Management of inguinal lymph node metastases in patients with carcinoma of the anal canal: experience in a series of 270 patients treated in Lyon and review of the literature

Role of Sentinel Lymph Node Biopsy for Skin Cancer Based on Clinical Studies

The sentinel lymph node is the first lymph node from the primary tumor. Sentinel lymph node biopsy (SLNB) is a surgical procedure that can detect occult nodal metastasis with relatively low morbidity. It may also have a therapeutic effect via regional disease control. The Multicenter Selective Lymphadenectomy-I (MSLT-I) trial revealed a prognostic benefit from SLNB in melanoma patients. However, it remains unclear whether there is a prognostic benefit from SLNB in patients with nonmelanoma skin cancer owing to a lack of randomized prospective studies. Nevertheless, SLNB provides important information about nodal status, which is one of the strongest factors to predict prognosis and may guide additional nodal treatment. Currently, SLNB is widely used in the management of not only patients with melanoma but also those with nonmelanoma skin cancer. However, the utilization and outcomes of SLNB differ among skin cancers. In addition, SLNB is not recommended for routine use in all patients with skin cancer. In this review, we provide a summary of the role of SLNB and of the indications for SLNB in each skin cancer based on previously published articles.

Case report: a precancerous lesion associated with HPV in the anal canal diagnosed by magnifying endoscopy with narrow-band imaging and resected by endoscopic submucosal dissection

Although anal cancer remains rarely diagnosed in the world, its frequency is rising, especially in high-risk groups. The prognosis of advanced anal cancer is poor. However, there are still few reports on the endoscopic diagnosis and treatment of early anal cancer and its precancerous lesions. A 60-year-old woman was referred to our hospital for endoscopic treatment of a flat precancerous lesion in the anal canal, which was identified by narrow-band imaging (NBI) and confirmed by pathological examination in another hospital. The pathological results showed a high-grade squamous intraepithelial lesion (HSIL) in the biopsy specimen, and immunochemistry staining showed P16 positive, suggesting HPV infection. We performed pre-resection endoscopic examination for the patient. A lesion with a clear margin and tortuous dilated vessels was revealed under magnifying endoscopy with NBI (ME-NBI), which stayed unstained after iodine spraying. The lesion was successfully removed en bloc using ESD without complications, and the resected specimen was a low-grade squamous intraepithelial lesion (LSIL) with positive immunochemistry staining of P16. The patient underwent follow-up coloscopy a year after ESD, and the anal canal healed well with no suspicious lesions found. From this case, we can learn that ESD is safe and effective for curative resection of precancerous lesions of the anal canal.

Management of inguinal lymph node metastases from rectal and anal canal adenocarcinoma

AIM

The surgical treatment of inguinal lymph node (ILN) metastases secondary to anorectal adenocarcinoma remains controversial. This study aimed to clarify the surgical treatment and management of ILN metastasis according to its classification.

METHODS

This retrospective, multi-centre, observational study included patients with synchronous or metachronous ILN metastases who were diagnosed with rectal or anal canal adenocarcinoma between January 1997 and December 2011. Treatment outcomes were analysed according to recurrence and prognosis.

RESULTS

Among 1181 consecutively enrolled patients who received treatment for rectal or anal canal adenocarcinoma at 20 referral hospitals, 76 (6.4%) and 65 (5.5%) had synchronous and metachronous ILN metastases, respectively. Among 141 patients with ILN metastasis, differentiated carcinoma, solitary ILN metastasis and ILN dissection were identified as independent predictive factors associated with a favourable prognosis. No significant difference was found in the frequency of recurrence after ILN dissection between patients with synchronous (80.6%) or metachronous (81.0%) ILN metastases. Patients who underwent R0 resection of the primary tumour and ILN dissection had a 5-year survival rate of 41.3% after ILN dissection (34.1% and 53.1% for patients with synchronous and metachronous ILN metastases, respectively, P = 0.55).

CONCLUSION

The ILN can be appropriately classified as a regional lymph node in rectal and anal canal adenocarcinoma. Moreover, aggressive ILN dissection might be effective in improving the prognosis of low rectal and anal canal adenocarcinoma with ILN metastases; thus, prophylactic ILN dissection is unnecessary.

Laparoscopic abdominosacral resection for rectal and anal canal carcinoma with pagetoid spread

INTRODUCTION

Perianal Paget's disease is associated with adenocarcinoma and can spread to the perianal skin. It often requires extensive resection of the perianal skin and rectum. Many studies have shown the efficacy of laparoscopic abdominoperineal resection for lower rectal cancer. However, extensive resection of the dorsal side of the perineal skin is difficult in the lithotomy position. We report a laparoscopic abdominosacral approach using the jackknife position for perianal Paget's disease.

MATERIALS AND SURGICAL TECHNIQUE

Surgery was started using the lithotomy position, and total mesorectal excision with central lymphadenectomy was performed laparoscopically. Pelvic floor muscles were divided 2 cm away from the rectum. The sigmoid colon was then divided with a linear stapler, and a terminal colostomy was made. The sacral approach was then followed with the patient placed in a jackknife position. A skin incision was made 1-2 cm from the negative margin confirmed by preoperative mapping biopsy and resected en-bloc. We used this approach in two patients with a mean operative time of 483 minutes, including 53.5 minutes for the position change. All tumor margins, including the skin, were cancer-free, and primary wound closure was possible in both of the cases. Both patients were doing well without any recurrence 10 and 13 months postoperatively.

CONCLUSION

Laparoscopic abdominosacral resection is safe and effective and facilitates extensive perineal skin resection, especially on the dorsal side, with a less invasive laparoscopic procedure.

Interobserver variability in clinical target volume delineation in anal squamous cell carcinoma

We evaluated the inter-physician variability in the target contouring of the radiotherapy for anal squamous cell carcinoma (ASCC). Clinical target volume (CTV) of three patients diagnosed with ASCC was delineated by seven experienced radiation oncologists from multi-institution. These patients were staged as pT1N1a, cT2N0, and cT4N1a, respectively, according to 8^th edition of the American Joint Committee on Cancer staging system. Expert agreement was quantified using an expectation maximization algorithm for Simultaneous Truth and Performance Level Estimation (STAPLE). The maximum distance from the boundaries of the STAPLE generated volume with confidence level of 80% to those of the contour of each CTV in 6 directions was compared. CTV of pelvis which includes primary tumor, perirectal tissue and internal/external iliac lymph node (LN) area (CTV-pelvis) and CTV of inguinal area (CTV-inguinal) were obtained from the seven radiation oncologists. One radiation oncologist did not contain inguinal LN area in the treatment target volume of patient 2 (cT2N0 stage). CTV-inguinal displayed moderate agreement for each patient (overall kappa 0.58, 0.54 and 0.6, respectively), whereas CTV-pelvis showed substantial agreement (overall kappa 0.66, 0.68 and 0.64, respectively). Largest variation among each contour was shown in the inferior margin of the CTV-inguinal. For CTV-pelvis, anterior and superior margin showed the biggest variation. Overall, moderate to substantial agreement was shown for CTV delineation. However, large variations in the anterior and cranial boarder of the CTV-pelvis and the caudal margin of the CTV-inguinal suggest that further studies are needed to establish a clearer target volume delineation guideline.

Prognostic implications of advancing nodal stage in anal cancer: evaluating AJCC 8 staging changes through an NCDB analysis

PURPOSE

In the AJCC8, nodal staging for squamous cell carcinoma of the anus (SCCA) has been changed to a binary format (N0 or N+), and overall stage groups have been redefined. We evaluated the effect of AJCC8 nodal stage by T stage and hypothesized similar survival regardless of the extent of AJCC7-defined nodal involvement.

METHODS

The National Cancer Database (NCDB) was used to identify patients' SCCA. Overall survival (OS) for each T stage within the AJCC7 was compared with increasing nodal stage, as well as for the new AJCC8 overall stage groups and subsets.

RESULTS

There were 6738 patients analyzed. The 5-year OS by AJCC8 stage was I = 81%, IIA = 78%, IIB = 64%, IIIA = 69%, IIIB = 59%, IIIC = 57% (p < 0.0001). In AJCC8 IIIA (T1-2, N+), there was no difference in 5-year OS between T1N+ or T2N+ patients (70.3% vs 68.6%, p = 0.09). A significant survival difference was demonstrated between AJCC7 N1, N2, and N3 for patients with either T1 (p = 0.0047) or T2 (p = 0.0389) disease. In the AJCC 8 IIIC (T3-4, N+) group, there was no difference in 5-year OS between T3N+ and T4N+ (58% vs 55%, p = 0.81). There was no OS difference between AJCC7 N1-3 for either T3 (p = 0.19) or T4 (0.35) disease.

CONCLUSION

For earlier T stages, advancing nodal stage per AJCC7 retains prognostic implications for OS. Survival in AJCC8 stage IIIA is heterogeneous and is largely driven by burden of nodal disease in patients with T1-2 disease.

Tailoring the radiotherapy approach in patients with anal squamous cell carcinoma based on inguinal sentinel lymph node biopsy

BACKGROUND AND OBJECTIVES

The aim of our study was to analyze the results of selective inguinal node irradiation in patients with anal cancer, based on the biopsy of the inguinal sentinel lymph node (SLN), in terms of local control and prognosis.

METHODS

Records of patients with anal squamous cell carcinoma from January 2001 to December 2016 were retrospectively reviewed. Tc99 lymphoscintigraphy was performed in all the clinically inguinal negative patients, followed by radio-guided surgical removal of the inguinal SLN. All patients were treated with combined radiochemotherapy. In patients with negative sentinel nodes, the inguinal area was excluded in the radiotherapy field.

RESULTS

A total of 123 patients, 76 females (61.8%), mean age 60.1 ± 12.19 years old, underwent intraoperative lymph node retrieval. The histological analysis showed metastasis in the SLN in 28 patients (22.8%). The mean follow-up was 43.44 ± 31.86 months. No inguinal recurrence was observed in patients with negative inguinal sentinel node(s). A statistically significant difference was observed for overall and disease-free survivals in a patient with positive and negative inguinal sentinel nodes.

CONCLUSIONS

In patients with anal canal cancer, the exclusion of the inguinal regions from the radiotherapy field, in patients with negative SLN, does not compromise locoregional control nor prognosis.

Impact of sentinel lymph-node biopsy and FDG-PET in staging and radiation treatment of anal cancer patients

To assess the role of sentinel lymph-node biopsy (SLNB) and FDG-PET in staging and radiation treatment (RT) of anal cancer patients. This retrospective study was performed on 80 patients (male: 32, female: 48) with a median age of 60 years (39-89 years) with anal squamous cell carcinoma who were treated from March 2008 to March 2018 at the IRCCS San Raffaele Hospital. Patients without clinical evidence of inguinal LNs metastases and/or with discordance between clinical evidence and imaging features were considered for SLNB. FDG-PET was performed in 69/80 patients. Patients with negative imaging in inguinal region and negative SLNB could avoid RT on groin to spare inguinal toxicity. CTV included GTV (primary tumour and positive LNs) and pelvic ± inguinal LNs. PTV1 and PTV2 corresponded to GTV and CTV, respectively, adding 0.5 cm. RT dose was 50.4 Gy/28 fractions to PTV2 and 64.8 Gy/36 fractions to PTV1, delivered with 3DCRT (n = 24) or IMRT (n = 56), concomitant to Mitomycin-C and 5-FU chemotherapy. FDG-PET showed inguinal uptake in 21/69 patients (30%) and was negative in 48/69 patients (70%). Lymphoscintigraphy was performed in 11/21 positive patients (4 patients SLNB confirmed inguinal metastases, 6 patients false positive and 1 patient SLN not found), and in 29/48 negative patients (5/29 showed metastases, 23/29 true negative and 1 SLN not found). Sensitivity, specificity, positive and negative predictive value of FDG-PET were 62%, 79%, 40% and 82%, respectively. Median follow-up time from diagnosis was 40.3 months (range: 4.6-136.4 months): 69 patients (86%) showed a complete response, 10 patients (13%) a partial response, 1 patient (1%) a stable disease. Patients treated on groin (n = 54) versus not treated (n = 26) showed more inguinal dermatitis (G1-G2: 50% vs. 12%; G3-G4: 17% vs. 0%, p < 0.05). For patients treated on groin, G3-G4 inguinal dermatitis, stomatitis and neutropenia were significantly reduced with IMRT against 3DCRT techniques (13% vs. 36%, p = 0.10; 3% vs. 36%, p = 0.003; 8% vs. 29%, p = 0.02, respectively). SLNB improves the FDG-PET inguinal LNs staging in guiding the decision to treat inguinal nodes. IMRT technique significantly reduced G3-G4 toxicities when patients are treated on groin.

Additional Value of 2-[18F]FDG PET/CT Comparing to MRI in Treatment Approach of Anal Cancer Patients

Accurate staging and treatment planning are imperative for precise management in Anal Cancer (ACa) patients. We aimed to evaluate the additive and prognostic value of pre-treatment 2-[¹⁸F]fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (2-[¹⁸F]FDG PET/CT) in the staging and management of ACa compared to magnetic resonance imaging (MRI). This retrospective study was conducted on 54 patients. Pre-treatment 2-[¹⁸F]FDG PET/CT studies and MRI reports were compared considering the primary tumor, pelvic lymph nodes, and metastatic lesions. The impact of 2-[¹⁸F]FDG PET/CT in the management and its prognostic value, using maximum standardized uptake value (SUVmax), were assessed. Discordant findings were found in 46.3% of patients (5 in T; 1 in T and N; 18 in N; and 1 in M stage). 2-[¹⁸F]FDG PET/CT resulted in up-staging in 9.26% and down-staging in 3.7% of patients. Perirectal lymph nodes were metabolically inactive in 12.9% of patients. Moreover, 2-[¹⁸F]FDG PET/CT resulted in management change in 24.1% of patients. Finally, SUVmax provided no prognostic value. 2-[¹⁸F]FDG PET/CT altered staging and management in a sizable number of patients in this study, and supports a need for a change in guidelines for it to be used as a routine complementary test in the initial management of ACa.

Recurrent ilioinguinal lymph node metastasis from primary anal adenocarcinoma: what should we do?-A case report and review of literature

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Anal adenocarcinoma is more common in the Asian population than previously thought.

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Treatment of ilioinguinal lymph node metastasis from anal canal squamous cell carcinoma has been well described, but the management for primary adenocarcinoma is less so.

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Groin dissection for recurrent ilioinguinal lymph node metastasis from primary anal adenocarcinoma is a reasonable approach.

Introduction

Anal canal tumors are uncommon amongst gastrointestinal tumors or anorectal tumors. While the majority of them seem to be squamous cell carcinoma in nature, adenocarcinoma may be equally as common amongst the Asian population. Recurrent nodal metastasis from a primary anal malignancy is not a rare occurrence in view of the anatomy of the anal canal.

Case presentation

A 70 year-old patient underwent surgery for synchronous sigmoid and anal adenocarcinoma in 2015. He then re-presented 2 years later with recurrence in the right inguinal lymph nodes. He subsequently underwent a right ilio-inguinal lymph node block dissection with a Sartorius flap creation.

Discussion

As most anal canal tumors are squamous cell carcinomas, the optimal treatment for recurrent ilioinguinal lymph node disease has been well-established. This usually involves groin dissection as surgical treatment, with consideration for adjuvant combined chemoradiotherapy. Such an approach is likely to be beneficial for ilioinguinal lymph node disease from primary anal canal adenocarcinomas as well.

Conclusion

Physicians caring for patients with primary anal adenocarcinoma should be vigilant for possible ilioinguinal lymph node metastasis as this is not a rare occurrence. Surgical treatment appears to be a reasonable approach, with consideration for adjuvant therapy.

Dosimetric comparison of organs at risk using different contouring guidelines for definition of the clinical target volume in anal cancer

Background

There are different contouring guidelines for definition of the clinical target volume (CTV) for intensity-modulated radiation therapy (IMRT) of anal cancer (AC). We conducted a planning comparison study to evaluate and compare the dose to relevant organs at risk (OARs) while using different CTV definitions.

Methods

Twelve patients with a primary diagnosis of anal cancer, who were treated with primary chemoradiation (CRT), were selected. We generated four guideline-specific CTVs and subsequently planned target volumes (PTVs) on the planning CT scan of each patient. An IMRT plan for volumetric arc therapy (VMAT) was set up for each PTV. Dose parameters of the planned target volume (PTV) and OARs were evaluated and compared, too.

Results

The mean volume of the four PTVs ranged from 2138 cc to 2433 cc. The target volumes contoured by the authors based on the recommendations of each group were similar in the pelvis, while they differed significantly in the inguinal region. There were no significant differences between the four target volumes with regard to the dose parameters of the cranially located OARs. Conversely, some dose parameters concerning the genitals and the skin varied significantly among the different guidelines.

Conclusion

The four contouring guidelines differ significantly concerning the inguinal region. In order to avoid inguinal recurrence and to protect relevant OARs, further investigations are needed to generate uniform standards for definition of the elective clinical target volume in the inguinal region.

Post-operative radiation therapy with or without chemotherapy for anal squamous cell carcinoma incidentally discovered after local excision: a propensity score matched analysis of retrospective multicenter study

OBJECTIVE

To evaluate the results of post-operative radiation therapy (RT) for anal squamous cell carcinoma (ASCC) incidentally detected after excision, and compare these outcomes with those of definitive RT without excision for exploring the possibility of treatment de-intensification.

METHODS AND MATERIALS

A total of 25 patients with T1-2N0-1 ASCC who underwent RT following incidental tumor resection were selected from multicenter retrospective database. And, we selected one-to-one matched 25 patients receiving definitive RT from the same database using propensity score matching method, and the outcomes were compared.

RESULTS

Median age was 60 years (range, 30-76), and 18 patients (72%) were female. 19 patients (76%) had T0/1 tumors and four patients (16%) had regional lymph node metastases. Hemorrhoidectomy was performed in eight patients (32%) and the others underwent local excision. 12 patients (48%) had microscopic or gross residual diseases. Median RT dose to the primary lesion was 50.4 Gy (range, 40-60). Concurrent chemotherapy was delivered to 23 patients (92%). Median follow-up period was 71 months (range, 4.5-203.1 months). None of the patients showed recurrence during follow-up. However, one patient died after 6 months due to the chemotherapy-related hematologic toxicity. When compared with those patients receiving definitive RT, clinicopathological variables were well-balanced between the two groups. While matched paired patients treated with definitive RT received a higher median RT dose of 54 Gy (range, 45-61.2) and concurrent chemotherapy was given to 22 patients (88%), overall survival was not significantly different (p = 0.262).

CONCLUSION

Patients treated with RT for early stage ASCC after local excision showed favorable treatment outcomes. Further study is warranted to justify the de-intensification of the treatment for these patients.

ADVANCES IN KNOWLEDGE

Post-operative RT can achieve favorable treatment outcomes in incidental ASCC with residual diseases after local excision.

Prognostic value of fluorodeoxyglucose positron emission tomography/computed tomography and inguinal sentinel lymph node biopsy in patients with anal cancer

AIM

The aim of this study was to assess the value of positron emission tomography (PET)/CT and sentinel lymph node (SLN) biopsy in staging inguinal lymph nodes in anal cancer patients and to determine if the results of the two methods could be of prognostic value.

METHOD

Sixty-three patients with anal cancer and clinically negative inguinal lymph nodes underwent lymphoscintigraphy and inguinal SLN biopsy and/or fluorodeoxyglucose (FDG) PET/CT scan. All patients were treated with radiotherapy combined with 5-fluorouracil and mitomycin-C.

RESULTS

Overall (OS) and disease-free survival (DFS) were 43 months (range 5-211) and 43 months (range 4-142) respectively. PET/CT examination showed high FDG uptake in the inguinal lymph nodes in 25% of patients. Thirty-five patients with inguinal uptake at lymphoscintigraphy underwent inguinal SLN biopsy and metastatic nodes were found in 31.4%. There was no statistical difference in OS (55 vs 41 months; P = 0.652) and DFS (48 vs 38 months; P = 0.992) between the group which showed inguinal uptake on PET/CT and the group which did not, while a positive inguinal SLN was associated with a worse OS (28 vs 59 months; P = 0.028) and DFS (56 vs 21 months; P = 0.046). When the two examinations were compared PET/CT showed a sensitivity, specificity, positive predictive value and negative predictive value of 22%, 82%, 33% and 73% respectively.

CONCLUSION

The technique of SLN biopsy had a better diagnostic accuracy than total body FDG-PET/CT for the staging of inguinal lymph nodes in anal cancer patients; moreover it was a stronger predictor of OS and DFS than PET/CT.

Have we achieved adequate recommendations for target volume definitions in anal cancer? A PET imaging based patterns of failure analysis in the context of established contouring guidelines

Background

There are different contouring guidelines for the clinical target volume (CTV) in anal cancer (AC) which vary concerning recommendations for radiation margins in different anatomical regions, especially on inguinal site. PET imaging has become more important in primary staging of AC as a very sensitive method to detect lymph node (LN) metastases. Using PET imaging, we evaluated patterns of LN spread, and examined the differences of the respective contouring guidelines on the basis of our results.

Methods

We carried out a retrospective study of thirty-seven AC patients treated with chemoradiation (CRT) who underwent FDG-PET imaging for primary staging in our department between 2011 and 2018. Patients showing PET positive LN were included in this analysis. Using a color code, LN metastases of all patients were delineated on a template with “standard anatomy” and were divided indicating whether their location was in- or out-field of the standard CTV as recommended by the Radiation Therapy Oncology Group (RTOG), the Australasian Gastrointestinal Trials Group (AGITG) or the British National Guidance (BNG). Furthermore, a detailed analysis of the location of LN of the inguinal region was performed.

Results

Twenty-two out of thirty-seven AC patients with pre-treatment PET imaging had PET positive LN metastases, accumulating to a total of 154 LN. The most commonly affected anatomical region was inguinal (49 LN, 32%). All para-rectal, external/internal iliac, and pre-sacral LN were covered by the recommended CTVs of the three different guidelines. Of forty-nine involved inguinal LN, fourteen (29%), seven (14%) and five (10%) were situated outside of the recommended CTVs by RTOG, AGITG and BNG. Inguinal LN could be located up to 5.7 cm inferiorly to the femoral saphenous junction and 2.8 cm medial or laterally to the big femoral vessels.

Conclusion

Pelvis-related, various recommendations are largely consistent, and all LN are covered by the recommended CTVs. LN “misses” appear generally cranially (common iliac or para-aortic) or caudally (inguinal) to the recommended CTVs. The established guidelines differ significantly, particular regarding the inguinal region. Based on our results, we presented our suggestions for CTV definition of the inguinal region. LN involvement of a larger number of patients should be investigated to enable final recommendations.

Long-term outcomes after surgical dissection of inguinal lymph node metastasis from rectal or anal canal adenocarcinoma

Background

The 8th edition of the tumor-node-metastasis (TNM) classification classifies inguinal lymph nodes as regional lymph nodes for anal canal carcinoma but non-regional lymph nodes for rectal carcinoma. This difference might reflect the different prognosis of inguinal lymph node metastasis from anal canal carcinoma and rectal carcinoma. However, long-term outcomes of inguinal lymph node metastasis from rectal or anal canal adenocarcinoma are unclear, which we aimed to investigate in this study.

Methods

The study population included 31 consecutive patients with rectal or anal canal adenocarcinoma who underwent inguinal lymph node dissection with curative intent at the National Cancer Center Hospital from 1986 to 2017. Long-term outcomes were assessed and clinicopathologic variables analyzed for prognostic significance.

Results

Of the 31 patients, 12 patients had rectal adenocarcinoma and 19 patients had anal canal adenocarcinoma. Synchronous metastasis were observed in 14 patients and metachronous metastasis in 17 patients. After dissection of inguinal lymph node metastasis with curative intent, the 5-year overall survival rate was 55.2%, with 12 patients surviving for more than 5 years. Median survival time was 66.6 months. Multivariate analyses revealed that location of primary tumor (rectum versus anal canal) was not a prognostic factor, whereas lateral lymph node metastasis and histological findings were independent prognostic factors.

Conclusion

Given the good prognosis, inguinal lymph node metastasis in patients with rectal or anal canal adenocarcinoma appears to be regional rather than distant. If R0 resection can be achieved, inguinal lymph node dissection may be indicated for these patients.

Comparative accuracy of qualitative and quantitative 18F-FDG PET/CT analysis in detection of lymph node metastasis from anal cancer

PURPOSE

To compare the diagnostic performance of qualitative and quantitative 18F-FDG PET/CT in detection of regional and distant lymph node metastasis in patients with anal cancer.

METHODS

Between 2004 and 2017, 28 patients with anal cancer who had staging PET/CT and pathological assessment of suspicious lymph nodes were included. For qualitative analysis, positive lymph nodes were defined as uptake visually higher than the liver reference uptake. For quantitative study, lymph nodes were contoured to determine maximum standard uptake value (SUV_max) and metabolic tumor volume (MTV). Receiver operating characteristic (ROC) curves were plotted to extract the optimal cut-offs and area under the curve (AUC) of SUV_max, lesion to background (L/B) ratio, short axis diameter (SAD), and MTV of lymph nodes. Histopathologic analysis was a reference standard.

RESULTS

A total of 28 lymph nodes (24 inguinal, 2 external iliac, 1 internal iliac, and 1 paraaortic nodes) in 28 patients on PET/CT were included. With the qualitative visual analysis, 19 patients were categorized as positive for nodal metastasis with sensitivity, specificity, and accuracy of 85%, 75%, and 82%. The optimal SUV_max and L/B ratio cut-offs were 2.6 and 1.0 with both sensitivity and specificity of 95% and 75% (AUC of SUV_max = 0.893, AUC of L/B ratio = 0.912). Using the best cut-off of 1.6 cm for SAD and 3.65 cm³ for MTV, both sensitivity and specificity were 80% and 100% (AUC of SAD = 0.950, AUC of MTV = 0.931).

CONCLUSIONS

SUV_max optimization may be helpful in enhancing the diagnostic accuracy of 18F-FDG PET/CT in nodal staging patients with anal cancer.

Management of locally advanced anal canal carcinoma with intensity-modulated radiotherapy and concurrent chemotherapy

The best curative option for locally advanced (stages II-III) squamous-cell carcinomas of the anal canal (SCCAC) is concurrent chemo-radiotherapy delivering 36-45 Gy to the prophylactic planning target volume with an additional boost of 14-20 Gy to the gross tumor volume with or without a gap-period between these two sequences. Although 3-dimensional conformal radiotherapy led to suboptimal tumor coverage because of field junctions, this modality remains a standard of care. Recently, intensity-modulated radiotherapy (IMRT) techniques improved tumor coverage while decreasing doses delivered to organs at risk. Sparing healthy tissues results in fewer severe acute toxicities. Consequently, IMRT could potentially avoid a gap-period that may increase the risk of local failure. Furthermore, these modalities reduce severe late toxicities of the gastrointestinal tract as well as better functional conservation of anorectal sphincter. This report aims to critically review contemporary trends in the management of locally advanced SCCAC using IMRT and concurrent chemotherapy.

Dosimetric quantification of the incidental irradiation of the 'true' (deep) ano-inguinal lymphatic drainage of anal cancer patients not described in conventional contouring guidelines

INTRODUCTION

The ano-inguinal lymphatic drainage (AILD) is located in the subcutaneous adipose tissue of the proximal medial thigh. Findings from fluorescence methods give us new information about anatomical conditions of the AILD. Current contouring guidelines do not advise the inclusion of the 'true' AILD into the clinical target volume (CTV). Aim of this work was the retrospective analysis of the incidental dose to the AILD in an anal cancer (AC) patient cohort who underwent definitive chemoradiation (CRT) therapy with Volumetric Arc Therapy - Intensity Modulated Radiation Therapy (VMAT-IMRT).

METHODS

VMAT-IMRT plans of 15 AC patients were analyzed. Based on findings from new fluorescence methods we created a new volume, the expected AILD. The examined dosimetric parameters were the minimal, maximal and mean dose and V10-V50 that were delivered to the AILD, respectively.

RESULTS

The median volume of AILD was 1047 cm³. Mean D_min, D_max and D_mean were 7.5 Gy, 58.9 Gy and 40.8 Gy for AILD. The clinical relevant dose of 30.0 Gray covered in mean 76% of the volume of the AILD, respectively.

CONCLUSIONS

Only 76% of the AILD-volume received at least an expected required treatment dose of 30 Gy incidentally. Concerning the low number of loco-regional relapses in AC patients after definitive CRT one has to balance increased side effects against a rigid oncological-anatomical interpretation of the local lymphatic drainage by including the AILD into the standard CTV.

Radiotherapy for anal squamous cell carcinoma: must the upper pelvic nodes and the inguinal nodes be treated?

BACKGROUND

Loco-regional failure is the predominant cause of death in anal squamous cell carcinoma. We assessed patterns of loco-regional recurrence to determine the impact of radiotherapy (RT) volumes on patient outcome.

METHODS

Retrospective clinical study, including patients treated curatively with RT or chemo-radiotherapy between 1994 and 2007. RT fields/volumes were reviewed and compared with patterns of failure. Patients were classified as having whole pelvic radiotherapy (WPRT) if RT extended to L5/S1 or lower pelvic radiotherapy (LPRT) if it extended to the lower sacroiliac joints or below. Patients with negative inguinal nodes either underwent prophylactic inguinal radiotherapy (PIRT) or had inguinal observation (IO). Patterns of failure were compared.

RESULTS

Twenty-seven patients (53%) had WPRT and 24 (47%) had LPRT. Forty-two patients had negative inguinal nodes: 29 (69%) had PIRT and 13 (31%) had IO. Median follow-up was 5.8 years. Twelve regional failures occurred in eight patients: three pelvic, one inguinal and four pelvic and inguinal. All patients with regional failure died of disease. Pelvic nodal failure was 7.7% in N0 and 33% in N1-3 patients (P = 0.012). There was no difference in pelvic regional failure between WPRT and LPRT (11% versus 16%, P = 0.64). There was only one possible regional failure above LPRT in this group (4%). Inguinal failure was 0% in the PIRT group compared with 23% in IO group (P = 0.009).

CONCLUSION

There was no difference in pelvic regional failure between WPRT and LPRT. LPRT is likely to be safe in N0 patients. Inguinal nodes should be treated in all patients.

Complex Reconstruction with Flaps After Abdominoperineal Resection and Groin Dissection for Anal Squamous Cell Carcinoma: A Difficult Case Involving Many Specialities

BACKGROUND Anal squamous cell carcinoma accounts for about 2-4% of all lower gastrointestinal malignancies, with a distant disease reported in less than 5%. Although surgical treatment is rarely necessary, this often involve large dissections and difficult reconstructive procedures. CASE REPORT We present a complex but successful case of double-flap reconstruction after abdominoperineal resection and groin dissection for anal squamous cell carcinoma (cT3N3M0) with metastatic right inguinal lymph nodes and ipsilateral threatening of femoral vessels. A multi-specialty team was involved in the operation. A vascular and plastic surgeon performed the inguinal dissection with en bloc excision of the saphenous magna and a cuff of the femoral vein, while colorectal surgeons carried out the abdominoperineal excision. The 2 large tissue gaps at the groin and perineum were covered with an oblique rectus abdominis myocutaneous flap and a gluteal lotus flap, respectively. A partially absorbable mesh was placed at the level of the anterior sheath in order to reinforce the abdominal wall, whereas an absorbable mesh was used as a bridge for the dissected pelvic floor muscles. The post-operative period was uneventful and the follow-up at 5 months showed good results. CONCLUSIONS An early diagnosis along with new techniques of radiochemotherapy allow patients to preserve their sphincter function. However, a persistent or recurrent disease needs major operations, which often involve a complex reconstruction. Good team-work and experience in specialized fields give the opportunity to make the best choices to perform critical steps during the management of complex cases.

Anal adenocarcinoma requires prophylactic inguinal nodal treatment: Results from a single Chinese institution

Background: Literature pertaining to prophylactic inguinal nodal treatment for anal adenocarcinoma in China is scarce.

Methods: In this retrospective study, we analyzed 126 patients from 1965 to 2015. Among these, 67 patients received surgery only, 18 patients received chemoradiotherapy only, 27 patients received a combination of both, and the remaining 14 patients received palliative treatment.

Results: The median follow up period was 30 months. The 1-year, 3-year, and 5-year overall survival rates were 85.8%, 62.5%, and 43.4%, respectively. The 5-year overall survival was 46.9% for patients with negative inguinal lymph nodes and 19.1% for patients with positive inguinal lymph nodes (p=0.007). The overall 5-year inguinal node relapse-free survival was 83.0%. The 5-year inguinal node relapse-free survival was 87.5% for stage I, 86.9% for stage II, and 76.5% for stage III cancers. Among those with negative inguinal nodes, the 5-year inguinal node relapse-free survival was 85.7% for negative regional lymph nodes and 75.4% for positive regional lymph nodes (p=0.089).

Conclusion: Inguinal lymph node is a high-risk subclinical area. Prophylactic inguinal nodal treatment is necessary for patients with anal adenocarcinoma irrespective of positive or negative inguinal lymph nodes.

Initial Results from the Royal College of Radiologists' UK National Audit of Anal Cancer Radiotherapy 2015

AIMS

UK guidance was recently developed for the treatment of anal cancer using intensity-modulated radiotherapy (IMRT). We audited the current use of radiotherapy in UK cancer centres for the treatment of anal cancer against such guidance. We describe the acute toxicity of IMRT in comparison with patient population in the audit treated with two-phase conformal radiotherapy and the previous published data from two-phase conformal radiotherapy, in the UK ACT2 trial.

MATERIALS AND METHODS

A Royal College of Radiologists' prospective national audit of patients treated with radiotherapy in UK cancer centres was carried out over a 6 month period between February and July 2015.

RESULTS

Two hundred and forty-two cases were received from 40/56 cancer centres (71%). In total, 231 (95%) underwent full dose radiotherapy with prophylactic nodal irradiation. Of these, 180 (78%) received IMRT or equivalent, 52 (22%) two-phase conformal (ACT2) technique. The number of interruptions in radiotherapy treatment in the ACT2 trial was 15%. Interruptions were noted in 7% (95% confidence interval 0-14%) of courses receiving two-phase conformal and 4% (95% confidence interval 1-7%) of those receiving IMRT. The percentage of patients completing the planned radiotherapy dose, irrelevant of gaps, was 90% (95% confidence interval 82-98%) and 96% (95% confidence interval 93-99%), in two-phase conformal and IMRT respectively. The toxicity reported in the ACT2 trial, in patients receiving two-phase conformal in the audit and in patients receiving IMRT in the audit was: any toxic effect 71%, 54%, 48%, non-haematological 62%, 49%, 40% and haematological 26%, 13%, 18%, respectively.

CONCLUSIONS

IMRT implementation for anal cancer is well underway in the UK with most patients receiving IMRT delivery, although its usage is not yet universal. This audit confirms that IMRT results in reduced acute toxicity and minimised treatment interruptions in comparison with previous two-phase conformal techniques.

The prospect of endoscopic submucosal dissection for early anal canal squamous cell carcinoma

Squamous cell carcinoma (SCC) of the anal canal is seldom diagnosed at an early stage. Chemoradiation therapy is a standard in Europe and the United States, though in squamous cell carcinoma there is no evidence-based therapy. In Japan, endoscopic submucosal dissection (ESD) is the standard minimally invasive treatment for early stage cancer of the digestive tract, including the colorectum. Therefore, if the lesion is diagnosed at an early stage, ESD may be selected for anal canal lesions. We experienced two cases of early stage anal canal cancer in which the diagnosis and the extent of the lesions were confirmed using magnifying endoscopy with narrow-band imaging (NBI), as well as performing ESD. Pathological examination showed the resected specimen to be SCC in situ; the horizontal and vertical margins were free of tumor; and in one case there was no lymphovascular invasion. In the other case it showed the tumor was contained within the epithelium; horizontal and vertical margins were free of tumor; The follow-up period is not long enough to assert that ESD for anal canal squamous cell carcinoma may be an option of minimally invasive therapy. However, if there is a possibility of lymphatic invasion as in one of our cases, we need to give serious consideration to ESD for these lesions, and careful follow-up is necessary even if the lesion is in situ.

Background and Current Treatment of Squamous Cell Carcinoma of the Anus

In this review, a summary of our current understanding of squamous cell carcinoma of the anus (SCCA) and the advances in our knowledge of SCCA regarding screening, prevention, the role of the immune system, current treatment and the potential for novel targets are discussed. The present standard of care in terms of treatment is 5-fluorouracil (5-FU) and mitomycin C (MMC) concurrently with radiation, which results in a high level of disease control for small early cancers. Preservation of the anal sphincter is achieved in the majority, although anorectal function is often impaired. Although evidence from prospective studies to support a change in the treatment strategy is lacking, patients with HPV-negative SCCA appear to be less responsive to chemoradiation (CRT) and relapse more frequently. In contrast, HPV-positive tumours usually fare better, but oncological outcomes are modified by smoking and immune incompetence. There is current interest in escalating the radiotherapy dose for larger, more advanced tumours, and de-escalating treatment for HPV-positive tumours. The use of novel immunological treatments to target the underlying different molecular pathways of HPV-positive cancers is exciting.

Can we omit prophylactic inguinal nodal irradiation in anal cancer patients?

Purpose

To evaluate the appropriateness of prophylactic inguinal nodal irradiation (PINI), we analyzed patterns of failure in anal cancer patients who were inguinal node-negative at presentation and did not receive PINI.

Materials and Methods

We retrospectively reviewed the records of 33 anal cancer patients treated by definitive concurrent chemoradiation therapy (CCRT) between 1994 and 2013. Radiotherapy consisted of a total dose of 44-45 Gy (22-25 fractions in 5 weeks) on the whole pelvis, anus, and perineum. Except inguinal lymphadenopathy was present at initial diagnosis, the entire inguinal chain was not included in the radiation field. In other words, there was no PINI.

Results

The median follow-up duration was 50 months (range, 4 to 218 months). Median survival and progression-free survival (PFS) were 57 months (range, 10 to 218 months) and 50 months (range, 4 to 218 months), respectively. Among the survival, the median follow-up duration was 51 months (range, 12 to 218 months). The 5-year overall survival and PFS rates were 93.4% and 88.8%, respectively. Although none of the patients received inguinal node irradiation for prophylactic purposes, there was no inguinal recurrence.

Conclusion

Treatment of anal cancer by omitting PINI might be considered in selected patients with clinically uninvolved inguinal nodes.

Anal carcinoma - Survival and recurrence in a large cohort of patients treated according to Nordic guidelines

OBJECTIVE

To evaluate treatment outcome in a large population-based cohort of patients with anal cancer treated according to Nordic guidelines.

MATERIAL

Clinical data were collected on 1266 patients with anal squamous cell carcinoma diagnosed from 2000 to 2007 in Sweden, Norway and Denmark. 886 of the patients received radiotherapy 54-64Gy with or without chemotherapy (5-fluorouracil plus cisplatin or mitomycin) according to different protocols, stratified by tumor stage.

RESULTS

High age, male gender, large primary tumor, lymph node metastases, distant metastases, poor performance status, and non-inclusion into a protocol were all independent factors associated with worse outcome. Among patients treated according to any of the protocols, the 3-year recurrence-free survival ranged from 63% to 76%, with locoregional recurrences in 17% and distant metastases in 11% of patients. The highest rate of inguinal recurrence (11%) was seen in patients with small primary tumors, treated without inguinal irradiation.

CONCLUSIONS

Good treatment efficacy was obtained with Nordic, widely implemented, guidelines for treatment of anal cancer. Inguinal prophylactic irradiation should be recommended also for small primary tumors.

Cancers of the anal canal: diagnosis, treatment and future strategies

Anal cancer is an uncommon cancer; however, it is rising in incidence. There is confusion regarding nomenclature and the distinction between anal canal cancer and anal margin cancer. This article discusses the modern definition, etiology and staging of anal canal and anal margin cancers. Modern chemotherapy and radiotherapy regimens are discussed, in addition to modern imaging and radiotherapy techniques. Future preventative strategies and potential novel treatments are discussed.

Anal cancer: current standards in care and recent changes in practice

Answer questions and earn CME/CNE The management of squamous cell carcinomas of the anal canal has evolved from surgery as first-line treatment to curative chemoradiation, with surgery reserved for salvage. Significant progress has been made in understanding how to most effectively deliver chemotherapy and reduce toxicity through advancements in radiation delivery. The purpose of this article is to review the multimodality approach to the diagnosis and management of anal cancer based on a review of the published data and in light of available guidelines.

Clitoral involvement of squamous cell carcinoma of the vulva: localization with the worst prognosis

OBJECTIVE

The overall 5-year survival of patients with vulvar squamous cell carcinoma (SCC) is 70%. The clinical impression is that localization of SCC on the clitoris may lead to worse prognosis. The aim of this study is to assess the disease specific survival (DSS) in patients with clitoral SCC compared to patients with SCC without clitoral involvement.

METHODS

All consecutive patients with primary vulvar SCC treated with surgery at the Department of Gynaecologic Oncology at the Radboud university medical centre (Radboudumc) between March 1988 and January 2012, were analysed. The clinical and histopathological characteristics and DSS rates of patients with (N = 72) and without clitoral SCC (N = 275) were compared. Furthermore, patients with clitoral involvement were compared to patients with perineal SCCs (N = 52) and other central SCCs without clitoral and/or perineal involvement (N = 117).

RESULTS

Patients with clitoral SCC more often had larger and deeper invaded tumours, lymphovascular space involvement (LVSI), positive surgical margins and a higher percentage of positive lymph nodes. Kaplan-Meier survival analyses showed worse DSS in patients with a clitoral SCC compared to patients without clitoral involvement. Multivariable analysis showed that not clitoral involvement, but invasion depth, differentiation grade and lymph node status are independent prognostic factors.

CONCLUSIONS

Patients with clitoral SCC have worse survival compared to patients without clitoral involvement. This is probably caused by unfavourable histopathological characteristics of the tumour rather than the localization itself. Prospective studies are needed to further assess the influence of localization of the vulvar SCC on prognosis.

Technical aspects of radiation therapy for anal cancer

Historically treated with surgery, current practice recommends anal carcinoma to be treated with a combination of chemotherapy and radiation. This review will examine the anatomy, modes of disease spread and recurrence, and evaluate the existing evidence for treatment options for these tumors. An in-depth examination of specific radiation therapy (RT) techniques-such as conventional 3D-conformal RT and intensity-modulated RT-will be discussed along with modern dose constraints. RT field arrangement, patient setup, and recommended gross and clinical target volume (CTV) contours will be considered. Areas in need of further investigation, such as the role in treatment for positron emission tomography (PET) will be explored.

Inguinal lymph node recurrence in the untreated groin of patients with anal carcinoma

BACKGROUND

Inguinal lymph node metastasis is predictive of locoregional recurrence and poor overall survival in anal carcinoma. Metachronous lymph node metastasis occurs in 10% of all anal cancer patients, but multiple studies have shown that the benefit of elective irradiation of the groin depends on T-stage, and the toxicity of groin irradiation must not be underestimated.

OBJECTIVE

To analyze the inguinal recurrence rates among patients with anal carcinoma (T1-4, N0-1) who did not receive elective irradiation therapy to the groin and to determine predictors of inguinal recurrence.

DESIGN

Data on 119 patients treated between 1987 and 2005 were retrospectively analyzed. Patients were treated with 3-dimensional radiotherapy. The median dose was 60 Gy. During radiotherapy, 108 patients also received chemotherapy (5-fluorouracil and mitomycin-C).

RESULTS

AJCC staging showed a distribution of 21 T1 (18%), 58 T2 (49%), 27 T3 (23%), 13 T4 (11%), 101 N0 (85%) and 18 N1 (15%) tumors. The median follow up was 65 months (range, 1-240 months). The 5-year inguinal recurrence rate was 0% for T1, 10% for T2, 21% for T3 and 19% for T4 tumors (p = 0.034). T2 tumors of the perianal skin and the anal canal had 5-year inguinal recurrence rates of 12% and 8%, respectively. The 5-year inguinal recurrence rate was 21% for tumors ≥4 cm vs. 2% for tumors <4 cm in size (p = 0.003).

LIMITATIONS

Eleven patients did not receive chemotherapy.

CONCLUSIONS

Elective irradiation of the groin should be considered for local control in patients (N0-N1) with T2 tumors ≥4 cm in size and/or located in the perianal skin, and in all patients with T3 and T4 tumors.

Surgical treatment for isolated inguinal lymph node metastasis in lower rectal adenocarcinoma patients improves outcome

PURPOSE

No consensus has been formed on the optimal treatment strategy for the prognosis of patients with inguinal lymph node (ILN) metastasis from lower rectal adenocarcinoma. We, therefore, retrospectively analyzed outcomes of patients with ILN metastasis from lower rectal adenocarcinoma.

METHODS

Of 323 patients with lower rectal adenocarcinoma treated at a single institution between November 1993 and March 2010, 10 had synchronous or metachronous ILN metastasis, as confirmed by curative resection (R0) of the primary lesion. Outcomes of these 10 patients were assessed.

RESULTS

The 10 patients with ILN metastasis were divided into two groups: group A (two patients who did not undergo ILN resection surgery because of metastases at other sites) and group B (eight patients with no other metastases who underwent surgery). Both patients in group A, with median overall survival of 5.2 months, died due to the other metastases, whereas five out of eight patients in group B survived (P = 0.001). Group B patients were further subclassified into synchronous (group B1) and metachronous (group B2) metastasis (n = 4 each) groups. Two patients in group B1 died of other metastases, which was diagnosed later, whereas three patients in group B2 survived.

CONCLUSIONS

Some patients with isolated inguinal lymph node metastasis show a good prognosis after lymph node excision and, therefore, should be treated surgically. Patients with metachronous metastases have a better prognosis than patients with synchronous ILN metastases. Nevertheless, assessment of additional patients for prognosis and treatment strategy is warranted.

A novel biomarker-based analysis reliably predicts nodal metastases in anal carcinoma: preliminary evidence of therapeutic impact

AIM

Routine prophylactic inguinal irradiation in anal cancer may cause significant toxicity associated with overtreatment bias. The aim of this study was to determine the risk of regional node metastases in anal carcinoma by identifying predictive molecular biomarkers.

METHOD

Clinicohistopathological data from 50 pretreatment anal carcinoma biopsies were collected. Immunohistochemical analyses with antibodies against Ki67, p53, epidermal growth factor receptor (EGFR) and YKL-40 were performed. Statistical correlations between biomarkers and clinicopathological features and outcomes were studied. Sentinel lymph node biopsy was performed in a subset of 36 patients.

RESULTS

All patients had undergone synchronous radiochemotherapy; tumour recurrence had developed in 26%, and 16% had died. YKL-40 tumour expression correlated with lymph node metastasis, whereas no inguinal node metastases were found in any of the (14%) patients presenting with a YKL-40/EGFR-negative tumour. YKL-40 expression and node metastasis were both significantly associated with shorter overall and disease-free survival. Tumour grade significantly correlated with disease-free survival only. HIV, tumour histological type, Ki67, p53 and EGFR were not associated with outcome.

CONCLUSION

YKL-40 expression in anal carcinoma is correlated with a poor outcome and can predict lymph node metastases. The combined absence of YKL-40 and EGFR expression in a first biopsy of anal carcinoma reliably selects a subset of patients without inguinal metastases. Such patients could be spared sentinel lymph node biopsy and/or inguinal radiotherapy.

Elective inguinal node irradiation in early-stage T2N0 anal cancer: prognostic impact on locoregional control

PURPOSE

To evaluate the influence of elective inguinal node radiation therapy (INRT) on locoregional control (LRC) in patients with early-stage T2N0 anal cancer treated conservatively with primary RT.

METHODS AND MATERIALS

Between 1976 and 2008, 116 patients with T2 node-negative anal cancer were treated curatively with RT alone (n=48) or by combined chemoradiation therapy (CRT) (n=68) incorporating mitomycin C and 5-fluorouracil. Sixty-four percent of the patients (n=74) received elective INRT.

RESULTS

Over a median follow-up of 69 months (range, 4-243 months), 97 (84%) and 95 patients (82%) were locally and locoregionally controlled, respectively. Rates for 5-year actuarial local control, LRC, cancer-specific, and overall survival for the entire population were 81.7% ± 3.8%, 79.2% ± 4.1%, 91.1% ± 3.0%, and 72.1% ± 4.5%, respectively. The overall 5-year inguinal relapse-free survival was 92.3% ± 2.9%. Isolated inguinal recurrence occurred in 2 patients (4.7%) treated without INRT, whereas no groin relapse was observed in those treated with INRT. The 5-year LRC rates for patients treated with and without INRT and with RT alone versus combined CRT were 80.1% ± 5.0% versus 77.8% ± 7.0% (P=.967) and 71.0% ± 7.2% versus 85.4% ± 4.5% (P=.147), respectively. A trend toward a higher rate of grade ≥3 acute toxicity was observed in patients treated with INRT (53% vs 31%, P=.076).

CONCLUSIONS

In cases of node-negative T2 anal cancer, the inguinal relapse rate remains relatively low with or without INRT. The role of INRT in the treatment of early-stage anal carcinoma needs to be investigated in future prospective trials.

Value of staging squamous cell carcinoma of the anal margin and canal using the sentinel lymph node procedure: an update of the series and a review of the literature

Background:

Inguinal metastases in patients affected by anal cancer are an independent prognostic factor for local failure and overall mortality. Since 2001, sentinel lymph node biopsy was applied in these patients. This original study reports an update of personal and previous published series, which were compared with Literature to value the incidence of inguinal metastases T-stage related and the overall incidence of false negative inguinal metastases at sentinel node.

Methods:

In all, 63 patients diagnosed with anal cancer submitted to inguinal sentinel node. Furthermore a research in the Pub Med database was performed to find papers regarding this technique.

Results:

In our series, detection rate was 98.4%. Inguinal metastases were evidentiated in 13 patients (20.6%). Our median follow-up was 35 months. In our series, no false negative nodes were observed.

Conclusion:

Sentinel node technique in the detection of inguinal metastases in patients affected by anal cancer should be considered as a standard of care. It is indicated for all T stages in order to select patients to be submitted to inguinal radiotherapy, avoiding related morbidity in negative ones. An overall 3.7% rate of false negative must be considered acceptable.

Sphincter preservation in anal cancer: a brief review

Management of anal cancer is a challenge. The goal of treatment is to eradicate tumor without sacrificing the anal sphincters. The idea of organ preservation emerged following the discovery of a high complete response rate from preoperative combined chemoradiation (CRT) prior to abdominoperineal resection.CRT is widely accepted as the standard therapy for treating anal squamous cell cancer. The combination of external beam radiotherapy with interstitial brachytherapy increases the dose to the tumor volume and decreases dose to normal tissues. The current goal is to avoid colostomy, and surgery has become a salvage or secondary therapy. In this article, we review the non-surgical management of anal cancer with special emphasis on CRT, role of intensity modulated radiation therapy and brachytherapy.

New approach to anal cancer: Individualized therapy based on sentinel lymph node biopsy

Oncological treatment is currently directed toward a tailored therapy concept. Squamous cell carcinoma of the anal canal could be considered a suitable platform to test new therapeutic strategies to minimize treatment morbidity. Standard of care for patients with anal canal cancer consists of a combination of radiotherapy and chemotherapy. This treatment has led to a high rate of local control and a 60% cure rate with preservation of the anal sphincter, thus replacing surgical abdominoperineal resection. Lymph node metastases represent a critical independent prognostic factor for local recurrence and survival. Mesorectal and iliac lymph nodes are usually included in the radiation field, whereas the inclusion of inguinal regions still remains controversial because of the subsequent adverse side effects. Sentinel lymph node biopsies could clearly identify inguinal node-positive patients eligible for therapeutic groin irradiation. A sentinel lymph node navigation procedure is reported here to be a feasible and effective method for establishing the true inguinal node status in patients suffering from anal canal cancer. Based on the results of sentinel node biopsies, a selective approach could be proposed where node-positive patients could be selected for inguinal node irradiation while node-negative patients could take advantage of inguinal sparing irradiation, thus avoiding toxic side effects.

Role of positron emission tomography-computed tomography in the management of anal cancer

PURPOSE

Pre- and post-treatment staging of anal cancer are often inaccurate. The role of positron emission tomograpy-computed tomography (PET-CT) in anal cancer is yet to be defined. The aim of the study was to compare PET-CT with CT scan, sentinel node biopsy results of inguinal lymph nodes, and anal biopsy results in staging and in follow-up of anal cancer.

METHODS AND MATERIALS

Fifty-three consecutive patients diagnosed with anal cancer underwent PET-CT. Results were compared with computed tomography (CT), performed in 40 patients, and with sentinel node biopsy (SNB) (41 patients) at pretreatment workup. Early follow-up consisted of a digital rectal examination, an anoscopy, a PET-CT scan, and anal biopsies performed at 1 and 3 months after the end of treatment. Data sets were then compared.

RESULTS

At pretreatment assessment, anal cancer was identified by PET-CT in 47 patients (88.7%) and by CT in 30 patients (75%). The detection rates rose to 97.9% with PET-CT and to 82.9% with CT (P=.042) when the 5 patients who had undergone surgery prior to this assessment and whose margins were positive at histological examination were censored. Perirectal and/or pelvic nodes were considered metastatic by PET-CT in 14 of 53 patients (26.4%) and by CT in 7 of 40 patients (17.5%). SNB was superior to both PET-CT and CT in detecting inguinal lymph nodes. PET-CT upstaged 37.5% of patients and downstaged 25% of patients. Radiation fields were changed in 12.6% of patients. PET-CT at 3 months was more accurate than PET-CT at 1 month in evaluating outcomes after chemoradiation therapy treatment: sensitivity was 100% vs 66.6%, and specificity was 97.4% vs 92.5%, respectively. Median follow-up was 20.3 months.

CONCLUSIONS

In this series, PET-CT detected the primary tumor more often than CT. Staging of perirectal/pelvic or inguinal lymph nodes was better with PET-CT. SNB was more accurate in staging inguinal lymph nodes.