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Abstract: Aim: Chemoradiotherapy remains the first line of treatment for anal cancer with surgery reserved for cancer recurrence or persistence. The low incidence of anal cancer means that the numbers undergoing surgery is small with centralization for excision to regional cancer centres. We present our experience of abdominal perineal excision, with reconstruction of the perineal defect (APERR), within a tertiary centre. Method: Over a 15‐year period, data were collected retrospectively from notes of patients who underwent an APERR. The aim was to look at disease‐free and overall survival and complications associated with flap reconstruction. Results: In the study period, 29 patients [median age = 62 (range: 42–81; interquartile range: 54–68) years] underwent APERR. Median follow‐up was 77 (4–200) months. Thirteen patients died during follow‐up; eight from their disease, with a median survival time of 16 (4–63) months. Five‐year survival was 67%. Nine (31%) patients had recurrence during the follow up period; this was local (n = 2), regional (n = 4), distant (n = 2) or a combination (n = 1). Sixteen (55%) patients developed 24 complications, including nine (31%) flap complications and 10 (34%) parastomal hernias. Flap complications were flap failure (n = 1) requiring direct closure, flap dehiscence (n = 2), necrosis of flap tip (n = 1), wound infection (n = 4) and a bulky flap (n = 1) requiring liposuction. Conclusion: APERR of anal cancer is a feasible technique with excellent oncological treatment and acceptable long‐term complications, although a higher than expected rate of parastomal hernia was noted. [ABSTRACT FROM AUTHOR]

Aim There is ambiguity with regard to the optimal management of anal intraepithelial neoplasia ( AIN) III. The aim of this review was to assess and compare international/national society guidelines currently available in the literature on the management, treatment and surveillance of AIN III. We also aimed to assess the quality of the studies used to compile the guidelines and to clarify the terminology used in histological assessment. Method An electronic search of PubMed and Embase was performed using the search terms 'anal intraepithelial neoplasia', ' AIN', 'anal cancer', 'guidelines', 'surveillance' and 'management'. Literature reviews and guidelines or practice guidelines in peer reviewed journals from 1 January 2000 to 31 December 2014 assessing the treatment, surveillance or management of patients with AIN related to human papilloma virus were included. The guidelines identified by the search were assessed for the quality of evidence behind them using the Oxford Centre for Evidence-based Medicine 2011 Levels of Evidence. Results The database search identified 5159 articles and two further guidelines were sourced from official body guidelines. After inclusion criteria were applied, 28 full-text papers were reviewed. Twenty-five of these were excluded, leaving three guidelines for inclusion in the systematic review: those published by the Association of Coloproctology of Great Britain and Ireland, the American Society of Colon and Rectal Surgeons and the Italian Society of Colorectal Surgery. No guidelines were identified on the management of AIN III from human papilloma virus associations and societies. All three guidelines agree that a high index of clinical suspicion is essential for diagnosing AIN with a disease-specific history, physical examination, digital rectal examination and anal cytology. There is interchange of terminology from high-grade AIN ( HGAIN) (which incorporates AIN II/ III) and AIN III in the literature leading to confusion in therapy use. Treatment varies from immunomodulation and photodynamic therapy to targeted destruction of areas of HGAIN/ AIN II/ III using infrared coagulation, electrocautery, cryotherapy or surgical excision but with little consensus between the guidelines. Recommendations on surveillance strategies are similarly discordant, ranging from 6-monthly physical examination to annual anoscopy ± biopsy. Over 50% of the recommendations are based on Level 3 or Level 4 evidence and many were compiled using studies that were more than 10 years old. Conclusion Despite concordance regarding diagnosis, there is significant variation in the guidelines over recommendations on the treatment and surveillance of patients with HGAIN/ AIN II/ III. All three sets of guidelines are based on low level, outdated evidence originating from the 1980s and 1990s. [ABSTRACT FROM AUTHOR]

Aim There is debate about whether the traditional three-tiered grading of anal intraepithelial neoplasia ( AIN) should be replaced by a more reproducible two-tiered system. In this study, we review our experience with AIN to determine the most suitable classification system. Method We performed a retrospective review of all histological reports over a 19 year period. All specimens were graded on haemataloxin and eosin appearance and those with dysplasia had immunohistochemistry for p16 and Ki67 performed. Results Cases included 25 condyloma acuminata, 11 dysplastic cases and 24 invasive squamous cell carcinomas. On review, 18 were classified as condyloma acuminata without dysplasia. Seven had AIN I, five had AIN II and six had AIN III when using a three-tiered system. All cases classified as dysplastic ( n = 18) showed an increased proliferation index as measured by Ki67. p16 positivity was seen in all AIN III, two AIN II and none of the AIN I cases. Recurrence was not observed in any of the AIN I cases. Five of eleven AIN II and AIN III cases recurred or persisted at a similar, higher or lower grade. Both of the AIN II cases which recurred or persisted were p16 positive. None of the AIN II cases that were p16 negative recurred. Three of the p16-positive AIN III cases did not recur. None of the 18 AIN cases progressed to carcinoma. Conclusion The findings support the slow progression of AIN as described in the literature. In our small series, a two-tiered system with further subclassification of the traditional AIN II group using p16 appears to be clinically useful. [ABSTRACT FROM AUTHOR]

There is a lack of standardization regarding diagnosis, treatment and surveillance of patients with anal HPV infection. An Internet-based survey was sent to members of international, surgical and dermatological societies. Answers were obtained from 1017 dermatologists and 393 colorectal surgeons ( n = 1410). More dermatologists than surgeons provided noninvasive treatment of anal condyloma with 5% imiquimod (80.4 vs 28.2%; P < 0.001), whereas the situation was reversed for surgical excision (56.8 vs 91.3%; P < 0.001). To detect dysplastic lesions, 42.0% of surgeons used acetic acid only, 23.2% used this in combination with high-resolution anoscopy and 19.5% applied intra-anal cytological smears. Likewise, 64.6% of dermatologists applied acetic acid only, 16.5% combined acetic acid with high-resolution anoscopy and 30.2% performed intra-anal cytological smears (all P < 0.001 compared with surgeons). The therapy for anal intraepithelial lesions was not influenced by the grade of dysplasia, but it was by immune status. There were significant differences in practice between colorectal surgeons and dermatologists. These findings highlight the need for international and cross-disciplinary clinical guidelines. [ABSTRACT FROM AUTHOR]

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