Behind the knife

FULL Patient History Below: (Video starts a bit late and does not include full history)
60F w/intense anal itching + burning for 1 mo. Tried using witch hazel + Prep H. No fiber, no laxatives, Western diet. 2 BM per day. No incontinence. Well-controlled DM. Anxiety, no medications. Monogamous, sexually active, no hx STI. CSP 7 years prior. Exam: external excoriations. No masses. Normal tone. Flex sig: no proctitis, masses Causes? Dietary Systemic illnesses Autoimmune + dermatologic conditions Contact dermatitis (ex: fragrances in her hygiene regimen) Topical steroid 1 mo. F/U w/o improvement Consider stopping Metformin Other treatment options? Topical capsaicin, refer to Dermatology Intra-dermal methylene blue injection using 27 Gg, non-hair bearing portion, 1:10 dilution Complications? Anaphylaxis, necrosis, temporary incontinence Alternative: 2 cm perianal lesion distal to anal verge, erythematous + scaly Poss. Paget's? Punch BX w/local anesthesia Inguinal exam CSP (-) OR: anal mapping WLE w/2 mm margin + leave open Other options? Raise flaps on either side + primarily close Alternative: CSP showed 3.5 cm mass in rectum 7 cm from anal verge, ant. BX: adenoCA Stage w/MRI, CT C/A/P (-) MRI: T2N0M0 Pathologic features: no adverse Assess continence Council re robotic LAR w/DLI How to treat Paget's w/rectal CA? APR Alternative: 85F w/Paget's only - topical treatment Alternative: 60F w/pruritis found 3 cm ulcerated lesion in anal verge, tender, soiling, can't get good exam in office Additional Qs? Gyn hx, abnormal paps, HPV vaccine, TOB or XRT, anoreceptive intercourse Book for EUA w/BX No invasion in vagina, invades into IAS Path: SCC HIV testing Staging: MRI, CT C/A/P, CEA? No inguinal LN p16 (+), what does that mean? HPV-related Multiple BL liver lesions suspicious for mets Refer to Med + RadOnc for neoadjuvant chemoTX w/checkpoint inhibitors T2N0M0 stage 2 Neoadjuvant Nigro protocol 54Gy XRT, 5-FU, MMC 5 weeks post-TX F/U lesion smaller but wait until 3 mo. Mass gone but scar remains MRI, endoscopy BX? No Surveillance protocol MRI, CT at 6 mo. w/anoscopy + exam/CEA Q6 mo. Mass decreased in size at 3 mo. Possibly grew at 6 mo. Re-stage w/MRI + CT Salvage APR Metachronous inguinal LAD unilaterally PET: isolated L groin L lymphadenectomy - refer to Surg Onc Inguinal + primary disease Radiate groin Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.