Review of 120 anal cancer patients

Premalignant and Malignant Perianal Lesions

Anal cancer is a heterogeneous and rare disease process that accounts for ∼1.5% of all gastrointestinal tract malignancies. The perianal skin plays host to a variety of different premalignant and malignant lesions, all with variable histology, treatment options, and prognosis. Anal cancers in general are notorious for having a delayed or missed diagnosis leading to treatment delays and may have an impact on survival. This delay is in part due to the nonspecific symptomatology and also improper physical examination of the sensitive and anatomically complex perianal region and anal canal. This article examines the various types of perianal cancers and their precursor lesions and will explore treatment options as well as outcomes and prognosis.

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

INTRODUCTION

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

METHOD

A systematic literature review.

RESULTS

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

CONCLUSION

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

Anal canal squamous cell cancer: are surgical alternatives to chemoradiation just as effective?

PURPOSE

The purpose of this paper is to study long-term oncologic outcomes after different treatment strategies for anal canal cancer (SCAC).

METHODS

Patients with SCAC (2004-2013) were identified from Surveillance, Epidemiology, and End Results (SEER) database. Patients undergoing radiation (RT) were compared to those undergoing local excision (LE), abdominoperineal resection (APR), and abdominoperineal resection after radiation (RT + APR). Overall survival (OS) and cancer-specific survival (CSS) data were evaluated using Kaplan-Meier and Cox regression.

RESULTS

Two thousand seven hundred and seventy-two (83.8%) patients underwent RT, 382 (11.6%) LE, 77 (2.3%) APR, 76 (2.3%) RT + APR. Median age for the four groups was 60, 57, 64, and 56 years and 32, 49.7, 53.2, and 39.5% were male, respectively, while median tumor size was 4.4, 2.6, 5.3, and 5.5 cm, respectively. Five-year OS of RT, LE, APR, and RT + APR groups was 63.7, 79.6, 25.8, and 41.8% while CSS was 79.6, 92.5, 75.6, and 58.8%, respectively, (p < 0.001). Adjusted hazard ratios for OS for LE, APR, and RT + APR with RT as reference were 1.007 (0.702-1.444), 2.311 (1.367-3.906), and 2.072 (1.016-4.228), respectively.

CONCLUSION

These data suggest that APR does not provide better outcomes in treatment of SCAC. Chemoradiation remains the gold standard treatment for majority of patients. Local excision is associated with favorable outcomes in some circumstances.

Five year experience of the treatment of squamous cell carcinoma of the anus

OBJECTIVES

The best treatment of early stage anal squamous cell carcinoma (SCC) is under debated. Wide local excision (WLE) may be considered adequate for stage 1 anal margin cancer. This study demonstrates our experience in treatment of patients with SCC over 5 years.

PATIENTS AND METHODS

We conducted a retrospective study of patients who had undergone anal screening or anal cancer surveillance between October 2010 and 2015 in our department. Each patient underwent anal Pap test, HPV test PCR HPV DNA and cytology by Thin Prep. The examinations were performed by Proctostation THD©. Data were collected and analysed.

RESULTS

We included 25 patients, 16 male (64%) and 9 female (36%). Twenty-four patients had SCC and 1 patient had adenocarcinoma. Of this cohort: 10 underwent chemoradiotherapy (CRT) because T3-4 N1-2 M0, 13 underwent only surgery because T1/T2 and 2 patients had CRT and surgery because they already have had anal cancer treated in the past with CRT. Seventeen patients (68%) of this cohort, including 5 with micro-invasive SCCs, had regular follow-up without recurrences. Four patients (17%) died from metastatic disease and 4 patients (17%) had recurrent disease.

CONCLUSIONS

In this small cohort we demonstrated satisfactory results in treatment of SCCs, underlining the effective role of surgery in early stages of SCC. Screening program and follow up were fundamental to identify early stage and recurrent disease. Also we found the High-resolution video-proctoscopy a valid diagnostic tool.

Pelvic radiotherapy and sexual function in women

BACKGROUND

During the past decade there has been considerable progress in developing new radiation methods for cancer treatment. Pelvic radiotherapy constitutes the primary or (neo) adjuvant treatment of many pelvic cancers e.g., locally advanced cervical and rectal cancer. There is an increasing focus on late effects and an increasing awareness that patient reported outcomes (PROs) i.e., patient assessment of physical, social, psychological, and sexual functioning provides the most valid information on the effects of cancer treatment. Following cure of cancer allow survivors focus on quality of life (QOL) issues; sexual functioning has proved to be one of the most important aspects of concern in long-term survivors.

METHODS

An updated literature search in PubMed was performed on pelvic radiotherapy and female sexual functioning/dysfunction. Studies on gynaecological, urological and gastrointestinal cancers were included. The focus was on the period from 2010 to 2014, on studies using PROs, on potential randomized controlled trials (RCTs) where female sexual dysfunction (FSD) at least constituted a secondary outcome, and on studies reporting from modern radiotherapy modalities.

RESULTS

The literature search revealed a few RCTs with FSD evaluated as a PRO and being a secondary outcome measure in endometrial and in rectal cancer patients. Very limited information could be extracted regarding FSD in bladder, vulva, and anal cancer patients. The literature before and after 2010 confirms that pelvic radiotherapy, independent on modality, increases the risk significantly for FSD both compared to data from age-matched healthy control women and compared to data on patients treated by surgery only. There was only very limited data available on modern radiotherapy modalities. These are awaited during the next five years. Several newer studies confirm that health care professionals are still reluctant to discuss treatment induced sexual dysfunction with patients.

CONCLUSIONS

Pelvic radiotherapy has a persistent deteriorating effect on the vaginal mucosa impacting negatively on the sexual functioning in female cancer patients. Hopefully, modern radiotherapy modalities will cause less vaginal morbidity but results are awaited to confirm this assumption. Health care professionals are encouraged to address potential sexual dysfunction both before and after radiotherapy and to focus more on quality than on quantity.

Systematic review of the quality of life issues associated with anal cancer and its treatment with radiochemotherapy

PURPOSE

Radiochemotherapy is the standard of care for the treatment of anal carcinoma achieving good loco-regional control and sphincter preservation. This approach is however associated with acute and late toxicities including haematological, skin, bowel function and genito-urinary complications. This paper systematically reviews studies addressing the quality of life (QoL) implications of anal cancer and radiochemotherapy. The paper also evaluates how QoL is assessed in anal cancer.

METHODS

Medline, EMBASE, CINAHL, PsycInfo, Web of Science and the Cochrane Library were searched for publications (1996-2014) reporting the effects on patients of anal cancer and radiochemotherapy.

RESULTS

Of the 152 papers reporting treatment-related effects on patients, only 11 provided a formal assessment of QoL. In the absence of an anal cancer-specific measure, QoL was assessed using generic cancer instruments such as the core EORTC quality of life questionnaire (EORTC QLQ-C30) or colorectal cancer tools such as the EORTC QLQ-CR29. Bowel function, particularly diarrhoea, and sexual problems were the most commonly reported QoL concerns. The review of QoL issues of anal cancer patients treated with radiochemotherapy is limited by the QoL assessment measures used. It is argued that certain treatment-related toxicities, for example skin-induced radiation problems, are overlooked or inadequately represented in existing measures.

CONCLUSIONS

This review emphasises the need to develop an anal cancer-specific QoL measure and to incorporate QoL as an outcome of future trials in anal cancer. The results of this review are informative to clinicians and patients in terms of treatment decision-making.

Sacral resection with pelvic exenteration for advanced primary and recurrent pelvic cancer: a single-institution experience of 100 sacrectomies

BACKGROUND

Recurrent and advanced primary pelvic cancers present a complex clinical issue requiring multidisciplinary care and radical extended surgery. Sacral resection is necessary for tumors that invade posteriorly but is associated with increased morbidity and mortality.

OBJECTIVE

This study aimed to analyze the morbidity and survival associated with pelvic exenteration involving sacrectomy for advanced pelvic cancers at a single institution.

DESIGN

This study used patient demographics, operative and pathologic reports, and prospective survival data to determine factors affecting patient outcomes.

SETTINGS

Data were collected for patients who had operations between July 1998 and April 2012 at Royal Prince Alfred Hospital.

PATIENTS

One hundred patients underwent pelvic exenteration with a sacrectomy for advanced pelvic cancers. Sacrectomy was performed for 18 primary and 61 recurrent rectal cancers, 17 anal cancers, and 4 other cancers.

MAIN OUTCOME MEASURES

This study looked at postoperative major and minor morbidity rates, as well as disease-free and overall survival rates after sacral resection. It compared the outcomes of high sacrectomy (at or above S2) versus low sacrectomy.

RESULTS

Clear margins were achieved in 72 of 100 patients. The overall complication rate was 74% (43% major and 67% minor) with no 30-day or in-hospital mortality. Estimated overall and disease-free survival rates after curative resection were 38% and 30% at 5 years. Involved margins (p = 0.006), lymph node involvement (p = 0.008), and anterior organ invasion (p = 0.008) had a negative impact on patient survival. High sacrectomy increased the incidence of neurologic deficit postoperatively (p = 0.04) but did not alter the rate of R0 resection or patient survival.

LIMITATIONS

Retrospective data were required to analyze patient morbidity, as well as operative and pathologic factors.

CONCLUSIONS

This series supports sacral resection for curative surgery in advanced pelvic cancers, achieving excellent R0 and long-term survival rates. Cortical bone invasion and high sacrectomy were not contraindications to surgery and had acceptable outcomes.

[Curative radiotherapy in patients with anal cancer: clinical outcomes and prognostic factors in a single-institution experience]

PURPOSE

Our aim was to retrospectively analyse a series of patients with anal cancer treated with curative intent at a single institute in terms of survival and local disease control.

MATERIALS AND METHODS

Forty-two patients with anal cancer were treated with primary radiotherapy with or without concurrent chemotherapy. The influence of the prognostic factors on overall (OS), disease-free (DFS), disease-specific (DSS), colostomy-free (CFS) and metastasis-free (MFS) survival was evaluated.

RESULTS

Nine patients had stage I, 15 stage II, four stage IIIA and 14 stage IIIB disease. Tumour progression/ persistence occurred in five patients (12%). The 5-year OS, DSS, DFS, CFS and MFS were 72.7%, 84.2%, 85.7%, 81.1% and 87.1%, respectively. On univariate analysis, T stage emerged as highly significant for OS, DSS, CFS and DFS, whereas N status was a significant prognostic factor for DSS. On multivariate analysis, T stage was a significant prognostic factor for OS and CFS.

CONCLUSIONS

Our data support the view that combined chemoradiation treatment of anal cancer is feasible and may provide survival benefits with an acceptable rate of adverse effects. We should consider T and N stages as important prognostic factors for survival.

Postoperative versus definitive chemoradiation in early-stage anal cancer. Results of a matched-pair analysis

BACKGROUND AND PURPOSE

The goal of the present study was to comparatively assess the results of definitive chemoradiation (CRT) with or without previous macroscopically complete resection in patients with early-stage node-negative (T1-2 N0) anal carcinoma.

PATIENTS AND METHODS

A total of 20 patients with T1-2 N0 anal carcinoma who received radiotherapy (RT) with or without chemotherapy following incidental R0/1 tumor resection (S/CRT group) were selected. These were matched to 20 comparable patients who underwent definitive chemoradiation without previous surgery (CRT group). Major objectives of this analysis were treatment outcomes in terms of locoregional tumor control (LRC), overall survival (OS), colostomy-free survival, and toxicity.

RESULTS

Patients treated postoperatively received significantly lower RT doses (median 54.0 Gy vs. 59.7 Gy; p < 0.001) and less frequently concomitant chemotherapy than those treated definitely. The 5-year LRC and 5-year OS rates were 97.5% and 90.0%, respectively, without significant differences between the S/CRT and the CRT groups. The distribution of acute and late toxicities was comparable, and the 5-year colostomy-free survival was 95% in both groups.

CONCLUSION

This matched-pair comparison of incidental R0/1 resection plus dose-reduced CRT with standard definitive CRT of early-stage anal cancer shows similar treatment results. Thus, dose-reduced RT with or without chemotherapy may be considered in R0/1 resected patients with T1-2 N0 anal carcinoma.

Four decades of anal cancer in Tasmania, Australia: what do the case data tell us?

Background Anal cancer is a rare cancer analogous to cervical cancer, largely caused by exposure to oncogenic human papillomavirus. We have sought to study this disease in the epidemiologically distinct population of Tasmania. Methods: Medical records at all tertiary and secondary referral centres in Tasmania were audited for records with corresponding International Classification of Diseases (ICD)-10 codes. Statistical significances of trends were evaluated using Fisher’s exact test, logistic regression or linear regression. Results: Of ~1350 screening records, 170 cases of anal cancer were found with patient presentation during 1973–2010, corresponding to 132 patients. This cohort was mostly female (66.7%), with squamous cell histology (81.8%) and anal canal primaries (72.0%). Most cases were detected at Stage II or below and the majority remained disease-free after treatment. Relatively few cases had documentation of typical risk factors for anal cancer, such as HIV seropositivity, a history of cancer or smoking. After 2000, there was a trend towards a lower stage at presentation, correlating with an increased 5-year survival. After 2000, no anal margin tumours presented beyond Stage II; nearly half were detected in situ and none were fatal. For anal canal tumours, there was virtually no change in the mean stage at detection or in survival. Conclusion: This is the first case series of anal cancer in Tasmania. We find that in many ways, including symptoms and pathology at presentation, epidemiology is typical. However, our cohort is distinct in its paucity of known risk groups, including HIV-positive people, those with a history of cancer and smokers.

Cause-Specific Colostomy Rates After Radiotherapy for Anal Cancer: A Danish Multicentre Cohort Study

Purpose

In anal cancer, colostomy-free survival is a measure of anal sphincter preservation after treatment with radiotherapy or chemoradiotherapy. Failure to control anal cancer and complications of treatment are alternative indications for colostomy. However, no data exist on cause-specific colostomy rates. We examined this in a cohort study.

Patients and Methods

Through national registries and review of medical records, we identified patients with anal cancer diagnosed from 1995 to 2003 who had curative-intent radiotherapy or chemoradiotherapy in four Danish centers. We computed cumulative incidence of tumor-related colostomy and therapy-related colostomy, treating colostomy and death as competing events. Follow-up started at completion of radiotherapy and continued throughout 2008. We used competing risk regression to compute hazard ratios (HRs) to compare the cumulative incidence of cause-specific colostomies between age, sex, tumor size, chemotherapy, and local excision before radiotherapy.

Results

We included 235 patients with anal cancer. The 5-year cumulative incidences of tumor-related and therapy-related colostomy were 26% (95% CI, 21% to 32%) and 8% (95% CI, 5% to 12%), respectively. Tumor size greater than 6 cm versus less than 4 cm was a risk factor for tumor-related colostomy (adjusted HR, 3.8; 95% CI, 1.7 to 8.1), and local excision before radiotherapy was a risk factor for therapy-related colostomy (adjusted HR, 4.5; 95% CI, 1.5 to 13.5).

Conclusion

After curative-intent radiotherapy or chemoradiotherapy, one third of patients had a colostomy, of which one third were related to therapy. Large tumor size was associated with a higher risk of tumor-related colostomy, whereas history of prior excision was associated with an increased incidence of therapy-related colostomy.