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Christopher Crank
Christopher Crank

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Physical examination upon admission: Examination confirmed a large anal mass with ulceration and necrosis. His tumor did involve the anal sphincters and the patient presented with anal incontinence.

Ulcerated lesions should be biopsied to exclude invasive carcinoma. In certain instances, a deep core biopsy of the base is necessary to evaluate histologically the invasion of the basement membrane as the tumor arises in the basal layer of the epidermis infected with the HPV. Deep biopsy may be performed using an 18-gauge needle under mild sedation. This can also be done under CT guidance or endo-ultrasonography. A complete anorectal endoscopic exam is mandatory as some lesions extend proximal into the anal canal. Staging with CT scan or PET scan is useful if invasive cancer is diagnosed and to evaluate the extent of the involvement of the pelvic tissues. A magnetic resonance imaging scan with rectal contrast or endo-coil may also be useful to evaluate extent of perianal sphincter involvement and perirectal tissue involvement. Preoperative EUS may be useful to evaluate rectal and anal sphincter involvement[8]. A multidisciplinary team approach is necessary and should include medical oncologist, radiation oncologist and plastic and reconstructive surgeons. These patients often carry HPV in other muco-cutaneous areas such as penis and oropharynx and require a complete examination. Further risk for other STDs commonly HIV, HSV and Syphilis are higher[6].

Defects can be closed primarily, or left to heal as secondary intention with granulation tissue[16,18]. Larger wounds may require to be closed with a variety of reconstructive skin grafts[16,18]. If the patient has received radiation or anticipating radiation as adjuvant therapy then tissue flap techniques such as V-Y skin flaps, rotational gluteal flaps, and VRAM (Vertical rectus abdominis muscle) myo-cutaneous flap have a higher success rates[19-21]. Simultaneous pelvic reconstructive surgery with excision of the primary tumor decreases the length of recovery, minimizes anal stricture and has better patient satisfaction rates in terms of sexual function and anogenital function. However, reconstruction techniques in the perineum are difficult and may add to further problems with additional wounds such as hematoma, wound infection and dehiscence. Meticulous hemostasis and avoidance of tension is required for optimal outcomes[20,21].

Preoperative the patients should be encouraged to quit smoking and optimize diabetes (glycemic control) and exclude peripheral vascular disease for graft success. Radical procedures such as abdominoperineal resection for these tumors have generally fallen out of favor due to newer techniques and adjuvant therapies. However large perianal lesions with rectal involvement may need fecal diversion and a temporary colostomy[9]. This is primarily done to aid with perianal wound healing as was described in our patient (case 2).

Treatment of SCC associated with perianal GCA has not been standardized due to its rarity. Surgical resection or standard chemo radiation therapy by itself alone has a high recurrence rate. The current standard therapy of primary anal SCC is Nigro protocol consist of combined chemo radiation with mitomycin and 5-fluorouracil followed by radiation therapy[22] with salvage resection limited for residual disease .The use of modern radiotherapy methods, such as intensity modulated radiotherapy can reduce radiation dose and toxicity to normal tissue, while allowing safe administration for higher doses to the gross tumor volume[23]. This permits preservation of anorectal function with improved survival and local control compared with radical resection. This protocol has also been used with success in SCC in GCA treated with preoperative chemo-radiation and followed by radical surgery with success and no recurrences[7,24]. Our patient (case 1) was treated in a similar fashion with preoperative chemo-radiation followed by surgery. No residual cancer was detected in resected specimens and he remains disease free after three years.

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Background: Giant condyloma acuminatum or Buschke - Loewenstein tumor is a very rare disease usually located in the genital, anorectal, and perianal regions. It is locally invasive but in mostly cases displays a benign cytology on preoperative tissue sampling. Because of its low incidence little is known about treatment outcomes. Complete surgical excision is the treatment of choice. Different surgical methods have been applied to reach curability. To our knowledge such an advanced sized tumors in this localization has only been reported few times before with different surgical techniques being applied.

Case presentation: We describe a case of 56 years old female with 20 years persisting condyloma acuminatum progressing to a very huge dimensions perianal Buschke-Lowenstein tumor with one of the widest excision in the literature without the need for diverting stoma. The tumor size and its location determined the choice of treatment option and suspected prognosis for the patient outcome. Treatment was impeded by patient's malnutrition. The giant Buschke - Loewenstein tumor was resected from the anus, perineum and gluteal areas. The large tissue losses were simultaneously covered with rotational skin and fatty subcutaneous tissue flaps, mobilized from neighboring gluteal and femoral areas. The circumferential part of the anal canal was covered with skin grafted from the mentioned flaps and it was attached to the anal mucosa. No protective stoma was formed. Despite temporary problems with healing of the covering skin flaps, full permanent coverage of the resection site has been achieved. Anal canal function has also improved within the time. 041b061a72


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