Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
Ranging from asymptomatic mild symptoms (eg, pruritus) visible/palpable lump/mass or skin changes increasing pain,
possible bleeding, etc.
Differential Diagnosis
Idiopathic pruritus ani.
Perianal skin irritation.
Manifest anal cancer.
Pathology
CYTOLOGY FROM ANAL PAP SMEAR
Classification according to revised Bethesda system for cervical cytology:
Normal.
Atypical squamous cells of uncertain significance (ASCUS).
Low-grade squamous intraepithelial lesion (LSIL).
High-grade squamous intraepithelial lesion (HSIL).
HISTOPATHOLOGY
Biopsy: nuclear polymorphism with hyperchromasia and mitotic figures; increasing replacement of the stratified squamous
epithelium architecture with immature cells similar to basal cells, no signs of invasiveness, ie, no disruption of basement
membrane.
Evaluation
REQUIRED MINIMAL STANDARD
History: risk stratification HIV-positive, anal intercourse? Presence/absence of symptoms, lumps/bumps? Time since HIV
infection? Current HAART medications? Recent podophyllin applications? Previous Pap smears?
Immune status: CD4 count, viral load.
Clinical examination: external inspection, digital palpation, and anoscopy
skin appearance, condylomata, lumps/bumps,
induration?
ADDITIONAL TESTS (OPTIONAL)
Any visible/palpable pathology biopsy.
No visible pathology but AIN on Pap
high-resolution anoscopy (3% acetic acid or Lugol iodine solution) biopsy of
dysplastic areas to characterize AIN.
Classification
ASCUS: atypical squamous cells of uncertain significance.
AIN I: mild dysplasia (LSIL).
AIN II: moderate dysplasia.
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
AIN III: severe dysplasia, intraepithelial carcinoma (HSIL).
Bowen disease: intraepithelial squamous cell carcinoma in visible anal margin lesion.
Nonoperative Treatment
Expectant approach (watchful waiting) with recurrent clinical and pap monitoring.
Topical imiquimod.
Topical 5-FU (with/without topical imiquimod).
Operative Treatment
INDICATION
Any visible or palpable lesion/mass at least biopsy, or excision if possible.
AIN III: operative treatment vs watchful waiting?
OPERATIVE APPROACH
Anal mapping multiple circumferential punch biopsies at defined concentric intervals.
Wide local excision, potentially with flap reconstruction.
Outcome
Anal Pap screening: sensitivity 65–90% and specificity 30–60% for diagnosing AIN.
Surgical AIN eradication: extensive surgery with significant morbidity (painful recovery, wound care, stricture)
80%
recurrent AIN III within 12 months.
Expectant approach (watchful waiting)
6–10% invasive cancer.
Topical medications (imiquimod, 5-FU)
> 60% chance of AIN resolution?
Follow-Up
Clinical examination and Pap smears: high-grade lesions every 3 months, low-grade lesions annually.
Cross-Reference
HIV-associated anorectal diseases (042) (Ch. 4)
Bowen disease (235.5) (Ch. 4)
Anal cancer (154.2, 154.3) (Ch. 4)
Medications against viral pathogens (App. 1)
BOWEN DISEASE (235.5)
Overview
Bowen disease is an intraepithelial squamous cell carcinoma (caveat: Paget disease is an intraepithelial adenocarcinoma).
Etiologically, it is frequently associated with chronic/recurrent exposure to arsenic or sunlight ( location on trunk and
extremities) or infection with HPV16 or HPV18 ( location in genital/perianal region).
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
Distinction between AIN III and Bowen disease inadequately defined and lacking consensus varying and inconsistent
terminology and possible need to entirely eliminate terms in the future.
Suggested distinction of clinical entities (Table 4–2): in contrast to invisible AIN I–III (located in nonkeratinizing anal canal
anoderm), Bowen disease is located inside or outside anal margin (distal to anal verge in keratinizing squamous epithelium)
presenting as macroscopically visible/palpable skin lesion in form of a scaly or thickened erythematous plaque with an
irregular but usually sharp demarcation (Figure 4–8).
Table 4–2. Comparison of Intraepithelial Neoplasias.
AIN Bowen Disease Paget Disease
Visible/palpable lesion No Yes Yes
Pap smear Yes No No
Histology Squamous cell
dysplasia
Intraepithelialsquamous cell carcinoma Intraepithelial
adenocarcinoma
Location Anal canal Anal margin genital area extragenital
locations
Anal canal to anal margin
HPV-related + + (extra-anogenital: arsenic, sunlight) –
Multifocal 100% 10–20% ?
Malignant potential 6–10% 6–10% 30–50%
Association with internal
malignancies
– – 20–50%
AIN, anal intraepithelial neoplasia; HPV, human papillomavirus; +, positive; – , negative; ?, uncertain.
Figure 4–8.
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
Bowen disease.
Bowen disease is not associated with internal GI malignancies (in contrast to Paget disease
20–50% internal malignancy!).
Epidemiology
Incidence: 14–120 new cases per 100,000 per year.
Symptoms
Range: asymptomatic mild symptoms (eg, pruritus) enlarging skin changes increasing irritation, possible bleeding,
etc.
Differential Diagnosis
Idiopathic pruritus ani.
Perianal skin irritation.
Candidiasis.
Manifest anal cancer.
Bowenoid papulosis.
AIN I–III.
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
Paget disease.
Pathology
MACROPATHOLOGY
Scaly or thickened erythematous skin alteration with irregular but usually sharp demarcation.
HISTOPATHOLOGY
Epithelium with nuclear polymorphism with hyperchromasia and mitotic figures replacement of the stratified squamous
epithelium architecture with immature cells similar to basal cells up to the surface, no signs of invasiveness, ie, no disruption
of basement membrane.
Evaluation
REQUIRED MINIMAL STANDARD
See discussion of AIN, earlier.
ADDITIONAL TESTS (OPTIONAL)
Any visible/palpable pathology: biopsy.
Classification
Bowen disease: intraepithelial squamous cell carcinoma in visible lesion.
Nonoperative Treatment
Expectant approach (watchful waiting).
Topical imiquimod.
Topical 5-FU (with/without topical imiquimod).
Topical photodynamic therapy.
Operative Treatment
INDICATION
Any visible or palpable lesion/mass: at least biopsy, excision if possible.
OPERATIVE APPROACH
Anal mapping: multiple circumferential punch biopsies at defined concentric intervals.
Wide local excision with negative margins, potentially with flap reconstruction.
Outcome
Surgical treatment: high risk of local recurrence. Associated morbidity: discomfort, wound dehiscence, anal stenosis,
incontinence.
Expectant approach (watchful waiting): < 6–10% developing invasive cancer
watchful waiting and selective treatment
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
justifiable.
Follow-Up
Clinical examination every 3 months; biopsy or excision if progression.
Cross-Reference
Skin rash (Ch. 1)
HIV-associated anorectal diseases (042) (Ch. 4)
Anal condylomata (078.10) (Ch. 4)
Anal intraepithelial neoplasia (AIN, 235.5) (Ch. 4)
Anal cancer (154.2, 154.3) (Ch. 4)
Medications against viral pathogens (App. 1)
BUSCHKE-LOWENSTEIN GIANT CONDYLOMATA (078.10, 235.5)
Overview
Buschke-Lowenstein giant condylomata represent large and expansive verrucous growth with invasive squamous cell
carcinoma (verrucous carcinoma): locally destructive growth pattern with high risk for local recurrence but low tendency to
metastasize.
The condition (like other condylomata and anal cancer) is an STD (
located on penis, anus, vulva) related to HPV infection,
but other as of yet unknown factors result in this characteristic growth pattern. Aggravated progression is observed during
pregnancy and in immunosuppressed patients.
Epidemiology
Rare anecdotal series only.
Symptoms
Visible/palpable mass.
Differential Diagnosis
Extensive anal condylomata.
Pathology
MACROSCOPIC
Visible exophytic and verrucous mass.
MICROSCOPIC
Epidermal hyperplasia with hyper-/parakeratosis, koilocytosis, lack of horn pearls; invasion of dermis, but no vascular or
lymphovascular invasion; inflammatory reaction.
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
Evaluation
REQUIRED MINIMAL STANDARD
HIV testing, pregnancy test. Generous and deep biopsy.
Otherwise as for anal cancer.
ADDITIONAL TESTS (OPTIONAL)
As for anal cancer.
Classification
Buschke-Lowenstein giant condylomata.
Verrucous carcinoma.
Nonoperative Treatment
Immunomodulation: antiretroviral therapy (HAART) in HIV-positive patients.
Topical imiquimod.
Injection of interferon or bleomycin?
Chemoradiation (Nigro protocol): Caveat: the verrucous carcinoma and Buschke-Lowenstein giant condylomata are the one
exception to the otherwise primarily nonsurgical approach to anal cancer.
Operative Treatment
INDICATIONS
Large bulky tumor.
OPERATIVE APPROACH
Depending on location:
Wide local excision if possible (anal margin).
Cautery ablation of tumor bulk ( chemoradiation).
Rarely: abdominoperineal resection.
Outcome
Anecdotal data only.
Follow-Up
Oncologic follow-up with regular clinical examination every 3–6 months.
Cross-Reference
Lump or mass (Ch. 1)
Anal condylomata (078.10) (Ch. 4)
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
Anal intraepithelia neoplasia (AIN, 235.5) (Ch. 4)
Bowen disease (235.5) (Ch. 4)
Anal cancer (154.2, 154.3) (Ch. 4)
Excision/fulguration of anal warts (Ch. 5)
Anorectal flaps (Ch. 5)
Abdominoperineal resection (APR) (Ch. 5)
Medications against viral pathogens (App. 1)
ANAL CANCER (154.2, 154.3)
Overview
Anal cancer historically was relatively rare (1.5–2% of all GI tumors) and a disease affecting persons of middle to advanced
age, predominantly women. The HIV epidemic and prolonged survival due to highly active antiretroviral therapy (HAART)
have resulted in a dramatic increase in the incidence of anal cancer among HIV-positive patients, predominantly men who
have sex with men (MSM) and at a younger age, along with an associated risk of cervical, vaginal, and vulvar cancer in
women, and other STDs.
Anal cancer is considered an STD: transmission of HPV occurring through repetitive anal intercourse with serotype 16, but
also 18, 33, (31, 35) represents the highest risk. Other risk factors: immunosuppression (HIV, drug-induced, etc), smoking,
chronic trauma/wounds.
Numerous pathologic subtypes, wide spectrum of special manifestations, and precursor diseases: AIN I–III, Bowen disease,
verrucous cancer, anal cancer in fistula, perianal cancer. Although cancer screening is expanding (anal Pap smears), its role is
not precisely defined.
An overwhelming percentage of new anal cancers are misdiagnosed by noncolorectal specialists as a benign condition.
Staging is based on tumor size, not on depth of penetration (see Appendix 2).
For treatment decisions, anatomic location is crucial:
Anal canal involved: primary location or secondary involvement from large perianal tumor.
Anal canal not involved: perianal (anal margin) cancer.
Treatment in the past: primary radical surgery with wide local excision (anal margin) or APR (anal canal). Modern strategy for
anal canal has shifted to highly effective and sphincter-saving chemoradiation (Nigro protocol) as the first-line approach,
with radical surgery reserved for patients with incomplete response (large tumors more likely) or recurrences. Nonetheless a
substantial fraction of patients (> 25%) ultimately require colostomy for various reasons.
Epidemiology
Classical form (before HIV): women in their 50s–60s, 0.7 new cases per 100,000 men overall, 25–37 new cases per 100,000
MSM.
New epidemic (since advent of HIV): younger HIV-positive males (MSM)
relative increased risk ratio compared with pre-
HIV era: 84.1 in homosexual and 37.7 in nonhomosexual patients. Epidemic rise in annual incidence in US: from 3400 new
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
cases in 1997 to 4700 new cases and 700 cancer-related deaths in 2007.
Symptoms
Bleeding (55–60%), anal pain and tenesmus (40–50%), visible or palpable mass (25–40%), change in bowel habits (eg,
pencil-like stools, incontinence), constipation, diarrhea, mucous discharge, pruritus. Completely asymptomatic (20%).
Associated benign anorectal pathology in > 25% of patients: hemorrhoids, condylomata acuminata (> 50% in MSM), Bowen
disease, fissure, fistula, leukoplakia, pruritus
symptoms frequently ignored or misallocated for > 3 months before diagnosis
of cancer is established.
Differential Diagnosis
Perianal (anal margin) tumors: distal to transition of hairless anal canal to hair-containing perianal skin, but < 5 cm away
from anal verge.
Skin cancer: > 5 cm away from anal verge.
Rectal cancer (
adenocarcinoma): above dentate line.
Infiltration from extensive cancer of the bladder, cervix, vagina, vulva, etc.
Other rare (pre-)malignant anorectal tumors: Paget disease, Bowen disease, carcinoid, lymphoma, GIST, melanoma, small
cell cancer, Kaposi sarcoma.
Benign lesions: anal condylomata, Buschke-Lowenstein giant condylomata, fistula with chronic perifistular induration, fissure
with sentinel skin tag, thrombosed external hemorrhoid.
Pathology
MACROSCOPIC
Visible or palpable mass, ulcerative lesion, asymmetric "fissure" primarily locally destructive growth pattern (Figure 4–9).
Inguinal lymph node involvement at time of diagnosis: 10–25%.
Figure 4–9.
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
Anal cancer.
MICROSCOPIC
Several histopathologic subtypes (little impact on clinical decision-making process and outcome):
Squamous cell (cloacogenic) carcinoma (SCC, large cell keratinizing, 70–80%): with subtypes, transitional (large cell
nonkeratinizing) and basaloid.
Adenocarcinoma (10–15%): arising from anal glands or apocrine skin glands.
Other histologies (2–10%): eg, small cell carcinoma.
Evaluation
REQUIRED MINIMAL STANDARD
History: bleeding, change in bowel habits, obstructive symptoms, weight loss? Any nonhealing anorectal condition? HIV
status?
Clinical examination:
– Inspection: visible skin changes (symmetric, asymmetric), lumps/bumps, eccentric ulcerations, secondary fistula
openings, discoloration? Anything unusual? Concomitant pathology (eg, condylomata, hemorrhoids, tags, etc)?
– Digital exam: perirectal induration, exact anatomic location, size, and internal extension of tumor? Sphincter tone?
– Palpation of inguinal lymph nodes.