Combination therapy for epidermoid carcinoma of the anal canal

Late gastrointestinal toxicity after radiotherapy for anal cancer: a systematic literature review

INTRODUCTION

There is a paucity of data on incidence and mechanisms of long-term gastrointestinal consequences after chemoradiotherapy for anal cancer. Most of the adverse effects reported were based on traditional external beam radiotherapy whilst only short-term follow-ups have been available for intensity-modulated radiotherapy, and there is lack of knowledge about consequences of dose-escalation radiotherapy.

METHOD

A systematic literature review.

RESULTS

Two thousand nine hundred and eighty-five titles (excluding duplicates) were identified through the search; 130 articles were included in this review. The overall incidence of late gastrointestinal toxicity was reported to be 7-64.5%, with Grade 3 and above (classified as severe) up to 33.3%. The most commonly reported late toxicities were fecal incontinence (up to 44%), diarrhea (up to 26.7%), and ulceration (up to 22.6%). Diarrhea, fecal incontinence and buttock pain were associated with lower scores in radiotherapy specific quality of life scales (QLQ-CR29, QLQ-C30, and QLQ-CR38) compared to healthy controls. Intensity-modulated radiation therapy appears to reduce late toxicity.

CONCLUSION

Late gastrointestinal toxicities are common with severe toxicity seen in one-third of the patients. These symptoms significantly impact on patients' quality of life. Prospective studies with control groups are needed to elucidate long-term toxicity.

Salvage abdominoperineal resection after failure of conservative treatment in anal epidermoid cancer

PURPOSE

Radiotherapy alone or with combined chemotherapy is the first therapeutic option for epidermoid carcinoma of the anal canal. Failure of this conservative treatment may benefit of salvage abdominoperineal resection. This study was designed to analyze postoperative outcome and oncologic results in a single anticancer institution.

METHODS

Medical charts of 36 patients (median age, 57.9 years) who underwent salvage abdominoperineal resection after failure of conservative treatment between 1987 and 2002 were reviewed retrospectively. There were 15 patients treated for immediate failure (Group I) and 21 patients for recurrence (Group II). Twenty-two patients have undergone primary use of flap reconstruction of the perineal wound. There were ten rectus abdominis myocutaneous flaps, nine omental flaps, two gracilis muscular flaps, and one combined flap.

RESULTS

There was no postoperative mortality. Median follow-up was 67 (range, 15-155) months. Primary closure of the perineum was obtained in 33 patients (92 percent). Secondary wound breakdown occurred in 23 of 33 patients (70 percent). Complications unrelated to the perineal wound occurred in 13 patients. The overall crude five-year survival after salvage abdominoperineal resection was 69.4 percent. The crude five-year survival in Group I and Group II was 60.7 and 71.5 percent respectively (P = 0.28). The crude five-year, disease-free survival in Groups I and II was 31.1 and 48.2 percent respectively (P = 0.10). Twenty-three patients experienced recurrences after salvage abdominoperineal resection (64 percent) with a mean delay of 30 months.

CONCLUSIONS

Despite high incidence of perineal morbidity, salvage abdominoperineal resection for epidermoid carcinomas of the anal canal has a high long-term survival rate.

Surgical salvage therapy of anal canal cancer

AIM: To evaluate the results of salvage resection in the management of persistent or locally recurrent anal canal cancer.

METHODS: Details of all patients with anal canal cancer treated from 1978 to 1994 at Cancer Hospital of Chinese Academy of Medical Sciences (CAMS) were reviewed retrospectively. Sixteen patients who presented with persistent or locally recurrent anal canal cancer received salvage surgery. Before surgery all of the patients had received radiotherapy alone as their primary treatments.

RESULTS: Of the 16 patients, 14 received salvage abdominoperineal resection (APR) and two had transanal local excision. There were no deaths attributable to operation. Delayed healing of the perineal wound occurred in eight patients. Complications unrelated to the perineal wound were found in five patients. The median follow-up time was 120 (range 5 - 245) months after salvage surgery. Nine patients died of disease progression, with a median survival time of 16 (range 5 - 27) months. Six patients had a long-term survival.

CONCLUSION: Salvage resection after radiotherapy can yield a long-time survival in selected patients with anal canal cancer. However it offers little hope to patients with T₄ and/or N_2-3 tumors.

Pathological staging of epidermoid anal carcinoma for the new era

Chemoradiotherapy is the standard treatment for most patients with epidermoid anal cancer. Pre-treatment staging is based on size for T1-T3 lesions and clinical and radiological assessment of adjacent organ invasion for T4 lesions. For patients with residual or recurrent carcinoma, anorectal excision offers the best chance of oncological salvage. Pathological staging systems for anorectal excision specimens were validated at the time when surgical treatment was first line therapy. A validated staging system is necessary for salvage surgical excision specimens following an attempt to cure by radiotherapy and chemotherapy for the purpose of prognosis and further treatment planning.

Sentinel lymph node biopsy for squamous cell carcinoma of the anal canal

BACKGROUND

The current Trans-Tasman Radiation Oncology Group (TROG) protocol for T1 and T2 anal cancers is combination chemotherapy and radiotherapy excluding the inguinal region from the field. Several centres worldwide irradiate both inguinal regions as there is a small incidence of involvement with early stage tumours. The presence of inguinal lymph node metastases is not accurately detected using clinical and most radiological assessment modalities. We have developed a method of sampling the sentinel node in the groin using established node mapping techniques.

METHODS

A combination of radio-labelled Antimony Sulphide and Patent Blue dye injected around the anal cancer enable identification of the sentinel node in the groin, using a gamma probe and direct visualization of the blue node.

RESULTS

This technique has been used in four patients. A groin sentinel node was identified and removed in three of these, with pathological assessment excluding metastatic disease in the inguinal region. The fourth patient had a sentinel node mapped to a meso-rectal node. This was not sampled.

CONCLUSIONS

The application of this effective technique will allow accurate staging of anal cancers to better plan future treatment regimes.

The efficacy of chemoradiation therapy in HIV seropositive patients with squamous cell carcinoma of the anus

OBJECTIVE

The aim was to assess the efficacy of chemoradiation therapy for squamous cell carcinoma of the anal canal in HIV seropositive patients.

PATIENTS AND METHODS

A retrospective review of all patients with squamous cell carcinoma of the anus treated primarily with combined chemotherapy (5-fluorouracil and mitomycin) and radiotherapy or local excision was undertaken comparing HIV seropositive to HIV seronegative patients.

RESULTS

Thirteen HIV seronegative patients were compared with 6 HIV seropositive patients. The HIV positive group included a higher proportion of males and a significantly greater history of prior treatment for condyloma. There was no difference in the median radiation dose (5020 cGy vs 4500 cGy, P=0.10). There was a trend towards higher local tumour recurrence in the HIV seropositive patients although this was not statistically significant (30% vs 66%). The CD4 count of HIV positive patients did not correlate either with their ability to complete the prescribed treatment regimen or with subsequent recurrence.

CONCLUSION

Combined chemoradiation is feasible in HIV positive patients, however, local recurrence rates in HIV positive patients may be higher. Tolerance of this therapy in HIV seropositive patients or recurrence after therapy are not related to the patient's CD4 cell count.

Results of salvage abdominoperineal resection for anal cancer after radiotherapy

PURPOSE

Nonsurgical treatment of anal cancer by radiotherapy alone or combined with chemotherapy is the standard therapy for epidermoid carcinoma of the anal canal. Surgery is only recommended for treatment failures. Very few studies have been devoted to the outcome of this salvage surgery. The aim of this study is to evaluate these results.

METHODS

A retrospective review from 1986 to 1995 revealed 21 patients with residual or recurrent anal canal carcinoma after initial radiotherapy, operated on by abdominoperineal resection. Patients were reviewed as to age, gender, initial treatment, any symptoms of recurrence, duration until recurrence, any diagnosis imaging, treatment, and outcome.

RESULTS

None of these 21 patients had known lymph node involvement or metastases at radiotherapy or at salvage abdominoperineal resection. Eleven patients had residual disease (positive biopsy less than 6 months after the end of radiotherapy) and 10 had tumor recurrence (more than 6 months after cessation of treatment). Recurrence occurred at a mean of 15 (range, 9-41) months after radiotherapy. All 21 patients underwent an abdominoperineal resection. Pathologic examination of the 21 specimens showed complete excision in all cases except one and lymph node metastases in two cases. There was no perioperative mortality. The mean follow-up after surgery was 40 months; no patients were lost to follow-up. Of the 21 patients, 10 died and 11 lived, of whom 9 are disease free. The overall survival rate at three years after salvage abdominoperineal resection was 58 percent. The overall survival rate for patients with residual disease (vs. recurrence) at three years was 72 percent (vs. 29 percent) and at five years was 60 percent (vs. 0 percent; P = 0.06).

CONCLUSIONS

Salvage abdominoperineal resection for anal cancer can be expected to yield a number of survivors from residual disease, but the low rate of survival after abdominoperineal resection for recurrent disease suggests the need for additional postoperative treatment if salvage abdominoperineal resection is performed.

Conservative treatment of anorectal tumors

PURPOSE

To evaluate the results of interstitial radiotherapy of anorectal tumors.

PATIENTS AND METHODS

From 1972 to 1993, one of the authors treated 45 patients by an interstitial implant for anorectal tumors. Of these, 33 patients suffered from primary tumors, 19 from squamous carcinoma, 2 from basaloid carcinoma of the anus and the other 12 from primary adenocarcinoma of the rectum. Of 12 patients treated for local recurrence, 10 had adenocarcinoma and 2 squamous cell carcinoma. Of the 33 patients with primary tumors, 27 received a course of external-beam radiotherapy before the implant. The median follow-up was 35 months.

RESULTS

Local response depended on the tumor volume treated. All 21 anal tumors showed complete response, 5 patients developed local recurrence and 4 distant metastases: 3 died from their disease. Of 12 rectal adenocarcinomas, 9 responded completely, 4 patients developed local recurrence and 4 distant metastases; 6 died from active disease. In the last group of 12 patients who were treated for recurrent tumors, 7 responded completely. One patient developed local recurrence and 9 distant metastases, only 4 are alive.

CONCLUSIONS

A combination of external-beam and interstitial radiotherapy is a relatively simple, non-mutilating, but well-tolerated and very effective method of treatment for early carcinoma of the lower rectum and anus.