Anal intraepithelial neoplasia associated with high-grade vulva injury (usual-type vulvar intraepithelial neoplasia): surgical treatment with cutaneous flap advancement

The aim of the present article is to report the case of a young patient with bowenoid papulosis who was a carrier of other sexually-transmitted infections (STIs), such as HIV and high-grade vulva lesion (usual-type vulvar intraepithelial neoplasia, VIN), and to demonstrate the strategy used to manage the case, as well as to discuss important issues regarding the standardization of intraepithelial lesions. (AU)

Estudio comparativo de los resultados del tratamiento del carcinoma anal escamoso en los pacientes HIV positivos y negativos / Comparative study of the results of the treatment of squamous anal carcinoma in HIV positive and negative patients

Introducción: El tratamiento del carcinoma anal escamoso (CAE) en los pacientes HIV positivos resulta controvertido. Si bien las guías actuales recomiendan realizar en los pacientes con buen estado inmunológico la quimiorradioterapia (QRT) concurrente estándar, algunos autores consideran que estos pacientes presentan mayor toxicidad y peores resultados a largo plazo, por lo que requerirían un abordaje diferente. El objetivo de este trabajo es comparar los resultados del tratamiento del CAE en los pacientes VIH positivos y negativos. Diseño: Estudio retrospectivo comparativo. Pacientes y métodos: Se revisaron retrospectivamente las historias clínicas de los pacientes tratados en el Sector Coloproctología, Hospital Fernández, entre 01/2007 y 10/2018. Los del conducto anal se dividieron en: Grupo I: VIH negativos y Grupo II: VIH positivos. Se compararon variables demográficas, factores de riesgo específicos, estadificación, QRT (drogas, toxicidad y respuesta), tratamiento quirúrgico curativo/paliativo, persistencia/recurrencia y supervivencia específica y global. Resultados: Se incluyeron 28 pacientes (18 mujeres); margen: 2, conducto: 26 (Grupo I: 15. Grupo II: 11). Los VIH positivos eran en su mayoría hombres que tienen sexo con hombres vs. 100% de mujeres VIH negativas (p<0,01), más jóvenes (45,2±0,9 vs. 63,6±8; p<0,01) y tabaquistas (82% vs. 27%; p=0,005). No hubo diferencia significativa en la estadificación, aunque el Grupo II tuvo tumores con complicaciones más severas. Pudieron completar el tratamiento: Grupo I: 93%, Grupo II: 64% (p<0,05). Tuvieron respuesta completa a la QRT 13/14 (93%) pacientes del Grupo I y 3/7 (43%) del Grupo II (p<0,01). Hubo 3 recurrencias, 2 locorregionales y 1 a distancia (p=NS). Los VIH positivos requirieron más cirugías (82% vs. 27%; p<0,01). A 5 pacientes (4 del Grupo II) se les realizó una resección abdominoperineal (RAP). Tuvieron colostomía definitiva, con o sin RAP, el 46% de los pacientes, la mayoría VIH positivos (82% vs. 27%; p=0,002). En los VIH positivos el RR de mortalidad por cáncer fue 4 (IC95%: 1,01-16,5; p=0,02) y el RR de mortalidad global fue 5,45 (IC95%: 1,42-20,8; p=0,002). Tuvieron menor supervivencia, tanto global (p=0,001) como libre de enfermedad (p=0,01). Mediana de seguimiento: 27 meses (4-216).Conclusiones: Los pacientes VIH positivos con CAE se diferenciaron de los VIH negativos en una menor tasa de respuesta completa a la QRT y una mayor necesidad de tratamiento quirúrgico. Además, tuvieron una supervivencia global y libre de enfermedad significativamente menor que los VIH negativos. (AU)

INTRODUCTION: The treatment of anal squamous cell carcinoma (SCC) in HIV-positive patients is controversial. Although current guidelines recommend performing standard concurrent chemoradiotherapy (CRT) in patients with good immune status, some authors believe that these patients have greater toxicity and worse long-term results, so they would require a different approach. The purpose of this study was to compare the results of SCC treatment in HIV-positive and HIV-negative patients.DESIGN: Comparative retrospective study.PATIENTS AND METHODS: The records of patients treated in the Coloproctology Section, Hospital Fernández, between 01/2007 and 10/2018 were retrospectively reviewed. Those of the anal canal were divided into: Group I: HIV-negative and Group II: HIV-positive. Demographic variables, specific risk factors, staging, CRT (drugs, toxicity, and response), curative/palliative surgical treatment, persistence/recurrence, and cancer-specific and global survival were compared.RESULTS: 28 patients (18 women), margin: 2, conduit: 26 (Group I: 15. Group II: 11). The HIV-positive were mostly men who have sex with men (vs. 100% HIV-negative women; p<0.01), younger (45.2 ± 0.9 vs. 63.6 ± 8; p<0.01) and smokers (82% vs. 27%; p=0.005). There was no significant difference in staging, although Group II had tumors with more severe complications. Completed the treatment: Group I: 93%, Group II: 64% of patients (p<0,05). Thirteen out of 14 (93%) patients in Group I, and 3/7 (43%) patients in Group II had a complete response to CRT (p<0.01). There were 3 recurrences, 2 loco-regional and 1 distance (p=NS). HIV-positive required more surgery (82% vs. 27%; p<0.01). 5 patients (4 of Group II) underwent an abdominal-perineal resection (APR). Forty six percent of patients had permanent colostomy, with or without APR, most of them were HIV-positive (82% vs. 27%; p=0.002). In HIV-positive patients, the RR of cancer mortality was 4 (95% CI: 1.01-16.5; p=0.02) and the RR of overall mortality was 5.45 (95% CI: 1.42-20, 8; p=0.002). They also had lower overall (p=0.001) and disease-free survival (p=0.01). Median follow-up: 27 months (4 - 216).CONCLUSION: HIV-positive patients with anal SCC were different from HIV-negative patients in that they had a lower complete response rate to CRT, and a greater need for surgical treatment. They had a significantly lower overall and disease-free survival than HIV-negative patients. (AU)

Tratamiento del cáncer de canal anal. Descripción de técnica y resultados de tratamiento radiante con o sin quimioterapia. Estudio retrospectivo en una población no seleccionada (1988 - 2016) / Treatment of cancer of the anal canal. Description of technique and results of radiation therapy with or without chemotherapy. Retrospective study in a non-selected population (1988 - 2016) / Tratamento do câncer de canal anal. Descrição de técnica e resultados de tratamento radiante comou sem quimioterapia. Estudo retrospectivo em uma população não selecionada (1988 - 2016)

Introducción: el cáncer de canal anal representa aproximadamente un 2% a 3% de todas las neoplasias digestivas. Nigro describió el tratamiento conservador del cáncer de canal anal utilizando radioterapia y quimioterapia con 5-fluorouracilo (5-FU) y mitomicina C (MMC), desde entonces este tratamiento es estándar. Objetivo: describir la técnica utilizada en nuestro servicio y los resultados en el control locorregional del cáncer de canal anal. Método: descriptivo, longitudinal, retrospectivo. Se analizaron historias de 72 pacientes consecutivos sin exclusiones, portadores de cáncer de canal anal, entre 1988 y 2016. El 67% recibió radioquimioterapia y el 33% de los pacientes radioterapia exclusiva por presentar contraindicaciones médicas específicas y fueron analizados en su conjunto. No se planificaron interrupciones en los tratamientos. Las interrupciones obligatorias fueron de 1 a 17 días con una media de 3 días. Las reacciones agudas fueron moderadas y no se comprobaron complicaciones tardías. Todos recibieron radioterapia locorregional. Resultados: el control local en N0 fue de 86% en T1 y T2 versus 42% en T3 y T4 a seis años, p=0,01 significativo. Conclusiones: la radioterapia con la técnica utilizada en nuestro servicio es efectiva en el tratamiento del cáncer de canal anal. La recidiva local ha sido la causa principal de persistencia lesional o recidiva. La curabilidad de la enfermedad está en relación directa con la extensión clínica/imagenológica de la lesión local.

Introduction: cancer of the anal canal accounts for approximately 2 to 3% of all digestive neoplasms. Nigro described the conservative treatment of cancer of the anal canal using radiation and chemotherapy of 5-fluorouracil (5-FU) and mitomycin-C (MMC). Since then, this is the standard therapy. Objective: to describe the technique used in our service and its results in the locoregional follow up of cancer of the anal canal. Method: descriptive, longitudinal, retrospective. The medical history of 72 consecutive patients with no exclusions, who were carriers of cancer of the anal canal were analysed between 1988 and 2016. 67% underwent radiation and chemotherapy and 33% only radiation therapy due to specific medical contraindications. All cases were comprehensively studied and no interruption of treatments were planned. Mandatory interruptions were from 1 to 17 days long and average length was 3 days. Severe reactions were moderate and no late complications were seen. All patients underwent locoregional radiation therapy. Results: local control in N0 was 86% in T1 and T2 versus 42% in T3 and T4 after 6 years p=0,01 meaningful. Conclusions: radiation therapy with the technique used in our service is effective to treat cancer of the anal canal. Local relapse has been the main cause of lesions or relapse. Curability of the disease is directly linked to the clinical/imaging extent of the local lesion.

Introdução: o câncer de canal anal representa aproximadamente 2 a 3% das neoplasias digestivas. Nigro descreveu o tratamento conservador do câncer de canal anal utilizando radioterapia e quimioterapia com 5-Fluorouracilo (5-FU) e Mitomicina C (MMC) que tem sido o tratamento padrão. Objetivo: descrever a técnica utilizada no nosso serviço e os resultados do controle locorregional do câncer de canal anal. Método: descritivo, longitudinal, retrospectivo. Foram analisados os prontuários de 72 pacientes consecutivos sem exclusões, portadores de câncer de canal anal, do período 1988-2016. 67% receberam radio quimioterapia e 33% radioterapia exclusivamente devido a contraindicações médicas específicas; os resultados foram analisados conjuntamente. Não se planejou interrupções nos tratamentos. As interrupções obrigatórias foram de 1 a 17 dias com uma média de 3 dias. As reações agudas foram moderadas e não se comprovaram complicações tardias. Todos receberam radioterapia locorregional. Resultados: o controle local em N0 foi de 86% em T1 e T2 versus 42% em T3 e T4 a 6 anos p=0,01 significativo. Conclusões: a radioterapia com a técnica utilizada no nosso Serviço é efetiva no tratamento do câncer de canal anal. A recidiva local foi a causa principal de persistência lesional ou recidiva. A curabilidade da enfermidade está diretamente relacionada com a extensão clínica e das imagens da lesão local.

Retalho VY de avanço após recidiva de neoplasia perianal: relato de caso e revisão da literatura / V-Y flap of advancement after the recurrence of perineal cancer: case report and literature review

Introdução: O câncer anal é uma doença rara, cuja incidência está aumentando. Os retalhos são opções complexas de fechamento quando abrangem grandes áreas. A região perineal pode ser acometida por extensas lesões, requerendo utilização de retalhos. Relato de Caso: Paciente feminina, 56 anos, diagnosticada com adenocarcinoma anal, foi submetida à cirurgia de amputação abdominoperineal do reto associada à radioterapia pós-operatória há 2 anos. Apresentou recidiva cutânea da lesão neoplásica, com indicação de ampliação de margem cirúrgica para controle da recidiva. Após ampla ressecção com margem de segurança o defeito cutâneo, optou-se por duplo retalho em V-Y com 15 cm de comprimento cada e espessura total do tecido celular subcutâneo (TCS) de região glútea para preenchimento do espaço morto deixado pela ressecção e avanço sobre o defeito. Implementou-se antibioticoprofilaxia endovenosa e profilaxia para trombose venosa profunda. Paciente evoluiu bem do procedimento sem intercorrências. Discussão: Retalho é um tecido que é mobilizado conforme sua anatomia vascular. Retalhos baseados no plexo subdérmico incluem os bipediculados, de avanço (V-Y), retalhos de rotação e transposição. Reconstruções de períneo são indicadas devido a tumores, traumas, infecções, queimaduras ou úlceras de pressão. A região anal é dividida em canal anal e margem anal. Dentre os tipos histológicos de neoplasia na região do canal anal, podem ser citados: carcinoma de células escamosas (histologia mais comum), adenocarcinoma, melanoma, carcinoma de pequenas células e sarcomas. O risco de recidiva locorregional, após tratamento, pode atingir cerca de 30% dos casos e é o padrão de recidiva mais frequente.

Introduction: Anal cancer is a rare disease, with an increasing incidence. Flaps are complex options for closing large areas. The perineal region may be affected by extensive lesions that require the use of flaps for repair. Case Report: A 56-year-old female patient with anal adenocarcinoma underwent abdominoperineal amputation surgery of the rectum with postoperative radiotherapy for 2 years. She had cutaneous recurrence of the neoplastic lesion with indication of surgical margin expansion to control the local recurrence. After extensive resection with safety margins of the skin defect, we selected double V-Y flap of length 15 cm each and a total thickness of the gluteal subcutaneous tissue (ST) to fill up the dead space caused by resection and advancement of the defect. Intravenous antibiotic prophylaxis and deep venous thrombosis prophylaxis were administered. The patient progressed well from the procedure, with no problems. Discussion: A flap is a tissue that is mobilized based on vascular anatomy. Flaps based on the subdermal plexus include bipedicle, advancement (V-Y), rotation, and transposition flaps. Perineum reconstructions are often indicated for tumors, trauma, infections, burns, or pressure sores. The anal region is divided into the anal canal and the anal margin. Among the histological types of anal cancer, the most prevalent are squamous cell carcinoma (most common histology), adenocarcinoma, melanoma, small cell carcinoma, and sarcomas. The risk of regional recurrence after treatment can reach approximately 30% of cases and is the most frequent recurrence pattern.

Carcinoma epidermoide del margen anal contra calidad de vida / Epidermoid carcinoma of the anal margin against the quality of life

La calidad de vida de los pacientes debe tenerse en cuenta. Esta representa el resultado final de la actuación médica desde la perspectiva del paciente. En ocasiones solo nos basamos en este criterio para tomar decisiones terapéuticas ante determinadas enfermedades, como el carcinoma epidermoide de margen anal en estadío terminal. El tratamiento y conducta con fines paliativos tiene como objetivo mejorar la calidad de vida de estas personas. Presentamos el caso de paciente varón de 48 años de edad que acude a consulta por presentar lesión en el ano que no le permitía sentarse y después de realizársele todo el estudio necesario para determinar su diagnóstico definitivo (carcinoma epidermoide de ano) evaluarlo y determinar el tratamiento requerido para el grado de la enfermedad, nos percatamos que el tratamiento radical no cambiaba la evolución de su estado y se decide tratamiento paliativo para mejorar la calidad de vida. En ocasiones acuden a consulta pacientes que al culminar su estudio, obtienen el diagnóstico de una enfermedad avanzada y es, a partir de este momento, que nuestro pensamiento médico debe cambiar y encaminar nuestros esfuerzos a mejorar la calidad de vida y no llevarlos a un final tormentoso con el objetivo de revertir la evolución de una enfermedad que no tiene regresión(AU)

The quality of life of patients should be always borne in mind since it represents the final outcome of medical performance from the viewpoint of the patient. Occasionally, this is the only element that we have at our disposal to make therapeutic decisions in order to manage certain diseases such as terminal epidermoid carcinoma of the anal margin. The treatment and the behavior for palliative care are aimed at improving the quality of life of these patients. This is the case of 48 years-old male who went to the doctor´s because he presented with anal injure that prevents him from seating. After making all the necessary tests to arrive to a final diagnosis (epidermoid carcinoma of the anus), to assess him and to indicate the required treatment according to the extent of disease, we realized that the radical treatment would not change his condition and then we decided to apply palliative treatment to improve his quality of life. Some patients come to this service, and after being fully examined, they are diagnosed with advanced disease. From this moment on, our medical thinking should change to direct our efforts to the improvement of their quality of life rather than to guide them to a stormy end to reverse the progression of a disease that has no regression(AU)

Avances en el diagnóstico precoz y tratamiento del cáncer de ano / Advances in the early diagnosis and treatment of anal cancer

El cáncer de ano es una neoplasia poco frecuente en la población general, pero, en poblaciones de riesgo, su incidencia sobrepasa al cáncer de cérvix en la era pre-Papanicolaou. El virus del HPV está directamente relacionado con su desarrollo, sumado a factores predisponentes, como infección por HIV, costumbres sexuales, hábito de fumar, inmunosupresión e infección genital por el primer virus. La detección precoz sólo está indicada a determinados grupos, con las muestras de citología anal y anoscopía de alta resolución como principales herramientas para diagnosticar y tratar las lesiones preneoplásicas. Un correcto diagnóstico histológico e imagenológico es indispensable para un tratamiento óptimo cuando estas lesiones progresan a cáncer, con nuevas técnicas radio-quimioterápicas, reservando cirugías de rescate con reconstrucciones perineales en caso de recaídas locales, que se diagnostican con un seguimiento adecuado.

Anal cancer is an unusual neoplasia in the general population, but, in at-risk populations, its incidence surpasses the cervical cancer in the pre-Papanicolaou test era. The HPV virus is directly related to its development, in addition to other predisposing factors such as infection caused by HIV, sexual behavior, smoking habit, immunosuppression and genital infection caused by the first virus. The early detection is only indicated to certain groups, with the anal cytology samples and the high resolution anoscopy being the main tools to diagnose and treat preneoplastic lesions. When these lesions develop into cancer, a proper histological and imaging diagnosis is essential to carry out an ideal treatment with new radiation therapy techniques, reserving salvage surgeries with perineal reconstructions for the cases of local reIapse, which are diagnosed with an appropriate monitoring.

Anorectal melanoma: review of diagnosis and treatment based on a case report

Anorectal Melanoma is a rare and very aggressive tumor that should be part of the range of differential diagnoses of colorectal diseases. Today, the main discussion on the topic is about the best treatment, whether it should be more conservative or more aggressive. In order to review the main points on the subject, the authors report a case of a patient treated at the Coloproctology Service at the São Lucas Hospital, PUCRS. (AU)

O melanoma anorretal é uma patologia de baixa frequência, porém de agressividade expressiva, devendo fazer parte da gama de diagnósticos diferenciais do Coloproctologista. A principal discussão sobre o tema versa hoje sobre a melhor forma de tratamento, seja mais invasivo ou mais conservador. A fim de revisar os principais pontos sobre o assunto, relataremos o caso de uma paciente atendida no Serviço de Coloproctologia do Hospital São Lucas da PUCRS. (AU)

Anus neoplasm: study of a case series

Anus neoplasm accounts for 2 to 4% of colorectal tumors, being more prevalent around the seventh and the eighth decades. Females are mostly affected, and the ratio is 3:1. Its increased prevalence amongst the population in the past years is probably related to the higher number of people that are affected by sexually transmitted diseases, mainly human papillomavirus (types 16 and 18, mostly) and/or the human immunodeficiency virus. Diagnosis is based on clinical findings and anatomopathological tests. The treatment of choice is radiochemotherapy, and the rescue surgery with abdominoperineal resection is used for recurrence and persistence cases. A retrospective and prospective longitudinal observational study was performed with 11 patients diagnosed with anal neoplasm from 2004 to 2010. Six (54.5%) were females and five (45.5%) were males. The incidence was higher in the sixth decade, at the mean age of 54.45 years. The most frequent histological type observed was the epidermoid carcinoma, and the most frequent cell differentiation type was the moderately differentiated. Chemotharapy associated with radiotherapy was used in 81.9% of the patients, and abdominoperineal resection was necessary as a rescue surgery in 18.2% of the patients. (AU)

Neoplasias do ânus correspondem de 2 a 4% dos tumores de intestino grosso, sendo predominante nas sétima e oitava décadas. A maior prevalência é em gênero feminino, com proporção de 3:1. O aumento da prevalência na população nos últimos anos provavelmente está relacionado ao número maior de pessoas com doenças sexualmente transmissíveis, principalmente o papilomavírus humano (tipos 16 e 18, mais comumente) e/ou o vírus da imunodeficiência humana. O diagnóstico é feito a partir de achados clínicos somados ao exame anatomopatológico. O tratamento de escolha baseia-se na radioquimioterapia, sendo a cirurgia de resgate com amputação abdominoperineal utilizada para casos de recidiva ou persistência. Foi feito um estudo observacional longitudinal retrospectivo e prospectivo, com 11 pacientes diagnosticados com neoplasia anal no período de 2004 a 2010. Seis (54,5%) eram do gênero feminino e 5 (45,5%) do masculino. O pico de incidência foi em sexta década, com média de idade de 54,45 anos. O tipo histológico mais encontrado foi o carcinoma epidermoide (72,7%), sendo o moderadamente diferenciado o mais frequente grau de diferenciação. A quimioterapia associada à radioterapia foi instituída em 81,9% dos pacientes, sendo necessária a cirurgia de amputação abdominoperineal como terapia de resgate em 18,2% dos pacientes. (AU)

Disease profile and treatment results of anal canal SCC: experience from AIIMS, New Delhi

Anal Canal squamous cell carcinoma [SSC] accounts for nearly 2% of all cancers of the alimentary tract. Over the past few years, the management of anal canal cancer has changed from primary surgery to primary chemoradiotherapy [CRT]. A total of 83 patients' [pts] records [62 males, 21 females] were retrospectively reviewed. Length of disease was <5 cm in 44 pts and confined to primary in 46 pts. Ten pts have anti-cancer therapy outside. We delivered radiotherapy [RT] alone to 16 pts, chemotherapy [CT] alone to 4 pts, CRT in 51 pts and pre-operative [pre-op] RT in 2 pts. RT dose was up to 30 Gray [Gy] =16; 30-50 Gy=12 and >50 Gy=41 pts. RT compliance was optimal in 64/69, grade [Gr] /= 2 in 13/69 pts. Thirteen pts [18.84%] were hospitalized during RT. No response [NR] was found in 4/83, <50% in 18/83, >50-<`00% in 39.83 and complete response [CR] in 22/83 pts. Recurrence at primary site was seen in 7 and loco-regional in 2 pts. Salvage therapy was done in all 9 pts [surgery =8 and CT=1]. Status at last follow up, alive without disease = 22/83 and with disease = 61/83. This retrospective analysis revealed that the advanced disease was in 47%, the optimal anti-cancer therapy could be delivered to 63.9%. Despite heterogeneity of patient population and management, the overall disease-free survival [DFS] with sphincter-preservation was achieved in 26.5% pts

Melanoma de ano / Melanoma of the anus

Objetivo: Las lesiones malignas del ano no son frecuentes. Entre 0,1 a 1 por ciento de estas corresponden a melanomas primarios de ano y en ellos se destacan su diagnóstico tardío, rápida progresión y mal pronóstico. Su tratamiento es todavía discutido. Se presenta un caso de melanoma primario de ano con revisión de la literatura. Pacientes y Métodos: Mujer de 69 años, sin antecedentes médico-quirúrgicos, consultó por hemoproctorragia y tumoración anal de 6 meses de evolución, de 6 cm de diámetro, indolora, de coloración oscura. Se realizó biopsia incisional. La anatomía patológica informó “melanoma”. La TAC de abdomen y pelvis demostró múltiples imágenes nodulares en hígado. Se realizó resección local. Resultados: Evolucionó favorablemente. Alta al 2º día. Se realizó adyuvancia con Dacarbazina (TTIC). Óbito a los 16 meses, con metástasis pulmonares. Conclusiones: El melanoma primario de ano es infrecuente. Su tratamiento es discutido, prefiriéndose la resección local en los pacientes con enfermedad avanzada por presentar ésta menor morbilidad con igual tasa de sobrevida.

Objective: The malign injuries of the anus are rare. Between 0,1 to 1 per cent of these correspond to melanoma primary of anus and in them stand out its diagnose delayed, fast progression and badly foretell. Its treatment still is discussed. A primary case of melanoma ofthe anus with revision of literature appears. Patients and methods: Woman of 69 years old without surgical or medical antecedents. She consult by bleeding and anal tumor of 6 months of evolution, of 6 cm, painless, of dark coloration. We are made incisional biopsy. The pathology informed melanoma. CT of abdomen and pelvis showed many images cleared in liver. We are made wide local excision with a negative margin. Results: She evolves favorably, whit hospital stay of two days. We are made adyuvancy with Dacarbazyne (TTIC). Development pulmonary metastasis. She was death 16 months after surgical treatment. Conclusions: Primary melanomas of the anus are infrequent. The treatment is discussed, preferring wide local resection in patients with disease outpost to present this one, smaller morbidity and equal rate of survival.

Resultados do tratamento do carcinoma espinocelular anal e do seu precursor em doentes HIV-positivos / Outcome of treatment of anal squamous cell carcinoma and its precursor in HIV-infected patients

OBJETIVO: A incidência de carcinomas espinocelulares anais vem aumentando nos doentes HIV-positivos. O tratamento consiste de radio e/ou quimioterapia, eventualmente seguidos pela ressecção do tumor. O objetivo é avaliar o seguimento desses doentes para verificar as recidivas e a evolução do NIAA para câncer. Apresentação da casuística da Equipe Técnica de Proctologia do Instituto de Infectologia Emílio Ribas, de São Paulo. MÉTODOS: Acompanhamos 45 doentes HIV-positivos portadores de carcinoma espinocelular anal e seu precursor no período de 1996 a 2006. Eram 30 neoplasias intra-epiteliais anais de alto grau (NIAA), tratadas com ressecção local e 15 carcinomas invasores do canal anal. Nove das 15 lesões invasivas foram submetidas ao esquema de Nigro isolado ou associado à ressecção local, amputação abdominoperineal ou colostomia para derivação. RESULTADOS: No seguimento ambulatorial das NIAA tivemos recidiva em 16,7 por cento e não observamos evolução para carcinoma, num período mínimo de três anos. Entre os nove tumores submetidos ao esquema de Nigro, com ou sem operação complementar, cinco estão livres de tumor. Nenhum tratamento foi feito em cinco doentes. Em três, devido às péssimas condições clínicas, e em dois, pois recusaram tratamento. Outro teve diagnóstico na vigência de oclusão intestinal sendo submetido à colostomia de derivação. CONCLUSÃO: Concluímos que a NIAA pode reincidir após excisão local em doentes HIV-positivos, mas não evolui para carcinoma invasor e que os doentes de câncer anal invasor podem ser tratados da mesma maneira que a população soronegativa para o HIV desde que as condições clínicas o permitam.

OBJECTIVE: Incidence of anal squamous cell carcinoma is increasing mainly among HIV-positive patients. Treatment consists of radiotherapy and chemotherapy, sometimes followed by tumor resection. The objective was to evaluate the follow-up of such patients to verify recurrences and evolution from HAIN to cancer. This is a report of cases treated at the "Instituto de Infectologia Emílio Ribas", Sao Paulo, Brazil. METHODS: We attended 45 HIV-positive patients between July 1996 and June 2006. Most were male (97.7 percent), with ages ranging from 23 to 55 years (mean: 38.5 years). Thirty patients had high grade anal intra-epithelial neoplasia (HAIN), treated with local resection, and 15 with anal canal invasive squamous cell carcinoma were first submitted to chemo radiation, while biopsies were obtained during follow-up. RESULTS: Patients with HAIN had recurrences in 16.7 percent of cases and remained cancer free for up to five years. Chemoradiation was not possible in five patients with invasive carcinoma (40 percent) because three had advanced AIDS and two refused treatment. Eight (88.8 percent) out of nine patients had complete response to chemoradiation and remained cancer free for a period from three to six years. Chemoradiation failed in the ninth patient: abdominal perineal resection was performed, and there was no recurrence over a five-year period. CONCLUSION: We concluded that HAIN can recur after local resection in HIV-positive patients but does not evolve to invasive carcinoma. Invasive cancer can be treated in the same way as in HIV seronegative persons, when clinical conditions permit.

Análise retrospectiva das neoplasias de ânus em pacientes atendidos no HC-FMRP-USP de 1979 a 2004 e revisão da literatura / Retrospective analysis of patients with anal tumors diagnosed at the school of medicine of Ribeirão Preto Hospital and clinics (HC-FMRP), between 1979 and 2004 and literature review

Foram analisados, retrospectivamente, 49 casos de pacientes com neoplasia de ânus, sendo 23 de 1979-1996 e 26 de 1997-2004, 49 por cento masculinos e 51 por cento femininos. Em 81,6 por cento dos pacientes o tratamento foi adjuvante, com radioterapia e esquema de NIGRO, 12,2 por cento metástases à distância e 36,7 por cento perderam o seguimento. Obitos ocorreram em 20,4 por cento. Notou-se diminuição da necessidade da cirurgia de Miles (30,8 por cento vs 43,3 por cento). A perda de seguimento foi menor (19,5 por cento vs 56,5 por cento), mas a mortalidade foi discretamente maior (23,1 por cento vs 17,4 por cento). O tratamento neo-adjuvante com radio e quimioterapia em 96 por cento dos pacientes com neoplasia anal foi capaz de promover remissão da lesão na maioria dos casos (57,5 por cento), confirmados pela biópsia da cicatriz residual, evitando-se amputação cirúrgica do reto. Dados mais recentes mostram que 45 por cento dos pacientes permanecem sem recidiva (seguimento médio 3,5 anos). A alta taxa de mortalidade e o diagnóstico de lesões avançadas podem decorrer da procura tardia do serviço médico.

In total, 49 cases of anal tumor were studied, 23 cases from 1979-1996 and 26 cases from 1997-2004. From the cases studied, 49 percent were male and 51 percent were female patients. Patients that were submitted to radio and chemotherapy by the "nigro scheme" totalized 81.6 percent; 12.2 percent presented metastasis, 36.7 percent lost follow up and 20.4 percent died. There was a reduction of the Miles surgery indication (30.8 percent vs 43.3 percent) and the follow up loss (19.5 percent vs 56.5 percent). The mortality rate was a little higher (23.1 percent vs 17.4 percent). Radio and chemotherapy was used in 96 percent of patients, and promoted lesion remission in 57.5 percent of cases (confirmed by negative anal scar biopsy), avoiding the anal amputation surgery indication. Recent data indicate that 45 percent of patients (3.5 years of average follow up) are still with no recidivated tumor. The prevalence of high mortality rates and the diagnosis of high stage lesions are due to a delay of patients in search for a diagnosis. This might be due to a difficult access to a medical service and to the low social-economical level of our patients. These conditions make the diagnosis and treatment of anal tumors difficult, impairing its prognosis.

Tratamento do carcinoma do canal canal com quimiorradioterapia ou radioterapia exclusiva / Localized Anal Canal Carcinoma treated by Chemoradiotherapy (CRT) or Radiatherapy (RT) Alone

O melhor esquema de quimioterapia (QT) no tratamento do carcinoma anal ainda permanece indeterminado. O esquema quimioterápico aceito como padrão é a combinação de mitomicina-C com a infusão venosa continua (CIVI) de 5-FU. Resultados preliminares de estudo de Fase III randomizado têm confirmado sua equivalência das taxas de resposta clínica e de cura quando comparada à taxas obtidas com a combinação de cisplatina e 5-FU. Atualmente, três estudos clínicos prospectivos e randomizados em desenvolvimento estão utilizando a combinação de CP como comparação para esclarecer esta questão. Entretanto, a utilização de quimiorradioterapia na população idosa (> 70 anos) nem sempre é possível, levando estes pacientes à radioterapia exclusiva com objetivo de preservação esfincteriana. Entre o período de 1987 e 2000, um total de 179 pacientes com carcinoma localizado de canal anal foi tratado no Instituto Nacional de Câncer (INCA) com QT/RXT. As combinações quimioterápicas utilizadas foram CP (100 mg/m2 dia1 e dia 28) com 5-FU (750-1000 mg/m2 CIVI no dia1 a dia 5 e no dia 28 ao dia 32) ou MMC (10 mg/m2 dia 1) com 5-FU (mesmo esquema de administração) seguido concomitantemente de RXT (4140 a 4500 cGy). Durante o mesmo período, um grupo de pacientes idosos (> 70 anos) foi tratado com RXT exclusiva (4140 a 4500 cGy) principalmente por não terem condições clínicas para receber QT. Os pacientes com doença persistente no sítio primário e com linfonodos clínicamente comprometidos receberam dose adicional de reforço de 10 Gy a 14,4 Gy, após um descanso das irradiações de 2 semanas. Noventa por cento dos pacientes do grupo da CP (80/86), oitenta e dois por cento do pacientes da MMC (75/93) e oitenta e oito por cento dos pacientes da RXT exclusiva (30/34) eram mulheres. A idade mediana foi de 58 anos (35-77), 55 anos (31-75) e 76 anos (70-87) para os pacientes da CP, MMC e RXT exclusiva, respectivamente. Pelos critérios de estadiamento da UICC de 1987, o número das categorias TX/1/2/3/4 dos pacientes da CP foram de 3/3/33/18/29, 5/3/27/26/30 para os pacientes da MMC e 1/0/15/11/7 para os pacientes da RXT. O número e a porcentagem para a categoria de linfoadenopatias N1/2/3 foram para CP, MMC e RXT, 1/16/11 (32,6%), 2/23/11 (39,6%) e 0/3/8 (32,3%), respectivamente. As taxas de respostas completas clínica foram semelhantes para ambos os grupos de QT/RXT (CP=72,1% e MMC=71,4%) e inferior para o grupo de RXT exclusiva (53%). Somente o sexo masculino teve um impacto negativo na predição de resposta completa (p = 0,01) à quimiorradiação. O seguimento mediano para a QT/RXT foi de 83 meses e para a RXT exclusiva 60 meses (variação 3-179 meses). As taxas de sobrevida atuarial livre de doença (SLD) e global (SG) em 10 anos foram para a CP 49% e 54%, e para a MMC 53% e 52%, respectivamente (p = 0,32 e p = 0,92). As taxas de sobrevida livre de colostomia foram para a CP = 73% e MMC = 65% (p=0,16)...

The optimal chemotherapy (CT) regimen for anal carcinoma remains undetermined. Mitomycin - C (MMC) with continuous venous infusion (CIVI) of 5-FU is still accepted as standard chemotherapy regime and it has been confirmed by preliminary results of recent randomized phase III trial, yielding equivalent response and cure rates to the Cisplatinum (CP) and 5-FU combination. Three prospective randomized clinical trials are currently using CP combinations for comparison to define this matter. However, CRT is not always appropriated to be used in the elderly population (> 70 years), driving these patients to be treated by radiotherapy alone. From 1987 to 2000, 179 patients with localized anal carcinoma were treated at the Brazilian National Cancer Institute (INCA) with CRT using CP (100 mg/m2 day1 and day28) plus 5-FU (750-1000 mg/m2 CIVI day1 to day5 and day28 to day32) or MMC (10 mg/m2 day1) plus 5-FU at same schedule, followed by concomitant RT (4140 to 4500 cGy). During the same period, a group of thirty-four aged patients were treated with RT alone (same dose above) mainly because they were not fit to receive chemotherapy. Additional RT (10.0 to 14.4 Gy) was given to patients with persistent disease at primary site and clínically involved nodal regions received after a twoweek radiation break. Ninety percent (80/86) of CP patients, 82% (75/93) of MMC patients and 88% (30/34) of RT alone patients were female. Median age was 58 years (35-77), 55 years (31-75) and 76 years (70 -87) for CP, MMC and RT alone patients, respectively. By UICC criteria of 1987, the number of TX/1/2/3/4 patients was 3/3/33/18/29 for CP patients, 5/3/27/26/30 for MMC patients and 1/0/15/11/7 for RT. The number of N1/2/3 and the percentage of lymphadenophaty for CP, MMC and RT were 1/16/11 (32,6%), 2/23/11 (39,6%) and 0/3/8 (32,3%), respectively. Complete response rate were similar in both CRT groups (CP = 72.1% and MMC = 71.4%) and inferior in RT alone group (53%). Only male gender had a negative effect on clínical complete response (p = 0.01) to chemoradiation. Median follow-up for CRT was 83 months and for RT alone 60 months (range 3-179). The actuarial 10- year overall (OS) and disease-free survival (DFS) rates for CP were 54% and 49% and for MMC 52% and 53% respectively. (p = 0.32 and p = 0.92). Colostomy-free survival (CFS) rates for CP and MMC were 73% and 65%, respectively (p=0.16). RT alone in aged patients had inferior actuarial 5-year OS and DFS rates (43% and 37%, respectively). However, in the early stages of disease acceptable survivals rates were reached (DFS = 59% and OS=55%). After multivariate analysis, male gender (p=0,042) and advanced T3/T4 disease (p<0.0001) were statistically significant for worse disease free survival. T3/T4 disease (P=0.039), and N+ disease (p=0.039), remained independently significant for overall survival. Long-term follow-up confirms the good results...

Imiquimod 5 por ciento tópico en control de carcinoma verrucoso inguinal: caso clínico: seguimiento a siete años / Imiquimod 5 percent cream in control of verrucous carcinoma: seven years follow up

El carcinoma de Verrucous en el área anogenital ha sido reportado bajo una variedad de nombres, incluyendo el condiloma acuminado gigante o tumor de Buschke-Loewenstein. Histológicamente, corresponde a un carcinoma espinocelular bien diferenciado. Se ha descrito una variedad de alternativas terapéuticas, siendo de primera elección la extirpación quirúrgica. El Imiquimod en crema al 5 por ciento representa un modificador tópico de la respuesta inmune. Actualmente está siendo utilizado en el tratamiento de una variedad de enfermedades cutáneas. Objetivo: Revisión del tema y presentación del primer caso de carcinoma verrucous anogenital tratado con cirugía shaving más criocirugía e imiquimod al 5 por ciento en crema con un seguimiento de siete años. Caso clínico: Paciente de sexo masculino, de 55 años, heterosexual, con antecedentes de lesión tumoral inguino-escroto-perineal derecha de 15 años de evolución y de crecimiento lentamente progresivo. Su primera consulta dermatológica se efectúa el 04.02.99. Se extirpa nódulo de tamaño mayor tamaño para examen histopatológico tipificación VPH por PCR (positivo para genotipos 6 y 11) Se diagnostica carcinoma espinocelular de bajo grado de malignidad. Se utilizaron en su tratamiento múltiples técnicas combinadas con métodos citodestructivos e inmunoterapia. Posteriormente se iniciaron ciclos de imiquimod 5 por ciento (una aplicación nocturna tres veces por semana) por seis semanas y luego ciclos de cuatro semanas cada uno, dos-tres veces al año. Se hizo un seguimiento a siete años, logrando erradicar exitosamente la enfermedad clínica y controlando las recidivas de forma satisfactoria.

Verrucous carcinoma of the anogenetal region has been reported under a series of names, including giant condyloma acuminatum or Buschke-Loewenstein tumor. Histologically, it corresponds to a well differentiated squamous carcinoma. A number of therapeutic alternatives have been described, the first choice being surgical removal. Imiquimod cream 5 percent represents a topical modifier of the immune response, and is currently being used in the treatment of a series of skin diseases. Objective: We present a review of the literature and the first case of anogenital verrucous carcinoma treated with a seven-year follow-up. Clinical case: A55-year-old man, with a history of a giant condyloma acuminatum with histological evidence of a low degree multiple techniques combined with cytodestructive methods and immunotherapy. A seven-year follow-up was carried out, success-fully eradicating the clinical disease and controlling recurrence with cycles of imiquimod cream 5 percent treatment (average 3 monthly treatment cycles per year).

El tratamiento de los pacientes con carcinoma epidermoide del canal anal en los últimos 20 años en nuestro hospital / Treatment of patients with squamous cell carcinoma of the anal canal in the last 20 years in a gastroenterology hospital

Anal cancers compromise only 1.5% of all digestive tumors. At present, concurrent radiochemotherapy (RT-CT) is the treatment of choice for most of these lesions. OBJECTIVE: To collect and analyze clinical data from the medical records of all consecutive patients with squamous cell carcinoma of the anal canal (SCCAC) treated by the Oncology Section in 20 years. PATIENTS AND METHODS: The medical records of 108 patients with SCCAC were reviewed: 64% were women, mean age was 57.6 years (27-85), only 1 patient was HIV(+). RESULTS: Initial treatment: 87 patients were treated with RT-CT (81%), 5 CT only, 2 RT only, 8 local resection and 6 abdominoperineal resection (APR). 1) Patients initially treated with RT-CT: cobalt therapy was given to 76% of pts and linear accelerator was used in 24% of patients. 24% of patients received Mitomycin C based CT (modified Nigro), 66% Cisplatin based CT and 10% 5FU alone; 66% had clinical complete response (CCR) (26% of them relapsed). Median follow up was 2.16 years (1 month-15.5 years), median time to progression was 11.8 months and overall survival was 76.7% at 3 years (CI 95%: 65.2-87.7). 2) Patients initially treated with local resection: 6 patients NED and 2 relapsed (1 had CCR after RT-CT). 3) Patients initially treated with APR: 5 with curative intent (4 had local recurrence), and 1 was palliative. 4) Surgical rescue after RT-CT in 6 patients with curative intent (4 APR and 2 local resections), and in 15 patients was palliative (2 APR and other surgeries in 13). CONCLUSIONS: Our group is pioneer in the use of Cisplatin based RT-CT for the treatment of patients with SCCAC. Complete response rate and overall survival at 3 years, were similar to those reported by international data. As this is probably one of the largest series of SCCAC in Argentina, we hope that this analysis of our data would be a starting point to develop prospective clinical trials.

El carcinoma epidermoide del canal anal (CCA) constituye el 1.5% de los cánceres del sistema digestivo. Lamayoría de los pacientes puede acceder a la cura a través de radioquimioterapia (RT-QT) concurrente. Objetivos:evaluar qué ocurrió con todos los pacientes con CCA registrados por la Sección Oncología en 20 años.Pacientes y métodos: se revisaron las fichas de 108 pacientes:64% eran mujeres y la edad media fue de 57.6 años (27-83), sólo 1 paciente tenía confirmación de HIV (+). Resultados: tratamiento inicial: 87 pacientes recibieron RT-QT (81%), 5 QT sola, 2 RT sola, 8 resecciónlocal y 6 resección abdominoperineal (RAP). 1) Grupo con RT-QT de inicio: 76% realizó telecobaltoterapiay 24% acelerador lineal, 24% de los pacientes recibió un esquema con Mitomicina (Nigro modificado),66% esquemas con Cisplatino y 10% 5FU solo; respuesta clínica completa 66% (26% de ellos recidivaron).La mediana de seguimiento fue de 2.16 años (1 mes-15.5 años), la mediana de tiempo a la progresión fue de 11.8 meses y la sobrevida global fue de76.7% a los 3 años (IC 95%: 65.2-87.7). 2) Grupo con resección local de inicio: 6 pacientes sin enfermedada largo plazo y 2 recidivas (1 de ellas rescatada con RT-QT con respuesta completa). 3) RAP de inicio: 5con intención curativa (4 recidivaron localmente) y 1 paliativa. 4) Cirugía luego de RT-QT: en 6 pacientescon intención curativa (4 RAP y 2 resecciones locales), y en 15 pacientes con intención paliativa (2 RAP y 13otras cirugías). Conclusiones: nuestro grupo es pionero en el empleo de RT-QT basada en Cisplatino para eltratamiento de pacientes con CCA. Las tasas de respuesta completa y la de pacientes vivos a 3 años fueronsimilares a las reportadas en la literatura internacional. Dado que esta es probablemente la experiencia actualizada en CCA más grande de nuestro país, confiamos en que la elaboración de los datos que aquí presentamos sea el punto de partida para desarrollar ensayos clínicos prospectivos.

Diganóstico, tratamento e aspectos relacionados à prevenção do câncer anal / Diagnosis, treatment and prevention aspects of anal cancer

O câncer anal é uma neoplasia rara, mas sua incidência tem aumentado nas últimas três décadas. Retardos no diagnóstico fazem com que cerca de uma terço dos pacientes faleçam vítimas desta doença. Os principais desafios terapêuticos continuam sendo o diagnóstico precoce, a prevenção de metástases e a preservação da função esfincteriana em longo prazo

Anal cancer is a very rare tumor but its incidence had risen significantly during the past three decades. About one-third of patients die mainly due to delays in the diagnosis. Early detection, avoiding metastasis and preserving long term sphincterian function are still the main challenges concerning anal cancer treatment

Cáncer anal: a propósito de un caso en un paciente VIH+ / Anal cancer in a patient with HIV+ infection

Paciente con sida de 38 años que presentó un carcinoma espinocelular. Se revisa la asociación entre esta neoplasia, el virus papiloma humano, la homosexualidad, la promiscuidad sexual y el sida. También, alguna información sobre conductas terapéuticas.