1
|
Mishra H, Mishra R, Singh A, Mandal A, Singh TB, Asthana AK. Evaluation of survival outcomes and prognostic factors of carcinoma anal canal at a tertiary cancer center. J Cancer Res Ther 2023; 19:1998-2004. [PMID: 38376309 DOI: 10.4103/jcrt.jcrt_357_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 06/01/2022] [Indexed: 02/21/2024]
Abstract
CONTEXT Concurrent chemoradiotherapy is considered a standard of care for patients with carcinoma anal canal. Being an unusual malignancy, there is limited Indian data regarding survival outcomes and prognostic factors. AIM To evaluate survival outcomes and associated prognostic factors in patients with carcinoma anal canal treated with radical intent. METHODS AND MATERIAL Patients with squamous cell carcinoma of the anal canal, treated with radical intent between 2015 and 2019 were included in the study. Data regarding the baseline characteristics of the patients and treatment outcomes were collected and analyzed. Survival rates were estimated using Kaplan-Meier method. To determine survival difference between the groups, log-rank test was used. Multivariate analyses were performed with Cox proportional hazard models and P value < 0.05 was considered significant. RESULTS Forty-two patients were identified after applying suitable eligibility criteria. The median age was 55 years (range: 26-80 years).The median follow-up duration was 23.5 months (range: 1.9-51.9 months). The 3-year overall survival (OS), disease-free survival (DFS), and locoregional (LRC) were 78.5%, 53.1%, and 66.4%, respectively. On multivariate analysis, inferior DFS was significantly affected by lack of concurrent chemotherapy (CT) (hazard ratio [HR], 11.50; 95% confidence interval [CI], 1.92-68.78; P = 0.007) and radiotherapy (RT) dose of 45 Gy or less (HR, 35.96; 95% CI, 6.32-204.56; P = 0.000). CONCLUSION For patients of carcinoma anal canal, concurrent CT and RT dose are independent prognostic factors influencing DFS.
Collapse
Affiliation(s)
- Himanshu Mishra
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
| | - Ritusha Mishra
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
| | - Ankita Singh
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
| | - Abhijit Mandal
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
| | - Tej B Singh
- Department of Biostatistics, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
| | - Anupam K Asthana
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
| |
Collapse
|
2
|
Gul SK, Tepetam H, Yildiz F, Er I, Oksuz DC, Parvizi M, Ozden AS, Alicikus ZA, Sari SY, Alomari O, Gorken IB. Revisiting the Radical Radiotherapy-Radiochemotherapy Results in Anal Canal Cancers: (TROD Gastrointestinal Group Study 02-005). Clin Colorectal Cancer 2023; 22:318-326. [PMID: 37336706 DOI: 10.1016/j.clcc.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND AND AIM This study aimed to determine treatment outcomes and factors affecting prognosis in patients diagnosed with anal canal cancer who received radical radiotherapy (RT) or radiotherapy combined with chemotherapy (CT-RT) in radiation oncology centers in Turkey and compare the results with literature. MATERIAL AND METHOD The study included 193 patients with anal canal cancer reported between 1995 and 2019, of which 162 had complete data. The study was conducted in 11 radiation oncology centers, and a joint database was shared among them. Patients received radiotherapy doses of 45 Gy to 60 Gy. Data analysis was done using SPSS for Windows version 20. RESULTS Median follow-up was 48.51 months (2-214). All patients received radiotherapy, and 140 (86.4%) received concurrent chemotherapy. Radiotherapy doses of 50.4 Gy to 60 Gy were administered to 74 patients (45.7%) using 2-dimensional-3-dimensional (2D-3D) conformal therapy and 70 patients (43.2%) using intensity modulated radiotherapy technique (IMRT). Acute phase hematologic toxicity was observed in 62 patients (38.3%), and nonhematologic toxicity in 123 patients (75.9%). The 5-year overall survival (OS) rate was 75.1% and disease-specific survival (DSS) rate was 76.4%. OS without colostomy was achieved in 79,8 % at 5 years, and complete response in 112 patients (69.1%). OS rate was significantly higher in 142 patients with positive response (P < .000) and 112 with complete response (P < .000). Anemia (P < .002), local progression, and systemic progression (P < .000) resulted in lower OS (P < .002). In univariate analysis, factors affecting OS rate were: gender, age, stage, lymph node status, T stage, RT treatment duration, and treatment planning with PET fusion, which were found to be statistically significant. Completing radiotherapy in less than 45 days, concurrent chemotherapy, and continued administration of mitomycin and 5 FU as chemotherapy had a significant positive effect on overall survival. OS rate was higher in patients receiving RT dose of 58 Gy or less and undergoing IMRT planning in radiotherapy. IMRT was associated with lower acute and late side effects. CONCLUSION Radiochemotherapy is the primary treatment for anal canal cancer and advanced radiotherapy techniques may increase survival by reducing side effects and improving treatment continuation. Higher treatment doses require further investigation. The efficacy of treatment can be improved by including patients treated with modern radiotherapy techniques in multicenter prospective studies using new and more effective chemotherapy and immunotherapy agents.
Collapse
Affiliation(s)
- Sule Karabulut Gul
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kirdar Kartal Training and Research Hospital, Istanbul, Turkey.
| | - Huseyin Tepetam
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kirdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Ferah Yildiz
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ilhami Er
- Department of Radiation Oncology, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Didem Colpan Oksuz
- Istanbul University Department of Radiation Oncology, Hospital of Cerrahpasa school of Medicine, Istanbul, Turkey
| | - Murtaza Parvizi
- Department of Radiation Oncology, Manisa State Hospital, Manisa, Turkey
| | - Ayse Sevgi Ozden
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kirdar Kartal Training and Research Hospital, Istanbul, Turkey
| | | | - Sezin Yuce Sari
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Omar Alomari
- Hamidiye International School of Medicine, University of Health Sciences, Istanbul, Turkey
| | - Ilknur Bilkay Gorken
- Department of Radiation Oncology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| |
Collapse
|
3
|
Lin D, Alam MBE, Jaoude JA, Kouzy R, Phan JL, Elnaggar JH, Resendiz B, Medrano AYD, Lynn EJ, Nguyen ND, Noticewala SS, Mathew GG, Holliday EB, Minsky BD, Das P, Morris VK, Eng C, Mezzari MP, Petrosino JF, Ajami NJ, Klopp AH, Taniguchi CM, Colbert LE. Microbiome Dynamics During Chemoradiotherapy for Anal Cancer. Int J Radiat Oncol Biol Phys 2022; 113:974-984. [DOI: 10.1016/j.ijrobp.2022.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
|
4
|
Shah NK, Qureshi MM, Dyer MA, Truong MT, Mak KS. Optimal Radiotherapy Dose in Anal Cancer: Trends in Prescription Dose and Association with Survival. J Gastrointest Cancer 2021; 52:229-236. [PMID: 32152823 DOI: 10.1007/s12029-020-00393-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Definitive chemoradiotherapy represents a standard of care treatment for localized anal cancer. National Comprehensive Cancer Network guidelines recommend radiotherapy (RT) doses of ≥ 45 Gy and escalation to 50.4-59 Gy for advanced disease. Per RTOG 0529, 50.4 Gy was prescribed for early-stage disease (cT1-2N0), and 54 Gy for locally advanced cancers (cT3-T4 and/or node positive). We assessed patterns of care and overall survival (OS) with respect to the RT dose. METHODS The National Cancer Database identified patients with non-metastatic anal squamous cell carcinoma from 2004 to 2015 treated with chemoradiotherapy. Patients were stratified by RT dose: 40-< 45, 45-< 50, 50-54, and > 54-60 Gy. Crude and adjusted hazard ratios (HR) were computed using Cox regression modeling. RESULTS A total of 10,524 patients were identified with a median follow-up of 40.7 months. The most commonly prescribed RT dose was 54 Gy. On multivariate analysis, RT doses of 40-< 45 Gy were associated with worse OS vs. 50-54 Gy (HR 1.68 [1.40-2.03], P < 0.0001). There was no significant difference in OS for patients who received 45-< 50 or > 54-60 Gy compared with 50-54 Gy. For early-stage disease, there was no significant association between RT dose and OS. For locally advanced disease, 45-< 54 Gy was associated with worse survival vs. 54 Gy (HR 1.18 [1.04-1.34], P = 0.009), but no significant difference was detected comparing > 54-60 Gy vs. 54 Gy (HR 1.08 [0.97-1.22], P = 0.166). CONCLUSIONS For patients with localized anal cancer, RT doses of ≥ 45 Gy were associated with improved OS. For locally advanced disease, 54 Gy but not > 54 Gy was associated with improved OS.
Collapse
Affiliation(s)
- Nishant K Shah
- Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA
- University of Pennsylvania Radiation Oncology Residency Program, 3400 Civic Center Boulevard, Concourse Level, Philadelphia, PA, 19104, USA
| | - Muhammad M Qureshi
- Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA
- Department of Radiation Oncology, Boston Medical Center, 830 Harrison Ave, Moakley Building LL 237, Boston, MA, 02118, USA
| | - Michael A Dyer
- Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA
- Department of Radiation Oncology, Boston Medical Center, 830 Harrison Ave, Moakley Building LL 237, Boston, MA, 02118, USA
| | - Minh Tam Truong
- Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA
- Department of Radiation Oncology, Boston Medical Center, 830 Harrison Ave, Moakley Building LL 237, Boston, MA, 02118, USA
| | - Kimberley S Mak
- Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA.
- Department of Radiation Oncology, Boston Medical Center, 830 Harrison Ave, Moakley Building LL 237, Boston, MA, 02118, USA.
| |
Collapse
|
5
|
Dee EC, Byrne JD, Wo JY. Evolution of the Role of Radiotherapy for Anal Cancer. Cancers (Basel) 2021; 13:1208. [PMID: 33801992 PMCID: PMC8001637 DOI: 10.3390/cancers13061208] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/05/2021] [Accepted: 03/06/2021] [Indexed: 12/11/2022] Open
Abstract
Prior to the 1980s, the primary management of localized anal cancer was surgical resection. Dr. Norman Nigro and colleagues introduced neoadjuvant chemoradiotherapy prior to abdominoperineal resection. Chemoradiotherapy 5-fluorouracil and mitomycin C afforded patients complete pathologic response and obviated the need for upfront surgery. More recent studies have attempted to alter or exclude chemotherapy used in the Nigro regimen to mitigate toxicity, often with worse outcomes. Reductions in acute adverse effects have been associated with marked advancements in radiotherapy delivery using intensity-modulated radiation therapy (IMRT) and image-guidance radiation delivery, resulting in increased tolerance to greater radiation doses. Ongoing trials are attempting to improve IMRT-based treatment of locally advanced disease with efforts to increase personalized treatment. Studies are also examining the role of newer treatment modalities such as proton therapy in treating anal cancer. Here we review the evolution of radiotherapy for anal cancer and describe recent advances. We also elaborate on radiotherapy's role in locally persistent or recurrent anal cancer.
Collapse
Affiliation(s)
| | - James D. Byrne
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA 02115, USA;
| | - Jennifer Y. Wo
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA;
- Department of Radiation Oncology, Massachusetts General Hospital, 100 Blossom St., Boston, MA 02114, USA
| |
Collapse
|
6
|
Kouzy R, Abi Jaoude J, Lin D, El Alam MB, Minsky BD, Koay EJ, Das P, Holliday EB, Klopp AH, Colbert LE, Taniguchi CM. Patient-Reported GI Outcomes in Patients With Anal Cancer Receiving Modern Chemoradiation. JCO Oncol Pract 2020; 16:e1524-e1531. [PMID: 32609585 DOI: 10.1200/op.20.00122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Among patients with anal cancer, chemoradiotherapy is often associated with toxicities that diminish quality of life. We describe the GI-related patient-reported outcomes (PROs) of patients with anal cancer receiving chemoradiotherapy to improve patient-physician communication. METHODS We prospectively followed patients with nonmetastatic squamous cell carcinoma of the anal canal who received definitive chemoradiotherapy. Patients completed the bowel subdomain of the Expanded Prostate Cancer Index Composite (EPIC) questionnaire before treatment and at 4 subsequent timepoints. We used the paired Wilcoxon test to compare EPIC scores at different times. RESULTS The study included 21 patients; median age was 57 years. Most patients (52%) had T2 and either N0 or N1 disease (81%). Most patients (91%) received chemotherapy with cisplatin-fluorouracil and either intensity-modulated radiotherapy or volumetric modulated arc therapy. Compared with the patients' median overall summary score at baseline (66), their median score at 1 week (82) was higher (P = .009), whereas their median score at 5 weeks (54) was lower (P = .025). The patients' median overall summary score at baseline and at 3 months did not differ (P = .919). Three months after radiotherapy, most patients reported minimal adverse effects compared with baseline. CONCLUSION The GI-related PROs of patients with anal cancer tend to fluctuate during radiotherapy but return to baseline by 3 months, at which time most patients report few or no residual adverse effects. We provide a clear timeline of GI acute toxicity using sequential PRO measurements that will improve patient-physician communication regarding expectations for cancer treatment.
Collapse
Affiliation(s)
- Ramez Kouzy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joseph Abi Jaoude
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Molly B El Alam
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Emma B Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lauren E Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cullen M Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
7
|
Ladbury C, A Goodman K, Schefter TE, Olsen JR. Anal Cancer in the Era of Dose Painted Intensity Modulated Radiation Therapy: Implications for Regional Nodal Therapy. Semin Radiat Oncol 2019; 29:137-143. [PMID: 30827451 DOI: 10.1016/j.semradonc.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Since the initial development of 5-fluorouracil and mitomycin as a standard of care platform for definitive anal cancer chemoradiotherapy, multiple studies have evaluated the optimal chemotherapy regimen, and radiotherapy technique. Refinements in treatment technique have taken place during an era of improved diagnostic imaging, including incorporation of FDG-PET, with implications for a possible stage migration effect. This has introduced an opportunity to develop stage-specific recommendations for primary tumor, involved nodal, and elective nodal irradiation dose. Elective nodal irradiation remains standard given the low rates of elective nodal failure with current practice, although may be subject to evolving controversy for patients with early stage disease. In this review, development of the current standard of care for anal cancer chemoradiotherapy is reviewed in the context of modern staging and dose-painted radiotherapy treatment techniques.
Collapse
Affiliation(s)
- Colton Ladbury
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Karyn A Goodman
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Tracey E Schefter
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Jeffrey R Olsen
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO.
| |
Collapse
|
8
|
Pan YB, Maeda Y, Wilson A, Glynne-Jones R, Vaizey CJ. Late gastrointestinal toxicity after radiotherapy for anal cancer: a systematic literature review. Acta Oncol 2018; 57:1427-1437. [PMID: 30264638 DOI: 10.1080/0284186x.2018.1503713] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
Collapse
Affiliation(s)
- Yi Bin Pan
- Sir Alan Parks Physiology Unit, St. Mark’s Hospital, Harrow, UK
- Longhua Hospital, Shanghai University of TCM, Shanghai, China
| | - Yasuko Maeda
- Sir Alan Parks Physiology Unit, St. Mark’s Hospital, Harrow, UK
- Imperial College London, London, UK
| | - Ana Wilson
- Imperial College London, London, UK
- Wolfson Unit of Endoscopy, St. Mark’s Hospital, Harrow, UK
| | | | | |
Collapse
|
9
|
The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Anal Squamous Cell Cancers (Revised 2018). Dis Colon Rectum 2018; 61:755-774. [PMID: 29878949 DOI: 10.1097/dcr.0000000000001114] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
10
|
De Bari B, Jumeau R, Bouchaab H, Vallet V, Matzinger O, Troussier I, Mirimanoff RO, Wagner AD, Hanhloser D, Bourhis J, Ozsahin EM. Efficacy and safety of helical tomotherapy with daily image guidance in anal canal cancer patients. Acta Oncol 2016; 55:767-73. [PMID: 27034083 DOI: 10.3109/0284186x.2015.1120886] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and purpose Intensity-modulated radiotherapy (IMRT), also using volumetric modulated arc therapy (VMAT) and helical tomotherapy (HT) techniques, has been only recently introduced for treating anal cancer patients. We report efficacy and safety HT, and daily image-guided RT (IGRT) for anal cancer. Materials and methods We retrospectively analyzed efficacy and toxicity of HT with or without chemotherapy for anal cancer patients. Local control (LC) and grade 3 or more toxicity rate (CTC-AE v.4.0) were the primary endpoints. Overall (OS), disease-free (DFS), and colostomy-free survival (CFS) are also reported. Results Between October 2007 and May 2014, 78 patients were treated. Fifty patients presented a stage II or stage IIIA (UICC 2002), and 33 presented a N1-3 disease. Radiotherapy consisted of 36 Gy (1.8 Gy/fraction) delivered on the pelvis and on the anal canal, with a sequential boost up to 59.4 Gy (1.8 Gy/fraction) delivered to the anal and to nodal gross tumor volumes. Concomitant chemotherapy was delivered in 73 patients, mainly using mitomycin C and 5-fluorouracil (n = 30) or mitomycin C and capecitabine combination (n = 37). After a median follow-up period of 47 months (range 3-75), the five-year LC rate was 83.8% (95% CI 76.2-91.4%). Seven patients underwent a colostomy because of local recurrence (n = 5) or pretreatment dysfunction (n = 2). Overall incidence of grade 3 acute toxicity was 24%, mainly as erythema (n = 15/19) or diarrhea (n = 7/19). Two patients presented a late grade 3 gastrointestinal toxicity (anal incontinence). No grade 4 acute or late toxicity was recorded. Conclusions HT with daily IGRT is efficacious and safe in the treatment of anal canal cancer patients, and is considered in our department standard of care in this clinical setting.
Collapse
Affiliation(s)
- Berardino De Bari
- Radiation Oncology Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Raphael Jumeau
- Radiation Oncology Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Hasna Bouchaab
- Medical Oncology Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Véronique Vallet
- Medical Physics, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Oscar Matzinger
- Radiation Oncology Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Idriss Troussier
- Radiation Oncology Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - René-Olivier Mirimanoff
- Radiation Oncology Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Anna Dorothea Wagner
- Medical Oncology Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Dieter Hanhloser
- Surgery Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Jean Bourhis
- Radiation Oncology Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Esat Mahmut Ozsahin
- Radiation Oncology Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| |
Collapse
|
11
|
Abstract
Chemoradiotherapy is the standard-of-care treatment of squamous-cell carcinoma of the anus (SCCA), and this has not changed in decades. Radiation doses of 50-60 Gy, as used in many phase III trials, result in substantial late morbidities and fail to control larger and node-positive tumours. Technological advances in radiation therapy are improving patient outcomes and quality of life, and should be applied to patients with SCCA. Modern techniques such as intensity-modulated radiotherapy (IMRT), rotational IMRT, image-guided radiotherapy using cone-beam CT, and stereotactic techniques have enabled smaller margins and highly conformal plans, resulting in decreased radiation doses to the organs at risk and ensuring a shorter overall treatment time. In this Perspectives article, the use of novel approaches to target delineation, optimized radiotherapy techniques, adaptive radiotherapy, dose-escalation with external-beam radiotherapy (EBRT) or brachytherapy, and the potential for modified fractionation are discussed in the context of SCCA.
Collapse
|
12
|
Lower Gastrointestinal Brachytherapy: Anus. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
13
|
Muirhead R, Partridge M, Hawkins MA. A tumor control probability model for anal squamous cell carcinoma. Radiother Oncol 2015; 116:192-6. [PMID: 26243680 DOI: 10.1016/j.radonc.2015.07.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 06/18/2015] [Accepted: 07/16/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE A recent update of the RTOG 9811, reported differing relapse rates for early and late anal squamous cell carcinoma following chemoradiotherapy (CRT). There may be a role for dose-individualization, however the dose-response relationship for anal cancer is not currently known. Intensity-modulated radiotherapy (IMRT) has been widely adopted with multiple series published. The aim is to fit a tumor control probability (TCP) model to the published IMRT data. MATERIALS AND METHODS We performed a systematic review of PubMed and Embase databases to identify thirteen appropriate papers, including 625 patients. Predefined data fields were collected. A standard linear quadratic TCP model, which included repopulation, was fit by least squares minimization. RESULTS The fitted TCP curve demonstrated a dose-response relationship with α=0.196 Gy(-1). The curve suggests: in early stage tumours, a dose reduction from 50 Gy to 45 Gy reduces 2 year local control from 98% to 95%; in late stage tumours, a dose escalation from 50 Gy to 55 Gy improves the 2 year local control rate from approximately 50% to 80%. CONCLUSIONS The published data are broadly consistent with a linear quadratic dose-response model. Dose-individualization in anal cancer should be further investigated in the context of clinical trials.
Collapse
Affiliation(s)
- Rebecca Muirhead
- Department of Oncology, CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, United Kingdom.
| | - Mike Partridge
- Department of Oncology, CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, United Kingdom
| | - Maria A Hawkins
- Department of Oncology, CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, United Kingdom
| |
Collapse
|
14
|
Shridhar R, Shibata D, Chan E, Thomas CR. Anal cancer: current standards in care and recent changes in practice. CA Cancer J Clin 2015; 65:139-62. [PMID: 25582527 DOI: 10.3322/caac.21259] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Ravi Shridhar
- Associate Professor, Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
| | | | | | | |
Collapse
|
15
|
Squamous Cell Carcinoma of the Anal Canal. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
16
|
Scher ED, Ahmed I, Yue NJ, Jabbour SK. Technical aspects of radiation therapy for anal cancer. J Gastrointest Oncol 2014; 5:198-211. [PMID: 24982768 DOI: 10.3978/j.issn.2078-6891.2014.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/22/2014] [Indexed: 01/26/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Eli D Scher
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| | - Inaya Ahmed
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| | - Ning J Yue
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| | - Salma K Jabbour
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| |
Collapse
|
17
|
Abstract
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.
Collapse
|
18
|
De Bari B, Buglione M, Maddalo M, Lestrade L, Spiazzi L, Vitali P, Barbera F, Magrini SM. External beam radiotherapy ± chemotherapy in the treatment of anal canal cancer: a single-institute long-term experience on 100 patients. Cancer Invest 2014; 32:248-55. [PMID: 24766302 DOI: 10.3109/07357907.2014.907420] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
One-hundred patients treated with curative radiotherapy (RT) ± chemotherapy (CT) for an anal canal carcinoma (T1-4N0-3M0) were retrospectively analyzed. Five- and 10-year local control (LC) rates were 73% and 67%, respectively. Acute and late G3-G4 toxicity rates were 32% and 12%, respectively. Two patients underwent a colostomy for a G4 anal toxicity. This study confirms the outcomes of RT ± CT in the treatment of anal canal cancer. Concomitant CT and LC statistically influenced Overall Survival and Colostomy-Free Survival. CT also statistically reduced the risk of nodal relapse. High rates of acute skin toxicity impose tailored volumes and techniques of irradiation.
Collapse
Affiliation(s)
- Berardino De Bari
- 1Department of Radiation Oncology, Istituto del Radio, Spedali Civili di Brescia - University of Brescia , Brescia , Italy
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Role of brachytherapy in the treatment of cancers of the anal canal. Strahlenther Onkol 2014; 190:546-54. [DOI: 10.1007/s00066-014-0628-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
|
20
|
Zilli T, Betz M, Bieri S, Ris F, Roche B, Roth AD, Allal AS. Elective inguinal node irradiation in early-stage T2N0 anal cancer: prognostic impact on locoregional control. Int J Radiat Oncol Biol Phys 2013; 87:60-6. [PMID: 23608237 DOI: 10.1016/j.ijrobp.2013.03.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 03/04/2013] [Accepted: 03/06/2013] [Indexed: 11/19/2022]
Abstract
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.
Collapse
Affiliation(s)
- Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.
| | | | | | | | | | | | | |
Collapse
|
21
|
Abstract
Anal cancer accounts for only 1.5% of gastrointestinal malignancies but this disease has shown a steady increase in incidence particularly in HIV positive males. The understanding of pathophysiology and treatment of anal cancer has changed radically over last thirty years. Risk factors have been identified and organ preservation by chemoradiotherapy has become a standard. This article aims to review the clinical presentation, diagnostic evaluation, and treatment options for anal cancer in the light of current literature.
Collapse
Affiliation(s)
- Sajad Ahmad Salati
- Department of Surgery, College of Medicine, Qassim University, Qassim, Kingdom of Saudi Arabia
| | | |
Collapse
|
22
|
Abstract
PURPOSE The aim of this study was to evaluate long-term oncologic outcomes after concurrent chemoradiation treatment for anal cancer. MATERIALS AND METHODS Between January 1979 and December 2008, the records of 50 consecutive patients with anal cancer and who were treated by chemoradiation or radiation only with a curative intent were retrospectively reviewed. The oncologic outcomes and the risk factors for recurrence were analyzed. RESULTS Of the 50 patients, 49 underwent concurrent chemoradiation and one underwent radiation only. After these definitive treatments, 43 (86.0%) achieved a clinical complete response. During the median follow-up of 60 months (range: 2-202 months), the 5-year overall survival, disease-free survival, and locoregional recurrence-free survival were 84.2%, 72.7%, and 69.9%, respectively. Multivariate analysis revealed that the performance status (p=0.031) and a clinical complete response (p=0.039) were the independent predictors for overall survival; lymph node involvement (p=0.031) was the only independent predictor for disease-free survival. CONCLUSION The performance status and a clinical complete response may be reliable predictors of survival after chemoradiation for anal cancer. The addition of irradiation to the inguinal area may not be significantly associated with the outcomes.
Collapse
Affiliation(s)
- Hun Jin Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Korea
| | - Jung Wook Huh
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Korea
| | - Chang Hyun Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Korea
| | - Sang Woo Lim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Korea
| | - Hyeong Rok Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Korea
| | - Young Jin Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Korea
| |
Collapse
|
23
|
Abstract
Anal canal cancer is a rare cancer with incidence that continues to rise. This has been in large part due to increased prevalence of immunosuppressed conditions such as organ transplantation and human immunodeficiency virus along with transmission of the human papillomavirus. Identification of high-risk groups and close monitoring of these groups can help to detect earlier stages of cancer. Chemoradiation therapy remains the mainstay of treatment with excellent outcomes. Surgery for anal canal carcinoma remains as a salvage technique for failed chemoradiation or recurrent disease.
Collapse
Affiliation(s)
- Shawn P Webb
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
| | | |
Collapse
|
24
|
Oblak I, Petric P, Anderluh F, Velenik V, Fras PA. Long term outcome after combined modality treatment for anal cancer. Radiol Oncol 2012; 46:145-52. [PMID: 23077451 PMCID: PMC3472931 DOI: 10.2478/v10019-012-0022-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 01/25/2012] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The aim of the retrospective study was to evaluate the effectiveness and toxicity of radiochemotherapy in patients with squamous cell carcinoma of the anal canal treated at a single institution. PATIENTS AND METHODS Between 1/2003 and 9/2010, 84 patients were treated with radical radiochemotherapy at the Institute of Oncology Ljubljana, Slovenia. The treatment consisted of 3-dimensional conformal external beam radiotherapy with concurrent chemotherapy (5-fluorouracil and mytomycin C), followed by brachytherapy or external beam boost. The toxicity of therapy and its effectiveness were assessed. RESULTS The treatment was completed according to the protocol in 79.8% of patients. The median follow-up time of 55 survivors was 53 months (range: 16-105 months). The 5-year locoregional control (LRC), disease-free survival (DFS), disease-specific survival (DSS), overall survival (OS) and colostomy-free survival (CFS) rates were 71%, 68%, 81%, 67% and 85%, respectively. No treatment-related mortality was observed. The most frequent acute side-effect of the treatment was radiodermatitis (grade 3-4 in 58.2% of patients). LENT-SOMA grade 3-4 late radiation side effects were observed in 15 (18%) patients. In patients with brachytherapy boost a trend of less late side effects was observed compared to patients with external beam boost (P=0.066). On multivariate analysis, complete clinical disease response was identified as an independent prognostic factor for LRC, DFS and DSS, the salvage surgery for LRC and DFS, whereas Hb below 120 g/l retained its independent prognostic value for OS. CONCLUSIONS Radiochemotherapy provides an excellent disease control and the survival with preserving anal sphincter function in majority of patients. Surgical salvage with abdominoperineal resection for persistent or recurrent disease has curative potential.
Collapse
Affiliation(s)
- Irena Oblak
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Primoz Petric
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Franc Anderluh
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Vaneja Velenik
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Peter Albert Fras
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
25
|
Twenty-year experience in the management of squamous cell anal canal carcinoma with interstitial brachytherapy. Clin Transl Oncol 2011; 13:472-9. [PMID: 21775274 DOI: 10.1007/s12094-011-0684-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The aim of this study was to retrospectively evaluate clinical characteristics, local control, acute and late toxicity, and prognostic factors of patients with anal canal carcinoma treated with brachytherapy. METHODS From 1989 to 2009, 38 patients were treated with iridium 192 low-dose-rate (N = 26) or pulsed-dose-rate (N = 12) interstitial brachytherapy at a single institution. The median age was 62 years (range, 38-86 years). The TNM classification was as follows: 10 T1, 22 T2, 5 T3 and 1 T4; 32 N0, 3 N1 and 3 N2. Most patients (32/38) received either a first course of radiochemotherapy (N = 22) or radiotherapy alone (N=10) consisting of a total delivered dose of 45 Gy to the pelvis (range, 32-50) followed by a boost a median of 18 days later of 15-35 Gy (median 20 Gy) to the anal canal. The remaining 6 cases were treated with brachytherapy alone (dose range, 60-65 Gy). RESULTS With a median follow-up of 30 months (range, 4-200), 2- and 5-year local control rates were 91% and 87%, respectively. Preservation of the anal sphincter was achieved in 32 patients (84%). Three patients experienced incontinence after brachytherapy. Only 2 patients showed chronic mucositis grade 3/4. Age proved to be a statistically significant prognostic factor for overall survival in the univariate (p = 0.033) and multivariate analyses (p = 0.018). Concurrent chemotherapy with external beam radiotherapy was a statistically significant prognostic factor for disease-free survival in the univariate and multivariate analyses (p = 0.007 and p = 0.044, respectively). CONCLUSIONS Interstitial brachytherapy appears to be an effective and well tolerated treatment for anal carcinoma offering both high local tumour control and anal sphincter preservation.
Collapse
|
26
|
Lim F, Glynne-Jones R. Chemotherapy/chemoradiation in anal cancer: A systematic review. Cancer Treat Rev 2011; 37:520-32. [DOI: 10.1016/j.ctrv.2011.02.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 02/07/2011] [Accepted: 02/27/2011] [Indexed: 12/27/2022]
|
27
|
Bannas P, Weber C, Adam G, Frenzel T, Derlin T, Mester J, Klutmann S. Contrast-Enhanced [18F]fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography for Staging and Radiotherapy Planning in Patients With Anal Cancer. Int J Radiat Oncol Biol Phys 2011; 81:445-51. [DOI: 10.1016/j.ijrobp.2010.05.050] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Revised: 05/10/2010] [Accepted: 05/21/2010] [Indexed: 11/30/2022]
|
28
|
Ortholan C, Resbeut M, Hannoun-Levi JM, Teissier E, Gerard JP, Ronchin P, Zaccariotto A, Minsat M, Benezery K, François E, Salem N, Ellis S, Azria D, Champetier C, Gross E, Cowen D. Anal canal cancer: management of inguinal nodes and benefit of prophylactic inguinal irradiation (CORS-03 Study). Int J Radiat Oncol Biol Phys 2011; 82:1988-95. [PMID: 21570207 DOI: 10.1016/j.ijrobp.2011.02.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Revised: 01/16/2011] [Accepted: 02/09/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the benefit of prophylactic inguinal irradiation (PII) in anal canal squamous cell carcinoma (ASCC). METHODS AND MATERIALS This retrospective study analyzed the outcome of 208 patients presenting with ASCC treated between 2000 and 2004 in four cancer centers of the south of France. RESULTS The population study included 35 T1, 86 T2, 59 T3, 20 T4, and 8 T stage unknown patients. Twenty-seven patients presented with macroscopic inguinal node involvement. Of the 181 patients with uninvolved nodes at presentation, 75 received a PII to a total dose of 45-50 Gy (PII group) and 106 did not receive PII (no PII group). Compared with the no PII group, patients in the PII group were younger (60% vs. 41% of patients age <68 years, p = 0.01) and had larger tumor (T3-4 = 46% vs. 27% p = 0.01). The other characteristics were well balanced between the two groups. Median follow-up was 61 months. Fourteen patients in the no PII group vs. 1 patient in the PII group developed inguinal recurrence. The 5-year cumulative rate of inguinal recurrence (CRIR) was 2% and 16% in PII and no PII group respectively (p = 0.006). In the no PII group, the 5-year CRIR was 12% and 30% for T1-T2 and T3-T4 respectively (p = 0.02). Overall survival, disease-specific survival, and disease-free survival were similar between the two groups. In the PII group, no Grade >2 toxicity of the lower extremity was observed. CONCLUSION PII with a dose of 45 Gy is safe and highly efficient to prevent inguinal recurrence and should be recommended for all T3-4 tumors. For early-stage tumors, PII should also be discussed, because the 5-year inguinal recurrence risk remains substantial when omitting PII (about 10%).
Collapse
Affiliation(s)
- Cécile Ortholan
- Department of Radiation Therapy, Antoine Lacassagne Cancer Center, Nice, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
El-Haddad M, Ahmed RS, Al-Suhaibany A, Al-Hazza M, Al-Sanae N, Al-Jabbar AA, Hamoud S, Ashaary L, Bazerbashy S, Balaraj K. Anal canal carcinoma treatment results: the experience of a single institution. Ann Saudi Med 2011; 31:158-62. [PMID: 21403412 PMCID: PMC3102475 DOI: 10.4103/0256-4947.77488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Prior to the mid-1980s, the treatment of choice for anal cancer was abdominoperineal resection. Currently, combined chemoradiation is the standard of care. Or objective was to analyze results of treatment for anal canal carcinoma treated with combined chemoradiation. DESIGN AND SETTING Retrospective review of data in local cancer registry at King Faisal Specialist Hospital and Research Centre (KFSHRC) from a 12-year period (1993 to 2005). METHODS We identified patients with confirmed diagnosis of anal canal squamous cell carcinoma. RESULTS Of 40 patients identified, 33 were considered eligible for our analysis. All patients were treated by concurrent chemoradiation with mandatory treatment break (MTB) There were 10 (30%) local recurrences. Five-year progression-free survival (PFS) was 50.9%; overall survival (OS) at 5 years was 73.4%. Patients with stage II disease had a median PFS period of 10 years, with no relapses until their last follow-up. There was no statistically significant difference in PFS between patients with stage IIIA disease and those with stage IIIB disease-44.7% and 45%, respectively (P=.8). Five-year PFS according to 'T' stages was as follows: T1, 66%; T2, 71%; T3, 59%; T4, 30% (P>.05). The 5-year colostomy-free survival (CFS) for all patients was 74%. Distant metastases were observed in 4 patients. CONCLUSION Combined chemoradiation in treatment of anal cancer is effective in terms of local control and sphincter preservation. Five-year estimates of PFS, OS, as well as CFS, in patients treated with a MTB were surprisingly comparable to those determined in most non-MTB series. However, we reported a higher local failure rate, for which we are reevaluating our treatment protocol.
Collapse
Affiliation(s)
- Mostafa El-Haddad
- Department of Radiation Oncology, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
| | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Welzel G, Hägele V, Wenz F, Mai SK. Quality of life outcomes in patients with anal cancer after combined radiochemotherapy. Strahlenther Onkol 2011; 187:175-82. [PMID: 21347639 DOI: 10.1007/s00066-010-2175-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Accepted: 12/01/2010] [Indexed: 01/04/2023]
Abstract
PURPOSE To assess self-reported quality of life (QoL) experienced by anal cancer patients after radiochemotherapy, and to identify patient- and disease-related factors associated with QoL. PATIENTS AND METHODS A total of 88 patients treated for anal cancer at our institution between 1990 and 2006 were identified from our database. Of these, 15 patients had died, and 4 were lost to follow-up. QoL was assessed using the EORTC QLQ-C30 questionnaire (cancer-specific QoL) and the colorectal cancer module QLQ-CR38 (site-specific QoL); 52 responses were received. The median follow-up was 36 months (range, 5-137 months). RESULTS As for cancer-specific QoL, global health QoL score (mean 60.4) was similar to the general German population, whereas most of the function and symptom scale scores were considerably lower/higher in anal cancer patients. The most prominent mean score differences were observed in role functioning (-21.8 points), emotional functioning (-20.7 points), social functioning (-28.9 points), diarrhea (+34.6 points), and financial difficulties (+26.9 points; p < 0.001). As for site-specific QoL, the mean function scale scores ranged from 22.1 (sexual function) to 63.2 (body image), and the mean symptom scale scores from 14.7 (weight loss) to 69.0 (stoma-related problems, 4 patients) and 67.9 (male sexual dysfunction), respectively. Most of the QoL scores were not affected by late toxicity, patient- or disease-related factors. Fatigue (+18.2 points) emerged as the strongest predictor of impaired QoL. CONCLUSION The global health QoL of anal cancer patients is comparable with that of the general German population, but there are specific limitations, e.g., sexual dysfunction, urological/gastrointestinal complaints, financial difficulties, fatigue, and a reduction in emotional and social well-being.
Collapse
Affiliation(s)
- Grit Welzel
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Germany.
| | | | | | | |
Collapse
|
31
|
Moureau-Zabotto L, Viret F, Giovaninni M, Lelong B, Bories E, Delpero J, Pesenti C, Caillol F, de Chaisemartin C, Minsat M, Monges G, Sarran A, Resbeut M. Is neoadjuvant chemotherapy prior to radio-chemotherapy beneficial in T4 anal carcinoma? J Surg Oncol 2011; 104:66-71. [DOI: 10.1002/jso.21866] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 12/21/2010] [Indexed: 01/09/2023]
|
32
|
Hannoun-Levi JM, Ortholan C, Resbeut M, Teissier E, Ronchin P, Cowen D, Zaccariotto A, Bénézery K, François E, Salem N, Ellis S, Azria D, Gerard JP. High-dose split-course radiation therapy for anal cancer: outcome analysis regarding the boost strategy (CORS-03 study). Int J Radiat Oncol Biol Phys 2010; 80:712-20. [PMID: 20619552 DOI: 10.1016/j.ijrobp.2010.02.055] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 01/22/2010] [Accepted: 02/17/2010] [Indexed: 12/17/2022]
Abstract
PURPOSE To retrospectively assess the clinical outcome in anal cancer patients treated with split-course radiation therapy and boosted through external-beam radiation therapy (EBRT) or brachytherapy (BCT). METHODS AND MATERIALS From January 2000 to December 2004, a selected group (162 patients) with invasive nonmetastatic anal squamous cell carcinoma was studied. Tumor staging reported was T1 = 31 patients (19%), T2 = 77 patients (48%), T3 = 42 patients (26%), and T4= 12 patients (7%). Lymph node status was N0-1 (86%) and N2-3 (14%). Patients underwent a first course of EBRT: mean dose 45.1 Gy (range, 39.5-50) followed by a boost: mean dose 17.9 Gy (range, 8-25) using EBRT (76 patients, 47%) or BCT (86 patients, 53%). All characteristics of patients and tumors were well balanced between the BCT and EBRT groups. RESULTS The mean overall treatment time (OTT) was 82 days (range, 45-143) and 67 days (range, 37-128) for the EBRT and BCT groups, respectively (p < 0.001). The median follow-up was 62 months (range, 2-108). The 5-year cumulative rate of local recurrence (CRLR) was 21%. In the univariate analysis, the prognostic factors for CRLR were as follows: T stage (T1-2 = 15% vs. T3-4 = 36%, p = 0.03), boost technique (BCT = 12% vs. EBRT = 33%, p = 0.002) and OTT (OTT <80 days = 14%, OTT ≥80 days = 34%, p = 0.005). In the multivariate analysis, BCT boost was the unique prognostic factor (hazard ratio = 0.62 (0.41-0.92). In the subgroup of patients with OTT <80 days, the 5-year CRLR was significantly increased with the BCT boost (BC = 9% vs. EBRT = 28%, p = 0.03). In the case of OTT ≥80 days, the 5-year CRLR was not affected by the boost technique (BCT = 29% vs. EBRT = 38%, p = 0.21). CONCLUSION In anal cancer, when OTT is <80 days, BCT boost is superior to EBRT boost for CRLR. These results suggest investigating the benefit of BCT boost in prospective trials.
Collapse
|
33
|
Engineer R, Mallik S, Mahantshetty U, Shrivastava S. Impact of radiation dose on locoregional control and survival on squamous cell carcinoma of anal canal. Radiother Oncol 2010; 95:283-7. [DOI: 10.1016/j.radonc.2010.04.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 04/06/2010] [Accepted: 04/06/2010] [Indexed: 11/17/2022]
|
34
|
Oehler C, Provencher S, Donath D, Bahary JP, Lütolf UM, Ciernik IF. Chemo-radiation with or without mandatory split in anal carcinoma: experiences of two institutions and review of the literature. Radiat Oncol 2010; 5:36. [PMID: 20465811 PMCID: PMC2879246 DOI: 10.1186/1748-717x-5-36] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Accepted: 05/13/2010] [Indexed: 11/21/2022] Open
Abstract
Background The split-course schedule of chemo-radiation for anal cancer is controversial. Methods Eighty-four patients with invasive anal cancer treated with definitive external beam radiotherapy (RT) with a mandatory split of 12 days (52 patients, Montreal, Canada) or without an intended split (32 patients, Zurich, Switzerland) were reviewed. Total RT doses were 52 Gy (Montreal) or 59.4 Gy (Zurich) given concurrently with 5-FU/MMC. Results After a mean follow-up of 40 ± 27 months, overall survival and local tumor control at 5 years were 57% and 78% (Zurich) compared to 67% and 82% (Montreal), respectively. Split duration of patients with or without local relapse was 15 ± 7 d vs. 14 ± 7 d (Montreal, NS) and 11 ± 11 d vs. 5 ± 7 d (Zurich; P < 0.001). Patients from Zurich with prolonged treatment interruption (≥ 7 d) had impaired cancer-specific survival compared with patients with only minor interruption (<7 d) (P = 0.06). Bowel toxicity was associated with prolonged RT (P = 0.03) duration as well as increased relapse probability (P = 0.05). Skin toxicity correlated with institution and was found in 79% (Montreal) and 28% (Zurich) (P < 0.0001). Conclusions The study design did not allow demonstrating a clear difference in efficacy between the treatment regimens with or without short mandatory split. Cause-specific outcome appears to be impaired by unplanned prolonged interruption.
Collapse
Affiliation(s)
- Christoph Oehler
- Department of Radiation Oncology, Zurich University Hospital, Zurich, Switzerland.
| | | | | | | | | | | |
Collapse
|
35
|
Ulrich S, Sterzing F, Nill S, Schubert K, Herfarth KK, Debus J, Oelfke U. Comparison of arc-modulated cone beam therapy and helical tomotherapy for three different types of cancer. Med Phys 2009; 36:4702-10. [DOI: 10.1118/1.3223633] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
|
36
|
Bui T, Harvey J, Brown E, Scott M, Haines T, Davidson K. Conformal external beam radiotherapy in the treatment of anal canal carcinoma: A retrospective study of a genital organ sparing technique. J Med Imaging Radiat Oncol 2009; 53:396-404. [DOI: 10.1111/j.1754-9485.2009.02083.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
37
|
Can the Radiation Dose to CT-Enlarged but FDG-PET-Negative Inguinal Lymph Nodes in Anal Cancer Be Reduced? Strahlenther Onkol 2009; 185:254-9. [DOI: 10.1007/s00066-009-1944-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Accepted: 11/07/2008] [Indexed: 11/26/2022]
|
38
|
Radiation dose associated with local control in advanced anal cancer: retrospective analysis of 129 patients. Radiother Oncol 2008; 87:367-75. [PMID: 18501453 DOI: 10.1016/j.radonc.2008.05.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2008] [Revised: 04/04/2008] [Accepted: 05/01/2008] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE To retrospectively analyse a large consecutive cohort of patients with anal cancer for treatment-related factors influencing local control and survival. MATERIALS AND METHODS All patients referred for primary radiotherapy at Medical University of Vienna in 1990-2002 with anal canal carcinoma without distant metastases were analysed. Treatment consisted of external radiotherapy with or without brachytherapy and with or without chemotherapy. Patient-, tumour-, and treatment-factors were tested for influence on survival and local control using Cox multivariate analysis. RESULTS Median age was 67 years (n=129), the UICC stage distribution was 15%, 58%, and 27% for stages I, II, and III, respectively. With median follow-up of 8.0 years for surviving patients (3.9 years including deceased patients), five-year overall survival and disease-free-survival were 57% and 51%, respectively. Local control at 5 years was 87%. Stage and age were significant factors for overall and colostomy-free-survival, N-stage for disease-free-survival. Shorter overall treatment time favoured local control in stage T1-2 (p=.015), higher total radiation dose and female gender were associated with improved local control in T3-4 tumours (p=.021). CONCLUSIONS These results support potential improvement of anal cancer treatment by studying advanced technology such as IMRT, making it possible to tailor high-dose regions.
Collapse
|
39
|
Mai SK, Welzel G, Hermann B, Bohrer M, Wenz F. Long-Term Outcome after Combined Radiochemotherapy for Anal Cancer – Retrospective Analysis of Efficacy, Prognostic Factors, and Toxicity. ACTA ACUST UNITED AC 2008; 31:251-7. [DOI: 10.1159/000121362] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
40
|
Menkarios C, Azria D, Laliberté B, Moscardo CL, Gourgou S, Lemanski C, Dubois JB, Aillères N, Fenoglietto P. Optimal organ-sparing intensity-modulated radiation therapy (IMRT) regimen for the treatment of locally advanced anal canal carcinoma: a comparison of conventional and IMRT plans. Radiat Oncol 2007; 2:41. [PMID: 18005443 PMCID: PMC2204019 DOI: 10.1186/1748-717x-2-41] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Accepted: 11/15/2007] [Indexed: 11/10/2022] Open
Abstract
Background To compare the dosimetric advantage of three different intensity-modulated radiation therapy (IMRT) plans to a three dimensional (3D) conventional radiation treatment for anal cancer with regards to organs-at-risk (OAR) avoidance, including iliac bone marrow. Methods Five patients with T1-3 N0-1 anal cancer and five with T4 and/or N2-3 tumors were selected. Clinical tumor volume (CTV) included tumor, anal canal and inguinal, peri-rectal, and internal/external iliac nodes (plus pre-sacral nodes for T4/N2-3 tumors). Four plans were generated: (A) AP/PA with 3D conformal boost, (B) pelvic IMRT with conformal boost (C) pelvic IMRT with IMRT boost and (D) IMRT with simultaneous integrated boost (SIB). The dose for plans (A) to (C) was 45 Gy/25 followed by a 14.4 Gy/8 boost, and the total dose for plan (D) (SIB) was 59.4 Gy/33. Coverage of both PTV and the volume of OAR (small bowel, genitalia, iliac crest and femoral heads) receiving more than 10, 20, 30, and 40 Gy (V10, V20, V30, V40) were compared using non parametric statistics. Results Compared to plan (A), IMRT plans (B) to (D) significantly reduced the V30 and V40 of small bowel, bladder and genitalia for all patients. The V10 and V20 of iliac crests were similar for the N0-1 group but were significantly reduced with IMRT for the N2-3/T4 group (V20 for A = 50.2% compared to B = 33%, C = 32.8%, D = 34.3%). There was no statistical difference between 2-phase (arm C) and single-phase (SIB, arm D) IMRT plans. Conclusion IMRT is superior to 3D conformal radiation treatment for anal carcinoma with respect to OAR sparing, including bone marrow sparing.
Collapse
Affiliation(s)
- Cathy Menkarios
- Département de Radio-Oncologie, Hôpital Maisonneuve-Rosemont, Montréal, Canada.
| | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Hatfield P, Cooper R, Sebag-Montefiore D. Involved-field, low-dose chemoradiotherapy for early-stage anal carcinoma. Int J Radiat Oncol Biol Phys 2007; 70:419-24. [PMID: 17919842 DOI: 10.1016/j.ijrobp.2007.06.072] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Revised: 06/24/2007] [Accepted: 06/26/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE To report the results of patients with early-stage anal cancer treated using a low-dose, reduced-volume, involved-field chemoradiotherapy protocol. METHODS AND MATERIALS Between June 2000 and June 2006, 21 patients were treated with external beam radiotherapy (30 Gy in 15 fractions within 3 weeks) and concurrent chemotherapy (bolus mitomycin-C 12 mg/m(2) on Day 1 to a maximum of 20 mg followed by infusion 5-fluorouracil 1,000 mg/m(2)/24 h on Days 1-4). Of the 21 patients, 18 underwent small-volume, involved-field radiotherapy and 3 were treated with anteroposterior-posteroanterior parallel-opposed pelvic fields. Of the 21 patients, 17 had had lesions that were excised with close (<1 mm) or involved margins, 1 had had microinvasive disease on biopsy, and 3 had had macroscopic tumor <2 cm in diameter (T1). All were considered to have Stage N0 disease radiologically. RESULTS After a median follow-up of 42 months, only 1 patient (4.7%) had experienced local recurrence and has remained disease free after local excision. No distant recurrences or deaths occurred. Only 1 patient could not complete treatment (because of Grade 3 gastrointestinal toxicity). Grade 3-4 hematologic toxicity occurred in only 2 patients (9.5%). No significant late toxicity was identified. CONCLUSION The results of our study have shown that for patients with anal carcinoma who have residual microscopic or very-small-volume disease, a policy of low-dose, reduced-volume, involved-field chemoradiotherapy produces excellent local control and disease-free survival, with low rates of acute and late toxicity.
Collapse
Affiliation(s)
- Paul Hatfield
- Leeds Cancer Centre, Cookridge Hospital, Leeds, West Yorkshire, United Kingdom
| | | | | |
Collapse
|
42
|
Das P, Bhatia S, Eng C, Ajani JA, Skibber JM, Rodriguez-Bigas MA, Chang GJ, Bhosale P, Delclos ME, Krishnan S, Janjan NA, Crane CH. Predictors and patterns of recurrence after definitive chemoradiation for anal cancer. Int J Radiat Oncol Biol Phys 2007; 68:794-800. [PMID: 17379452 DOI: 10.1016/j.ijrobp.2006.12.052] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Revised: 12/20/2006] [Accepted: 12/22/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate patterns of locoregional failure, and predictors of recurrence and survival in patients treated with chemoradiation for anal cancer. METHODS AND MATERIALS Between September 1992 and August 2004, 167 patients with nonmetastatic squamous cell anal carcinoma were treated with definitive chemoradiation. The median dose of radiotherapy was 5500 cGy. Concurrent chemotherapy was given with 5-fluorouracil and cisplatin in 117 patients, 5-fluorouracil and mitomycin C in 24 patients, and other regimens in 26 patients. RESULTS The estimated 3-year rates of locoregional control, distant control, disease-free survival, and overall survival were 81%, 88%, 67%, and 84%, respectively. Multivariate analysis showed that higher T stage and N stage independently predicted for a higher rate of locoregional failure; higher N stage and basaloid subtype independently predicted for a higher rate of distant metastasis; and higher N stage and positive human immunodeficiency virus status independently predicted for a lower rate of overall survival. Among the patients who had locoregional failure, 18 (75%) had failure involving the anus or rectum, 5 (21%) had other pelvic recurrences, and 1 (4%) had inguinal recurrence. The 5 pelvic recurrences all occurred in patients with the superior border of the radiotherapy field at the bottom of the sacroiliac joint. CONCLUSIONS Trials of more aggressive and innovative locoregional and systemic therapies are warranted in high-risk patients, based on their T and N stages. The majority of locoregional failures involve the anus and rectum, whereas inguinal recurrences occur rarely. Placing the superior border of the radiotherapy field at L5/S1 could potentially reduce pelvic recurrences.
Collapse
Affiliation(s)
- Prajnan Das
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Deniaud-Alexandre E, Touboul E, Tiret E, Sezeur A, Hannoun L, Houry S, Huguet F, Pène F, Parc R, Schlienger M. [Epidermoid carcinomas of anal canal treated with radiation therapy and concomitant chemotherapy (5-fluorouracil and cisplatin)]. Cancer Radiother 2006; 10:572-82. [PMID: 17110148 DOI: 10.1016/j.canrad.2006.09.116] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Revised: 08/28/2006] [Accepted: 09/26/2006] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate our results after radiation therapy and concomitant chemotherapy in terms of local control, survival and toxicity in patients with anal cancer. METHODS AND PATIENTS Between November 1990 and January 2002, 60 patients (pts) were treated with radiation therapy and concomitant chemotherapy. The T-stage according to the 2001 UICC classification were: 2 T1, 26 T2, 25 T3, and 7 T4. There were 20 pts with nodal involvement at presentation. The treatment started with external beam RT (median dose: 45 Gy) and concomitant chemotherapy using 5-fluorouracil and cisplatin during the first week and the fifth week of external beam RT (EBRT). After a rest period of 4 to 6 weeks, a boost of 20 Gy was delivered by EBRT in 58 pts and by interstitial (192)Ir brachytherapy in 2 pts. Mean follow-up were 78.5 months. RESULTS At the end of RT with concomitant chemotherapy local tumor clinical complete response rate was 83%. Out of 10 non responders or local progression, 5 (50%) were salvaged with abdominoperineal resection (APR). Out of 5 local tumor relapses, 3 were salvaged with APR. The overall local tumor control (LC) rate with or without salvage local treatment were 88%. LC rate with a good anal function scoring (score 0 and 1) was 70%. Among 43 pts who preserved their anus, 98% had a good anal function scoring. The 5-year disease-free survival was 75%. After multivariate analysis, 2 independent predicting factors significantly influenced the disease-free survival: HIV-positive pts (negative vs positive, P=0.032) and clinical tumor response after the first course of radiotherapy (<50% vs >or=50%, P=0.00032). Acute grade 2 or 3 toxicities were low: haematological toxicity in 4 pts and intestinal complication corresponding to diarrhea in 10 pts. Late severe complication was observed in 3 pts: 2 pts with painful necrosis of the anus requiring colostomy and 1 pt with grade 3 rectal bleeding. CONCLUSION We confirm the good results with RT and concomitant chemotherapy. The clinical tumor response after the first course of RT and concomitant chemotherapy is probably the most important predictive factor on the disease-free survival. For patients with T3 or T4 lesion and tumor regression <or=50% after the first course of radiation therapy, surgical non conservative treatment should be discussed.
Collapse
Affiliation(s)
- E Deniaud-Alexandre
- Service d'Oncologie-Radiothérapie, Hôpital Tenon, APHP, 4, rue de la Chine, 75970 Paris cedex 20, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Fallai C, Cerrotta A, Valvo F, Badii D, Olmi P. Anal carcinoma of the elderly treated with radiotherapy alone or with concomitant radio-chemotherapy. Crit Rev Oncol Hematol 2006; 61:261-8. [PMID: 17085056 DOI: 10.1016/j.critrevonc.2006.09.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Revised: 09/14/2006] [Accepted: 09/27/2006] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To analyse the results achieved with radio-chemotherapy (RTCT) or radiotherapy alone (RT) in elderly patients (pts) affected with squamous cell anal cancer. METHODS AND MATERIALS From 1990 to 2002, 62 pts aged > or =70 years were treated with RT (14) or RTCT (48). There were 9 stage I, 29 stage II, 11 stage IIIa and 13 stage IIIb. MMC+5FU was given concomitantly with RT in an early period, later replaced by Cddp+5FU. In the RTCT group, 36Gy were delivered to pelvic+inguinal lymph nodes, with a tumor boost (18Gy). RESULTS Stage II fared significantly better than stage III in terms of locoregional control (LRC) but not overall survival (OS). Pts treated with RTCT had improved LRC, but not OS. LRC was 81% at 3 and 5 years for the RTCT group; the RT group had a LRC of 61% at 3 years. There were more locoregional relapses in the MMC group (29%) versus the Cddp group (19%) and in pts treated with a split (32%) versus no split (19%). No G3 acute toxicity was observed in the RT group; in the RTCT group 15 pts (31%) developed a G3+ acute toxicity. G3+ late damage occurred in 2 pts in the RT only group and in 3 pts in the RTCT group. CONCLUSIONS Elderly people considered fit for RTCT should undergo the same schedules used for younger people. MMC or Cddp+5FU are feasible in the elderly, even without a planned split.
Collapse
Affiliation(s)
- Carlo Fallai
- Radioterapia, Istituto Nazionale Tumori, Via Venezian 1, 20133 Milano, Italy.
| | | | | | | | | |
Collapse
|
45
|
Abstract
Despite the small number of patients affected by carcinoma of the anal canal it remains one of the most challenging cancers to treat. For although it is one of the few malignancies that may be cured with chemoradiation alone, the use of combined modality therapy may result in significant treatment-related morbidity. Novel approaches currently are underway in this select patient population and will be addressed for the purposes of this manuscript.
Collapse
Affiliation(s)
- Cathy Eng
- University of Texas MD Anderson Cancer Center, Department of Gastrointestinal Medical Oncology, Houston, TX 77030, USA
| |
Collapse
|
46
|
de Bree E, van Ruth S, Dewit LGH, Zoetmulder FAN. High risk of colostomy with primary radiotherapy for anal cancer. Ann Surg Oncol 2006; 14:100-8. [PMID: 17066231 DOI: 10.1245/s10434-006-9118-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Revised: 06/06/2006] [Accepted: 06/06/2006] [Indexed: 01/22/2023]
Abstract
BACKGROUND Radiotherapy (RT) has become the primary treatment of choice for anal cancer in an effort to avoid colostomy. The current role of surgery appears generally to be underestimated, since diverting colostomy or abdominoperineal resection still often seems to be necessary for complications and local treatment failure after RT. METHODS The data of 83 patients primarily treated by RT with curative intent throughout a 20-year period in our institute were analyzed regarding the need for colostomy. RESULTS Totally, 28 patients (34%) required creation of a colostomy after primary RT for local failure or treatment-related complications during a mean follow-up period of 39 months. The 3-year actuarial colostomy-free rate was 59% (mean 85 +/- 9 months). Early stage disease, low T-score and absence of infiltration in adjacent organs were associated with a reduced need for colostomy in univariate analysis. In multivariate analysis only T-score was an independent variable in predicting prolonged colostomy-free interval. In this study, no statistically significant differences were noted for gender, age, nodal status, total radiation dose, radiation boost and concurrent chemotherapy. CONCLUSIONS In approximately one-third of the patients treated by anal sphincter saving management with curative aimed primary RT, the creation of a colostomy appeared to be necessary for RT complications and local treatment failure. Therefore, patients should be well informed regarding the considerable risk of need for colostomy after RT for anal cancer.
Collapse
Affiliation(s)
- Eelco de Bree
- Department of Surgical Oncology, Antoni van Leeuwenhoek Hospital/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | | | | |
Collapse
|
47
|
Dallan LAP, Cruz SHA, Rosa DLD, Bin FC, Nadal SR, Capelhuchnik P, Klug WA. Avaliação dos resultados do tratamento de 14 doentes de carcinoma espinocelular anal. ACTA ACUST UNITED AC 2006. [DOI: 10.1590/s0101-98802006000100004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A radioquimioterapia (RT/QT) tornou-se o tratamento de escolha para o carcinoma espinocelular anal (CEC). Na recidiva local ou na persistência da doença, deve-se instituir o tratamento cirúrgico. OBJETIVO: O objetivo deste estudo retrospectivo foi analisar os resultados do tratamento de doentes de CEC anal. MÉTODO: Acompanhamos 17 pacientes com diagnóstico anátomo-patológico de carcinoma espinocelular anal. Eram 14 (82,3%) do sexo feminino e três (17,8%) do masculino. A idade variou de 36 a 78 anos, com média de idade de 59,1 anos. Utilizando a classificação TNM, tivemos quatro (23,6%) no estádio I, seis (35,2%) no II, quatro (23,6%) no IIIa e três (17,6%) no IIIb. Todos foram submetidos a tratamento inicial com RT/QT, exceto um submetido a ressecção local. Definimos que a biópsia negativa, realizada entre 12 e 16 semanas após esse tratamento, determinaria o controle local da doença. RESULTADOS: Perdemos seguimento de três doentes (17,6%). Seguimos os 14 restantes (82,3%) entre um e cinco anos. Todos os doentes nos estádios I e II (10) apresentaram regressão total da doença, enquanto que três (75%) nos estádios IIIa e IIIb tiveram remissão completa. Realizamos a amputação abdomino-perineal de resgate em dois doentes e ressecção local em outros dois. A recidiva local ocorreu em dois (20%) nos estádios I e II e em dois (75%) nos estádios mais avançados (IIIa e IIIb). A sobrevivência em 3 anos foi de 100% nos que se encontravam nos estádios I e II, embora o controle da doença fosse atingido em oito (80%). Nos quatro doentes que estavam nos estádios IIIa e IIIb, a sobrevivência em um ano foi de 75% e em três anos foi de 25%. Esse último permanece livre da doença. Complicações do tratamento radioterápico ocorreram em oito doentes (57,1%). Nenhum óbito foi constatado durante o tratamento RT/QT. Os dois doentes, (14,3%) com sorologia positiva para HIV, apresentavam infecção anal pelo Papilomavírus humano (HPV). CONCLUSÃO: A análise dos nossos resultados evidenciou que o esquema de tratamento empregado foi efetivo para o controle local e preservação da função esfincteriana do ânus e que, na falha do tratamento radioquimioterápico, a operação de resgate controlou localmente a doença.
Collapse
|