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

Salvage Treatment of Recurrent or Persistent Anal Squamous Cell Carcinoma: The Role of Multi-modality Therapy

BACKGROUND

The standard treatment for recurrent or persistent anal squamous cell carcinoma is surgical salvage, but disease control and survival are suboptimal.

PATIENTS/METHODS

Patients treated for recurrent or persistent anal squamous cell carcinoma at our institution from 2002 to 2022 were included. Patients were classified by type of salvage treatment received: surgery alone vs. reirradiation followed by surgery and by whether they received intraoperative radiation at the time of surgery. Clinical and pathologic variables were collected and assessed for association with risk of second local recurrence and death from any cause.

RESULTS

Sixty four patients were included; 55(85.9%) were treated with surgery alone and 9 (14.1%) were treated with reirradiation followed by surgery. Median (IQR) follow up from the time of salvage treatment was 40.0 (20.3-68.0) months. The 3-year cumulative incidence of second local recurrence (95% CI) after salvage surgery was 36% (24%-48%); 39% (26%-52%) for patients treated with surgery alone and 15% (0.46%-51%) for patients treated with reirradiation followed by surgery. Factors associated with increased second local recurrence after salvage surgery included a locoregional recurrence, lymphovascular space invasion and positive surgical margins. The 3-year overall survival (95% CI) after salvage surgery was 70% (59%-83%); 68% (7%-56%) after surgery alone and 89% (10.5%-70.6%) after reirradiation followed by surgery. Factors associated with worse overall survival included male sex, a larger recurrent tumor and positive surgical margins.

CONCLUSIONS

Approximately 60% of patients achieved pelvic control after salvage therapy for recurrent or persistent anal squamous cell carcinoma. Although receipt of reirradiation and intraoperative radiation were not associated with improved second local recurrence or overall survival in our cohort, patients with positive surgical margins and lymphovascular space invasion on surgical pathology had higher rates of pelvic recurrence after salvage surgery and may benefit from escalated salvage therapy.

Perineal wound complications after vertical rectus abdominis myocutaneous flap and mesh closure following abdominoperineal surgery and pelvic exenteration of anal and rectal cancers: A meta-analysis

A meta-analysis research was implemented to appraise the perineal wound complications (PWCs) after vertical rectus abdominis myocutaneous (VRAM) flap and mesh closure (MC) following abdominoperineal surgery (AS) and pelvic exenteration (PE) of anal and rectal cancers. Inclusive literature research till April 2023 was done and 2008 interconnected researches were revised. Of the 20 picked researches, enclosed 2972 AS and PE of anal and rectal cancers persons were in the utilized researchers' starting point, 1216 of them were utilizing VRAM flap, and 1756 were primary closure (PC). Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the consequence of VRAM flap in treating AS and PE of anal and rectal cancers by the dichotomous approach and a fixed or random model. VRAM flap had significantly lower PWCs (OR, 0.64; 95% CI, 0.42-0.98, p < 0.001), and major PWCs (OR, 0.50; 95% CI, 0.32-0.80, p = 0.004) compared to PC in AS and PE of anal and rectal cancers persons. However, VRAM flap and PC had no significant difference in minor PWCs (OR, 1; 95% CI, 0.54-1.85, p = 1.00) in AS and PE of anal and rectal cancer persons. VRAM flap had significantly lower PWCs, and major PWCs, however, no significant difference was found in minor PWCs compared to PC in AS and PE of anal and rectal cancers persons. However, caution needs to be taken when interacting with its values since there was a low sample size of most of the chosen research found for the comparisons in the meta-analysis.

Clinical and oncological outcomes of pelvic exenteration surgery for anal squamous cell carcinoma

AIM

Anal cancer incidence and mortality rates are rising in the United Kingdom (UK). Surgery is an important treatment modality for persistent or recurrent disease. There is a paucity of data on outcomes for patients undergoing pelvic exenteration for anal squamous cell carcinoma (SCC) for persistent or recurrent disease. The aim of this study was to investigate the outcomes for patients who were treated with pelvic exenteration for anal SCC from two high-volume, high-complexity pelvic exenteration units in the UK.

METHOD

A retrospective review of prospectively maintained databases from 2011 to 2020 was undertaken. Primary endpoints included R0 resection rates, overall and disease-free survival at 2 and 5 years.

RESULTS

From 2011 to 2020, 35 patients with anal SCC were selected for exenteration. An R0 resection was achieved in 26 patients (77%). Of the remaining patients, seven patients had an R1 resection and one had a R2 resection. One further patient was excluded from additional analysis as the disease was inoperable at the time of laparotomy. With a median follow-up of 19.5 months (interquartile range 7.9-53.5 months), overall survival was 50% (17/34). Patients with an R1/2 resection had a significantly poorer overall survival [0.27 (0.09-0.76), p = 0.021] than those patients in whom R0 resection was achieved. Disease-free survival was 38.2% (13/34) and an R1/R2 resection was associated with a significantly reduced disease-free survival [0.12 (0.04-0.36), p < 0.001].

CONCLUSION

Complete R0 resection for recurrent or persistent anal SCC is possible in the majority of patients and improves overall and disease-free survival compared with R1/R2 resection.

Comparison of Perineal Closure Techniques after Abdominoperineal Resections for Carcinoma of the Anus

BACKGROUND

Perineal reconstruction following salvage APR's for squamous cell carcinoma of the anus (SCCA) are scant with conflicting results from large and single center studies. We analyzed these techniques taking into account sociodemographic and oncologic variables.

METHODS

This is a retrospective cohort study from 2016-2019 using a targeted ACS/NSQIP database stratified into primary closure (PC), abdominal myocutaneous (AM), lower extremity (LE), and omental pedicled (OP) flaps. We analyzed major and wound complications through univariate and multivariate regression analysis.

RESULTS

A total of 766 patients were analyzed, 512 (67%) had PC, 196 (25%) AM, 36 (5%) OP and 22 (3%) LE. Rates of chemotherapy and radiation within 90 days were similar between the groups. Having 2 or more additional organs resected was more common for the AM group (AM 4.1%, PC 1.6%, OP 3.3%, LE 0%). Overall, major complication rate was 41% (n = 324). Primary closure had 35.0%, OP 47.2%, AM 52.6%, and LE 45.5%. Wound complication rate was highest in AM with 11.7%, followed by OP 8.3%, PC 5.9%, and LE 0%. The multivariate regression analysis demonstrated none of the closure techniques to be associated with increasing or decreasing the probability of having a major or wound complication. Morbidity probability was the sole predictor of major complication (OR 1.07, 95% CI 1.04-1.1).

CONCLUSIONS

Myocutaneous and omental flaps are associated with comparable wound and major complications when taking into account the baseline, oncologic and perioperative variables that drive the clinical decision making when selecting a perineal reconstruction.

Oncologic and Functional Outcomes of Pelvic Perineal Reconstruction by Perineal Colostomy and Malone Procedure After Abdominoperineal Resection

BACKGROUND

Abdominoperineal resection is the standard curative surgical technique for locally advanced adenocarcinoma of the lower rectum and squamous cell carcinoma of the anal canal after chemoradiotherapy. However, it requires a definitive abdominal colostomy that modifies the body appearance.

OBJECTIVE

The study aim was to evaluate the combination of abdominoperineal resection with perineal colostomy reconstruction and Malone antegrade continence enema.

DESIGN

This was a retrospective study.

SETTINGS

The study was conducted at the Toulouse Hospital Digestive Surgery Department.

PATIENTS

All of the patients with advanced adenocarcinoma or squamous cell carcinoma who underwent abdominoperineal resection with perineal colostomy reconstruction and Malone antegrade continence enema (n = 80) between December 1999 and December 2016 were included.

MAIN OUTCOME MEASURES

The main outcome was the 5-year overall survival rate.

RESULTS

The 5-year overall survival was 74.89% (95% CI, 62.91%-83.50%), and the median recurrence-free survival was 107.6 months (95% CI, 65.1-198.1 mo). The median follow-up was 91.0 months (95% CI, 70.4-116.6 mo). R0 resection was obtained in 64 patients (80.0%). The median Cleveland Clinic Incontinence Score (to assess the functional outcomes) was 9.0 (interquartile range, 1.0-18.0), and it was lower in patients with advanced adenocarcinoma than with squamous cell carcinoma (7.0 (interquartile range, 2.0-18.0) vs 11.0 (interquartile range, 1.0-17.0); p = 0.01). Eleven patients (13.8%) reported perineal stains during the night, and 19 patients (23.8%) needed drugs to reduce colon motility. The rate of severe complications (Clavien-Dindo >II) was 11.7% (n = 9). Definitive colostomy was performed in 15 patients (18.8%).

LIMITATIONS

This retrospective study included a small number of patients from a single center. Moreover, the functional outcome was tested with self-report questionnaires (risk of response bias).

CONCLUSIONS

This study suggests that abdominoperineal resection associated with perineal reconstruction by perineal colostomy and Malone antegrade continence enema is safe and may improve patient quality of life. See Video Abstract at http://links.lww.com/DCR/B629.

RESULTADOS ONCOLGICOS Y FUNCIONALES DE LA RECONSTRUCCIN PLVIPERINEAL MEDIANTE COLOSTOMA PERINEAL Y PROCEDIMIENTO DE MALONE DESPUS DE LA RESECCIN ABDOMINOPERINEAL

ANTECEDENTES:La resección abdominoperineal es la técnica quirúrgica curativa estándar para el tratamiento del adenocarcinoma localmente avanzado del recto inferior y el carcinoma a células escamosas del canal anal, después de radio-quimioterapia. Sin embargo, requiere una colostomía abdominal definitiva que modifica la apariencia corporal.OBJETIVO:El propósito del presente estudio fue el evaluar la combinación de la resección abdominoperineal con la confección de una colostomía perineal asociada a enemas de continencia anterógrada según Malone.DISEÑO:Estudio retrospectivo.AJUSTES:Servicio de Cirugía Digestiva del Hospital de Toulouse, Francia.PACIENTES:Se incluyeron todos los pacientes con adenocarcinoma avanzado o carcinoma de células escamosas que se sometieron a resección abdominoperineal con la confección de una colostomía perineal asociada a enemas de continencia anterógrada según Malone (n = 80) entre diciembre de 1999 y diciembre de 2016.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fue la tasa de sobrevida global a 5 años.RESULTADOS:La sobrevida global a 5 años fue de 74,89% (IC del 95%, 62,91 a 83,50) y la mediana de supervivencia libre de recurrencia fue de 107,6 meses (IC del 95%, 65,1 a 198,1). La mediana de seguimiento fue de 91,0 meses (IC del 95%, 70,4-116,6). La resección R0 se obtuvo en 64 pacientes (80,0%). La mediana de puntuación de la escala de incontinencia de la Cleveland Clinic (para evaluar los resultados funcionales) fue de 9,0 [1,0; 18,0], y fue menor en pacientes con adenocarcinoma avanzado que con carcinoma de células escamosas (7,0 [2,0; 18,0] versus 11,0 [1,0; 17,0]; p = 0,01). Once pacientes (13,8%) refirieron manchado perineal nocurno y 19 pacientes (23,8%) necesitaron fármacos para reducir la motilidad del colon. La tasa de complicaciones graves (Clavien-Dindo > II) fue del 11,7% (n = 9). Se realizó colostomía definitiva en 15 (18,8%) pacientes.LIMITACIONES:Este estudio retrospectivo incluyó un pequeño número de pacientes y de un solo centro. Además, el resultado funcional se probó con cuestionarios de autoinforme (riesgo de sesgo de respuesta).CONCLUSIONES:Este estudio sugiere que la resección abdominoperineal asociada con la confección de una colostomía perineal asociada a enemas de continencia anterógrada según Malone es segura y puede mejorar la calidad de vida de los pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B629.

Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis

Simple Summary

Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer (mainly anal and rectal cancers) require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, Group C comparing PC and VRAMf in PE. The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total and major perineal wound complications. PC was associated with a decrease in total and major perineal complications in Group C.

Abstract

Background. Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers). Methods. We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE. Results. Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43–0.71; p < 0.01/Group B: OR 0.54, CI 0.17–1.68; p = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35–0.68; p < 0.001/Group B: OR 0.38, 95% CI 0.12–1.17; p < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39–4.35; p < 0.01) and major (OR 1.67, 95% CI 0.90–3.08; p = 0.1) perineal complications in Group C. Conclusions. Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.

Survival and Operative Outcomes After Salvage Surgery for Recurrent or Persistent Anal Cancer

Anal squamous cell carcinoma (SCC) is a relatively rare cancer comprising less than 2.5% of all gastrointestinal malignancies. The standard treatment for anal SCC is primary chemoradiation therapy which can result in complete regression. After successful treatment, the 5-year survival is approximately 80%. However, up to 30% of patients experience recurrent persistent or recurrent disease. The role of surgery in the treatment of anal cancer, therefore, is limited to the management of recurrent or persistent disease with abdominoperineal resection and/or en bloc adjacent organ excision. Salvage surgery after irradiated anal cancer can be technically demanding in terms of acquisition of oncologically safe surgical margins and minimization of postoperative morbidity. In addition, 5-year survival outcomes after salvage resection have been reported to vary from 23% to 69%. Positive resection margins are generally regarded as the important risk factor associated with poor survival outcome. Perineal wound complications are the most common major postoperative morbidity. Because of the challenges of primary wound closure after salvage abdominoperineal resection, myocutaneous flap reconstruction has been performed to reduce the severity of perianal would complications. We, therefore, descriptively reviewed contemporary published evidence describing the treatment and outcomes after salvage surgery for persistent or recurrent anal SCC.

A systematic review of outcomes after salvage abdominoperineal resection for persistent or recurrent anal squamous cell cancer

AIM

Up to 30% of patients with squamous cell cancer of the anus (SCCA) will require a salvage abdominoperineal resection (APR) for either persistent or recurrent disease. The objective of this study was to assess cancer-related outcomes in patients with (i) persistent or (ii) recurrent SCCA.

METHOD

Embase and MEDLINE were searched. Publications were included if they assessed overall survival (OS), disease-free survival (DFS) and locoregional recurrence or metastatic disease after salvage APR for persistent or recurrent SCCA.

RESULTS

A total of 28 retrospective case series (study size ranged from nine to 111) met our inclusion criteria. The median time to salvage APR was 2.6 months [interquartile range (IQR) 2.6-5.0 months, six studies] for persistent disease and 27.6 months (IQR 15.0-32.7 months, five studies) for recurrent disease. The median 5-year OS from the time of salvage APR was 45.0% (IQR 32.0%-52.3%, 10 studies) for persistent disease and 51.0% (IQR 36.0%-60.9%, 11 studies) for recurrent disease. The median 5-year DFS following salvage APR was 44.0% (IQR 29.5%-53.0%, 10 studies) for all patients. Following salvage APR, the median locoregional recurrence rate was 23.5% (IQR 15.8%- 46.9%, 19 studies) and 9.0% (IQR 6.4%-13.3%, 16 studies) of patients developed metastatic disease after salvage APR.

CONCLUSION

Our review characterizes the best evidence for outcomes following salvage APR for patients with persistent or recurrent SCCA. The evidence is limited by the quality of included studies, as many were single centre case series.

Salvage Abdominoperineal Resection for Squamous Cell Anal Cancer: A 30-Year Single-Institution Experience

Background

Failure of chemoradiotherapy (CRT) for anal squamous cell carcinoma (SCC) results in persistent or recurrent anal SCC. Treatment with salvage abdominoperineal resection (APR) can potentially achieve cure. The aims of this study are to analyze oncological and surgical outcomes of our 30-year experience with salvage APR for anal SCC after failed CRT and identify prognostic factors for overall survival (OS).

Methods

All consecutive patients who underwent salvage APR between 1990 and 2016 for histologically confirmed persistent or recurrent anal SCC after failed CRT were retrospectively analyzed.

Results

Forty-seven patients underwent salvage APR for either persistent (n = 24) or recurrent SCC (n = 23). Median OS was 47 months [95% confidence interval (CI) 10.0–84.0 months] and 5-year survival was 41.6%, which did not differ significantly between persistent or recurrent disease (p = 0.551). Increased pathological tumor size (p < 0.001) and lymph node involvement (p = 0.014) were associated with impaired hazard for OS on multivariable analysis, and irradical resection only (p = 0.001) on univariable analysis. Twenty-one patients developed local recurrence after salvage APR, of whom 8 underwent repeat salvage surgery and 13 received palliative treatment. Median OS was 9 months (95% CI 7.2–10.8 months) after repeat salvage surgery and 4 months (95% CI 2.8–5.1 months) following palliative treatment (p = 0.055).

Conclusions

Salvage APR for anal SCC after failed CRT resulted in adequate survival, with 5-year survival of 41.6%. Negative prognostic factors for survival were increased tumor size, lymph node involvement, and irradical resection. Patients with recurrent anal SCC after salvage APR had poor prognosis, irrespective of performance of repeat salvage surgery, which never resulted in cure.

Primary versus Flap Closure of Perineal Defects following Oncologic Resection: A Systematic Review and Meta-Analysis

BACKGROUND

Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity. Myocutaneous flaps have been proposed in place of primary closure to improve wound healing. A systematic review was conducted to compare primary closure with myocutaneous flap reconstruction of perineal defects following abdominoperineal resection or pelvic exenteration with regard to surgical-site complications.

METHODS

A comprehensive literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the MEDLINE, EMBASE, Google Scholar, and Cochrane Library databases. After data extraction from included studies, meta-analysis was performed to compare outcome parameters defining surgical-site complications of flap and primary closure.

RESULTS

Our systematic review yielded 10 eligible studies (one randomized controlled trial and nine retrospective studies) involving 566 patients (226 flaps and 340 primary closures). Eight studies described rectus abdominis myocutaneous flaps and two studies used gracilis flaps. In meta-analysis, primary closure was more than twice as likely to be associated with total perineal wound complications compared with flap closure (OR, 2.17; 95 percent CI, 1.34 to 3.14; p = 0.001). Rates of major perineal wound complications were also significantly higher in the primary closure group (OR, 3.64; 95 percent CI, 1.43 to 7.79; p = 0.005). There was no statistically significant difference between primary and flap closure for minor perineal wound complications, abdominal hernias, length of stay, or reoperation rate.

CONCLUSIONS

This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure for pelvic reconstruction. The authors' results have validated the use of myocutaneous flaps for reducing perineal morbidity following abdominoperineal resection or pelvic exenteration.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Locally Recurrent Disease Related to Anal Canal Cancers

Surgery for anal cancer is usually reserved for patients with persistent disease or local recurrence after definitive chemoradiation therapy. Patients with local recurrence should be re-evaluated for evidence of metastatic disease using positron emission tomography-computed tomography, and the local anatomy should be delineated with MRI. Eligible patients should undergo tailored surgery with the aim of achieving an R0 resection. Management is best undertaken within a specialized multidisciplinary setting. Careful patient selection and shared decision making are paramount for achieving acceptable patient-centered outcomes.

Optimal treatment strategies for anal cancer

OPINION STATEMENT

Squamous cell carcinoma (SCCA) of the anal canal is an underrecognized malignancy that is growing in annual incidence. Over the years, combined chemoradiation has been the mainstay of treatment for locally advanced SCCA of the anal canal. Currently, the human papilloma virus (HPV) vaccine is recommended to prevent the development of HPV and its associated precancerous lesion(s). Patients diagnosed with the human immunodeficiency virus (HIV+) are prone to develop anal cancer due to their high risk of contracting HPV infection. We will focus on the development and management of SCCA of the anal canal (both localized and metastatic), including special details on HIV-positive patients. Highlights will include the role of targeted therapy based on available literature. Our objective is to aid practicing physicians in formulating a treatment plan for both locally advanced and metastatic patients.

Anal squamous cell carcinoma: An evolution in disease and management

Anal cancer represents less than 1% of all new cancers diagnosed annually in the United States. Yet, despite the relative paucity of cases, the incidence of anal cancer has seen a steady about 2% rise each year over the last decade. As such, all healthcare providers need to be cognizant of the evaluation and treatment of anal squamous cell carcinoma. While chemoradiation remains the mainstay of therapy for most patients with anal cancer, surgery may still be required in recurrent, recalcitrant and palliative disease. In this manuscript, we will explore the diagnosis and management of squamous cell carcinoma of the anus.

Anal canal squamous cell carcinoma: overview, surveillance after treatment and management of local recurrence

SUMMARY Anal canal cancer is an uncommon gastrointestinal malignancy, although the incidence is increasing. Current treatment employs definitive chemoradiation, 5-fluorouracil, mitomycin C and a radiation dosage of 54–59 Gy for T3/T4 tumors, but not for T1 and T2 disease. Surveillance after completion of treatment is required. One acceptable strategy includes physical examinations every 3–6 months for 5 years and serial CT scans to detect advanced disease. A total of 40% of patients with T4 disease or immunosuppressed status may recur within the first 2 years after completion of treatment. Salvage therapy includes radical abdominoperineal resection. The most significant prognosticator after salvage surgery is the resection margin. Generally, patients with anal cancer should be treated by a multidisciplinary physician team and be assigned to clinical research trials, if feasible.

Salvage abdominoperineal resection for anal cancer following chemoradiation: a proposed scoring system for predicting postoperative survival

BACKGROUND AND OBJECTIVES

Anal carcinoma is treated primarily by chemoradiation. Failure of this treatment requires salvage surgery. The aims of this retrospective study were to assess the survival probability after rescue surgery and design a pathological risk score (PRS) to predict postoperative outcome.

METHODS

From 1982 to 2011, the clinical and pathological data of 111 patients treated with chemoradiation or radiation alone and abdominoperineal resection were reviewed. The Kaplan-Meier method was used to assess overall survival and parametric modeling was applied to determine prognostic factors and design a PRS.

RESULTS

The 2- and 5-year overall survival rates were 60% and 24.5%, respectively. The multivariate analysis showed that nodal disease (P < 0.03), resection margin (P < 0.001), and perineural and/or lymphovascular invasion (P < 0.0001) were significantly associated with survival. Patients who presented negative values for these three variables were estimated to show a 5-year survival rate of 55% compared with 0.03% for patients who presented positive values.

CONCLUSIONS

Positive surgical margin, the presence of perineural and/or lymphovascular invasion and positive nodal involvement were identified as significant independent predictors of mortality. The PRS was shown to be highly predictive of postoperative outcome.

Imaging of anal carcinoma

OBJECTIVE

The purpose of this article is to review the role of imaging in the management of patients with anal cancer. The relevant anatomy, imaging techniques, and interpretation of images of patients before and after therapy will be discussed.

CONCLUSION

Anal carcinomas are uncommon but increasing in frequency. Radiologists must recognize typical patterns of disease at initial evaluation, posttherapy appearances, and when to suspect residual or recurrent disease to guide clinicians and achieve optimal patient outcome.

Abdominoperineal resection for squamous cell anal carcinoma: survival and risk factors for recurrence

BACKGROUND

Despite the results of combined chemoradiation therapy for anal canal squamous cell carcinoma (SCC), up to 30 % of patients will undergo abdominoperineal resection (APR). The aim of this study was to evaluate oncologic outcomes, survival, and recurrence, following APR for anal canal SCC performed in a single center over a 13-year period.

METHODS

All patients who underwent APR for anal canal SCC between 1996 and 2009 were retrospectively included. Demographic data, details on treatments, pathological report, and follow-up were noted. Survival curves were plotted using the Kaplan-Meier method and potential prognostic factors were evaluated using Cox proportional hazards models.

RESULTS

A total of 105 patients (77 women) were included. Indications for APR included tumor persistence (n = 42; 40 %), recurrence (n = 55; 52.4 %), or a contraindication to radiotherapy (n = 8; 7.6 %). Median follow-up was 33.3 months (range, 1.5-174.3 months). Overall survival and disease-free survival were, respectively, 61 and 48 % at 5 years. In multivariate analysis, tumor stage (T3 or T4), positive margin on pathologic examination and existence of distant metastases at the time of the surgery were associated with a poor prognosis. The indication for APR (persistent vs recurrent disease), gender, concurrent HIV infection, or performance of a VRAM flap did not influence OS or DFS. Overall recurrence rate was 42.6 % (n = 43 of 101). The type of recurrence did not exert a significant effect on survival (p = .4571).

CONCLUSION

This study describes the largest single series of APR for anal carcinoma. Major prognostic factors for survival and recurrence were T status and involved margin. The 5-year overall survival was 60 %.

Squamous cell carcinoma of the anal canal: a review of the aetiology, presentation, staging, prognosis and methods available for treatment

Anal cancer is an uncommon malignancy, with the majority of cases comprised of squamous cell carcinomas. The increasing incidence of this disease reflects a rise in the transmission of the human papillomavirus, the causative organism of most tumours. Abdominoperineal resection (APR), once the primary mode of treatment, has been supplanted by sphincter-saving combination chemoradiation as the first-line therapy. However, surgeons continue to play a role in the multidisciplinary management of patients with anal cancer for diagnosis and post-treatment surveillance. Sentinel node biopsy may identify patients with clinically and radiographically negative inguinal lymph nodes who will benefit from groin irradiation. In very select cases, the controversial means of local excision has been employed as primary treatment, often in conjunction with radiation and chemotherapy. The management of persistent or recurrent anal cancers following primary chemoradiation remains a concern, for which only salvage APR currently offers the possibility of a cure. The introduction of human papillomavirus vaccines presents the exciting potential for the eradication of the disease.

Rectus abdominis myocutaneous flaps for perineal reconstruction: modifications to the technique based on a large single-centre experience

INTRODUCTION

Perineal wound breakdown with delayed wound healing represents a significant cause of morbidity following surgery and radiotherapy to the perineum. The rectus abdominis myocutaneous (RAM) flap has been used increasingly to reconstruct the perineum with good effect. We describe our six-year experience of reconstruction of the perineum with the RAM flap and share some surgical adjuncts we believe are useful.

METHODS

We conducted a retrospective case note review of all patients who underwent a reconstruction of the perineum using the RAM flap between August 2003 and October 2009. Indications for the flap, complication rates and outcomes were all observed.

RESULTS

We conducted 16 RAM flap procedures, 15 of which (94%) were primary repairs and 1 (6%) a secondary repair. Three (19%) developed donor site hernias, two (12.5%) developed minor perineal wound infections, eight (50%) developed minor perineal wound breakdown and in one (6%) flap failure was observed. No perineal hernias were observed. There were no surgical mortalities.

CONCLUSIONS

The RAM flap has a high success rate and an acceptable morbidity rate and is a useful tool in the reconstruction of complex perineal wounds. Modifications to the standard surgical technique may reduce complications and improve the versatility of this flap.

Anal carcinoma in HIV-infected patients in the era of antiretroviral therapy: a comparative study

BACKGROUND

Before the introduction of highly active antiretroviral therapy, prognosis of anal squamous-cell carcinoma was worse when patients were infected with HIV. Since then, contradictory results have been reported.

OBJECTIVE

To compare the results of chemoradiotherapy in HIV-infected and uninfected patients with anal carcinoma.

DESIGN

Retrospective analysis of medical records.

SETTING

Tertiary care center in France.

PATIENTS

Patients with invasive anal carcinoma treated from 2001 through 2006.

INTERVENTIONS

Chemoradiotherapy included 60 Gy pelvic irradiation and cisplatin-based chemotherapy. Surgery was performed for local failures or complications.

MAIN OUTCOME MEASURES

Tolerance for chemoradiotherapy, tumor control, and survival were evaluated.

RESULTS

A total of 46 patients (20 HIV-infected and 26 uninfected) were treated for nonmetastatic anal carcinoma. Median follow-up was 32.5 (range, 7-84) months. HIV-infected patients were more likely to be men (95% vs 23%, P < .001) and were younger (median age, 46 vs 62 years, P < .001) than uninfected patients. The viral load was less than 200 copies/mL in 15 (75%) of the HIV-infected patients. The duration of chemoradiotherapy was longer in HIV-infected than in uninfected patients (median, 103 vs 84 days, P = .027). Chemoradiotherapy failed to achieve local control in 10 (50%) HIV-infected and in 6 (23%) uninfected patients (P = .057). In HIV-infected patients, failure rates were higher in patients who required prolonged chemoradiotherapy than in those who received treatment as scheduled (7/11, 64% vs 1/7, 14%; P = .039). During follow-up, 7 (35%) of the HIV-infected and 3 (12%) of the uninfected patients died, all from anal carcinoma. The 5-year overall survival rate was 39% for HIV-infected and 84% for uninfected patients (P = .026); 5-year disease-free survival was 37% in HIV-infected and 75% in uninfected patients (P = .06).

LIMITATIONS

Retrospective design, lack of data regarding precise toxicity grading, and use of cisplatin-based chemoradiotherapy.

CONCLUSIONS

Even in the era of highly active antiretroviral therapy, HIV-infected patients with anal squamous-cell carcinoma show impaired tolerance to chemoradiotherapy, have a lower survival rate, and may have a higher rate of local failure compared with uninfected patients.

Neoplasms of anal canal and perianal skin

Tumors of the anus and perianal skin are rare. Their presentation can vary and often mimics common benign anal pathology, thereby delaying diagnosis and appropriate and timely treatment. The anatomy of this region is complex because it represents the progressive transition from the digestive system to the skin with many different co-existing types of cells and tissues. Squamous cell carcinoma of the anal canal is the most frequent tumor found in the anal and perianal region. Less-frequent lesions include Bowen's and Paget's disease, basal cell carcinoma, melanoma, and adenocarcinoma. This article aims to review the clinical presentation, diagnostic evaluation, and treatment options for neoplasms of the anal canal and perianal skin.

Impact of FDG PET/CT in the staging and the follow-up of anal carcinoma

PURPOSE

The purpose of the study was to assess the diagnostic performance of positron emission tomography/computed tomography and fluorodeoxyglucose (18F) (FDG PET/CT) for the staging and the follow-up of anal carcinoma, and to evaluate the impact of FDG PET/CT on patient management.

MATERIALS AND METHODS

Patients with anal carcinoma were referred to our department from October 2004 until July 2008. The diagnostic performance was evaluated on a perexamination basis and on a per-site basis, together with impact of PET/CT on patient management. The standard of truth was histology when available and, in all cases, follow-up data during at least 6 months.

RESULTS

Fifty-eight FDG PET/CT performed in 44 patients were analysed—22 for initial staging and 36 during follow-up. The detection rate of non-excised tumours on initial examination was 93%. During post-treatment follow-up, FDG PET/CT had, on a per-examination basis, sensitivity for the detection of persistent or recurrent disease of 93% and specificity of 81%, and on a per-site basis, 86% and 97%, respectively. Its negative predictive value was 94% on a per-examination basis and 98% on a per-site basis. FDG PET/CT had an impact on management in nine patients out of 44 (20%), which was relevant in eight of them (89%).

CONCLUSION

FDG PET/CT is an accurate imaging modality in anal cancer. It has an interesting added value during post-treatment follow-up, especially when persistence or recurrence of disease is suspected. Further studies are needed to evaluate whether surveillance by means of FDG PET/CT might have a positive impact on overall survival.

Abdomino-perineal resection for anal cancer: impact of a vertical rectus abdominis myocutaneus flap on survival, recurrence, morbidity, and wound healing

OBJECTIVES

To evaluate the results of a vertical rectus abdominis myocutaneus (VRAM) flap after abdomino-perineal resection (APR) for anal cancer (AC).

BACKGROUND DATA

APR is the only curative treatment for AC that recurs or persists after radiochemotherapy. To obtain a clear surgical margin, APR frequently includes a significant perineal exenteration, leaving a large defect surrounded by irradiated tissue. VRAM may facilitate the healing of such a wound and, by providing tissue that can cover a large defect, can facilitate a wide resection and thus may influence survival.

METHODS

All patients who underwent APR for AC between 1996 and 2007 were included.

RESULTS

Ninety-five patients (70 women) underwent APR, including 43 patients who subsequently received a VRAM flap. The remaining patients had an omentoplasty. Indications for APR were recurrence of AC (n = 46), persistence of disease (n = 41), and contraindication to radiotherapy (n = 8). The groups (VRAM vs. No VRAM) differed in age at surgery (56.3 vs. 62.1; P = 0.0263); administration of chemotherapy in addition to radiotherapy (81% vs. 59%; P = 0.0218); and stage (ypT3-T4 67.6% vs. 38.4%; P = 0.0394). Five-year overall and disease-free survival did not differ between the 2 groups (58.1% vs. 54.5%; P = 0.6756; 41.1% vs. 48.9%; P = 0.2756). Perineal complications were significantly less frequent following VRAM (26.8% vs. 48.9%; P = 0.0336), with reduced time to healing (18.7 vs. 117 days; P = 0.0019) and the ratio of wound healing to survival time (5.6% vs. 19.4%; P = 0.0176). No difference was observed in the incidence of abdominal incisional hernias (9.3% vs. 9.6%), but patients who underwent a VRAM flap pelvic reconstruction had fewer perineal hernias (0% vs. 15.4%; P = 0.0072).

CONCLUSIONS

Survival in the 2 groups was equivalent despite the presence of more advanced cancers in the VRAM flap cohort. This may be explained by the more extensive resections that were performed in this group. VRAM is an effective technique for reducing both the perineal complication rate and wound-healing delay in patients undergoing APR for AC that does not increase abdominal wall morbidity.

Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision

OBJECTIVE

Perineal wound complications after abdominoperineal excision (APE) for anorectal cancer represent a considerable source of morbidity for patients. Strategies to improve wound healing include reconstruction with myocutaneous flaps. This is an evidence-based review of reconstruction of pelvic defects after APE, using rectus abdominus (RAM), gracilis and gluteus maximus flaps.

METHOD

A Pubmed search was performed using MESH headings.

RESULTS

Thirty-six studies reported outcomes of interest. Five controlled studies reported improved outcomes after APE and chemoradiotherapy with RAM reconstruction and two controlled studies reported improved outcomes with gracilis reconstruction. There were seven patients with total flap loss after RAM reconstruction, in a combined 300 patients. There were eight patients with complete cutaneous necrosis after gracilis reconstruction in a combined 83 patients.

CONCLUSION

Data from the controlled studies support the use of myocutaneous flaps for single-stage reconstruction after APE in the presence of chemoradiotherapy. Ultimately, the choice of flap depends on the goals of reconstruction, size of the defect and the availability of donor tissue. The implications of an expanding role for radiotherapy in the treatment of low rectal cancer and radical dissection to achieve negative circumferential margins, necessitate close co-operation between colorectal and reconstructive surgeons to achieve APE with reduced wound morbidity.

Pelvic cancer recurrence: drop the arrow in the target

BACKGROUND

Local recurrence of pelvic cancer is a therapeutic challenge. Medical history retrieve frequently high dose radiotherapy and multiple pelvic surgery. Thus, surgical resection is complex and leads to hazardous postoperative courses. We report a case of radiofrequency thermoablation (RFTA) of an isolated pelvic recurrence.

CASE

A 53-year-old woman presented in 2006 with a small (20 mm) pelvic recurrence of an anal canal cancer initially treated by radiochemotherapy and amputation of the rectum. The recurrence was localized in the left vaginal wall, involving the obturator internus muscle. Treatment consisted on primary chemotherapy followed by RFTA under real time endovaginal sonography with cooling of the bladder. Small vaginal wall necrosis occurred in postoperative courses and rapidly cicatrized. The patient was still alive without evolution 22 months after the treatment.

CONCLUSIONS

RFTA is a feasible therapeutic option for some selected small isolated pelvic cancer recurrence. It allows good local control with survival improvement.

[Diagnosis and therapy for anal carcinoma]

Of all carcinomas in the anal canal, 75-80% are squamous cell carcinomas-the remaining 25% being adenocarcinomas. Carcinomas of the anal margin are to be differentiated from basal cell carcinomas and Paget's and Bowen's diseases. More than 80% of anal carcinomas show high-risk HP viruses. Every suspicious lesion in the anal canal and margins must be examined histologically. Primary radiochemotherapy is the first treatment option for epidermoid carcinomas of the anal canal and anal margin. Overall 5-year survival is reported at up to 90%. Surgery is reserved for the primary biopsy or excision of small tumors and for salvage abdominoperineal resection in patients with tumor persistence or local recurrence after radiochemotherapy. Systematic inguinal lymphadenectomy is not indicated. The first follow-up examination should be done 6 weeks after the end of radiochemotherapy. A biopsy is necessary after 3 months.

[Diagnosis and therapy for anal carcinoma]

Of all carcinomas in the anal canal, 75-80% are squamous cell carcinomas-the remaining 25% being adenocarcinomas. Carcinomas of the anal margin are to be differentiated from basal cell carcinomas and Paget's and Bowen's diseases. More than 80% of anal carcinomas show high-risk HP viruses. Every suspicious lesion in the anal canal and margins must be examined histologically. Primary radiochemotherapy is the first treatment option for epidermoid carcinomas of the anal canal and anal margin. Overall 5-year survival is reported at up to 90%. Surgery is reserved for the primary biopsy or excision of small tumors and for salvage abdominoperineal resection in patients with tumor persistence or local recurrence after radiochemotherapy. Systematic inguinal lymphadenectomy is not indicated. The first follow-up examination should be done 6 weeks after the end of radiochemotherapy. A biopsy is necessary after 3 months.

Perineal healing and survival after anal cancer salvage surgery: 10-year experience with primary perineal reconstruction using the vertical rectus abdominis myocutaneous (VRAM) flap

Salvage surgery of recurrent or persistent anal cancer following radiotherapy is often followed by perineal wound complications. We examined survival and perineal wound complications in anal cancer salvage surgery during a 10-year period with primary perineal reconstruction predominantly performed using vertical rectus abdominis myocutaneous (VRAM) flap. Between 1997 and 2006, 49 patients underwent anal cancer salvage surgery. Of these, 48 had primary reconstruction with VRAM. Overall survival was computed by the Kaplan-Meier method and mortality rate ratios (MRRs) by Cox regression. One patient (2%) died within 30 days postoperatively. Postoperative complications necessitated reoperation in eight (16%) patients. We found no major perineal wound infections. Major perineal wound breakdown occurred in the only patient in whom VRAM was not used. Five-year survival was 61% [95% confidence interval (CI) 43-75%]. Free resection margins (R0) were obtained in 78% of patients, with 5-year survival of 75% (95% CI 53-87%). Involved margins, microscopically only (R1) or macroscopically (R2), strongly predicted an adverse outcome [age-adjusted 2-year MRRs (95% CI) R1 vs. R0 = 4.1 (0.7-23.6), R2 vs. R0 = 10.9 (2.2-54.2)]. We conclude that anal cancer salvage surgery can yield long-time survival but obtaining free margins is critical. A low rate of perineal complications is achievable by primary perineal reconstruction using VRAM flap.

Abdominoperineal resection for anal cancer

PURPOSE

Following initial radiotherapy or chemoradiotherapy for the treatment of anal cancer, patients who present with either persistent or locally recurrent disease are treated by abdominoperineal resection. The aim of this retrospective study was to review the long-term survival and prognostic factors after such surgery in a single institution.

METHODS

Over a 34-year period (1969-2003), 422 patients with nonmetastatic anal cancer were treated with a curative intent. Of these, 83 (median age 61 years; 74 women) underwent abdominoperineal resection.

RESULTS

Forty-one patients underwent abdominoperineal resection for persistent disease and 42 for locally recurrent disease. Postoperative mortality was 4.8 percent and morbidity was 35 percent with 18 percent having perineal wound infections. Median follow-up was 104 months (range, 3-299). The 3-year and 5-year actuarial survival was 62.8 and 56.5 percent respectively. Using univariate analysis, patients below 55 years, females, T1-2 tumors, N0-N1 lymphadenopathy and the absence of locally advanced tumor were associated with significantly improved survival. Surgery, whether for persistent or locally recurrent disease, did not affect the 5-year survival rate.

CONCLUSIONS

Abdominoperineal resection for nonmetastatic anal cancer is associated with a high morbidity rate but may result in long-term survival regardless of the indication.

[Diagnosis and therapy for anal carcinoma]

Of all carcinomas in the anal canal, 75-80% are squamous cell carcinomas-the remaining 25% being adenocarcinomas. Carcinomas of the anal margin are to be differentiated from basal cell carcinomas and Paget's and Bowen's diseases. More than 80% of anal carcinomas show high-risk HP viruses. Every suspicious lesion in the anal canal and margins must be examined histologically. Primary radiochemotherapy is the first treatment option for epidermoid carcinomas of the anal canal and anal margin. Overall 5-year survival is reported at up to 90%. Surgery is reserved for the primary biopsy or excision of small tumors and for salvage abdominoperineal resection in patients with tumor persistence or local recurrence after radiochemotherapy. Systematic inguinal lymphadenectomy is not indicated. The first follow-up examination should be done 6 weeks after the end of radiochemotherapy. A biopsy is necessary after 3 months.

Outcomes of salvage surgery for squamous cell carcinoma of the anal canal

BACKGROUND

For patients with anal canal cancer who fail combined modality treatment (CMT), salvage surgery (SS) offers the potential for long term survival. The literature regarding SS is limited by small patient numbers and/or heterogeneous treatment protocols. We report on a large series of patients initially treated with chemoradiation at a major referral center.

METHODS

We identified 60 patients with persistent or recurrent anal cancer who had undergone SS; 20 were excluded. Overall and disease-free survival (OS, DFS) curves were constructed using the Kaplan Meier method. Univariate analysis was done using the Log-Rank test, and multivariable analysis using Cox proportional hazards.

RESULTS

The 40 patients (29 women, 11 men, median age 57) underwent curative intent resection. The initial procedure was multivisceral resection (n = 24), abdominoperineal resection alone (n = 14) or local excision (n = 2). Postoperative mortality was 5%. Postoperative complications were seen in 72%. Median follow-up was 18 months overall and 36 months in survivors. Median OS was 41 months; OS and disease free survival at 5 years were 39% and 30%, respectively. Recurrence was present in 21 patients at time of analysis. Failure was locoregional in 86% (18 of 21) and distant in 48% (10 of 21). Independent predictors of poor OS were male gender, Charlson Comorbidity Score and tumor size. Independent predictors of poor disease free survival were positive margins and lymphovascular invasion.

CONCLUSION

SS for anal canal cancer was associated with significant morbidity. Long-term survival was achieved in 39% of patients. Comorbidities should guide patient selection, and R0 resection should be the goal.

Results of surgical salvage after failed chemoradiation therapy for epidermoid carcinoma of the anal canal

BACKGROUND

The standard treatment for epidermoid carcinoma of the anal canal consists of combined radiation and chemotherapy. For patients who present with persistent or locally recurrent disease, salvage abdominoperineal resection is the treatment of choice. The purpose of this study is to review our experience with salvage surgery in this group of patients.

METHODS

From 1990-2002, 31 patients underwent radical salvage surgery with curative intent after failure of initial sphincter-conserving therapy, and the medical records of these patients were retrospectively reviewed. Clinicopathologic variables were determined and comparisons performed with the Cox proportional hazards model. Survival was calculated by the Kaplan-Meier method.

RESULTS

Eleven patients underwent radical salvage surgery for persistent disease and 20 patients for recurrent disease. The median follow-up time was 29 months. The actuarial 5-year overall survival was 64%. Twelve patients developed recurrent disease after radical salvage surgery. Patients who received an initial radiation dose of less than 55 Gy had a significantly worse survival than those who received at least 55 Gy as part of their initial treatment (5-year overall survival 37.5% vs. 75%; age-adjusted hazard ratio 8.2 [95% CI: 1.1-59.8], P = .037). The presence of positive lymph nodes at presentation also adversely affected survival (P < .05). Factors that were not found to have an impact on survival included the presence of persistent versus recurrent disease, tumor (T) stage, and margin status of resection.

CONCLUSIONS

Long-term survival following salvage surgery for persistent or locally recurrent epidermoid carcinoma of the anal canal can be achieved in the majority of patients. However, patients who initially present with node-positive disease and patients who receive a radiation dose of less than 55 Gy as part of their initial chemoradiation therapy regimen have a worse prognosis after radical salvage surgery.

Omentoplasty in abdominoperineal resection: a review of the literature using a systematic approach

PURPOSE

Abdominoperineal resection is associated with considerable morbidity, in particular, the perineal wound. Omentoplasty has been proposed as a means of reducing the perineal complication rate after abdominoperineal resection. This study was designed to assess the available evidence for omentoplasty in abdominoperineal resection.

METHODS

A MEDLINE search from January 1970 to July 2005 was performed to locate English language articles relating to omentoplasty in abdominoperineal resection. Manual search via reference lists identified additional articles. Articles reporting results from at least ten patients in whom abdominoperineal resection with an omentoplasty was performed were considered. All included reports were reviewed by using a predetermined protocol.

RESULTS

Among the ten reports identified, no randomized trials, four studies with control groups, and six case series were found. Primary healing was the outcome measure that was most consistently reported in the different articles. Most authors reported positive results after omentoplasty, and one study showed significant improvement in perineal healing rate at six months. Significant reduction in sinus formation and wound dehiscence also was reported. Only few complications related to the omentoplasty, none of which was fatal, were reported.

CONCLUSIONS

Although results from the studies included in this review indicate that there may be benefits from including an omentoplasty when performing an abdominoperineal resection, the lack of randomized studies results in only weak evidence.

Combined multimodal approach to the treatment of metastatic anal carcinoma: report of a case and review of the literature

BACKGROUND

We report on a patient with squamous cell anal carcinoma and liver metastases, who underwent multimodal treatment for cure, consisting of repeated partial hepatectomy in combination with chemoradiotherapy.

PATIENTS AND METHODS

A 54-year-old woman presented with squamous cell anal carcinoma and liver metastases. She was treated with a combination of chemoradiotherapy for the primary tumor and then underwent surgery for liver metastases. 2 and 5 years after presentation, the patient underwent repeated partial hepatectomies for recurrent liver disease. At present, 5 months after completing therapy and 71 months after the initial diagnosis, she is in good health with no evidence of disease.

RESULTS

Repeated partial hepatectomy led to prolonged survival in a patient with squamous cell anal carcinoma metastatic to the liver.

CONCLUSIONS

This is the first report of aggressive partial hepatectomy for recurrent liver metastases resulting from anal cancer. Based on our experience, we suggest that in selected patients repeated hepatectomy should be part of an aggressive multimodal treatment program with curative intent.

Tumor site predicts outcome after radiochemotherapy in squamous-cell carcinoma of the anal region: long-term results of 101 patients

PURPOSE

This study was designed to assess the long-term results following radiochemotherapy in patients with anal squamous-cell carcinoma and to evaluate the impact of tumor location on response, survival, and colostomy-free survival.

PATIENTS AND METHODS

Between 1985 and 2001, a total of 101 patients with anal carcinoma were registered for curative treatment, of whom 77 had involvement of the anal canal alone, 10 cases had extension into the perianal skin, and 14 patients had pure anal margin tumors. Small tumors of the anal margin were not included since they were treated by surgical excision only. Among the 101 patients were 74 women and 27 men with a median age of 62 (range, 26-84) years. T categories (International Union against Cancer) were T1 (15), T2 (36), T3 (34), and T4 (16). Seventy-one patients had no evidence of nodal disease, whereas 30 presented with involved regional nodes. Radiation treatment was directed to the primary tumor region and to the inguinal, perirectal, and internal iliac nodes using a three-field to four-field box technique with 10MV photons up to a total dose of 5040 cGy. Lesions greater than 5 cm received an additional boost by interstitial or external radiation depending on circumferential extension of the residual tumor. All patients were scheduled for simultaneous chemotherapy with two cycles of 5-fluorouracil at a dose of 1000 mg/m (2)/day as 120 hours of continuous intravenous infusion on Days 1 to 5 and 29 to 33 and mitomycin C at 10 mg/m (2)/day on Days 1 and 29. Median follow-up time was was 7.5 (range, 1-16) years.

RESULTS

Overall survival and colostomy-free survival rates for patients with anal canal cancer were 75 percent and 87 percent at five years, respectively. Patients with anal margin cancer had a less favorable outcome with five-year-overall and colostomy-free survival rates of 54 percent and 69 percent, respectively. After correction for imbalance between anal canal and anal margin tumors, i.e., exclusion of T1 tumors of the anal canal, difference in overall survival remained significant (73 percent vs. 54 percent, P = 0.01). Following multivariate analysis, tumor location (anal canal vs. anal margin, P = 0.02), age (P = 0.003), and dose intensity of chemotherapy (< or =75 percent vs. >75 percent, P = 0.03) remained independent significant factors for overall survival. Initial tumor response at six weeks (P = 0.03) was predictive for colostomy-free survival.

CONCLUSIONS

With colostomy-free survival rates around 85 percent, long-term treatment results for anal canal carcinoma have reached a satisfactory level. However, patients with larger lesions of the perianal skin are at high risk for locoregional recurrence and possible treatment intensification in this subgroup seems desirable.