Ignaz Schneider

Tumor Site Predicts Outcome After Radiochemotherapy in Squamous-Cell Carcinoma of the Anal Region: Long-Term Results of 101 Patients

PURPOSEThis study was designed to assess the long-term results following radiochemotherapy in patients with anal squamous-cell carcinoma and to evaluate the impact of tumor location on response, survival, and colostomy-free survival.PATIENTS AND METHODSBetween 1985 and 2001, a total of 101 patients with anal carcinoma were registered for curative treatment, of whom 77 had involvement of the anal canal alone, 10 cases had extension into the perianal skin, and 14 patients had pure anal margin tumors. Small tumors of the anal margin were not included since they were treated by surgical excision only. Among the 101 patients were 74 women and 27 men with a median age of 62 (range, 26–84) years. T categories (International Union against Cancer) were T1 (15), T2 (36), T3 (34), and T4 (16). Seventy-one patients had no evidence of nodal disease, whereas 30 presented with involved regional nodes. Radiation treatment was directed to the primary tumor region and to the inguinal, perirectal, and internal iliac nodes using a three-field to four-field box technique with 10MV photons up to a total dose of 5040 cGy. Lesions greater than 5 cm received an additional boost by interstitial or external radiation depending on circumferential extension of the residual tumor. All patients were scheduled for simultaneous chemotherapy with two cycles of 5-fluorouracil at a dose of 1000 mg/m 2/day as 120 hours of continuous intravenous infusion on Days 1 to 5 and 29 to 33 and mitomycin C at 10 mg/m 2/day on Days 1 and 29. Median follow-up time was was 7.5 (range, 1–16) years.RESULTSOverall survival and colostomy-free survival rates for patients with anal canal cancer were 75 percent and 87 percent at five years, respectively. Patients with anal margin cancer had a less favorable outcome with five-year-overall and colostomy-free survival rates of 54 percent and 69 percent, respectively. After correction for imbalance between anal canal and anal margin tumors, i.e., exclusion of T1 tumors of the anal canal, difference in overall survival remained significant (73 percent vs. 54 percent, P = 0.01). Following multivariate analysis, tumor location (anal canal vs. anal margin, P = 0.02), age (P = 0.003), and dose intensity of chemotherapy (≤75 percent vs. >75 percent, P = 0.03) remained independent significant factors for overall survival. Initial tumor response at six weeks (P = 0.03) was predictive for colostomy-free survival.CONCLUSIONSWith colostomy-free survival rates around 85 percent, long-term treatment results for anal canal carcinoma have reached a satisfactory level. However, patients with larger lesions of the perianal skin are at high risk for locoregional recurrence and possible treatment intensification in this subgroup seems desirable.

Treatment of ingrown toenails using a new conservative method : A prospective study comparing brace treatment with Emmert's procedure

Ingrown toenails cause incapacitation and pain for the patient and lost time from work. Many different conservative and surgical treatment methods have been described. European chiropodists and podologists have long treated ingrown toenails with orthonyxia, which consists of implantation of a small metal brace or plate onto the dorsum of the nail. To determine whether orthonyxia is an acceptable alternative to surgery, we compared the VHO-Osthold brace (VHO-Osthold-Spange GmbH, Deisenhofen, Germany), a new method of orthonyxia, with Emmerts procedure, a standard surgical method that is virtually identical to the Winograd-type procedure, in a prospective study of 41 patients (21 in the brace group and 20 in the Emmert procedure group). Pain due to treatment was significantly lower in the brace group than in the Emmert procedure group, and patients in the brace group could wear regular shoes again without appreciable pain much earlier than those in the Emmert procedure group. In the brace group, there were four recurrences, and one patient was still receiving treatment at the end of follow-up; in the Emmert procedure group, there were three recurrences. None of the patients in the brace group had to take time off from work, whereas in the Emmert procedure group, working patients were off from work for an average of 14.7 days. Brace treatment proved to be a good conservative alternative to operative procedures.

Sphincter preservation with chemoradiation in anal canal carcinoma

PURPOSE: This study contained herein assessed long-term results, toxicity, and prognostic variables following combined modality therapy of patients with International Union Against Cancer Classification T1–4, N0–3, M0 squamous-cell carcinoma of the anal canal. PATIENTS AND METHODS: Between 1985 and 1996, 62 patients completed treatment with combined modality therapy. A median total dose of 50 Gy was given to the primary, perirectal, presacral, and inguinal nodes followed by a local boost in selected cases. 5-Fluorouracil was scheduled as a continuous infusion of 1,000 mg/m2 per 24 hours on days 1 to 5 and 29 to 33 and mitomycin C as a bolus of 10 mg/m2 on days 1 and 29. Routinely processed paraffin-embedded sections were stained using monoclonal antibodies for detection of proliferating cell nuclear antigen and MIB1 (Ki-67) antigen to determine the labeling index. In addition, DNA ploidy was assessed after Feulgen staining. RESULTS: Actuarial cancer-related survival, no evidence of disease survival, and colostomy-free survival rates at five years were 81, 76, and 86 percent, respectively. In univariate analysis, T category (T1/2 vs. T3/4) was predictive for no evidence of disease survival (87vs. 59 percent;P=0.03) and colostomy-free survival (94vs. 73 percent;P=0.05). N category (N0vs. N1–3) influenced actuarial cancer-related survival (85vs. 58 percent;P=0.002) and no evidence of disease survival (80vs. 53 percent;P=0.02). A higher proliferative potential as measured by the MIB1 labeling index was associated with a better colostomy-free survival (90vs. 50 percent;P=0.04). In multivariate analysis, actuarial cancer-related survival was only influenced by the N category (P=0.03) and no evidence of disease survival by N category (P=0.03) and mitomycin C dose (P=0.04). Salvage abdominoperineal resection achieved long-term control in only four of seven patients with local failures. CONCLUSION: Treatment with a combination of radiotherapy and chemotherapy is safe and effective for patients with anal canal carcinoma. Abdominoperineal resection is indicated as a salvage procedure in nonresponding and recurrent lesions and may be of benefit in a small subgroup of patients with poor prognostic factors.

The differential diagnosis and interdisciplinary treatment of anal carcinoma.

BACKGROUND Anal carcinoma accounts for 2-4% of all cases of colorectal and anorectal carcinoma. Its peak incidence is from age 58 to age 64; women are affected somewhat more commonly than men. Its incidence has risen markedly in the past three decades. METHODS This article is based on a selective review of the literature, including the guidelines of the National Comprehensive Cancer Network and the European Society of Medical Oncology. RESULTS Anal carcinoma is often an incidental finding. About 85% of newly diagnosed cases are associated with an HPV infection with strain 16, 18, or 33. Radiochemotherapy with 5-fluorouracil and mitomycin C is the treatment of choice. The 5-year survival rate is 80-90%. Primary surgery with curative intent is indicated only for well-differentiated carcinoma of the anal margin (T1, N0). 10-30% of patients now undergo radical resection. The utility of endosonography and positron emission tomography for staging is debated and needs further study. CONCLUSION The treatment of patients with anal carcinoma requires a specialized multidisciplinary approach in accordance with the current evidence-based guidelines. The potential role of prophylactic vaccination against oncogenic types of HPV in the prevention of anal carcinoma merits further investigation.

Laparoscopic-assisted colon anastomosis using the Valtrac® ring

PURPOSE: For deep colon anastomoses in laparoscopic surgery, the mainstay is the circular stapler. Theoretically, however, such anastomoses can also be constructed with the aid of the Valtrac® ring. The aim of the present study was to investigate the feasibility of this approach. METHODS: In this approved animal study nine pigs weighing 15 to 20 kg were operated on under general anesthesia. After intracorporeal preparation, the colon was divided at the level of the entry to the pelvis. To fix the proximal half of the Valtrac® ring, the proximal limb of the colon was exteriorizedvia a minilaparotomy. After replacing this part of the colon—now bearing the Valtrac® ring—in the abdominal cavity and reestablishment of pneumoperitoneum, the ring was fixed to the applicator inserted transanally into the abdominal cavity. After placement of the distal half of the ring in the rectal limb and extracorporeal knotting of the pursestring suture previously placed with the aid of the laparoscopic pursestring clamp, the two halves of the Valtrac® ring were reliably closed with the help of the applicator. RESULTS: Eight of nine animals survived. One animal died on the fourth postoperative day as a result of an anastomotic insufficiency. At follow-up examination in the fifth postoperative week, none of the surviving eight animals showed any signs of prior anastomotic insufficiency. CONCLUSION: This animal study has shown that using the newly developed applicator system, the Valtrac® ring can be just as readily employed as the circular stapler for creation of a colonic anastomosis below the level of the promontorium.

PROGNOSTISCHE FAKTOREN BEI KOMBINIERTER RADIOCHEMOTHERAPIE DES ANALKANALKARZINOMS

Kombinierte Radiochemotherapie (RCT) ist eine effektive Behandlung fur alle Stadien des Analkanalkarzinoms. Die Rektumexstirpation bleibt Patienten mit ungenugender Tumorregression bzw. Rezidiven vorbehalten.

Erste experimentelle Erfahrungen mit einem rektal einzubringenden Applikationsgerät für laparoskopische Anastomosen mit einem biofragmentierbaren Anastomosenring

Abgesehen von der Anastomosierungstechnik mit Hilfe eines Zirkularstaplers im Bereich des Rektosigmoids gibt es bis heute in der laparoskopischen Chirurgie noch kein allgemein anerkanntes Verfahren zur Herstellung von Dunn- und Dickdarmanastomosen (Kockerling 1992, 1993, Schneider 1994, Wexner 1993, Cohen 1993). Deswegen haben wir im Rahmen eines fruheren Tierversuchs die Moglichkeit der Verwendung von biofragmentierbaren Anastomosenringen unter den Bedingungen der laparoskopischen Chirurgie uberpruft (Schneider 1994). Dabei stellte sich das Handling, das Aufbringen der Darmschenkel auf den Anastomosenring und der Verschlus des Ringes mit den herkommlichen Instrumenten als schwierig heraus. Um auch fur den Valtrac®-Ring ein der Staplertechnik vergleichbar einfaches Handling zu erreichen, haben wir fur den Bereich des Rektosigmoids ein spezielles Applikationsgerat entwickelt. Mit diesem Gerat sollte ein leichtes Fuhren und ein zuverlassiger Verschlus des Ringes moglich sein. Der jetzt durchgefuhrte Tierversuch galt der Uberprufung der Praktikabilitat des neuentwickelten Instrumentes.