The incidence of anal cancer is elevated in human immunodeficiency virus (HIV)‐infected men‐who‐have‐sex‐with‐men (MSM) compared to the general population. Anal high‐grade squamous intraepithelial ...lesions (HSIL) are common in HIV‐infected MSM and the presumed precursors to anal squamous cell cancer; however, direct progression of HSIL to anal cancer has not been previously demonstrated. The medical records were reviewed of 138 HIV‐infected MSM followed up at the University of California, San Francisco, who developed anal canal or perianal squamous cancer between 1997 and 2011. Men were followed up regularly with digital anorectal examination (DARE), high‐resolution anoscopy (HRA) and HRA‐guided biopsy. Although treatment for HSIL and follow‐up were recommended, not all were treated and some were lost to follow‐up. Prevalent cancer was found in 66 men. Seventy‐two HIV‐infected MSM developed anal cancer while under observation. In 27 men, anal cancer developed at a previously biopsied site of HSIL. An additional 45 men were not analyzed in this analysis due to inadequate documentation of HSIL in relation to cancer location. Of the 27 men with documented progression to cancer at the site of biopsy‐proven HSIL, 20 men progressed from prevalent HSIL identified when first examined and seven men from incident HSIL. Prevalent HSIL progressed to cancer over an average of 57 months compared to 64 months for incident HSIL. Most men were asymptomatic, and cancers were detected by DARE. Anal HSIL has clear potential to progress to anal cancer in HIV‐infected MSM. Early diagnosis is facilitated by careful follow‐up. Carefully controlled studies evaluating efficacy of screening for and treatment of HSIL to prevent anal cancer are needed.
What's new?
The elevated incidence of anal cancer seen among HIV‐infected men‐who‐have‐sex‐with‐men (MSM) is presumably linked to the common occurrence of anal high‐grade squamous intraepithelial lesions (HSIL) in this population. This study provides some of the first evidence for direct progression of the postulated HSIL precursors to anal cancer. MSM were followed for a period of more than 20 years with high‐resolution anoscopy and biopsy. The data provide conclusive evidence of the malignant potential of anal HSIL and underscore the potential to reduce anal cancer through targeted removal of anal HSIL.
BACKGROUND:National quality initiatives have mandated the earlier removal of urinary catheters after surgery to decrease urinary tract infection rates. A potential unintended consequence is an ...increased postoperative urinary retention rate.
OBJECTIVE:The aim of this study was to determine the incidence and risk factors for postoperative urinary retention after colorectal surgery.
DESIGN:This was a prospective observational study.
SETTINGS:A colorectal unit within a single institution was the setting for this study.
PATIENTS:Adults undergoing elective colorectal operations were included.
INTERVENTIONS:Urinary catheters were removed on postoperative day 1 for patients undergoing abdominal operations, and on day 3 for patients undergoing pelvic operations. Postvoid residual and retention volumes were measured.
MAIN OUTCOME MEASURES:The primary outcomes measured were urinary retention and urinary tract infection.
RESULTS:The overall urinary retention rate was 22.4% (22.8% in the abdominal group, 21.9% in the pelvic group) and was associated with longer operative time and increased perioperative fluid administration. Mean operative time for those with retention was 2.8 hours and, for those without retention, the mean operative time 2.2 hours (abdominal group 2 hours vs 1.4 hours, pelvic group 3.9 hours vs 3.1 hours, p ≤ 0.02). Patients with retention received a mean of 2.7L during the operation, whereas patients without retention received 1.8L (abdominal group 1.9L vs 1.4L, pelvic group 3.6L vs 2.2L, p < 0.01). In the abdominal group, patients with and without retention also received different fluid volumes on postoperative days 1 (2.2L vs 1.7L, p = 0.004) and 2 (1.6L vs 1L, p = 0.05). Laparoscopic abdominal group had a 40% retention rate in comparison with 12% in the open abdominal group (p = 0.004). Age, sex, preoperative radiation therapy, preoperative prostatism, preoperative diagnosis, and level of anastomosis were not associated with retention. The urinary tract infection rate was 4.9%.
LIMITATION:The lack of documentation of preoperative urinary function was a limitation of this study.
CONCLUSIONS:The practice of earlier urinary catheter removal must be balanced with operative time and fluid volume to avoid high urinary retention rates. Also important is increased vigilance for the early detection of retention.
Screening for Anal Cancer in Women Moscicki, Anna-Barbara; Darragh, Teresa M; Berry-Lawhorn, J Michael ...
Journal of lower genital tract disease,
07/2015, Letnik:
19, Številka:
3 Suppl 1
Journal Article
Recenzirano
Odprti dostop
The incidence of anal cancer is higher in women than men in the general population and has been increasing for several decades. Similar to cervical cancer, most anal cancers are associated with human ...papillomavirus (HPV), and it is believed that anal cancers are preceded by anal high-grade squamous intraepithelial lesions (HSIL). Our goals were to summarize the literature on anal cancer, HSIL, and HPV infection in women and to provide screening recommendations in women.
A group of experts convened by the American Society for Colposcopy and Cervical Pathology and the International Anal Neoplasia Society reviewed the literature on anal HPV infection, anal SIL, and anal cancer in women.
Anal HPV infection is common in women but is relatively transient in most. The risk of anal HSIL and cancer varies considerably by risk group, with human immunodeficiency virus-infected women and those with a history of lower genital tract neoplasia at highest risk compared with the general population.
While there are no data yet to demonstrate that identification and treatment of anal HSIL leads to reduced risk of anal cancer, women in groups at the highest risk should be queried for anal cancer symptoms and required to have digital anorectal examinations to detect anal cancers. Human immunodeficiency virus-infected women and women with lower genital tract neoplasia may be considered for screening with anal cytology with triage to treatment if HSIL is diagnosed. Healthy women with no known risk factors or anal cancer symptoms do not need to be routinely screened for anal cancer or anal HSIL.
The prognostic value of several hematologic parameters, including platelet, lymphocyte, and neutrophil counts, has been studied in a variety of solid tumors. In this study, we examined the ...significance of inflammatory markers and their prognostic implications in patients with colorectal cancer (CRC).
Patients with stage I-III CRC who underwent surgical resection at the Stanford Cancer Institute between 2005 and 2009 were included. Patients were excluded if they did not have preoperative complete blood counts performed within 1 month of surgical resection, underwent preoperative chemotherapy or radiation, had metastatic disease at diagnosis, or had another previous malignancy. We included 129 eligible patients with available preoperative complete blood counts in the final analysis.
A preoperative neutrophil-to-lymphocyte ratio of>3.3 was significantly associated with worse disease-free (DFS) and overall survival (OS) (P=0.009, 0.003), as was a preoperative lymphocyte-to-monocyte ratio of ≤2.6 (P=0.01, 0.002). Preoperative lymphopenia (P=0.002) was associated with worse OS but not DFS (P=0.09). In addition, preoperative thrombocytosis was associated with worse DFS (P=0.006) and OS (P=0.010). Preoperative leukocytosis was associated with worse OS (P=0.048) but not DFS (P=0.49). Preoperative hemoglobin was neither associated with OS (P=0.24) or DFS (P=0.15).
Pretreatment lymphopenia, thrombocytosis, a decreased lymphocyte-to-monocyte ratio, and an elevated neutrophil-to-lymphocyte ratio independently predict for worse OS in patients with CRC.
Purpose
This study was designed to determine whether high-resolution anoscopy and targeted surgical destruction of anal high-grade squamous intraepithelial lesions is effective in controlling ...high-grade squamous intraepithelial lesions while preserving normal tissues.
Methods
Retrospective review of 246 patients with high-grade squamous intraepithelial lesions treated with high-resolution anoscopy-targeted surgical destruction from 1996 to 2006, with at least one follow-up at a minimum two months with physical examination, high-resolution anoscopy, cytology, and biopsy when indicated.
Results
Lesions were extensive in 197 patients (81 percent); 207 (84 percent) were men, and 194 (79 percent) were immunocompromised (HIV or other). Persistent disease occurred in 46 patients (18.7 percent), requiring planned staged therapy; 10 required surgery. Recurrent high-grade squamous intraepithelial lesions occurred in 114 patients (57 percent) at an average 19 (range, 3–92) months; 26 of these required surgery. All other patients were retreated in-office with high-resolution anoscopy-directed therapies. Complications were seen in nine patients (4 percent). Despite treatment, three patients progressed to invasive cancer (1.2 percent). At their last visit, 192 patients (78 percent) had no evidence of high-grade squamous intraepithelial lesions.
Conclusions
High-resolution anoscopy-targeted destruction combined with office-based surveillance and therapy is effective in controlling high-grade squamous intraepithelial lesions and is superior to reports of expectant management or traditional mapping procedures.
CONTEXT Homosexual and bisexual men infected with human
immunodeficiency virus (HIV) are at increased risk for human
papillomavirus–related anal neoplasia and anal squamous cell carcinoma
(SCC). ...OBJECTIVE To estimate the clinical benefits and
cost-effectiveness of screening HIV-positive homosexual and bisexual
men for anal squamous intraepithelial lesions (ASIL) and anal SCC. DESIGN Cost-effectiveness analysis performed from a societal
perspective that used reference case recommendations from the Panel on
Cost-Effectiveness in Health and Medicine. A state-transition Markov
model was developed to calculate lifetime costs, life expectancy, and
quality-adjusted life expectancy for no screening vs several screening
strategies for ASIL and anal SCC using anal Papanicolaou (Pap) testing
at different intervals. Values for incidence, progression, and
regression of anal neoplasia; efficacy of screening and treatment;
natural history of HIV; health-related quality of life; and costs were
obtained from the literature. SETTING AND PARTICIPANTS Hypothetical cohort of homosexual and
bisexual HIV-positive men living in the United States. MAIN OUTCOME MEASURES Life expectancy, quality-adjusted life
expectancy, quality-adjusted years of life saved, lifetime costs, and
incremental cost-effectiveness ratio. RESULTS Screening for ASIL increased quality-adjusted life
expectancy at all stages of HIV disease. Screening with anal Pap tests
every 2 years, beginning in early HIV disease (CD4 cell count
>0.50×109/L), resulted in a 2.7-month
gain in quality-adjusted life expectancy for an incremental
cost-effectiveness ratio of $13,000 per quality-adjusted life
year saved. Screening with anal Pap tests yearly provided additional
benefit at an incremental cost of $16,600 per quality-adjusted
life year saved. If screening was not initiated until later in the
course of HIV disease (CD4 cell count
<0.50×109/L), then yearly Pap test
screening was preferred due to the greater amount of prevalent anal
disease (cost-effectiveness ratio of less than $25,000 per
quality-adjusted life year saved compared with no screening). Screening
every 6 months provided little additional benefit over that of yearly
screening. Results were most sensitive to the rate of progression of
ASIL to anal SCC and the effectiveness of treatment of precancerous
lesions. CONCLUSIONS Screening HIV-positive homosexual and bisexual men for
ASIL and anal SCC with anal Pap tests offers quality-adjusted life
expectancy benefits at a cost comparable with other accepted clinical
preventive interventions.
Introduction
Despite several meta-analyses and randomized controlled trials showing no benefit to patients, mechanical bowel preparation (MBP) remains the standard of practice for patients undergoing ...elective colorectal surgery.
Methods
We performed a systematic review of the literature of trials that prospectively compared MBP with no MBP for patients undergoing elective colorectal resection. We searched MEDLINE, LILACS, and SCISEARCH, abstracts of pertinent scientific meetings and reference lists for each article found. Experts in the field were queried as to knowledge of additional reports. Outcomes abstracted were anastomotic leaks and wound infections. Meta-analysis was performed using Peto Odds ratio.
Results
Of 4,601 patients (13 trials), 2,304 received MBP (Group 1) and 2,297 did not (Group 2). Anastomotic leaks occurred in 97(4.2%) patients in Group 1 and in 81(3.5%) patients in Group 2 (Peto OR = 1.214, CI 95%:0.899–1.64,
P
= 0.206). Wound infections occurred in 227(9.9%) patients in Group 1 and in 201(8.8%) patients in Group 2 (Peto OR = 1.156, CI 95%:0.946–1.413,
P
= 0.155).
Discussion
This meta-analysis demonstrates that MBP provides no benefit to patients undergoing elective colorectal surgery, thus, supporting elimination of routine MBP in elective colorectal surgery.
Conclusion
In conclusion, MBP is of no benefit to patients undergoing elective colorectal resection and need not be recommended to meet “standard of care.”
BACKGROUND:Locally advanced and recurrent colorectal cancers pose a significant therapeutic challenge. Orthovoltage intraoperative radiotherapy provides one potential means of improving disease ...control at the time of surgery.
OBJECTIVE:This study sought to analyze outcomes and identify prognostic factors of patients treated with orthovoltage intraoperative radiotherapy for locally advanced or recurrent colorectal cancer.
DESIGN AND SETTING:This study is a retrospective chart review conducted at a tertiary medical center.
PATIENTS:Between January 1990 and July 2009, 55 patients underwent intraoperative radiotherapy to a total of 61 sites for locally advanced (n = 14) or recurrent (n = 41) cancers of colon (n = 18) or rectum/rectosigmoid junction (n = 37).
INTERVENTIONS:Median dose was 12 Gy (range, 7.5–20 Gy). Among locally advanced rectal/rectosigmoid cases, surgery included abdominoperineal resection (n = 3) or low anterior resection (n = 9). Seven treated sites had gross residual (R2) disease, 28 had pathologic or clinical microscopic residual disease (R1), and 15 were complete resections (R0). Treated sites included sacrum (n = 22), anterior pelvis/pelvic sidewall (19), sacrum and sidewall (n = 1), aortic bifurcation (n = 2), vaginal cuff (n = 2), psoas (n = 3), perivesicular region (n = 2), and other (n = 10).
MAIN OUTCOMES MEASURES:Outcomes measures included in-field local control, locoregional control, overall survival, and grade ≥3 toxicity.
RESULTS:At a median follow-up of 27 months (range, 4–237) among living patients, 2-year Kaplan-Meier estimates of in-field local control, locoregional control, and overall survival were 69%, 51%, and 59%. Margin status predicted for improved locoregional control (p = 0.01) and overall survival (p = 0.01). Seventeen patients (31%) developed a grade 3 to 5 toxicity following surgery with intraoperative radiotherapy.
LIMITATIONS:This study was limited by its retrospective nature and relatively small sample size.
CONCLUSIONS:Local control with intraoperative radiotherapy for locally advanced and recurrent colorectal cancers is good despite the high risk of residual disease. Among carefully selected patients, multimodality regimens including intraoperative radiotherapy may permit long-term survival.
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