Carcinoma of the anus: strategies in management

Anal High-risk Human Papillomavirus Infection, Squamous Intraepithelial Lesions, and Anal Cancer in Patients with Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

BACKGROUND

Ulcerative colitis [UC] and Crohn's disease [CD] can be associated with severe comorbidities, namely opportunistic infections and malignancies. We present the first systematic review and meta-analysis evaluating the burden of anal human papillomavirus disease in patients with UC and CD.

METHODS

PubMed, Web of Science, and Scopus were searched until November 2022. Meta-analyses were performed using random effects models. The protocol was recorded at PROSPERO register with the number CRD42022356728.

RESULTS

Six studies, including 78 711 patients with UC with a total follow-up of 518 969 person-years, described the anal cancer incidence rate. For anal cancer incidence rate in CD, six studies were selected, including 56 845 patients with a total follow-up of 671 899 person-years. The incidence of anal cancer was 10.2 [95% CI 4.3 - 23.7] per 100 000 person-years in UC and 7.7 [3.5 - 17.1] per 100 000 person-years in CD. A subgroup analysis of anal cancer in perianal CD, including 7105 patients, was calculated with incidence of 19.6 [12.2 - 31.6] per 100 000 person-years [three studies included]. Few studies described prevalence of anal cytological abnormalities [four studies including 349 patients] or high-risk human papillomavirus [three studies including 210 patients], with high heterogeneity. Prevalence of cytological abnormalities or high-risk human papillomavirus was not associated with pharmacological immunosuppression in the studies included.

CONCLUSION

The incidence of anal cancer is higher in UC than in CD, with the exception of perianal CD. There are limited and heterogeneous data on anal high-risk human papillomavirus infection and squamous intraepithelial lesions prevalence in this population.

Clinicopathologic Features and Outcome of Adenocarcinoma of the Anal Canal: A Population-Based Study

Background

Anal canal adenocarcinoma (AA) is an uncommon tumor of the gastrointestinal tract. We seek to provide a detailed description of the incidence, demographics, and outcome of this rare tumor in the United States.

Methods

The data on anal canal adenocarcinoma from SEER Program, between 1973–2015, were extracted. We analyzed the incidence rates by demographics and tumor characteristics, followed by analysis of its impact on survival.

Results

The incidence of AA increased initially by 4.03% yearly from 1973 to 1985 but had a modest decline of 0.32% annually thereafter. The mean age for diagnosis of AA was 68.12 ± 14.02 years. Males outnumbered females by 54.8 to 45.2%. Tumors were mostly localized on presentation (44.4%) and moderately differentiated (41.1%). Age generally correlated with poor overall cancer survival. However, young patients (age <40 years) also showed poor long-term survival. Patients with localized disease and well-differentiated tumors showed better survival outcomes. Surgical intervention improved survival significantly as compared to patients who did not (116.7 months vs 42.7 months, p < 0.01).

Conclusions

Anal canal adenocarcinoma demonstrated a poor bimodal cancer-free survival in both younger and older patient groups. Surgery significantly improves odds of survival and should be offered to patients amenable to intervention.

Genital marginal failures after intensity-modulated radiation therapy (IMRT) in squamous cell anal cancer: no higher risk with IMRT when compared to 3DCRT

Intensity-modulated radiotherapy (IMRT) is considered the preferred option in squamous cell canal cancer (SCAC), delivering high doses to tumor volumes while minimizing dose to surrounding normal tissues. IMRT has steep dose gradients, but the technique is more demanding as deep understanding of target structures is required. To evaluate genital marginal failure in a cohort of patients with non-metastatic SCAC treated either with IMRT or 3DCRT and concurrent chemotherapy, 117 patients with SCAC were evaluated: 64 and 53 patients were treated with IMRT and 3DCRT techniques, respectively. All patients underwent clinical and radiological examination during their follow-up. Tumor response was evaluated with response evaluation criteria in solid tumors v1.1 guideline on regular basis. All patients' data were analyzed, and patients with marginal failure were identified. Concomitant chemotherapy was administered in 97 and 77.4% of patients in the IMRT and 3DCRT groups, respectively. In the IMRT group, the median follow-up was 25 months (range 6-78). Progressive disease was registered in 15.6% of patients; infield recurrence, distant recurrence and both infield recurrence and distant recurrence were identified in 5, 4 and 1 patient, respectively. Two out of 64 patients (3.1%) had marginal failures, localized at vagina/recto-vaginal septum and left perineal region. In the 3DCRT group, the median follow-up was 71.3 months (range 6-194 months). Two out of 53 patients (3.8%) had marginal failures, localized at recto-vaginal septum and perigenital structures. The rate of marginal failures was comparable in IMRT and 3DCRT groups (χ² test p = 0.85). In this series, the use of IMRT for the treatment of SCAC did not increase the rate of marginal failures offering improved dose conformity to the target. Dose constraints should be applied with caution-particularly in females with involvement of the vagina or the vaginal septum.

Carcinoma of the anal canal: Intensity modulated radiation therapy (IMRT) versus three-dimensional conformal radiation therapy (3DCRT)

INTRODUCTION

Patients with anal canal carcinoma treated with standard conformal radiotherapy frequently experience severe acute and late toxicity reactions to the treatment area. Roohipour et al. (Dis Colon Rectum 2008; 51: 147-53) stated a patient's tolerance of chemoradiation to be an important prediction of treatment success. A new intensity modulated radiation therapy (IMRT) technique for anal carcinoma cases has been developed at the Andrew Love Cancer Centre aimed at reducing radiation to surrounding healthy tissue.

METHODS

A same-subject repeated measures design was used for this study, where five anal carcinoma cases at the Andrew Love Cancer Centre were selected. Conformal and IMRT plans were generated and dosimetric evaluations were performed. Each plan was prescribed a total of 54 Gray (Gy) over a course of 30 fractions to the primary site.

RESULTS

The IMRT plans resulted in improved dosimetry to the planning target volume (PTV) and reduction in radiation to the critical structures (bladder, external genitalia and femoral heads). Statistically there was no difference between the IMRT and conformal plans in the dose to the small and large bowel; however, the bowel IMRT dose-volume histogram (DVH) doses were consistently lower.

CONCLUSION

The IMRT plans were superior to the conformal plans with improved dose conformity and reduced radiation to the surrounding healthy tissue. Anecdotally it was found that patients tolerated the IMRT treatment better than the three-dimensional (3D) conformal radiation therapy. This study describes and compares the planning techniques.

Neoadjuvant chemoradiation and duration of chemotherapy before surgical resection for pancreatic cancer: does time interval between radiotherapy and surgery matter?

BACKGROUND

Neoadjuvant chemoradiation and chemotherapy provided for borderline or locally advanced, potentially resectable pancreatic adenocarcinoma improves resectability rates. Response to therapy is also an important prognostic factor. There are no data in the literature regarding optimal time interval or duration of chemotherapy after chemoradiation before surgery, and pathologic response rates. Using our database, we evaluated these relationships and the effect on overall and progression-free survival.

METHODS

We retrospectively analyzed the records of 83 patients who underwent neoadjuvant chemoradiation for locally advanced, potentially resectable, and borderline resectable pancreatic cancers before definitive resection. We divided patients into three groups according to time interval between completion of chemoradiation and resection: group A (0-10 weeks), group B (11-20 weeks), and group C (>20 weeks). After chemoradiation, patients underwent ongoing chemotherapy before resection. Pathologic response was defined as major (>95% fibrosis), partial (50-94% fibrosis), or minor (<50% fibrosis).

RESULTS

There were 56 patients in group A, 17 patients in group B, and 10 patients in group C. Patients in groups B and C were significantly more likely to experience a major response than group A (p < 0.013). Patients in group C had significantly increased median progression-free and overall survival (p < 0.05). Multivariable classification and regression tree analysis demonstrated pathologic response to be the only significant factor in overall survival.

CONCLUSIONS

Patients who underwent a prolonged time interval after neoadjuvant chemoradiation with ongoing chemotherapy were more likely to have an improved pathologic response at time of surgical resection, which was associated with improved median overall survival.

Salvage surgery for residual primary and locally recurrent anal squamous cell carcinoma after chemoradiotherapy in HIV-positive individuals

BACKGROUND

The treatment of anal cancer in human immunodeficiency virus (HIV) patients-as in the general population-is primarily with chemoradiotherapy (CRT), and abdominoperineal resection of residual or recurrent primary disease. The aim of this study was to evaluate the extent of residual primary disease and local recurrence as well as the outcome of salvage surgery after CRT for anal carcinoma in HIV-positive individuals.

METHODS

We retrospectively studied HIV-positive anal carcinoma patients treated between February 1989 and November 2012 in a specialist London unit. Extent of residual primary disease, local recurrence after CRT, postoperative complications, and survival after salvage surgery were evaluated.

RESULTS

Complete response was experienced in 44 of 53 (83%) of HIV patients treated with CRT for anal carcinoma. One patient (2.3%) developed local recurrence. Nine patients (eight residual primary disease after CRT and one local recurrence) underwent salvage surgery after CRT. There were no perioperative deaths, and perioperative CD4 counts were sustained. Complications occurred in five patients (55%). Median interval to complete perineal healing was 4 months (range 2-11 months), and median hospital stay was 29 days. Survival (median 16 months) was 25% at 2 years from salvage surgery.

CONCLUSIONS

Results in HIV-positive patients receiving highly active antiretroviral therapy (HAART) suggest that loss of HIV sensitivity to HAART can be avoided, but that there is increased postoperative morbidity that may be related to HIV disease. Survival was comparable to that for salvage therapy after optimal CRT in non-HIV anal carcinoma patients.

Evaluation of Langerhans cells counts comparing HIV-positive and negative anal squamous cell-carcinoma patients

PURPOSE

To investigate the differences in Langerhans cells (LCs) populations between HIV-positive and negative anal squamous cell carcinomas patients.

METHODS

Twenty five patients (14 HIV-positive and 11 HIV-negative) were evaluated. Paraffin-block transversal thin sections from biopsies of anal squamous cell carcinomas (ASCC) were stained using the anti-CD1A antibody that identifies activated LCs. LCs counts were performed using histometry at 20 different sites, at baseline in the ASCC cases. These were then compared with LCs counts in anal canal specimens from HIV-negative and positive patients without ASCC (controls groups).

RESULTS

In patients with ASCC, the LC count was greater among HIV-negative individuals than among HIV-positive individuals (p<0.05). The LC count was greater in the control HIV-negative group than in HIV-positive patients with ASCC (p<0.05).

CONCLUSION

There was a lower amount of activated LCs in HIV-positive patients with anal squamous cell carcinomas than in HIV-negative patients, thereby suggesting worsening of the immune response.

Clinical update: colon, rectal, and anal cancers

OBJECTIVES

To present an updated review of the incidence, risk factors, staging, diagnosis, and treatment of colon, rectal, and anal cancers, as well as nursing care associated with managing patients diagnosed with these malignancies.

DATA SOURCES

Published research reports, epidemiologic data, published patient management guidelines, and institution-based clinical tools.

CONCLUSION

While significant advances in the management of colon, rectal, and anal cancers in the past decade have extended patient survival, there remain some unanswered questions. Further clinical and molecular research will help individualize patient care, refining current therapeutic strategies and treatment decision-making aids while minimizing symptoms of disease and treatment.

IMPLICATIONS FOR NURSING PRACTICE

Nurses need to be familiar with risk factors, disease course, and current and emerging therapies to assist patients with treatment decision-making, and to anticipate and intervene in managing disease and treatment-induced problems. Early identification and management of distressing symptoms can help to avoid life-threatening effects and promote patient adherence to prescribed therapies; timely patient/family education may minimize anxiety and promote self-management.

Human papillomavirus genotype distribution in anal cancer in France: the EDiTH V study

Anal cancer is a rare cancer but its incidence is increasing. Human papillomavirus (HPV) infection seems to be associated with the occurrence of most cases. The genotype-specific prevalence of HPV in anal cancer was estimated to assess the potential benefit of HPV vaccination in France. Anal cancer histological specimens were retrospectively recruited in 2008 from 16 French centres and centrally tested for HPV genotyping using the INNO-LiPA assay allowing the detection of 28 genotypes. Results were analyzed according to age, gender, HIV status when available and histological diagnosis. A total of 366 anal cancer cases were analyzed among which 62% were females. Mean age at diagnosis was 54.8 years in males and 66.4 years in females (p < 0.001). HPV was found in 96.7% of cases, 72% being infected by a single HPV type. Presence of at least one high-risk genotype was observed in 91% of cases (96% in females and 83% in males; p < 0.001). HPV16 was by far the most prevalent genotype (75%), followed by HPV18, HPV52, HPV33, and HPV51 (4-6%). HPV16/18 alone or in association were found in 78% of all cases. HIV-positive cases had a higher proportion of multiple HPV infection than HIV-negative cases and a slightly different HPV type distribution with an under-representation of HPV16 and an over-representation of other types. Our results indicate that anal cancer rarely occurs in the absence of HPV and emphasize the predominant role of HPV16. The potential benefit of HPV vaccine on the occurrence of anal cancer should be further evaluated.

Chemoradiotherapy in patients with anal cancer: impact of length of unplanned treatment interruption on outcome

The aim of this retrospective analysis was to evaluate feasibility and effectiveness of definitive chemoradiotherapy without split-course technique in anal cancer patients. From 1993 to 2003, 81 patients were treated; 13 were excluded due to various chemotherapeutic regimes, thus 68 patients were analysed. In case of acute grade 3 toxicities, treatment was halted until improvement or resolution independent of dose. Short interruption was defined as completing treatment without exceeding eight cumulative treatment days beyond scheduled plan, other patients were considered to have had prolonged interruption. Median follow-up was 46 months. Median overall treatment time was 53 days corresponding to an interruption of eight cumulative treatment days. Thirty-five patients (51%) had treatment interruption of <or=8 days. No acute grade 4 toxicities were observed; one fatality occurred during treatment due to ileus-like symptoms according to acute grade 5 toxicity. Comparing patients with short vs. prolonged interruption 5-year actuarial rates for local control were 85% vs. 81% (p = 0.605) and for colostomy-free survival 85% vs. 87% (p = 0.762), respectively. Chemoradiotherapy with short individualised treatment interruptions seems to be feasible with acceptable acute or late toxicities. Treatment is highly effective in terms of local control and colostomy-free survival.

Colon, rectal, and anal cancers

OBJECTIVES

To review the incidence, risk factors, staging, diagnosis, and treatment of colon, rectal, and anal cancers, as well as nursing care associated with managing patients diagnosed with these malignancies.

DATA SOURCES

Published research reports, epidemiologic data, published patient management guidelines, and institution-based clinical tools.

CONCLUSIONS

Significant advances in the management of colon, rectal, and anal cancers in the past decade have extended patient survival. Further clinical research will refine current therapeutic strategies and treatment decision-making aids while minimizing symptoms of disease and treatment.

IMPLICATIONS FOR NURSING PRACTICE

Nurses need to be familiar with risk factors, disease course, and current and emerging therapies to assist patients with treatment decision-making, and to anticipate and intervene in managing disease and treatment-induced problems. Early identification and management of distressing symptoms can help to avoid life-threatening effects and promote patient adherence to prescribed therapies; timely patient/family education may minimize anxiety and promote self-management.

Current understanding and potential immunotherapy for HIV-associated squamous cell carcinoma of the anus (SCCA)

Squamous cell carcinoma of the anus (SCCA) is a rare disease in the average population but is an increasing concern among immunocompromised individuals, such as the HIV-seropositive. Coinfection with human papillomavirus (HPV) in this population is common. HPV infection is difficult to clear with a compromised immune system, which results in a greater risk of tumor development and a more aggressive progression of the disease. The recent approval of a prophylactic HPV vaccine for cervical cancer has sparked an interest in a search for improved immunotherapeutic multimodality therapies to combat anogenital tumors associated with the virus. In this review, we discuss the known mechanisms of action of HIV-associated SCCA, examine the current treatments for the disease, and focus on the potential of an immunotherapeutic vaccine approach for both prophylactic and therapeutic application.

Reconstruction of the perineum following anorectal cancer excision

PURPOSE

Most patients with anal cancer receive chemoradiotherapy as first-line treatment. Persistent/recurrent tumours will subsequently require an abdomino-perineal resection (APR). A proportion of the 20,000 new cases of rectal carcinoma diagnosed in the UK each year receive neo-adjuvant chemoradiation and then an APR. Healing of the irradiated perineal bed is compromised, resulting in high morbidity. Reconstruction of the perineam with well-vasularised tissue is thought to enhance healing. This study investigates a series of 18 patients who underwent APR for anorectal cancer with flap reconstruction of their perineum.

MATERIALS AND METHODS

A retrospective analysis of all anorectal cancers requiring an APR and flap reconstruction was performed. Casenotes were reviewed and documentation made of risk factors putting them at increased risk of wound complications. Length of stay, morbidity and outcome variables including primary flap healing were recorded.

RESULTS

Between November 2000 and October 2007, 18 cases were performed (M/F = 7:11), six for anal cancer and 12 for low rectal tumours. Pre-operative treatment was chemoradiotherapy in 14 (78%), radiotherapy alone in two (11%) and none in two (11%). Perineal reconstruction consisted of 14 vertical rectus abdominis myocutaneous flaps, three free latissimus dorsi flap and one transverse rectus abdominis myocutaneous flap. Mean hospital stay was 21.8 days (10-54 days). Complete healing was noted in 16 cases with the remaining two continuing to improve under current follow-up. There were no flap losses.

CONCLUSIONS

Despite most patients being treated with pre-operative radiotherapy, we have had significant success in obtaining primary healing of the perineal defect after APR.

Combined bias suppression in single-arm therapy studies

RATIONALE, AIMS AND OBJECTIVES

For therapy evaluation studies, control groups are sometimes not feasible. In single-arm studies, various bias factors apart from the test therapy can affect clinical outcomes. The objective of this analysis was to improve the methods to minimize bias in single-arm studies.

METHOD

We present a procedure for combined suppression of several bias factors, using two methods: sample restriction to patients unaffected by bias, and score adjustment. The procedure was used for a secondary analysis of disease score (doctors' global rating, 0-10) in a cohort of patients receiving anthroposophic therapies for chronic diseases. Four bias factors were suppressed stepwise: attrition bias (by replacing missing values with the baseline value carried forward), bias from natural recovery (by sample restriction to patients with disease duration of >/=12 months), regression to the mean due to symptom-driven self-selection (by replacing baseline scores with scores three months before enrolment) and bias from adjunctive therapies (by sample restriction to patients not using adjunctive therapies).

RESULTS

In the cohort analysed, these four bias factors could together explain a maximum of 37% of the 0- to 6-month improvement of disease score.

CONCLUSION

Combined bias suppression, using sample restriction and score adjustment, is a transparent procedure to minimize bias in single-arm therapy studies. Further applicability of the procedure should be tested in future studies.

Assessing the order of magnitude of outcomes in single-arm cohorts through systematic comparison with corresponding cohorts: an example from the AMOS study

BACKGROUND

When a therapy has been evaluated in the first clinical study, the outcome is often compared descriptively to outcomes in corresponding cohorts receiving other treatments. Such comparisons are often limited to selected studies, and often mix different outcomes and follow-up periods. Here we give an example of a systematic comparison to all cohorts with identical outcomes and follow-up periods.

METHODS

The therapy to be compared (anthroposophic medicine, a complementary therapy system) had been evaluated in one single-arm cohort study: the Anthroposophic Medicine Outcomes Study (AMOS). The five largest AMOS diagnosis groups (A-cohorts: asthma, depression, low back pain, migraine, neck pain) were compared to all retrievable corresponding cohorts (C-cohorts) receiving other therapies with identical outcomes (SF-36 scales or summary measures) and identical follow-up periods (3, 6 or 12 months). Between-group differences (pre-post difference in an A-cohort minus pre-post difference in the respective C-cohort) were divided with the standard deviation (SD) of the baseline score of the A-cohort.

RESULTS

A-cohorts (5 cohorts with 392 patients) were similar to C-cohorts (84 cohorts with 16,167 patients) regarding age, disease duration, baseline affection and follow-up rates. A-cohorts had > or = 0.50 SD larger improvements than C-cohorts in 13.5% (70/517) of comparisons; improvements of the same order of magnitude (small or minimal differences: -0.49 to 0.49 SD) were found in 80.1% of comparisons; and C-cohorts had > or = 0.50 SD larger improvements than A-cohorts in 6.4% of comparisons. Analyses stratified by diagnosis had similar results. Sensitivity analyses, restricting the comparisons to C-cohorts with similar study design (observational studies), setting (primary care) or interventions (drugs, physical therapies, mixed), or restricting comparisons to SF-36 scales with small baseline differences between A- and C-cohorts (-0.49 to 0.49 SD) also had similar results.

CONCLUSION

In this descriptive analysis, anthroposophic therapy was associated with SF-36 improvements largely of the same order of magnitude as improvements following other treatments. Although these non-concurrent comparisons cannot assess comparative effectiveness, they suggest that improvements in health status following anthroposophic therapy can be clinically meaningful. The analysis also demonstrates the value of a systematic approach when comparing a therapy cohort to corresponding therapy cohorts.

Anal canal carcinoma: experience from a single Korean institution

PURPOSE

The clinical features, treatment modality approaches in clinical practice, and prognostic factors for anal canal carcinoma patients were retrospectively analyzed.

MATERIALS AND METHODS

Between October 1994 and December 2005, 50 patients with anal canal cancer were treated at Samsung Medical Center, Seoul, Korea.

RESULTS

After a median follow up of 37.8 months (range, 6.6-136.1 months), the 5-year and 10-year survival rates for the 38 patients with early and locally advanced squamous and cloacogenic carcinoma (squamous cell carcinoma and cloacogenic carcinoma) were 74.8% and 66.5%, respectively. The 5-year survival and disease-free survival rates (DFS) of the 31 patients who received chemoradiation therapy (CRT) were 83.6% and 74.3%, respectively. The overall and DFS could not be determined for the adenocarcinoma group due to the small number of cases (n=8). Univariate analysis showed that tumor size (p=0.04) and inguinal node status (p=0.04) significantly influenced patient survival in patients with squamous cell and cloacogenic carcinomas. Furthermore, univariate analysis also showed that, inguinal node status influenced patient survival in the adenocarcinoma group. Multivariate analysis showed that inguinal node metastasis is a single independent prognostic variable for survival (p=0.04) in patients with squamous cell and cloacogenic carcinomas.

CONCLUSION

Combined CRT has been adopted as standard treatment with outcomes that are comparable to those reported in randomized clinical trials. Due to the rarity and complexity of anal canal carcinoma, interdepartmental cooperation is required for disease treatment. Thus, proper treatment of patients should incorporate a team-approach and should be available to as many patients as possible.

Estudo demográfico do câncer de canal anal e ânus no estado de Sergipe

A carência de estudos demográficos específicos sobre o câncer de canal anal e ânus no Brasil e uma melhor compreensão do comportamento da patologia no estado de Sergipe motivaram a realização de tal estudo. Em análise retrospectiva (1993 - 2005), foram avaliadas as principais características demográficas do câncer anal em Sergipe. Foram estudados 91 pacientes, sendo 70 (76,9%) do gênero feminino e 21 (23,0%) do gênero masculino. A média de casos novos ao ano no período estudado foi de 0,39 por 100.000 pessoas, com desvio padrão de ± 0,16. O carcinoma de células escamosas (CEC) foi responsável por 68% dos casos de câncer anal. No presente estudo, constatou-se o mau preenchimento dos prontuários médicos e a necessidade de se criar um protocolo para o atendimento e acompanhamento dos pacientes com câncer de canal anal e ânus.

Factors influencing change of preoperative treatment intent in a gastrointestinal cancer practice

BACKGROUND

Postoperative assessment of indications for cancer directed surgical procedures frequently differs from preoperative plans.

METHODS

Specifically defined preoperative indications and postoperative results were followed prospectively over 48 months in a single surgeon academic practice, and relationships to postoperative outcomes evaluated.

RESULTS

Operations were performed on 406 patients with a median age of 61 (range: 18-90). Major operations (n = 303, 75%) involved 270 abdominal resections including pancreatectomies (37%), liver resections (23%), gastrectomies (19%), and others (21%). Preoperative curative (70%), diagnostic (38%), palliative (12%), access (9%), and non-cancer related therapy (21%) goals were in part combined in 176 patients (43%). Postoperative assessment differed from preoperative goals in 118 patients (29%). Predominant reasons were proof of benign disease (n = 35), incomplete resection (R1 or R2, n = 23), unresectability by laparoscopy (n = 21) or laparotomy (n = 21), or others (n = 18). Potential preoperative cure or palliation goals were not achieved in 37% or 15% of cases, respectively. Circumstances of changed treatment intent were specific for disease site.

CONCLUSION

Preoperative therapeutic intent frequently differs from postoperative assessments in gastrointestinal cancer, based on shortcomings in diagnosis or therapy. Formulations of precise operative indications are recommended to optimize individual outcomes and avoid unnecessary or ineffective procedures.

Avaliação dos resultados do tratamento de 14 doentes de carcinoma espinocelular anal

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.

Squamous cell carcinoma of the anal canal

Squamous cell carcinoma (SCC) of the anal canal is a rare condition with increasing incidence rates in the United States population in the past several decades. This review article provides a complete overview of the etiology, anatomy and the approach to the multidisciplinary management of the patient with anal SCC. Chemoradiation therapy for the treatment of SCC of the anal canal provides excellent disease control and survival while preserving anal sphincter function in the majority of patients. The surgeon plays a key role in the diagnosis and follow-up of this disease. Surgical salvage with APR for disease persistence or recurrence in carefully selected patients can result in reasonable 5-year survivals.

Overview of anal cancer for the surgeon

Cancers of the anal canal represent a diverse group of pathology and require a multidisciplinary approach for treatment. For the most common anal canal cancer, anal SCC, the primary therapy is CMT with systemic chemotherapy and radiation. The surgeon plays a key role in the diagnosis and follow-up after treatment, with surgical intervention reserved for residual or recurrent disease. The overall prognosis for this disease is favorable. For anal adenocarcinoma, aggressive surgical resection remains the mainstay of therapy, with radiation therapy and chemotherapy used to aid in local disease control and for treatment of metastatic disease. A high rate of distant failure in this disease is responsible for the poor long-term prognosis. Anorectal melanoma has a high rate of distant failure and a poor overall survival rate. Surgical intervention is focused on local disease control with preservation of sphincter function. The biggest improvements in survival for this disease will come with more effective systemic therapy.

Carcinoma of the anal canal: a local experience and review of the literature

BACKGROUND

Through the 1970s patients presenting with anal canal carcinoma were managed with a surgical approach--abdomino-perineal resection. Since then, the pioneering work of Nigro et al. and a series of large clinical trials have clearly demonstrated that combined chemotherapy and radiotherapy result in greater local control, colostomy-free survival and increase in overall patient survival. The aim of the present study is to determine how widely the combined modality approach has been adopted in routine clinical practice and what outcomes are achieved in this setting.

METHODS

All patients with anal cancer treated at three tertiary referral centres over an 11-year period (1991-2001) were identified. Data were collected by a retrospective record review.

RESULTS

Our search identified a total of 50 patients: 22 men and 28 women, with a median age of 62 years. Four patients had metastatic disease diagnosed at presentation. Nine patients (18%) were at least 75 years of age and three were known to be HIV positive. Median potential follow up is 52 months. Of the 46 patients treated for cure, 38 received a combination of chemotherapy and radiation, with 79% achieving a complete response. Efficacy was maintained in treated elderly patients (> or =75 years). The 5-year survival of the 38 patients with local or locoregional disease who received combined chemoradiation modality was 63%.

CONCLUSIONS

Overall this series demonstrates that combined chemotherapy and radiotherapy has been adopted as standard treatment with outcome data similar to those reported in the randomized clinical trials. Where possible elderly patients should receive combined modality therapy.

Anal cancer and its precursors in HIV-positive patients: perspectives and management

Anal cancer is an increasing problem among HIV-infected persons. Although patients are living longer and with better quality of life because of treatment with HAART, they remain at risk for invasive anal cancer and its precursor, anal HSIL. Given the substantial numbers of patients with anal HSIL, further studies need to be done to determine the efficacy and optimal mode of treatment of HSIL, to define the optimal method for screening patients at risk, to define the best way to follow up patients with documented HSIL to ensure early detection, to define prognostic factors for progression to invasive cancer, and to determine the progression rate of HSIL to invasive cancer. Although patients with good functional status and immunologic function seem to do relatively well with standard CMT for anal cancer, there are less fortunate patients who experience substantial morbidity from therapy and have a poorer outcome. It is difficult to draw definitive conclusions about the therapy of HIV-positive patients with anal cancer based on the available literature because of the retrospective nature of the analyses, the small number of patients, and the heterogeneity of the patients reported with regard to tumor size, pretreatment immunologic status, and the variety of treatments received by patients in some series. Identifying patients who develop invasive anal cancer as early as possible will improve results to some degree, but prospective, controlled, multi-institutional trials evaluating the treatment of anal cancer in HIV-infected persons are required to accurately define ways to improve outcome with less morbidity. The results of ongoing therapeutic HPV vaccine trials are eagerly awaited. Improvement may come by the following, determining ways to more accurately stage patients, such as endoanal ultrasound, sentinel lymph node sampling, or positron emission tomography scans; defining the role of cisplatin and whether it is indeed less toxic and equally or more effective; consideration of continuous protracted infusion of low-dose 5-FU; the optimum use of growth factors; and an evaluation of the role of conformal radiotherapy or the use of radio-protectants, such as amifostine. Meanwhile, the best way to treat anal cancer in HIV-infected persons may be to prevent it from occurring by screening persons at risk and treating HSIL, or at a minimum, following up patients carefully and detecting cancers, if they occur, at the earliest possible time.

Surgical salvage therapy of anal canal cancer

AIM: To evaluate the results of salvage resection in the management of persistent or locally recurrent anal canal cancer.

METHODS: Details of all patients with anal canal cancer treated from 1978 to 1994 at Cancer Hospital of Chinese Academy of Medical Sciences (CAMS) were reviewed retrospectively. Sixteen patients who presented with persistent or locally recurrent anal canal cancer received salvage surgery. Before surgery all of the patients had received radiotherapy alone as their primary treatments.

RESULTS: Of the 16 patients, 14 received salvage abdominoperineal resection (APR) and two had transanal local excision. There were no deaths attributable to operation. Delayed healing of the perineal wound occurred in eight patients. Complications unrelated to the perineal wound were found in five patients. The median follow-up time was 120 (range 5 - 245) months after salvage surgery. Nine patients died of disease progression, with a median survival time of 16 (range 5 - 27) months. Six patients had a long-term survival.

CONCLUSION: Salvage resection after radiotherapy can yield a long-time survival in selected patients with anal canal cancer. However it offers little hope to patients with T₄ and/or N_2-3 tumors.

Anal cancer: an HIV-associated cancer

Although not yet included in the Centers for Disease Control definition of AIDS, anal cancer clearly occurs more commonly in HIV-infected patients. An effective screening program for those groups who are at highest risk might be expected to impact rates of anal cancer just as significantly as did cervical Pap screening programs for the incidence of cervical cancer. Despite a relatively low rate of progression from AIN to invasive cancer, the scope of the problem is enormous based on the prevalence of anal HPV infection and the size of the HIV-infected, at-risk population. Thus, the potential benefits of screening, detection, and the development of more effective therapy also are enormous. Currently, therapeutic HPV vaccines for AIN represent an exciting avenue of research in HPV-related anogenital disease. Invasive anal cancer and HSIL (which is believed to be the precursor lesion) are expected to become increasingly important health problems for both HIV-infected men and women as their life expectancy lengthens. Although HAART may have improved the ability of many to tolerate CMT, it appears that toxicity of this therapy continues to be a problem for a proportion of HIV-infected subjects. The acute side effects present specific challenges to the clinician and patient, have an immediate impact on the patient's plan of care and dose intensity of the treatment, and ultimately may impact the outcome of the planned treatment. Late toxicity may influence the long-term quality of life. Small patient numbers, variable radiation therapy doses, limited information about viral load, and a potential confounding effect of higher CD4+ levels make it difficult to draw any conclusions about the effect of HAART on anal cancer outcome. Large, prospective studies will be required before solid conclusions about the impact of various factors on anal cancer prognosis and outcome can be drawn.