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Spinelli L, Martini S, Solla SD, Vigna Taglianti R, Olivero F, Gianello L, Reali A, Merlotti AM, Franco P. Nodal Elective Volume Selection and Definition during Radiation Therapy for Early Stage (T1-T2 N0 M0) Perianal Squamous Cell Carcinoma: A Narrative Clinical Review and Critical Appraisal. Cancers (Basel) 2023; 15:5833. [PMID: 38136378 PMCID: PMC10741760 DOI: 10.3390/cancers15245833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Distinction between anal canal and perianal squamous cell carcinomas (pSCCs) is essential, as these two subgroups have different anatomical, histological, and lymphatic drainage features. Early-stage true perianal tumors are very uncommon and have been rarely included in clinical trials. Perianal skin cancers and aCCs are included in the same tumor classification, even though they have different lymphatic drainage features. Furthermore, pSCCs are treated similarly to carcinomas originating from the anal canal. Radiation therapy (RT) is an essential treatment for anal canal tumors. Guidelines do not differentiate between treatment volumes for perianal tumors and anal cancers. So far, in pSCC, no study has considered modulating treatment volume selection according to the stage of the disease. We conducted a narrative literature review to describe the sites at higher risk for microscopic disease in patients with early-stage perianal cancers (T1-T2 N0 M0) to propose a well-thought selection of RT elective volumes.
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Affiliation(s)
- Lavinia Spinelli
- Radiation Oncology Department, Santa Croce and Carle Hospital, 12100 Cuneo, Italy; (L.S.); (S.M.); (S.D.S.); (R.V.T.); (F.O.); (L.G.); (A.M.M.)
| | - Stefania Martini
- Radiation Oncology Department, Santa Croce and Carle Hospital, 12100 Cuneo, Italy; (L.S.); (S.M.); (S.D.S.); (R.V.T.); (F.O.); (L.G.); (A.M.M.)
| | - Salvatore Dario Solla
- Radiation Oncology Department, Santa Croce and Carle Hospital, 12100 Cuneo, Italy; (L.S.); (S.M.); (S.D.S.); (R.V.T.); (F.O.); (L.G.); (A.M.M.)
| | - Riccardo Vigna Taglianti
- Radiation Oncology Department, Santa Croce and Carle Hospital, 12100 Cuneo, Italy; (L.S.); (S.M.); (S.D.S.); (R.V.T.); (F.O.); (L.G.); (A.M.M.)
| | - Francesco Olivero
- Radiation Oncology Department, Santa Croce and Carle Hospital, 12100 Cuneo, Italy; (L.S.); (S.M.); (S.D.S.); (R.V.T.); (F.O.); (L.G.); (A.M.M.)
| | - Luca Gianello
- Radiation Oncology Department, Santa Croce and Carle Hospital, 12100 Cuneo, Italy; (L.S.); (S.M.); (S.D.S.); (R.V.T.); (F.O.); (L.G.); (A.M.M.)
| | - Alessia Reali
- Radiation Oncology Department, Michele and Pietro Ferrero Hospital, 12060 Verduno, Italy;
| | - Anna Maria Merlotti
- Radiation Oncology Department, Santa Croce and Carle Hospital, 12100 Cuneo, Italy; (L.S.); (S.M.); (S.D.S.); (R.V.T.); (F.O.); (L.G.); (A.M.M.)
| | - Pierfrancesco Franco
- Department of Translational Medicine (DIMET), University of Eastern Piedmont, 28100 Novara, Italy
- Department of Radiation Oncology, ‘Maggiore della Carità’ University Hospital, 28100 Novara, Italy
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ECOG-ACRIN Guideline for Contouring and Treatment of Early Stage Anal Cancer Using IMRT/IGRT. Pract Radiat Oncol 2022; 12:335-347. [PMID: 35717050 DOI: 10.1016/j.prro.2022.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE Previous anal cancer guidelines delineate target volumes similarly for all patients with squamous cell carcinoma of the anal canal and/or perianal skin (SCCA), regardless of disease stage. The purpose of this guideline is to provide customized radiation treatment recommendations for early stage (T1-2 N0 M0) anal cancer treated with intensity modulated and image guided radiation therapy (RT). METHODS AND MATERIALS A contouring atlas and radiation treatment recommendations for the ongoing, randomized phase II trial of deintensified chemoradiation for early stage SCCA (EA2182) was created by an expert panel of radiation oncologists. A literature search was conducted to update and expand these recommendations into a guideline for routine clinical use. RESULTS For the majority of cases, we recommend treatment in the supine, frog leg position with the use of a customized immobilization device and daily image guided RT to ensure optimal bone and soft tissue alignment. Vaginal dilators can be used daily during RT to maximize genitalia sparing. We recommend use of a 10-mm margin on the gross tumor plus including the anal complex to create the primary clinical target volume. To define the elective lymph node clinical target volume, we recommend starting with a 7-mm expansion on blood vessels, but then further refining these volumes based on the anatomic location. A 5- to 10-mm planning target volume (PTV) margin is suggested based on institutional setup and patient-specific factors. When using a simultaneous integrated boost technique, a dose of 50.4 Gy to primary PTV and 42 Gy to lymph node PTV, both delivered over 28 fractions, with chemotherapy is appropriate for early stage anal cancer. CONCLUSIONS This guideline provides anatomic, clinical, and technical instructions to guide radiation oncologists in the planning and delivery of intensity modulated and image guided RT for early stage SCCA.
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Pulse-dose-rate interstitial brachytherapy in anal squamous cell carcinoma: clinical outcomes and patients' health quality perception. J Contemp Brachytherapy 2021; 13:263-272. [PMID: 34122565 PMCID: PMC8170522 DOI: 10.5114/jcb.2021.106247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 04/07/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose To examine clinical outcomes and quality of life of patients with anal squamous cell carcinoma treated with interstitial pulsed-dose-rate brachytherapy (PDR-BT) with a boost to residual tumor after external radiotherapy. Material and methods Medical records of patients receiving a brachytherapy boost after radiotherapy for anal squamous cell carcinoma in our Institute between 2008 and 2019 were retrospectively reviewed. After receiving pelvic irradiation ± concurrent chemotherapy, patients received PDR-BT boost to residual tumor, in order to deliver a minimal total dose of 60 Gy. Patients’ outcomes were analyzed, with primary focus on local control, sphincter preservation, morbidity, and quality of life. Results A total of 42 patients were identified, included 24, 13, and 5 patients with I, II, and III tumor stages, respectively. Median brachytherapy (BT) dose was 20 Gy (range, 10-30 Gy). Median dose per pulse was 42 cGy (range, 37.5-50 cGy). With median follow-up of 60.4 months (range, 5.4-127.4 months), estimated local control and colostomy-free survival rates at 5 years were both 88.7% (95% CI: 67.4-96.4%). The largest axis of residual lesion after external beam radiation therapy (EBRT) and poor tumor shrinkage were associated with more frequent relapses (p = 0.02 and p = 0.007, respectively). Out of 40 patients with more than 6 months follow-up, only one experienced severe delayed toxicity (fecal incontinence). Health quality perception was very good or good in 20 of 22 (91%) patients, according to their replies of quality-of-life surveys. A total dose ≥ 63 Gy was associated with higher number of anorectal grade 1+ toxicities (n = 1.5 vs. n = 0.61, p = 0.02). Conclusions In this cohort of 42 patients with mainly I and II tumor stages, PDR-BT boost allowed for local control in 88.7% of patients, with only one grade 3 anorectal toxicity.
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Kim KS, Cheong KH, Kim K, Koo T, Koh HK, Chang JH, Chang AR, Park HJ. Interobserver variability in clinical target volume delineation in anal squamous cell carcinoma. Sci Rep 2021; 11:2785. [PMID: 33531643 PMCID: PMC7854655 DOI: 10.1038/s41598-021-82541-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 01/20/2021] [Indexed: 12/24/2022] Open
Abstract
We evaluated the inter-physician variability in the target contouring of the radiotherapy for anal squamous cell carcinoma (ASCC). Clinical target volume (CTV) of three patients diagnosed with ASCC was delineated by seven experienced radiation oncologists from multi-institution. These patients were staged as pT1N1a, cT2N0, and cT4N1a, respectively, according to 8th edition of the American Joint Committee on Cancer staging system. Expert agreement was quantified using an expectation maximization algorithm for Simultaneous Truth and Performance Level Estimation (STAPLE). The maximum distance from the boundaries of the STAPLE generated volume with confidence level of 80% to those of the contour of each CTV in 6 directions was compared. CTV of pelvis which includes primary tumor, perirectal tissue and internal/external iliac lymph node (LN) area (CTV-pelvis) and CTV of inguinal area (CTV-inguinal) were obtained from the seven radiation oncologists. One radiation oncologist did not contain inguinal LN area in the treatment target volume of patient 2 (cT2N0 stage). CTV-inguinal displayed moderate agreement for each patient (overall kappa 0.58, 0.54 and 0.6, respectively), whereas CTV-pelvis showed substantial agreement (overall kappa 0.66, 0.68 and 0.64, respectively). Largest variation among each contour was shown in the inferior margin of the CTV-inguinal. For CTV-pelvis, anterior and superior margin showed the biggest variation. Overall, moderate to substantial agreement was shown for CTV delineation. However, large variations in the anterior and cranial boarder of the CTV-pelvis and the caudal margin of the CTV-inguinal suggest that further studies are needed to establish a clearer target volume delineation guideline.
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Affiliation(s)
- Kyung Su Kim
- Department of Radiation Oncology, Dongnam Institute of Radiological and Medical Sciences, Busan, Republic of Korea.,Department of Radiation Oncology, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro Yangcheon-gu, Seoul, 07985, Republic of Korea
| | - Kwang-Ho Cheong
- Department of Radiation Oncology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro Yangcheon-gu, Seoul, 07985, Republic of Korea.
| | - Taeryool Koo
- Department of Radiation Oncology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Hyeon Kang Koh
- Department of Radiation Oncology, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul Metropolitan Government, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Ah Ram Chang
- Department of Radiation Oncology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Hae Jin Park
- Department of Radiation Oncology, Hanyang University College of Medicine, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea.
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Garda AE, Navin PJ, Merrell KW, Martenson JA, Neben Wittich MA, Haddock MG, Sio TT, Rule WG, Ashman JB, Sheedy SP, Hallemeier CL. Patterns of inguinal lymph node metastases in anal canal cancer and recommendations for elective clinical target volume (CTV) delineation. Radiother Oncol 2020; 149:128-133. [DOI: 10.1016/j.radonc.2020.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/02/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
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Kim KS, Chang AR, Kim K, Koh HK, Jang WI, Park HJ, Chang JH, Kim MS. Post-operative radiation therapy with or without chemotherapy for anal squamous cell carcinoma incidentally discovered after local excision: a propensity score matched analysis of retrospective multicenter study. Br J Radiol 2020; 93:20190667. [PMID: 31825665 PMCID: PMC7055428 DOI: 10.1259/bjr.20190667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/29/2019] [Accepted: 12/06/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To evaluate the results of post-operative radiation therapy (RT) for anal squamous cell carcinoma (ASCC) incidentally detected after excision, and compare these outcomes with those of definitive RT without excision for exploring the possibility of treatment de-intensification. METHODS AND MATERIALS A total of 25 patients with T1-2N0-1 ASCC who underwent RT following incidental tumor resection were selected from multicenter retrospective database. And, we selected one-to-one matched 25 patients receiving definitive RT from the same database using propensity score matching method, and the outcomes were compared. RESULTS Median age was 60 years (range, 30-76), and 18 patients (72%) were female. 19 patients (76%) had T0/1 tumors and four patients (16%) had regional lymph node metastases. Hemorrhoidectomy was performed in eight patients (32%) and the others underwent local excision. 12 patients (48%) had microscopic or gross residual diseases. Median RT dose to the primary lesion was 50.4 Gy (range, 40-60). Concurrent chemotherapy was delivered to 23 patients (92%). Median follow-up period was 71 months (range, 4.5-203.1 months). None of the patients showed recurrence during follow-up. However, one patient died after 6 months due to the chemotherapy-related hematologic toxicity. When compared with those patients receiving definitive RT, clinicopathological variables were well-balanced between the two groups. While matched paired patients treated with definitive RT received a higher median RT dose of 54 Gy (range, 45-61.2) and concurrent chemotherapy was given to 22 patients (88%), overall survival was not significantly different (p = 0.262). CONCLUSION Patients treated with RT for early stage ASCC after local excision showed favorable treatment outcomes. Further study is warranted to justify the de-intensification of the treatment for these patients. ADVANCES IN KNOWLEDGE Post-operative RT can achieve favorable treatment outcomes in incidental ASCC with residual diseases after local excision.
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Affiliation(s)
| | - Ah Ram Chang
- Department of Radiation Oncology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Hyeon Kang Koh
- Department of Radiation Oncology, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Won Il Jang
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Republic of Korea
| | - Hae Jin Park
- Department of Radiation Oncology, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Mi-Sook Kim
- Department of Radiation Oncology, Konkuk University School of Medicine, Seoul, Republic of Korea
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Ngan D, Chu J, Chander S, Michael M, Heriot AG, Ngan SY, Rischin D, Leong T. A clinical trial with protracted infusion 5-fluorouracil and mitomycin C for localized squamous cell carcinoma of the anus. Asia Pac J Clin Oncol 2018; 15:75-81. [PMID: 30536770 DOI: 10.1111/ajco.13106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/27/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Mitomycin C (MMC) plus standard 5-fluorouracil (FU) infusion in weeks 1 and 5 often contributes to radiotherapy interruptions and possibly less-than-ideal outcomes in anal cancer. This study was to evaluate alternative strategies for chemotherapy delivery that might be less toxic or more efficacious, and outcomes of patient-initiated treatment interruption for severe acute toxicity. MATERIALS AND METHODS This was a prospective, nonrandomized study for patients with T1-4N0-3M0 anal squamous carcinoma. Radiotherapy of 54 Gy in 30 fractions over 6 weeks was given with infusion FU 300 mg/m2 /day for 96 hours/week for 6 weeks plus bolus MMC at 10 mg/m2 on D1. RESULTS Fifty patients were recruited (72% female). Median age was 60.5 years (35-84). Forty-seven patients (94%) received 54 Gy. Median duration of chemoradiation was 39 days (37-105). Grade 3 and 4 acute toxicity were observed in 66%. Thirty-one percent with severe acute toxicity developed severe late toxicity. Of those who experienced severe late skin toxicity, 29% did not have severe acute toxicity. Disease-free survival at 5 years was 74% (95% confidence interval [CI], 60-84), and at 9 years 61% (95% CI, 46-74). Overall survival at 5 years was 84% (95% CI, 71-92), and at 9 years 67% (95% CI, 50-81). Colostomy-free survival at 5 years was 70% (95% CI, 56-81), and at 9 years 57% (95% CI, 40-72). CONCLUSION It is feasible to deliver chemoradiation with bolus MMC and protracted infusion FU for anal cancer. Efficacy and toxicity of this regimen seem similar to conventional chemoradiation with FU/MMC. Acute skin toxicity is not a reliable predictor of severe late skin toxicity.
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Affiliation(s)
- David Ngan
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Julie Chu
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Sarat Chander
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Michael Michael
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Samuel Y Ngan
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Danny Rischin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Trevor Leong
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Dapper H, Habl G, Hirche C, Münch S, Oechsner M, Mayinger M, Sauter C, Combs SE, Habermehl D. Dosimetric quantification of the incidental irradiation of the 'true' (deep) ano-inguinal lymphatic drainage of anal cancer patients not described in conventional contouring guidelines. Acta Oncol 2018; 57:825-830. [PMID: 29297232 DOI: 10.1080/0284186x.2017.1415459] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The ano-inguinal lymphatic drainage (AILD) is located in the subcutaneous adipose tissue of the proximal medial thigh. Findings from fluorescence methods give us new information about anatomical conditions of the AILD. Current contouring guidelines do not advise the inclusion of the 'true' AILD into the clinical target volume (CTV). Aim of this work was the retrospective analysis of the incidental dose to the AILD in an anal cancer (AC) patient cohort who underwent definitive chemoradiation (CRT) therapy with Volumetric Arc Therapy - Intensity Modulated Radiation Therapy (VMAT-IMRT). METHODS VMAT-IMRT plans of 15 AC patients were analyzed. Based on findings from new fluorescence methods we created a new volume, the expected AILD. The examined dosimetric parameters were the minimal, maximal and mean dose and V10-V50 that were delivered to the AILD, respectively. RESULTS The median volume of AILD was 1047 cm³. Mean Dmin, Dmax and Dmean were 7.5 Gy, 58.9 Gy and 40.8 Gy for AILD. The clinical relevant dose of 30.0 Gray covered in mean 76% of the volume of the AILD, respectively. CONCLUSIONS Only 76% of the AILD-volume received at least an expected required treatment dose of 30 Gy incidentally. Concerning the low number of loco-regional relapses in AC patients after definitive CRT one has to balance increased side effects against a rigid oncological-anatomical interpretation of the local lymphatic drainage by including the AILD into the standard CTV.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Gregor Habl
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Christoph Hirche
- Department for Hand-, Plastic and Rekonstructive Surgery, Burn Centre BG-Trauma Centre Ludwigshafen/RhineBG – Klinik Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Michael Mayinger
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Christina Sauter
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
- Institute for Innovative Radiotherapie (iRT), Helmholtz Zentrum München, Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
- Institute for Innovative Radiotherapie (iRT), Helmholtz Zentrum München, Neuherberg, Germany
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Fish R, Sanders C, Ryan N, der Veer SV, Renehan AG, Williamson PR. Systematic review of outcome measures following chemoradiotherapy for the treatment of anal cancer (CORMAC). Colorectal Dis 2018; 20:371-382. [PMID: 29566456 PMCID: PMC5969105 DOI: 10.1111/codi.14103] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 01/26/2018] [Indexed: 12/18/2022]
Abstract
AIM Six Phase III randomized trials have determined the effectiveness of chemoradiotherapy as primary treatment for anal squamous cell carcinoma (ASCC), but outcomes reported in these trials varied widely, hindering evidence synthesis. To improve reporting in all future trials, we aim to develop a core outcomes set (COS). As the first stage of COS development, we undertook a systematic review to summarize the outcomes reported in studies evaluating chemoradiotherapy for ASCC. METHOD Systematic literature searches identified studies evaluating radiotherapy or chemoradiotherapy for ASCC. Outcomes and accompanying definitions were extracted verbatim and categorized into domains. RESULTS From 5170 abstracts, we identified 95 eligible studies, reporting 1192 outcomes and 533 unique terms. We collapsed these terms into 86 standardized outcomes and five domains: survival; disease activity; life impact [including quality of life (QoL)]; delivery of care; and toxicity. The most commonly reported domains were survival and disease activity, reported in 74 (86%) and 54 (62%) studies, respectively. No outcome was reported in every publication. Over half (43/86) of the standardized outcome terms were reported in fewer than five studies, and 21 (25%) were reported in a single study only. There was wide variation in definitions of disease-free survival, colostomy-free survival and progression-free survival (PFS). Anal continence was reported in only 35 (41%) studies. CONCLUSION Outcomes reported in studies evaluating chemoradiotherapy for ASCC were heterogenous and definitions varied widely. Outcomes likely to be important to patients, such as ano-rectal function, toxicity and QoL, have been neglected. A COS for future trials will address these issues.
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Affiliation(s)
- R. Fish
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Peritoneal and Colorectal Oncology CentreChristie NHS Foundation TrustManchesterUK
| | - C. Sanders
- Centre for Primary CareUniversity of ManchesterManchesterUK
| | - N. Ryan
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and Health Fifth Floor ‐ ResearchSt Mary's HospitalUniversity of ManchesterManchesterUK
| | - S. Van der Veer
- Centre for Health InformaticsInformatics, Imaging and Data ScienceSchool of Health SciencesFaculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Farr Institute of Health Informatics ResearchHealth eResearch CentreUniversity of ManchesterManchesterUK
| | - A. G. Renehan
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Peritoneal and Colorectal Oncology CentreChristie NHS Foundation TrustManchesterUK
| | - P. R. Williamson
- MRC North West Hub for Trials Methodology ResearchDepartment of BiostatisticsUniversity of LiverpoolLiverpoolUK
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Thompson SR, Lee ISY, Carroll S, Bishop S, Douglas P, Lam F, Brown C, Williams J, Goldstein D. Radiotherapy for anal squamous cell carcinoma: must the upper pelvic nodes and the inguinal nodes be treated? ANZ J Surg 2018. [PMID: 29514401 DOI: 10.1111/ans.14398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Loco-regional failure is the predominant cause of death in anal squamous cell carcinoma. We assessed patterns of loco-regional recurrence to determine the impact of radiotherapy (RT) volumes on patient outcome. METHODS Retrospective clinical study, including patients treated curatively with RT or chemo-radiotherapy between 1994 and 2007. RT fields/volumes were reviewed and compared with patterns of failure. Patients were classified as having whole pelvic radiotherapy (WPRT) if RT extended to L5/S1 or lower pelvic radiotherapy (LPRT) if it extended to the lower sacroiliac joints or below. Patients with negative inguinal nodes either underwent prophylactic inguinal radiotherapy (PIRT) or had inguinal observation (IO). Patterns of failure were compared. RESULTS Twenty-seven patients (53%) had WPRT and 24 (47%) had LPRT. Forty-two patients had negative inguinal nodes: 29 (69%) had PIRT and 13 (31%) had IO. Median follow-up was 5.8 years. Twelve regional failures occurred in eight patients: three pelvic, one inguinal and four pelvic and inguinal. All patients with regional failure died of disease. Pelvic nodal failure was 7.7% in N0 and 33% in N1-3 patients (P = 0.012). There was no difference in pelvic regional failure between WPRT and LPRT (11% versus 16%, P = 0.64). There was only one possible regional failure above LPRT in this group (4%). Inguinal failure was 0% in the PIRT group compared with 23% in IO group (P = 0.009). CONCLUSION There was no difference in pelvic regional failure between WPRT and LPRT. LPRT is likely to be safe in N0 patients. Inguinal nodes should be treated in all patients.
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Affiliation(s)
- Stephen R Thompson
- Department of Radiation Oncology, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Isabel S Y Lee
- Department of Radiation Oncology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Susan Carroll
- Department of Radiation Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Sarah Bishop
- Department of Radiation Oncology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | | | - Francis Lam
- Department of Colorectal Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Chris Brown
- National Health and Medical Research Council, Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Janet Williams
- Department of Radiation Oncology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - David Goldstein
- Prince of Wales Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Medical Oncology, Prince of Wales Hospital, Sydney, New South Wales, Australia
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Lestrade L, Zilli T, Kountouri M, Jumeau R, Matzinger O, Bourhis J, Miralbell R, Ozsahin M, De Bari B. Early-stage Favourable Anal Cancer: A Retrospective Analysis of Clinical Outcomes of a Moderately Low Dose Elective Nodal Intensity-modulated Radiotherapy Schedule. Clin Oncol (R Coll Radiol) 2017; 29:e105-e109. [DOI: 10.1016/j.clon.2017.01.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 01/16/2017] [Accepted: 01/24/2017] [Indexed: 11/28/2022]
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Geh I, Gollins S, Renehan A, Scholefield J, Goh V, Prezzi D, Moran B, Bower M, Alfa-Wali M, Adams R. Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Anal Cancer. Colorectal Dis 2017; 19 Suppl 1:82-97. [PMID: 28632308 DOI: 10.1111/codi.13709] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
| | | | - Andrew Renehan
- University of Manchester and Christie Hospital, Manchester, UK
| | - John Scholefield
- University of Nottingham and Queens Medical Centre, Nottingham, UK
| | - Vicky Goh
- King's College and Guy's & St Thomas' Hospital, London, UK
| | | | - Brendan Moran
- Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | - Mark Bower
- Imperial College and Chelsea & Westminster Hospital, London, UK
| | | | - Richard Adams
- Cardiff University and Velindre Cancer Centre, Cardiff, UK
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Su Z, Guo ZW, Mao YP, Tang J, Lan XW, Xie FY, Li Q. Anal adenocarcinoma requires prophylactic inguinal nodal treatment: Results from a single Chinese institution. J Cancer 2017; 8:1097-1102. [PMID: 28529624 PMCID: PMC5436264 DOI: 10.7150/jca.17513] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 12/23/2016] [Indexed: 01/09/2023] Open
Abstract
Background: Literature pertaining to prophylactic inguinal nodal treatment for anal adenocarcinoma in China is scarce. Methods: In this retrospective study, we analyzed 126 patients from 1965 to 2015. Among these, 67 patients received surgery only, 18 patients received chemoradiotherapy only, 27 patients received a combination of both, and the remaining 14 patients received palliative treatment. Results: The median follow up period was 30 months. The 1-year, 3-year, and 5-year overall survival rates were 85.8%, 62.5%, and 43.4%, respectively. The 5-year overall survival was 46.9% for patients with negative inguinal lymph nodes and 19.1% for patients with positive inguinal lymph nodes (p=0.007). The overall 5-year inguinal node relapse-free survival was 83.0%. The 5-year inguinal node relapse-free survival was 87.5% for stage I, 86.9% for stage II, and 76.5% for stage III cancers. Among those with negative inguinal nodes, the 5-year inguinal node relapse-free survival was 85.7% for negative regional lymph nodes and 75.4% for positive regional lymph nodes (p=0.089). Conclusion: Inguinal lymph node is a high-risk subclinical area. Prophylactic inguinal nodal treatment is necessary for patients with anal adenocarcinoma irrespective of positive or negative inguinal lymph nodes.
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Affiliation(s)
- Zhen Su
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Zhan-Wen Guo
- Department of Radiation Oncology, The General Hospital of Shenyang Military Area Command, No.83, Wenhua Road, Shenhe District, Shenyang, Liaoning province, 110016, China
| | - Yan-Ping Mao
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Jie Tang
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Xiao-Wen Lan
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Fang-Yun Xie
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Qun Li
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
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Muirhead R, Drinkwater K, O'Cathail SM, Adams R, Glynne-Jones R, Harrison M, Hawkins MA, Sebag-Montefiore D, Gilbert DC. Initial Results from the Royal College of Radiologists' UK National Audit of Anal Cancer Radiotherapy 2015. Clin Oncol (R Coll Radiol) 2017; 29:188-197. [PMID: 27810119 PMCID: PMC5304408 DOI: 10.1016/j.clon.2016.10.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/08/2016] [Accepted: 08/15/2016] [Indexed: 11/22/2022]
Abstract
AIMS UK guidance was recently developed for the treatment of anal cancer using intensity-modulated radiotherapy (IMRT). We audited the current use of radiotherapy in UK cancer centres for the treatment of anal cancer against such guidance. We describe the acute toxicity of IMRT in comparison with patient population in the audit treated with two-phase conformal radiotherapy and the previous published data from two-phase conformal radiotherapy, in the UK ACT2 trial. MATERIALS AND METHODS A Royal College of Radiologists' prospective national audit of patients treated with radiotherapy in UK cancer centres was carried out over a 6 month period between February and July 2015. RESULTS Two hundred and forty-two cases were received from 40/56 cancer centres (71%). In total, 231 (95%) underwent full dose radiotherapy with prophylactic nodal irradiation. Of these, 180 (78%) received IMRT or equivalent, 52 (22%) two-phase conformal (ACT2) technique. The number of interruptions in radiotherapy treatment in the ACT2 trial was 15%. Interruptions were noted in 7% (95% confidence interval 0-14%) of courses receiving two-phase conformal and 4% (95% confidence interval 1-7%) of those receiving IMRT. The percentage of patients completing the planned radiotherapy dose, irrelevant of gaps, was 90% (95% confidence interval 82-98%) and 96% (95% confidence interval 93-99%), in two-phase conformal and IMRT respectively. The toxicity reported in the ACT2 trial, in patients receiving two-phase conformal in the audit and in patients receiving IMRT in the audit was: any toxic effect 71%, 54%, 48%, non-haematological 62%, 49%, 40% and haematological 26%, 13%, 18%, respectively. CONCLUSIONS IMRT implementation for anal cancer is well underway in the UK with most patients receiving IMRT delivery, although its usage is not yet universal. This audit confirms that IMRT results in reduced acute toxicity and minimised treatment interruptions in comparison with previous two-phase conformal techniques.
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Affiliation(s)
- R Muirhead
- CRUK MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK.
| | | | - S M O'Cathail
- Oxford University Hospitals NHS Trust, Department of Oncology, Churchill Hospital, Oxford, UK
| | - R Adams
- Cardiff University Department of Cancer and Genetics and Velindre Hospital, Cardiff, UK
| | - R Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, UK
| | - M Harrison
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, UK
| | - M A Hawkins
- CRUK MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - D Sebag-Montefiore
- University of Leeds, Cancer Research UK Leeds Centre, St. James's University Hospital, Leeds, UK
| | - D C Gilbert
- Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, UK
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Vinayan A, Glynne-Jones R. Anal cancer - What is the optimum chemoradiotherapy? Best Pract Res Clin Gastroenterol 2016; 30:641-53. [PMID: 27644911 DOI: 10.1016/j.bpg.2016.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/16/2016] [Accepted: 06/23/2016] [Indexed: 01/31/2023]
Abstract
Radical concurrent chemoradiotherapy with 5FU and Mitomycin C is the standard-of-care for squamous-cell carcinoma of the anus (SCCA). Phase III trials combined radiation doses of 50-60 Gy with concurrent Fluoropyrimidines, Mitomycin C and Cisplatin in various doses and schedules. CRT is highly successful for early T1/T2 cancers, but results in appreciable late morbidities and still fails to control larger and node-positive tumours. Compliance to chemotherapy is important for local control. Modern radiotherapy techniques such as intensity-modulated radiotherapy (IMRT), rotational IMRT, image-guided radiotherapy (IGRT) 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. These advances offer the potential for integrating higher doses of radiation, escalation of the currently used drugs and the safe use of other more novel agents with acceptable toxicity. In this chapter potential novel approaches are discussed in the context of SCCA.
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Affiliation(s)
- A Vinayan
- Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex HA6 2RN, UK.
| | - R Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex HA6 2RN, UK.
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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.
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Reduced radiation dose for elective nodal irradiation in node-negative anal cancer: back to the roots? Strahlenther Onkol 2015; 191:845-54. [DOI: 10.1007/s00066-015-0885-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/29/2015] [Indexed: 12/25/2022]
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Lépinoy A, Lescut N, Puyraveau M, Caubet M, Boustani J, Lakkis Z, Fantoli M, Buffet-Miny J, Kim S, Bednarek C, Maingon P, Créhange G, Bosset JF. Evaluation of a 36 Gy elective node irradiation dose in anal cancer. Radiother Oncol 2015; 116:197-201. [DOI: 10.1016/j.radonc.2015.07.050] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/26/2015] [Accepted: 07/27/2015] [Indexed: 01/21/2023]
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Leon O, Guren M, Hagberg O, Glimelius B, Dahl O, Havsteen H, Naucler G, Svensson C, Tveit KM, Jakobsen A, Pfeiffer P, Wanderås E, Ekman T, Lindh B, Balteskard L, Frykholm G, Johnsson A. Anal carcinoma - Survival and recurrence in a large cohort of patients treated according to Nordic guidelines. Radiother Oncol 2015; 113:352-8. [PMID: 25499203 DOI: 10.1016/j.radonc.2014.10.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 10/01/2014] [Accepted: 10/05/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate treatment outcome in a large population-based cohort of patients with anal cancer treated according to Nordic guidelines. MATERIAL Clinical data were collected on 1266 patients with anal squamous cell carcinoma diagnosed from 2000 to 2007 in Sweden, Norway and Denmark. 886 of the patients received radiotherapy 54-64Gy with or without chemotherapy (5-fluorouracil plus cisplatin or mitomycin) according to different protocols, stratified by tumor stage. RESULTS High age, male gender, large primary tumor, lymph node metastases, distant metastases, poor performance status, and non-inclusion into a protocol were all independent factors associated with worse outcome. Among patients treated according to any of the protocols, the 3-year recurrence-free survival ranged from 63% to 76%, with locoregional recurrences in 17% and distant metastases in 11% of patients. The highest rate of inguinal recurrence (11%) was seen in patients with small primary tumors, treated without inguinal irradiation. CONCLUSIONS Good treatment efficacy was obtained with Nordic, widely implemented, guidelines for treatment of anal cancer. Inguinal prophylactic irradiation should be recommended also for small primary tumors.
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Affiliation(s)
- Otilia Leon
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Marianne Guren
- Department of Oncology, Oslo University Hospital, Norway
| | | | | | - Olav Dahl
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | | | - Gisela Naucler
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Christer Svensson
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Per Pfeiffer
- Department of Oncology, Odense Hospital, Denmark
| | - Eva Wanderås
- Department of Oncology, Oslo University Hospital, Norway
| | - Tor Ekman
- Department of Oncology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Birgitta Lindh
- Department of Oncology, Norrland University Hospital, Umeå, Sweden
| | - Lise Balteskard
- Centre for Clinical Documentation and Evaluation, Northern Regional Health Authority, Tromsö, Norway
| | - Gunilla Frykholm
- Department of Oncology, St. Olav's University Hospital, Trondheim, Norway
| | - Anders Johnsson
- Department of Oncology, Skåne University Hospital, Lund, Sweden.
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Interstitial pulsed-dose-rate brachytherapy for the treatment of squamous cell anal carcinoma: A retrospective single institution analysis. Brachytherapy 2015; 14:549-53. [PMID: 25935731 DOI: 10.1016/j.brachy.2015.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 03/11/2015] [Accepted: 03/20/2015] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To examine the outcome of patients receiving interstitial pulsed-dose-rate brachytherapy (PDR-BT) after pelvic radiation therapy for treatment of an anal squamous cell carcinoma. METHODS AND MATERIALS Twenty-one patients were identified: 13, six, and two with stages I, II, and III tumors, respectively. After receiving received pelvic irradiation +/- concurrent chemotherapy, patients were delivered a PDR-BT boost to the residual tumor, with intention to deliver a minimal total dose of 60 Gy. The greatest dimension of residual tumor at the time of brachytherapy procedure was 12.5 mm (range: 0-20 mm). Brachytherapy implantation was performed according to the Paris system, only one plane implant being used. RESULTS Median dose delivered through BT was 20 Gy (range: 10-30 Gy). Median number of pulses was 48 (range: 20-80 pulses). Median treated volume was 9 cm(3) (range: 5-16 cm(3)). Median dose per pulse was 40 cGy (range: 37.5-50 cGy). No Grade 3 or more acute toxicity was reported. No Grade 3 or more delayed toxicity was seen among 18 patients with more than 6 months follow-up. Median followup was 47 months (range: 6-73 months). Twenty patients (95%) were alive at last follow-up. Tumor relapses were experienced in four patients (19%), including local relapse in three patients (14%). CONCLUSION With almost 4 years median followup, this study confirms previous data suggesting that PDR-BT is effective and safe in this indication. Local control rate and toxicity were in the range of what was seen with continuous low-dose-rate BT.
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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.
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Affiliation(s)
- Ravi Shridhar
- Associate Professor, Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
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Cray A, Markham C, Ryan M, Herschtal A, Ngan SY, Chander S. Comparison of four 3D conformal treatment techniques to optimise radiotherapy treatment for anal cancer. J Med Radiat Sci 2014; 61:253-260. [PMID: 25598979 PMCID: PMC4282118 DOI: 10.1002/jmrs.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 10/16/2014] [Accepted: 10/16/2014] [Indexed: 11/10/2022] Open
Affiliation(s)
- Alison Cray
- Department of Radiation Therapy Services Peter MacCallum Cancer Centre Box Hill Victoria Australia
| | - Cathy Markham
- Department of Radiation Therapy Services Peter MacCallum Cancer Centre Box Hill Victoria Australia
| | - Michelle Ryan
- Department of Radiation Therapy Services Peter MacCallum Cancer Centre Box Hill Victoria Australia
| | - Alan Herschtal
- Department of Biostatistics and Clinical Trials Peter MacCallum Cancer Centre Melbourne Victoria Australia
| | - Samuel Y. Ngan
- Department of Radiation Oncology Peter MacCallum Cancer Centre Melbourne Victoria Australia
| | - Sarat Chander
- Department of Radiation Oncology Peter MacCallum Cancer Centre Melbourne Victoria Australia
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Russo M, Ovalle V. Radio-chemotherapy in anal cancer: Institutional experience at a large radiation oncology center in Chile. Rep Pract Oncol Radiother 2014; 19:230-3. [PMID: 25061522 DOI: 10.1016/j.rpor.2014.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 12/16/2013] [Accepted: 02/18/2014] [Indexed: 10/25/2022] Open
Abstract
AIM In this article the aim is to provide a concise narrative review and inform the institutional experience at a referral center in Chile with the use of radio-chemotherapy in anal cancer. BACKGROUND Cancer of the anus and anal canal is mainly a loco-regional disease. For years the standard of care has been concomitant radio-chemotherapy, which permits organ preservation and better local control than alternative surgical procedures. MATERIALS AND METHODS A retrospective analysis of 44 patients treated between 2002 and 2010 was performed. Local recurrence, distant recurrence and overall survival were analyzed with the Kaplan-Meier method. Relevant groups where compared with the log-rank test and univariate analysis were done with the Cox proportional hazards model. RESULTS Median follow-up of the cohort was 56 months, with a minimum follow-up of at least 24 months. There was a significant difference between clinical stages in disease free survival (log-rank trend p < 0.001), and a significant difference in overall survival (OS) when comparing clinical stages that were grouped in stage I-IIIa and IIIB (log-rank p = 0.001). On univariate analysis, age older than 60, having received full treatment and dose above 45 Gy were all significantly related to OS (p < 0.05). An overall survival of 45% and disease free survival of 45% at 5 years were found in our series. CONCLUSIONS Our findings show that results at the Instituto de Radiomedicina in Chile are comparable to published literature. Dismal results in stage IIIb cases indicate much work remains in therapies to achieve loco-regional control in locally advanced cases.
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Affiliation(s)
- Moisés Russo
- Instituto de Radiomedicina IRAM, Americo Vespucio Norte 1314, Santiago, Chile ; Faculty of Medicine, Universidad Diego Portales, Santiago, Chile
| | - Valentina Ovalle
- Instituto de Radiomedicina IRAM, Americo Vespucio Norte 1314, Santiago, Chile
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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.
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Myerson RJ. Favorable anal cancer: does it include T2N0 disease? How might the electively irradiated nodal volume be reduced? Int J Radiat Oncol Biol Phys 2013; 87:13-5. [PMID: 23920385 DOI: 10.1016/j.ijrobp.2013.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 05/31/2013] [Accepted: 06/03/2013] [Indexed: 11/18/2022]
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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.
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Affiliation(s)
- Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.
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De Nardi P, Carvello M, Staudacher C. New approach to anal cancer: Individualized therapy based on sentinel lymph node biopsy. World J Gastroenterol 2012; 18:6349-6356. [PMID: 23197880 PMCID: PMC3508629 DOI: 10.3748/wjg.v18.i44.6349] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Oncological treatment is currently directed toward a tailored therapy concept. Squamous cell carcinoma of the anal canal could be considered a suitable platform to test new therapeutic strategies to minimize treatment morbidity. Standard of care for patients with anal canal cancer consists of a combination of radiotherapy and chemotherapy. This treatment has led to a high rate of local control and a 60% cure rate with preservation of the anal sphincter, thus replacing surgical abdominoperineal resection. Lymph node metastases represent a critical independent prognostic factor for local recurrence and survival. Mesorectal and iliac lymph nodes are usually included in the radiation field, whereas the inclusion of inguinal regions still remains controversial because of the subsequent adverse side effects. Sentinel lymph node biopsies could clearly identify inguinal node-positive patients eligible for therapeutic groin irradiation. A sentinel lymph node navigation procedure is reported here to be a feasible and effective method for establishing the true inguinal node status in patients suffering from anal canal cancer. Based on the results of sentinel node biopsies, a selective approach could be proposed where node-positive patients could be selected for inguinal node irradiation while node-negative patients could take advantage of inguinal sparing irradiation, thus avoiding toxic side effects.
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Matthews J. Comment on Trans Tasman Radiation Oncology Group Study TROG 99/02. Radiother Oncol 2012. [DOI: 10.1016/j.radonc.2011.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Radiotherapy and oncology. Radiother Oncol 2012; 102:161-2; author reply 162. [DOI: 10.1016/j.radonc.2011.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 06/08/2011] [Indexed: 11/18/2022]
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