Epidermoid cancers of the anal canal: current treatment

Anal Carcinoma: A Series of Cases with a Literature Review

The aim of this study was to analyze the cases of five patients with squamous cell carcinoma (SCC) and to draw attention to the dilemma in the treatment of incontinence on admission of these patients and to present, through a literature review, locations of the surgical treatment.

The anal carcinoma is a rare disease which involves different histopathological (HP) types of cancer. They account for about 2.5% of all digestive cancers. The treatment of the disease is multimodal. There are dilemmas about screening of precancerous lesions and treatment of diagnosed incontinence. There is a high similarity between HPV infection and SCC. Our methods and results were compared with the data from the literature.

In the period of three years (from 2013 to 2015), five cases of the anal carcinoma were diagnosed and treated in the regional hospital. In all of our cases, the disease was histopathologically confirmed as SCC of the anal and perianal areas. It excluded the cases of anal adenocarcinoma (AAC).

Nearly half of the patients (40%) were incontinent and the rectum excision was one of the possible solutions. Distinction in histopathological structure created the confusion in the treatment of these patients. The dilemma we had was whether to do an amputation of the rectum in patients with incontinence before the standardized Chemoradiation therapy (CRT). The review of the literature sums up certain conclusions.

The diagnosis of SCC includes the perianal "ulcer" that does not heal, as well as atypical anoperianal growths. Surgical treatment of SCC is indicated when the diameter of lesion is small (2 cm), or the disease is persistent or recurrent. In the case of anal incontinence because of the tumor changes, the abdominoperineal resection of the rectum (APR) is an alternative to performing bipolar colostomy and CRT. The review of the literature using MEDLINE/PubMed databases did not find the case with restoring anal continence after this treatment. Testing a larger number of patients with incontinence on admission would provide a more clear answer to the question of the treatment of these patients.

Technical aspects of radiation therapy for anal cancer

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

Expression of gastrin-releasing peptide receptor in epidermoid carcinoma of the anal canal

Gastrin-releasing peptide is a neuroendocrine homolog of bombesin that demonstrated important growth-stimulatory effects in various types of cancer. High levels of expression of gastrin-releasing peptide receptors (GRPR) has been found in different malignancies, and the studies exploring the therapeutic use of GRPR antagonists have shown promising results. Our aim was to determine the GRPR expression in epidermoid carcinoma of the anal canal and discuss its potential clinical applications. We performed immunohistochemical analysis for GRPR on formalin-fixed and paraffin-embedded tumor samples obtained from 35 patients with anal cancer. As a control group, we analyzed 24 samples of nonmalignant anal tissues (hemorrhoidectomy specimens). GRPR expression was evaluated using a semiquantitative approach according to the intensity and distribution of staining. All analyzed tissues, except 1 control sample, showed positive GRPR immunoexpression. GRPR was strongly expressed in 54% of cancer specimens as compared with only 12% of the control specimens (P<0.003). In tumors, the receptor showed a diffuse and homogenous pattern of distribution within the specimens. In contrast, control specimens showed a focal pattern of staining restricted to the basal half of the epithelium. In conclusion, we demonstrated that GRPR is highly expressed in epidermoid carcinoma of the anal canal, suggesting this receptor might have a role in anal carcinogenesis. Our results provide a basis for exploiting GRPR as a target for diagnostic and therapeutic purposes in the anal cancer.

Outcomes of salvage surgery for epidermoid carcinoma of the anus following failed combined modality treatment

BACKGROUND

Chemoradiation is first-line therapy for epidermoid carcinoma of the anus (ECA). Surgery is reserved for treatment failures. The authors report outcomes after salvage procedures for ECA.

METHODS

All treatment failures managed with radical surgery between 1998 and 2006 in our institution were reviewed. The Kaplan-Meier method was used for survival analysis. Log-rank and Cox regression were used for univariate and multivariate analysis, respectively.

RESULTS

Fifty-one patients underwent salvage abdominoperineal resection for locoregional failure. Five-year overall survival after abdominoperineal resection was 29% (median, 22 months). Age, gender, human immunodeficiency virus status, tumor-node-metastasis stage, node status, and failure type did not predict survival. Negative resection margin was most strongly associated with improved overall and disease-free survival (P = .03 and P < .0001, respectively). Median survival for patients undergoing inguinal lymph node dissection for regional recurrence (n = 6) was 11 months, with freedom from cancer achieved in 2 of 6 patients.

CONCLUSIONS

Recurrent anal carcinoma after primary chemoradiotherapy carries a poor prognosis. Salvage abdominoperineal resection offers a potential for long-term survival.