Invasive Anal Squamous-Cell Carcinoma in the HIV-Positive Patient: Outcome in the Era of Highly Active Antiretroviral Therapy

Introduction The incidence of invasive anal squamous-cell carcinoma in patients with HIV is increasing. We report the outcome after combined chemoradiotherapy for anal squamous-cell carcinoma in HIV-infected individuals. Methods Thirty-two HIV-positive patients treated at the St. Vincent’s Cancer Care Center for anal squamous-cell carcinoma from 1997 through mid 2005 were reviewed retrospectively. All patients also received highly active antiretroviral therapy. Treatment consisted of radiotherapy concurrent with 5-fluorouracil and mitomycin C in most patients. Overall survival, anal cancer-specific survival, local recurrence, and toxicity were assessed. Results Median time from completion of radiotherapy to last follow-up of surviving patients was 35 months. Five-year locoregional relapse, anal cancer-specific survival, and overall survival were 16 , 75, and 65 percent, respectively. In multivariate analysis, locoregional recurrence, cancer-specific survival, and overall survival were all significantly associated with tumor size. Overall survival was independently associated with high viral load and low CD4 count. Acute toxicity included: Grade 3 skin in 25 percent of patients, Grade 3 diarrhea: 28 percent, and Grade 3 or 4 hematologic toxicity in 21 and 48 percent, respectively. More than two-thirds of patients required radiotherapy interruption. There was no negative impact of chemoradiotherapy on viral load. Conclusions Outcome after chemoradiotherapy for HIV-related anal squamous-cell carcinoma in the era of highly active antiretroviral therapy is comparable to outcome in patients without HIV. However, significant toxicity is seen with standard treatment regimens. Earlier diagnosis and risk-adapted therapy could lead to improved survival and decreased treatment-related morbidity. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Squamous-cell Carcinoma of the Anal Canal: Predictors of Treatment Outcome

Purpose The incidence of anal canal squamous-cell carcinoma is increasing. Limited data exist on predictors of treatment failure. This study was designed to identify predictors for relapse/persistence after first-line therapy. Methods Using one database, we identified 131 Stages I-III patients treated for primary anal canal squamous-cell carcinoma at our institution from December 1986 to August 2006, with minimum six-month follow-up. Demographic, pathologic, treatment, and outcome data were extracted. Treatment failure was defined as biopsy-proven persistence or relapse (local and/or distant). Univariate, bivariate, and multivariate survival analyses were performed. Results Of 131 patients (median age, 58.3 years; median follow-up, 2.9 (range, 0.6–11.2) years), 66 percent were females, 43.5 percent were Stage II, and 11 (8 percent) were HIV-positive. Surgery only (local excision) was uncommon (6.9 percent, n = 9). One hundred twenty-two patients (93.1 percent) received radiotherapy; two required preradiotherapy diversion. Although 114 (93.4 percent) completed radiotherapy, most required treatment breaks, making total duration of radiotherapy longer than planned. Almost all patients undergoing radiotherapy (96.7 percent, 118/122) also had chemotherapy: 118 (100 percent, Stages I-III) had concurrent chemotherapy: (98 (83.8 percent) mitomycin/5-fluorouracil, 12 (10.2 percent) cisplatin/5-fluorouracil, 8 (6.8 percent) 5-fluorouracil alone); 35 of 46 (76 percent) Stage III patients received induction chemotherapy (34 (97.1 percent) cisplatin/5-fluorouracil, 1 (2.8 percent) 5-fluorouracil alone). Many (44 percent Stages I/II, 48.9 percent Stage III) required dose adjustments. Thirty-seven patients (28.2 percent) failed first-line therapy. There were no differences between patients with relapse (n = 22) or persistence (n = 15) of disease. Bivariate analyses demonstrated that T stage (P = 0.0019), completion of radiotherapy, and total radiotherapy dose (P = 0.03) were all significantly associated with treatment failure. On multivariate analyses, disease stage (P = 0.05) and completion of radiotherapy (P = 0.01) remained significant predictors of relapse-free survival. Conclusions Tolerance of chemoradiation seems to be an important predictor of treatment success. Effective therapies with less acute toxicity must be identified. Dr. Temple is funded by the Society of University Surgeons and by the American Society of Clinical Oncology. Read at the meeting of The American Society of Colon and Rectal Surgeons, June 2 to 6, 2007. No reprints available. An erratum to this article can be found at     

Endoanal Ultrasound in the Staging and Management of Squamous-Cell Carcinoma of the Anal Canal

PURPOSE: This study was performed to determine whether endoanal ultrasound could be used to accurately stage patients with squamous-cell carcinoma of the anal canal and to determine the response of these tumors to multimodality therapy. METHODS: Thirteen consecutive patients with biopsy-proven squamous-cell carcinoma of the anal canal between 1996 and 1999 were included in the study. All patients underwent a pretreatment staging endoanal ultrasound with a B&K 3535 ultrasound machine using the 1850 rotating 360° probe with a 10-MHz transducer. Tumors were staged using our own modification of a 1984 TNM staging system. For our study, a uT1 tumor was confined to the submucosa; a uT2a lesion invaded only the internal anal sphincter; a uT2b lesion penetrated into the external anal sphincter; a uT3 lesion invaded through the sphincter complex into the perianal tissues; and a uT4 lesion invaded adjacent structures. After the initial study, patients decided on a course of treatment, either primary surgery or chemoradiation. For patients choosing chemoradiation, a clinical examination with biopsies and a repeat endoanal ultrasound was performed after completion of therapy. Findings on physical examination and biopsy results were compared with the follow-up endoanal ultrasound. For those choosing surgery, the pathology specimen from the abdominoperineal resection was reviewed and compared with the initial endoanal ultrasound interpretation to determine the accuracy of endoanal ultrasound staging. RESULTS: One patient died of complications from acquired immunodeficiency syndrome before undergoing definitive treatment for his anal cancer. Of the remaining 12 patients who comprised the study, the endoscopic staging was as follows: 1 uT1, 5 uT2a, 3 uT2b, 2 uT3, and 1 uT4. Five of the 12 patients selected surgery as the primary treatment modality for their disease. The other seven patients underwent a full course of chemoradiation. In all five patients who had an abdominoperineal resection, the surgical staging correlated with the endoanal ultrasound staging (2 T2a tumors and 3 T2b tumors). In the remaining seven patients, six to eight weeks after completion of therapy, there was no evidence of residual tumor by clinical examination and biopsies. In one of the seven patients, no abnormalities were detected on endoanal ultrasound, and it was interpreted as normal with no evidence of disease. In the remaining six patients, endoanal ultrasound revealed abnormalities that were judged to represent radiation-induced changes rather than residual disease. A repeat endoanal ultrasound was done in these patients two to four months after the biopsies. Complete resolution of the postradiation changes occurred in all patients, and the scans were interpreted as showing no evidence of disease. CONCLUSIONS: Endoanal ultrasound can accurately determine the depth of penetration of squamous-cell carcinoma into the sphincter complex and can be used to gauge accurately the response of these tumors to chemoradiation therapy. Our newly proposed ultrasound staging system may be more useful in choosing treatment options; future studies should be aimed at using endoanal ultrasound in identifying early lesions that may be amenable to less aggressive therapy as well as determining the utility of ultrasound in the surveillance of patients after successful treatment of their initial tumors.     

Anal Incontinence After Obstetric Sphincter Tears: Outcome of Anatomic Primary Repairs

PURPOSE Obstetric sphincter tears lead to anal incontinence in 40 to 60 percent of affected women. Primary repair is usually performed without identifying the internal anal sphincter. Since 1999 digestive surgeons have participated in the primary repair of such tears at our hospital. The intention was to perform separate repair of the internal and external anal sphincter in cases of combined tears to achieve a lower incontinence rate than is usually reported after conventional primary repair. The aim of the present study was to evaluate our results after anatomic primary repair.METHOD A follow-up study was undertaken after all primary repairs performed in 1999 and 2000. It included anal ultrasonography manometry and an assessment of incontinence (Wexner score).RESULTS A total of 74 women sustained obstetric sphincter tears during the study period, and 71 (96 percent) were assessed after a median of 27 months (range, 14–39 months). Nine women declined investigation with ultrasonography/manometry. Incontinence was present in 22 women (31 percent), of whom 17 had gas incontinence only. The symptoms were mild (Wexner score 1–2) in 11 women (50 percent). None of 17 women with normal ultrasonography results were incontinent versus 20 of 45 with pathologic ultrasonographic results (P = 0.001). The mean sphincter length, squeeze pressure, and resting pressure were significantly higher in women with Wexner scores of 0–2 vs. women with a score of more than 2. Sphincter length was inversely correlated with the degree of incontinence (P < 0.001).CONCLUSIONS The incontinence rate after anatomic primary repair is low compared with the last decades reported results after conventional primary repair. A short anal sphincter after repair is associated with a poorer outcome.Read at the XXXVI Nordic Meeting of Gastroenterology, Oslo, Norway, June 2 to 5, 2004.Reprints are not available.     

Squamous-Cell Carcinoma of the Rectum: A Rare but Curable Tumor

Purpose This study was designed to evaluate one institution’s experience with treatment outcomes for rectal squamous-cell carcinoma. Methods Using our prospective Colorectal Database, we identified patients diagnosed with rectal squamous-cell carcinoma at our institution between 1983 and 2005. Pathology was rereviewed, tumor immunophenotype was compared to control cases of anal squamous-cell carcinoma and rectal adenocarcinoma, treatment modalities and outcomes were analyzed. Results Twelve patients were identified (10 females median age, 58 years). Median distal extent of tumors was 7 (range, 5–8) cm from the anal verge. Treatment included chemotherapy only (n = 1), chemoradiation only (n = 2), induction chemotherapy followed by chemoradiation and surgery (n = 2), chemoradiation followed by surgery (n = 5), and surgery followed by chemoradiation (n = 2). The chemotherapy regimen was 5-fluorouracil-based. Radiotherapy total dose was 50.4 Gy (1.8 Gy/day, daily × 5) external iliac and inguinal nodes were not included in the radiation field. Complete clinical responders to chemoradiation (n = 2) received no further treatment. All seven partial responders underwent surgery; six had complete pathologic response; nodal status in two of six was unknown because they had local excision. Immunophenotypical analysis showed similar keratin expression profile between rectal squamous-cell carcinoma (n = 5) and rectal adenocarcinoma (n = 5), which is different from anal squamous-cell carcinoma (n = 10). All patients were alive without evidence of disease at follow-up (median follow-up, 2.6 (range, 0.5–16) years). Conclusions Our data suggest that most patients treated with upfront chemoradiation therapy followed by surgery did well. Sphincter-preserving surgery is usually feasible. Clinical judgment of tumor response after chemoradiation is not completely reliable. Immunohistochemistry suggests a common cellular origin for rectal squamous-cell carcinoma and rectal adenocarcinoma, which is different from anal squamous-cell carcinoma. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006. Reprints are not available.     

Merkel Cell (Neuroendocrine) Carcinoma of the Anal Canal

Merkel cell tumors are rare neuroendocrine tumors typically found on sun-exposed areas such as extremities. We describe the case of a 42-year-old female with a Merkel cell tumor arising in the anal canal. The tumor was initially thought to represent a hemorrhoid arising during pregnancy and was excised locally after confirmation of extensive metastatic disease. The patient died 13 months after diagnosis with extensive metastatic disease involving the liver. In our search of the world literature there are several reports of neuroendocrine tumors in the rectum; however, no cases of documented Merkel cell tumors arising in the anal canal have been reported. These tumors seem to behave in a very aggressive manner when found in other atypical areas. The presentation symptoms were perianal discomfort and bleeding. Local excision may be the only surgical treatment necessary to control symptoms, given the propensity to early metastases and short life expectancy.     

Evidence of Clinical Activity for Cetuximab Combined with Irinotecan in a Patient with Refractory Anal Canal Squamous-Cell Carcinoma: Report of a Case

Because of the high cure rate of localized anal cancers from combined modality treatment, there is little that is known for the treatment of patients who progress to have metastatic disease. Treatments currently used are based on activity demonstrated in other cancers with similar histology. Cetuximab, a molecular-targeted therapy, is an antibody directed against epidermal growth factor receptor that has demonstrated anticancer activity in several cancers. We report a female patient with refractory anal cancer who achieved an excellent response to the combination of cetuximab and irinotecan after having failed single-agent irinotecan. Reprints are not available.     

Squamous-Cell Carcinoma Developing After an Ileoanal Pouch Procedure: Report of a Case

PURPOSE This study was designed to report a new variant of a rare but serious complication of restorative proctocolectomy.METHODS We present a 47-year-old female who underwent restorative proctocolectomy after 16 years of disease. Twenty-five years after her pouch procedure, she underwent pouchoscopy for fever and poor pouch function. A suspicious mass was biopsied and pathology indicated squamous metaplasia. On referral, a mass could be palpated above the anorectal ring. Biopsy of the mass was read as invasive squamous carcinoma in the background of normal intestinal mucosa. This represents the twelfth reported case of carcinoma arising in a pouch, but the first report of a squamous carcinoma, as all previous reports had been of adenocarcinoma.RESULTS The patient has undergone chemoradiation. Response to therapy, functional status, and biopsy after treatment will determine whether the patient will be able to salvage the pouch.CONCLUSIONS Diligence and vigilance with regard to active follow-up, and a high index of suspicion, are required to prevent this from becoming a more frequently seen problem.Reprints are not available.     

Anal Carcinomas in HIV-Positive Patients: High-Dose Chemoradiotherapy Is Feasible in the Era of Highly Active Antiretroviral Therapy

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

Results of age-dependent anal canal cancer treatment: A single centre retrospective study

BackgroundInformation concerning management of anal canal cancer among the elderly is scarce and much less abundant than for younger subjects.Population and methodsWe retrospectively analysed 115 patients treated for anal epidermoid cancer between 2000 and 2010. The population was divided according to age (<70 years and ≥70 years).ResultsOf the 115 patients, 81 (70.4%) were <70 years old and 34 were ≥70 years (29.6%). Tumour characteristics were identical between the two groups and median follow-up was 62 months. Elderly patients had a less favourable performance status (p = 0.001) and fewer had received radiochemotherapy (61.8% vs 82.5%, p = 0.004). Treatment-related grade 3 and 4 hematologic toxicity was observed more often among elderly subjects. The results at 5 years were less favourable for overall, disease-specific, and disease-free survival (respectively p = 0.002, p = 0.001, and p = 0.001). For patients treated with a curative intent, at 5 years there was no difference between the two groups in terms of overall survival (p = 0.2). However, there was a statistically significant difference in favour of the younger group for disease-free survival and metastasis-free survival.ConclusionIf radiochemotherapy can be delivered to elderly subjects with a good general status, the effects appear less favourable than in younger patients.     

Complete Closure of Cancer-Related Anovaginal and Anoperineal Fistulas in Locally Advanced Anal Canal Carcinomas by Upfront Intra-Arterial Chemotherapy Followed by Combined Radiochemotherapy: Report of Two Cases

Purpose Cancer-related fistulas are a major problem in locally advanced anal canal carcinoma, because conservative radiochemotherapy may not be recommended in this setting. Therefore, it is usually recommended to proceed to an abdominoperineal resection with definitive colostomy in the presence of such lesions. Methods Because chemotherapy can lead to closure of cancer-related fistulas and local intra-arterial chemotherapy is effective in locally advanced anal canal cancer, we treated two anal canal carcinoma patients presenting with cancer-related fistulas with upfront intra-arterial chemotherapy followed by radiochemotherapy, leading to complete closure of fistulas. Results Both patients are free of colostomy and in complete remission after more than four years of follow-up. Conclusions This conservative approach combining local intra-arterial chemotherapy and standard radiochemotherapy is feasible and should be considered in the management of such locally advanced anal canal carcinoma. Reprints are not available.     

Long-Term Outcome of Delayed Primary or Early Secondary Reconstruction of the Anal Sphincter after Obstetrical Injury

Purpose Traditionally sphincter repair has not been performed during the puerperium. This prospective study was designed to determine the long-term outcome of delayed primary or early secondary sphincteroplasty in the puerperium. Methods Between 1991 and 2005, 22 females underwent delayed primary or early secondary repair after third-degree or fourth-degree anal sphincter rupture. Delayed primary reconstruction was performed more than 72 hours after delivery. Early secondary reconstruction was performed within 14 days postpartum. The reconstruction of the anal sphincter was performed without a covering stoma, in all cases. A control group of 19 age-matched and parity-matched females, without known anal sphincter injury after vaginal delivery, were included. Current degree of continence and associated quality of life were determined by a fecal incontinence severity questionnaire and a quality of life questionnaire. Results None of the females had complications postoperatively. Mean follow-up was 50 (range, 2–155) months in the case group and 60 (range, 12–132) months in the control group. At time of follow-up, the Wexner score was 4.1 (range, 0–13) in females with delayed primary or early secondary reconstruction and 1.1 (range, 0–8) in the control group (P < 0.01). The inconvenience of incontinence after reconstruction was significantly higher (P < 0.01) compared with the control group, but the quality of life was not significantly affected (P = 0.75). Conclusions It is safe to perform a delayed primary or early secondary reconstruction without a covering stoma in females who have sustained a third-degree or fourth-degree obstetric tear. The long-term functional outcome is acceptable. Poster presentation at the meeting of European Society of Coloproctology (ESCP), Lisbon, Portugal, September 13 to 16, 2006.     

Long-Term Outcome after Endoscopic Submucosal Dissection in Patients with Superficial Esophageal Squamous Cell Carcinoma: A Single-Center Study

Background/Aims

Superficial esophageal squamous cell carcinoma (SESCC) is being increasingly detected during screening endoscopy. Endoscopic submucosal dissection (ESD) allows for en bloc and histologically complete resection of lesions. This study assessed the technical feasibility and long-term outcomes of ESD for SESCCs.

Methods

Between January 2005 and August 2012, 27 patients with 28 SESCCs underwent ESD at Pusan National University Hospital. The en bloc and pathologically complete resection rates, complication (perforation and bleeding) rate, incidence of esophageal stricture after ESD, and overall and disease-specific survival rates were evaluated.

Results

The en bloc and pathologically complete resection rates were 93% and 83%, respectively. No significant bleeding occurred, and perforation with mediastinal emphysema was observed in two patients (7%). Post-ESD stricture occurred in two patients (7%) who had mucosal defects involving more than three-fourths of the esophageal circumference. During a mean follow-up of 23 months, local tumor recurrence was seen in two of four lesions with pathologically incomplete resection; one was treated by re-ESD, and the other was treated by surgical esophagectomy. The 5-year overall and disease-specific survival rates were 84% and 100%, respectively.

Conclusions

ESD seems to be a feasible, effective curative treatment for SESCCs. All patients should be closely followed after ESD.     

HBcrAg Predicts Hepatocellular Carcinoma Development in Chronic B Hepatitis Related Liver Cirrhosis Patients Undergoing Long-Term Effective Anti-Viral

Hepatitis B core-related antigen (HBcrAg) is a predictor of hepatocellular carcinoma (HCC) in chronic hepatitis B (CHB) patients. Studies on anti-viral therapy have shown that the use of NUC therapy in HBV patients could reduce the incidence of HCC. However, the incidence of HCC continues to increase after long-term anti-viral therapy. The relationship between HBcrAg and HCC development in CHB-related liver cirrhosis (LC) patients undergoing long-term anti-viral therapy is still unclear. This study enrolled 1108 treatment-naïve CHB patients diagnosed with HBV-related LC receiving NUC therapy from April 1999 to February 2015. The baseline biomarkers, disease history, and following results were collected by the hospital. Among the 1108 patients, 219 developed HCC within a median follow-up period of 6.85 years. A multivariable Cox regression model was used, with adjustment for age, gender, FIB-4, DM, and HBsAg-HQ. The adjusted hazard ratios for the HBcrAg tertile levels were 1.70 (95%CI: 1.21, 2.39) and 2.14 (95%CI: 1.50, 3.05) for levels 3.4–4.9 and >4.9 logU/mL, respectively, compared with levels ≤3.4. The effect of the HBcrAg level on HCC incidence was found to be significantly modified by HBsAg-HQ, where lower HBsAg-HQ (≤ 3) values were associated with a significantly higher risk, but HBsAg-HQ levels >3 were not. Our results highlight that, after adjustment for potential confounding factors, patients with CHB-related LC and higher HBcrAg levels are at significant risk for HCC development, even while undergoing long-term effective anti-viral therapy. The HBcrAg level is therefore an independent risk factor for HCC development, especially for patients with HBsAg-HQ levels <3.     

Asymmetric Dimethylarginine Predicts Long-Term Outcome in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Introduction

In chronic obstructive pulmonary disease (COPD), there is an activation of the l-arginine nitric oxide pathway. Pulmonary obstruction causes to elevated nitric oxide (NO) levels, which lead to higher production of the NO-inhibiting metabolites asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA).

Methods

We investigated the association of l-arginine, ADMA, and SDMA with clinical outcomes in a well-defined observational cohort of 150 patients with acute exacerbation of COPD. We measured l-arginine, ADMA, and SDMA by mass spectrometry in patients with pneumonic or non-pneumonic exacerbation of COPD included in a Swiss multicenter trial. We used Cox regression models to investigate the associations between blood marker levels and disease severity as well as all-cause mortality over a follow-up of 6.1 years.

Results

Six-year all-cause mortality was 54%. Admission levels of ADMA and SDMA (μmol L^?1) were increased in 6-year non-survivors compared to survivors’ median (0.60 vs. 0.46, p = 0.004; and 1.05 vs. 0.85, p = 0.012). In a multivariate Cox regression analysis, ADMA was associated with long-term mortality resulting in an age- and comorbidity-adjusted hazard ratio (HR) of 4.55 (95% confidence interval 1.02–20.43, p = 0.048). SDMA was only associated in univariate models and no association of l-arginine with outcome was found.

Conclusion

ADMA was found to be an independent risk factor for long-term all-cause mortality in patients with acute exacerbation of COPD. Whether therapeutic modification of the l-arginine–nitric oxide pathway has the potential to improve outcome should be evaluated in future interventional trials.

     

Expectant Management of Anal Squamous Dysplasia in Patients With HIV

Purpose Anal squamous dysplasia is commonly found in patients with HIV infection. There is no satisfactory treatment that eradicates this premalignant lesion with low morbidity and low recurrence. This study reviews a series of patients with HIV and an abnormal anal examination who had squamous dysplasia and who have been followed with physical examination alone and with repeat biopsies as necessary for new or suspicious lesions. Methods We reviewed the charts of 40 HIV-positive men who had squamous dysplasia of the anal canal and anal margin, focusing on history, physical findings, histologic diagnosis, and the occurrence of invasive squamous-cell carcinoma. Results Forty HIV-positive men (mean age, 39 years) were followed for anal squamous dysplasia. Biopsies revealed dysplasia, which was usually multifocal. The grade of dysplasia varied, but 28 of 40 patients had at least one area of severe dysplasia. All patients had a follow-up period greater than one year (mean, 32 months; range, 13–130 months). Three patients developed invasive carcinoma while under surveillance, and these were completely excised or cured with chemoradiation. Conclusions Extensive excision for dysplasia in the context of HIV confers high morbidity and questionable benefit, and other treatments are of uncertain value. In a group of patients followed expectantly, most did not develop invasive cancer, and in those who did, early cancers could be identified and cured. Physical examination surveillance for invasive carcinoma may be acceptable for following patients with HIV and biopsy-proven squamous dysplasia. Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.     

The Long-Term Efficacy of Fissurectomy and Botulinum Toxin Injection for Chronic Anal Fissure in Females

Introduction Healing rates for botulinum toxin injection for anal fissure may be improved if combined with fissurectomy. This procedure has a decreased risk of incontinence, which is particularly important in females. We investigated the long-term efficacy of fissurectomy and botulinum toxin injection for chronic resistant fissures in females. Methods Female patients who consented underwent excision of the fissure edges and injection of 25–100 units of botulinum into the intersphincteric space. Patients were followed up 2 months after the procedure and over a period of up to 39 months. Results Forty-six patients (mean age, 42 years) were recruited. No patient had incontinence symptoms preoperatively. At a median follow-up period of 11 months, there was a cure rate of 85 percent in 44 patients. After a median follow-up of 22 months, 12 more patients were lost to follow-up. Of the remaining patients, 16 (50 percent) suffered recurrence during the follow-up period. Five patients required further surgical intervention. Three patients suffered chronic perianal infection requiring antibiotic treatment or surgery. There was one case of incontinence at final assessment: the patient complained of urge incontinence, which has persisted for more than 18 months. Conclusions Fissurectomy and botulinum toxin injection for the treatment of chronic anal fissure in females seems to be effective in the medium-term but there is a high rate of late recurrence. However, only a minority of patients proceed to more invasive surgical intervention, which may make it a useful option in patients not suitable for lateral sphincterotomy. Presented at the meeting of the Royal Society of Medicine Coloproctology Section Overseas Meeting Prague, Czech Republic, 7–11 June 2006. Reprints are not available.