Human papillomavirus (HPV)-related lower genital cancers, including cervical cancer, anal squamous cell carcinoma (SCC), vaginal cancer, vulvar cancer, and penile cancer, pose a significant health burden, with approximately 45,000 new cases diagnosed annually. Current effective treatment modalities include chemoradiotherapy, systemic chemotherapy, and immune checkpoint inhibitors (ICIs). The tumor microenvironment in HPV-related cancers is characterized by immune evasion mechanisms, including the modulation of immune checkpoints such as PD-L1/PD-1. HPV oncoproteins E5, E6, and E7 play crucial roles in this process, altering the expression of immune inhibitory molecules and the recruitment of immune cells. ICIs, such as programmed cell death protein 1 (PD-1) inhibitors, have shown efficacy in enhancing the immune response against HPV-associated tumors by blocking proteins that allow cancer cells to evade immune surveillance. Recent studies have demonstrated that HPV-positive tumors exhibit a more favorable response to ICI-based therapies compared to HPV-negative tumors. The integration of ICIs into treatment regimens for HPV-related cancers has been supported by several clinical trials. The inclusion of ICIs in the treatment approach for HPV-related lower genital cancers presents a promising opportunity for improving patient outcomes. Ongoing research and clinical trials are advancing our understanding of the immune microenvironment and the therapeutic potential of immunotherapy for these cancers.

Perineal defects following abdominoperineal resections (APRs) for rectal cancer may require myocutaneous or omental flaps depending upon anatomic, clinical and oncologic variables. However, studies comparing their efficacy have shown contradictory results. We aim to compare postoperative complication rates of APR closure techniques in rectal cancer using propensity score-matching. The American College of Surgeons Proctectomy Targeted Data File was queried from 2016 to 2019. The study population was defined using CPT and ICD-10 codes for patients with rectal cancer undergoing APR, stratified by repair technique. Perioperative demographic and oncologic variables were controlled for by propensity-score matching. Multivariate logistic regression analysis was performed for wound and major complications (MCs). Of the 3291 patients included in the study, 85% underwent primary closure (PC), 8.3% rectus abdominis myocutaneous (RAM) flap, 4.9% pedicled omental flap with PC, and 1.9% lower extremity (LE) flap repair. Primary closure rates were significantly higher for patients with stage T1 and T2 tumors (p < 0.001). RAM and LE flaps were most used with multi-organ resections, 24% and 25%, respectively (p < 0.001). Similarly, cases with T4 tumors used these flaps more frequently, 30% and 40%, respectively (p < 0.001). After propensity score matching for comorbidities and oncologic variables, there was no significant difference in 30-day postoperative wound or MC rates between perineal closure techniques. The complication rates of the different closure techniques are comparable when tumor stage is considered. Therefore, tumor staging and concurrent procedures should guide clinical decision making regarding the appropriate use of each technique.

Background: Anal squamous cell carcinoma (SCC) generally carries a favorable prognosis, as most tumors are highly sensitive to standard of care chemoradiation. However, outcomes are poor for the 20–30% of patients who are refractory to this approach, and many will require additional invasive procedures with no guarantee of disease resolution. Methods: To identify the patients who are unlikely to respond to the current standard of care chemoradiation protocol, we explored a variety of objective clinical findings as a potential predictor of treatment failure and/or mortality in a single center retrospective study of 42 patients with anal SCC. Results: Patients with an increase in total peripheral white blood cells (WBC) and/or neutrophils (ANC) had comparatively poor clinical outcomes, with increased rates of death and treatment failure, respectively. Using pre-treatment biopsies from 27 patients, tumors with an inflamed, neutrophil dominant stroma also had poor therapeutic responses, as well as reduced overall and disease-specific survival. Following chemoradiation, we observed uniform reductions in nearly all peripheral blood leukocyte subtypes, and no association between peripheral white blood cells and/or neutrophils and clinical outcomes. Additionally, post-treatment biopsies were available from 13 patients. In post-treatment specimens, patients with an inflamed tumor stroma now demonstrated improved overall and disease-specific survival, particularly those with robust T-cell infiltration. Conclusions: Combined, these results suggest that routinely performed leukocyte subtyping may have utility in risk stratifying patients for treatment failure in anal SCC. Specifically, pre-treatment patients with a high WBC, ANC, and/or a neutrophil-dense tumor stroma may be less likely to achieve complete response using the standard of care chemoradiation regimen, and may benefit from the addition of a subsequent line of therapy.

Plasmablastic lymphoma (PBL) is a rare variant of diffuse large B-cell lymphoma (DLBCL) associated with human immunodeficiency virus (HIV)-positive patients. It accounts for only 2% of all acquired immune deficiency syndrome (AIDS)-related lymphomas (ARLs). We present the case of a 45-year-old male who presented to the emergency department (ED) with a three-month history of abdominal pain, diarrhea, and unintentional 50-lb weight loss. On an earlier presentation to the ED three months prior, the patient was diagnosed with norovirus and Helicobacter pylori infection and received outpatient treatment without resolution of his symptoms. This prompted further investigation with a CT of the abdomen and pelvis with IV contrast that revealed severe sigmoid colitis with pneumoperitoneum and a pericolonic air-containing fluid collection, consistent with a contained perforation with abscess formation. He was admitted, resuscitated, and initially treated with antibiotics and parenteral nutrition. The patient underwent a laparoscopic converted to open anterior resection with end colostomy. Pathology revealed HIV-related PBL. He was subsequently treated with dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (DA-EPOCH-R) chemotherapy regimen and an autologous stem cell transplant. Despite its rare association with HIV, PBL should be considered a differential diagnosis for HIV-positive patients who present with gastrointestinal (GI) pathology, and additional investigations should be conducted if symptoms do not resolve despite appropriate medical management at the time.

Objective: These experiments test the feasibility of tele-robotic surgery for the shipboard care of combat casualties. Summary Background Data: Limited research on the effects of telecommunications latency on tele-robotics has been a consistent concern in the growth of tele-robotic surgery. These experiments are designed to provide well-controlled real-world data on robotic surgical performance with electronically added latency that simulates combat-relevant, satellite-based tele-robotic communication. Methods: Surgeons at 2 university hospitals separated by 1096 km bi-directionally performed remote cholecystectomy (Ch) and right colectomy (Co) dissections on cadaver subjects. Varying latency between 0 and 300 ms was electronically added. Network performance, OR time, Global Performance (GP), and Surgery Task Load Index (TLX) were determined. Statistical analysis: simple linear regression. Results: Network latency was 28 ms, jitter 0.03 ms, with zero packet loss. Including robotic intrinsic latency of 50 ms, total latency (TOT) varied from 78 to 378 ms. 12 Ch and 14 Co were performed by 4 surgeons. Co OR time unexpectedly decreased with TOT ( P =0.005), but Ch did not ( P =0.47). OR time was strongly associated with general surgeon experience ( P =0.024). TLX was strongly associated with surgeon experience ( P <0.001) but not TOT ( P =0.47). GP was consistently between 4/5 and 5/5 across all domains and did not correlate with TOT ( P =0.41). Each surgeon showed rapid cognitive and motor adaptation to increasing latency. Conclusions: Experienced robotic surgeons rapidly develop cognitive and motor adaptation to tele-robotic latency. Satellite-based tele-robotic surgery in combat environments may add greater latency than fiber-optic-connected civilian applications. Our data indicate a significantly greater tolerance for latency than previously reported. Development of telerobotic surgery for combat casualties is highly feasible.

PURPOSE: The purpose of this study was to evaluate the complication rates associated with fecal management systems (FMS) and assess compliance with manufacturer guidelines at our institution. DESIGN: Retrospective review. SUBJECTS AND SETTING: Patients with FMS inserted between September 2010 and April 2019 at a tertiary care center located in the Midwestern United States. METHODS: Variables collected included demographics, history of liver cirrhosis, anticoagulation, indications for insertion, complications, and diagnostic or therapeutic interventions. Univariate analysis and Fisher exact test were performed to calculate odds ratio of potential predictive factors. RESULTS: A total of 202 patients were included, with a median age of 63 years. Of these, 3.5% (7 patients) experienced FMS-related complications, all presenting with rectal bleeding; 57% had rectal ulcerations, 71% required transfusions, and 1 patient required operative intervention. Notably, 96% of cases lacked documentation of a digital rectal examination before insertion. The median duration of FMS use was significantly longer in patients with complications (11 days) compared with those without (6 days, P = .05), suggesting that prolonged use may be associated with an increased risk of adverse effects. CONCLUSION: Prolonged use of FMS was associated with an increased risk of complications, and overall adherence to recommended guidelines was poor. Implementing structured documentation and assessment protocols may help improve adherence and promote safer use.