 years for HIV-positive and 27.5 for HIV-negative. In females, the mean age was 37.5 years for HIV-positive and 31.5 for HIV-negative. RESULTS: Twenty-four patients (16.3%) had normal cytology and anal colposcopy, 16 (10.9%) normal cytology and altered anal colposcopy, 52 (35.4%) normal anal colposcopy and altered cytology, and 55 (37.4%) had altered cytology and anal colposcopy. CONCLUSION: the eradication of clinical lesions failed to locally control HPV infection. .

OBJETIVO: verificar se a erradicação dos condilomas acuminados perianais foi efetiva no controle local da infecção pelo HPV, utilizando a colposcopia anal e a citologia anal com escova. MÉTODOS: avaliamos 147 pacientes tratados de condiloma da margem e/ou canal anal, sendo 108 HIV-positivos e 39 HIV-negativos. A média etária no sexo masculino foi 40 anos para os HIV-positivos e 27,5 anos para os HIV-negativos. No sexo feminino, a média etária foi 37,5 anos para os HIV positivos e 31,5 anos HIV-negativos. RESULTADOS: vinte e quatro pacientes (16,3%) apresentavam citologia e colposcopia normais, 16 (10,9%) citologia normal e colposcopia alterada, 52 (35,4%) citologia alterada e colposcopia normal e 55 (37,4%) citologia e colposcopia alteradas. CONCLUSÃO: a erradicação das lesões clínicas não controlou localmente a infecção pelo HPV. .

Evolução dos doentes com citologia oncótica alterada e colposcopia anal normal / Outcome of patients with anal oncotic cytology alterations and normal anal colposcopy

A citologia anal vem sendo usada para rastreamento do carcinoma anal e suas lesões precursoras nas populações de risco. Quando o raspado do canal anal mostra alterações citológicas está indicada o exame com colposcópio e ácido acético para identificar e realizar biópsia para confirmar o achado. Poucos estudos mostram o seguimento dos doentes tratados de condilomas acuminados perianais. Temos usado os métodos em associação e encontrado lesões subclínicas em metade dos doentes, cujo exame proctológico não revelava doença HPV induzida. Essas lesões são tratadas com tópicos. Entretanto, algumas citologias estavam alteradas e a colposcopia anal não revelou doença HPV induzida. O objetivo deste estudo foi observar o comportamento dessas lesões no seguimento semestral, durante 12 meses, e avaliar se a periodicidade da reavaliação foi suficiente para evitar o aparecimento das lesões de alto grau ou superior. Encontramos 58 (21 por cento) entre 273 doentes nessas condições. As reavaliações de 22 deles após um ano mostraram que as colposcopias permaneceram normais em 17 (74 por cento), sendo que em cinco (22 por cento) a citologia voltou aos padrões normais e 12 (52 por cento) persistiram com alterações. Os outros seis (26 por cento) desenvolveram lesões clínicas ou subclínicas provocadas pelo HPV. As contagens de linfócitos T CD4 dos doentes HIV-positivos foram inferiores nos doentes cujas lesões progrediram. Os resultados permitiram concluir que as alterações podem progredir ou regredir neste grupo distinto de doentes, sendo relacionada à imunidade, e que o intervalo de seis meses é suficiente para cada reavaliação.

Anal cytology has been used for screening the anal carcinoma and its precursors in risk populations. When anal canal smear shows cytological alterations, examination with colposcope and acetic acid is indicated to identify and perform biopsy to confirm the finding. Few studies show the follow-up of patients treated with anal HPV induced lesions. We are using both methods in association and subclinical lesions have been found in 50 percent of patients, whose proctological examinations are free from HPV lesions. However, some smears have cytological alterations, despite anal colposcopy being normal. The aim of this study was to observe these lesions' behavior in a six-month follow-up, during a year, and to assess whether this periodicity of re-evaluations was enough to avoid high grade or superior lesions. We have found 58 (21 percent) among 273 patients with these parameters. One year re-evaluations of 22 of the patients showed that anal colposcopies remained normal in 17 (74 percent). In five (22 percent), the cytology returned to normality and in 12 (52 percent), the same abnormality was seen. The other six patients (26 percent) developed clinical or subclinical HPV induced lesions. T CD4+ lymphocytes counts of HIV-positive patients were inferior in those whose lesions progressed. These results permitted us to conclude that cytological alterations can progress or clear in these patients, and they have close relationship with the immunity, and the six-month interval is enough to each re-evaluation.