The evolving treatment of anal cancer: How are we doing?

Revisiting the Radical Radiotherapy-Radiochemotherapy Results in Anal Canal Cancers: (TROD Gastrointestinal Group Study 02-005)

BACKGROUND AND AIM

This study aimed to determine treatment outcomes and factors affecting prognosis in patients diagnosed with anal canal cancer who received radical radiotherapy (RT) or radiotherapy combined with chemotherapy (CT-RT) in radiation oncology centers in Turkey and compare the results with literature.

MATERIAL AND METHOD

The study included 193 patients with anal canal cancer reported between 1995 and 2019, of which 162 had complete data. The study was conducted in 11 radiation oncology centers, and a joint database was shared among them. Patients received radiotherapy doses of 45 Gy to 60 Gy. Data analysis was done using SPSS for Windows version 20.

RESULTS

Median follow-up was 48.51 months (2-214). All patients received radiotherapy, and 140 (86.4%) received concurrent chemotherapy. Radiotherapy doses of 50.4 Gy to 60 Gy were administered to 74 patients (45.7%) using 2-dimensional-3-dimensional (2D-3D) conformal therapy and 70 patients (43.2%) using intensity modulated radiotherapy technique (IMRT). Acute phase hematologic toxicity was observed in 62 patients (38.3%), and nonhematologic toxicity in 123 patients (75.9%). The 5-year overall survival (OS) rate was 75.1% and disease-specific survival (DSS) rate was 76.4%. OS without colostomy was achieved in 79,8 % at 5 years, and complete response in 112 patients (69.1%). OS rate was significantly higher in 142 patients with positive response (P < .000) and 112 with complete response (P < .000). Anemia (P < .002), local progression, and systemic progression (P < .000) resulted in lower OS (P < .002). In univariate analysis, factors affecting OS rate were: gender, age, stage, lymph node status, T stage, RT treatment duration, and treatment planning with PET fusion, which were found to be statistically significant. Completing radiotherapy in less than 45 days, concurrent chemotherapy, and continued administration of mitomycin and 5 FU as chemotherapy had a significant positive effect on overall survival. OS rate was higher in patients receiving RT dose of 58 Gy or less and undergoing IMRT planning in radiotherapy. IMRT was associated with lower acute and late side effects.

CONCLUSION

Radiochemotherapy is the primary treatment for anal canal cancer and advanced radiotherapy techniques may increase survival by reducing side effects and improving treatment continuation. Higher treatment doses require further investigation. The efficacy of treatment can be improved by including patients treated with modern radiotherapy techniques in multicenter prospective studies using new and more effective chemotherapy and immunotherapy agents.

Management of inguinal lymph node metastases from rectal and anal canal adenocarcinoma

AIM

The surgical treatment of inguinal lymph node (ILN) metastases secondary to anorectal adenocarcinoma remains controversial. This study aimed to clarify the surgical treatment and management of ILN metastasis according to its classification.

METHODS

This retrospective, multi-centre, observational study included patients with synchronous or metachronous ILN metastases who were diagnosed with rectal or anal canal adenocarcinoma between January 1997 and December 2011. Treatment outcomes were analysed according to recurrence and prognosis.

RESULTS

Among 1181 consecutively enrolled patients who received treatment for rectal or anal canal adenocarcinoma at 20 referral hospitals, 76 (6.4%) and 65 (5.5%) had synchronous and metachronous ILN metastases, respectively. Among 141 patients with ILN metastasis, differentiated carcinoma, solitary ILN metastasis and ILN dissection were identified as independent predictive factors associated with a favourable prognosis. No significant difference was found in the frequency of recurrence after ILN dissection between patients with synchronous (80.6%) or metachronous (81.0%) ILN metastases. Patients who underwent R0 resection of the primary tumour and ILN dissection had a 5-year survival rate of 41.3% after ILN dissection (34.1% and 53.1% for patients with synchronous and metachronous ILN metastases, respectively, P = 0.55).

CONCLUSION

The ILN can be appropriately classified as a regional lymph node in rectal and anal canal adenocarcinoma. Moreover, aggressive ILN dissection might be effective in improving the prognosis of low rectal and anal canal adenocarcinoma with ILN metastases; thus, prophylactic ILN dissection is unnecessary.

Anal canal cancers

Although anal canal cancer is rare, its incidence has increased in the last 30 years, especially in young men. The most common pathological type is squamous cell carcinoma. Definitive histopathological diagnosis is made by biopsy. “American Joint Committee on Cancer” (AJCC) TNM staging is used for staging. The standard approach in treatment is radiochemotherapy, and surgery is applied in persistent or recurrent failure.

Temporal improvements in loco-regional failure and survival in patients with anal cancer treated with chemo-radiotherapy: treatment cohort study (1990-2014)

Background

We evaluated oncological changes in patients with squamous cell carcinoma of the anus (SCCA) treated by chemoradiotherapy (CRT) from a large UK institute, to derive estimates of contemporary outcomes.

Methods

We performed a treatment-cohort analysis in 560 patients with non-metastatic SCCA treated with CRT over 25 years. The primary outcomes were 3-year loco-regional failure (LRF), 5-year overall survival (OS), and 5-year cancer-specific survival (CSS). We developed prediction models; and overlaid estimates on published results from historic trials.

Results

Age distributions, proportions by gender and cT stage remained stable over time. The median follow-up was 61 (IQR: 36–79) months. Comparing the first period (1990–1994) with the last period (2010–2014), 3-year LRF declined from 33 to 16% (P_trends < 0.001); 5-year OS increased from 60% to 76% (P_trends = 0.001); and 5-year CCS increased from 62% in to 80% (P_trends = 0.001). For 2020, the models predicted a 3-year LRF of 14.7% (95% CIs: 0–31.3); 5-year OS of 74.7% (95% CIs: 54.6–94.9); and 5-year CSS of 85.7% (95% CIs: 75.3–96.0). Reported oncological outcomes from historic trials generally underestimated contemporary outcomes.

Conclusions

Current and predicted rates for 3-year LRF and 5-year survivals are considerably improved compared with those in historic trials.

Early anal gland adenocarcinoma with a characteristic submucosal tumor-like appearance: a case report

BACKGROUND

The clinical findings of early anal gland carcinoma (AGC) have not been well delineated because AGC is a rare malignancy usually diagnosed at an advanced stage. Knowledge of the characteristic findings will be helpful for both diagnosis and determination of the treatment options for early AGC.

CASE PRESENTATION

A 62-year-old man was referred to our hospital for treatment of a rectal submucosal tumor (SMT) detected during a medical checkup at another hospital. Trans-sacral resection of the tumor was performed under the diagnosis of a rectal benign cyst. Pathological examination of the resected tumor showed a mucin-producing adenoma. About 14 months later, a new cystic lesion was found by follow-up examination, and trans-sacral resection of the tumor was performed again. The second pathological diagnosis was a mucinous adenocarcinoma with a possible remnant tumor at the local site. After providing sufficient informed consent, the patient underwent intersphincteric resection (ISR) of the rectum to preserve anal function. The final diagnosis was mucinous adenocarcinoma of the anal gland, T1N0M0. The patient remained alive without recurrence or complications for 6 years 7 months postoperatively.

CONCLUSION

We have herein reported a case of early AGC with a characteristic SMT-like appearance. Because the anal gland is located within both the submucosal layer and the internal sphincter muscle, ISR may be selected when the tumor is limited to inside the gland.

Anal adenocarcinoma requires prophylactic inguinal nodal treatment: Results from a single Chinese institution

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.

Tumours and inflammatory lesions of the anal canal and perianal skin revisited: an update and practical approach

Tumours of the anal and perianal region are relatively rare, and clinically often interpreted as innocuous lesions, leading to frequent delays in diagnosis and adequate treatment. Although squamous cell neoplasia represents the most common entity encountered in this anatomically complex area, many conditions, both neoplastic and inflammatory, may occur. Adding to the challenge of correct diagnosis and patient management, recent years have seen major updates in the terminology of squamous cell neoplasia, created to reflect advances in our understanding of the role of human papilloma virus and unify previous terminologies used for different sites in the anogenital tract. However, squamous cell neoplasia in the anal canal and perianal region may differ in terms of histology, biological behaviour, staging and treatment. The aim of this review is to present an overview of neoplastic and non-neoplastic lesions that may be seen in this area, an update on important developments and terminology, potential pitfalls that may be encountered in routine pathology practice and a practical approach on how to resolve these issues.

Can we omit prophylactic inguinal nodal irradiation in anal cancer patients?

Purpose

To evaluate the appropriateness of prophylactic inguinal nodal irradiation (PINI), we analyzed patterns of failure in anal cancer patients who were inguinal node-negative at presentation and did not receive PINI.

Materials and Methods

We retrospectively reviewed the records of 33 anal cancer patients treated by definitive concurrent chemoradiation therapy (CCRT) between 1994 and 2013. Radiotherapy consisted of a total dose of 44-45 Gy (22-25 fractions in 5 weeks) on the whole pelvis, anus, and perineum. Except inguinal lymphadenopathy was present at initial diagnosis, the entire inguinal chain was not included in the radiation field. In other words, there was no PINI.

Results

The median follow-up duration was 50 months (range, 4 to 218 months). Median survival and progression-free survival (PFS) were 57 months (range, 10 to 218 months) and 50 months (range, 4 to 218 months), respectively. Among the survival, the median follow-up duration was 51 months (range, 12 to 218 months). The 5-year overall survival and PFS rates were 93.4% and 88.8%, respectively. Although none of the patients received inguinal node irradiation for prophylactic purposes, there was no inguinal recurrence.

Conclusion

Treatment of anal cancer by omitting PINI might be considered in selected patients with clinically uninvolved inguinal nodes.

Adenocarcinoma arising from an anal gland-Report of a case

INTRODUCTION

Adenocarcinoma arising from an anal gland is extremely rare. Most anal canal cancers are squamous cell carcinoma, and adenocarcinoma is infrequently diagnosed. Diagnostic criteria and the standard treatment for adenocarcinoma of the anal canal have not been clearly defined, in part because of the rarity of this lesion.

PRESENTATION OF CASE

An 84-year-old man who presented with a piece of tissue prolapsing from the anus. An incisional biopsy showed adenocarcinoma, and an abdomino-perineal resection was then performed. Cytokeratin 7 (CK7), cytokeratin 19 (CK19) stained positive in the specimen, suggesting that the tumor developed from an anal gland. The patient was discharged after surgery without any complications.

DISCUSSION

Exact diagnostic criteria for adenocarcinoma of the anal canal have not been previously described. In the present case, CK7 and CK19 were stained, and the tumor showed positivity for both of these markers, which is compatible with the staining patterns of anal gland origin cancer. Radical resection is recommended rather than local resection, because of the tumor's high recurrence rate. Some authors recommend combined modality treatment with preoperative or postoperative chemoradiotherapy because of the high rate of distant recurrence.

CONCLUSION

The preoperative diagnosis of adenocarcinoma arising from an anal gland is not easily established. However, it may be possible to suspect an anal glandular adenocarcinoma based on a meticulous physical examination, appropriate diagnostic studies and pathological findings on biopsy.

Anal canal squamous cell carcinoma: overview, surveillance after treatment and management of local recurrence

SUMMARY Anal canal cancer is an uncommon gastrointestinal malignancy, although the incidence is increasing. Current treatment employs definitive chemoradiation, 5-fluorouracil, mitomycin C and a radiation dosage of 54–59 Gy for T3/T4 tumors, but not for T1 and T2 disease. Surveillance after completion of treatment is required. One acceptable strategy includes physical examinations every 3–6 months for 5 years and serial CT scans to detect advanced disease. A total of 40% of patients with T4 disease or immunosuppressed status may recur within the first 2 years after completion of treatment. Salvage therapy includes radical abdominoperineal resection. The most significant prognosticator after salvage surgery is the resection margin. Generally, patients with anal cancer should be treated by a multidisciplinary physician team and be assigned to clinical research trials, if feasible.

Role of brachytherapy in the boost management of anal carcinoma with node involvement (CORS-03 study)

PURPOSE

To assess retrospectively the clinical outcome in anal cancer patients, with lymph node involvement, treated with split-course radiation therapy and receiving a boost through external beam radiation therapy (EBRT) or brachytherapy (BCT).

METHODS AND MATERIALS

From 2000 to 2005, among 229 patients with invasive nonmetastatic anal squamous cell carcinoma, a selected group of 99 patients, with lymph node involvement, was studied. Tumor staging reported was T1 in 4 patients, T2 in 16 patients, T3 in 49 patients, T4 in 16 patients, and T unknown in 14 patients and as N1 in 67 patients and N2/N3 in 32 patients. Patients underwent a first course of EBRT (mean dose, 45.1 Gy) followed by a boost (mean dose, 18 Gy) using EBRT (50 patients) or BCT (49 patients). All characteristics of patients and tumors were well balanced between the BCT and EBRT groups. Prognostic factors of cumulative rate of local recurrence (CRLR), cumulative rate of distant (including nodal) recurrence (CRDR), colostomy-free survival (CFS) rate, and overall survival (OS) rate were analyzed for the overall population and according to the nodal status classification.

RESULTS

The median follow-up was 71.5 months. The 5-year CRLR, CRDR, CFS rate, and OS rate were 21%, 19%, 63%, and 74.4%, respectively. In the overall population, the type of node involvement (N1 vs N2/N3) was the unique independent prognostic factor for CRLR. In N1 patients, by use of multivariate analysis, BCT boost was the unique prognostic factor for CRLR (4% for BCT vs 31% for EBRT; hazard ratio, 0.08; P=.042). No studied factors were significantly associated with CRDR, CFS, and OS. No difference with regard to boost technique and any other factor studied was observed in N2/N3 patients for any kind of recurrence.

CONCLUSION

In anal cancer, even in the case of initial perirectal node invasion, BCT boost is superior to EBRT boost for CRLR, without an influence on OS, suggesting that N1 status should not be a contraindication to use of a BCT boost technique, as well as emphasizing the important of investigating the benefit of BCT boost in prospective randomized trials.

Epidermoid cancers of the anal canal: current treatment

Epidermoid carcinoma of the anal canal is an uncommon disease, but has increased in incidence with the HIV epidemic. Prior to the 1970s, treatment consisted of radical surgery with abdominoperineal resection. With the pioneering work of Dr. Norman Nigro, this has shifted to a nonsurgical approach, with primary treatment consisting of multimodality therapy with radiation and chemotherapy. This review provides an overview of the historical, current, and future treatments of epidermoid anal canal malignancies.

Epstein-Barr virus (EBV) positive anal B cell lymphoma: a case report and review of literature

This case report is on a very rare case of giant anal canal ulcer with rectal prolapse causing total faecal incontinence. An elderly patient in her eighties presented to the emergency department with complaints of a mass protruding thorough anus along with fresh rectal bleeding. Examination revealed a large ulcer measuring 6 cm x 8 cm involving the entire anal canal with rectal prolapse. Here, we discuss the management of this patient with a rare cause of giant anal canal ulceration.

Abdominal perineal resection improves survival for nonmetastatic adenocarcinoma of the anal canal

BACKGROUND

There remains a lack of consensus regarding the optimal treatment for patients with curable adenocarcinoma of the anal canal (AAC). We sought to determine the role of definitive surgical resection and radiation in a large cohort of patients with AAC.

MATERIALS AND METHODS

We queried the Surveillance, Epidemiology, and End Results (SEER) registry to identify all patients with nonmetastatic AAC from 1988 to 2004 and analyzed clinical factors, treatment modalities, and overall survival in this cohort. Kaplan-Meier survival curves were constructed to compare 5-year overall survival based on treatment groups: abdominal perineal resection (APR) only, APR and external beam radiation (APR and EBR), and EBR only. We performed a Cox regression analysis to determine factors predictive of outcome.

RESULTS

A total of 165 patients were identified with nonmetastatic AAC. Of these, 30 patients were treated with an APR only, 42 patients with an APR and EBR, and 93 patients with EBR only. The 5-year survival for APR only, APR and EBR, and EBR only was 58%, 50%, and 30%, respectively. The difference in survival was statistically significant (APR vs. EBR, P = .02; APR and EBR vs. EBR, P = 0.04). Multivariate analysis completed on 86 patients in this cohort confirmed that factors accounting for the survival differences included age (P = 0.004), nodal stage (P = 0.001), and treatment groups (P = 0.03). The hazard ratio between EBR only compared with APR only was 2.78.

CONCLUSIONS

Definitive surgical treatment in the form of an APR with or without EBR is associated with improved survival in patients with AAC.

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.

Radiation dose associated with local control in advanced anal cancer: retrospective analysis of 129 patients

BACKGROUND AND PURPOSE

To retrospectively analyse a large consecutive cohort of patients with anal cancer for treatment-related factors influencing local control and survival.

MATERIALS AND METHODS

All patients referred for primary radiotherapy at Medical University of Vienna in 1990-2002 with anal canal carcinoma without distant metastases were analysed. Treatment consisted of external radiotherapy with or without brachytherapy and with or without chemotherapy. Patient-, tumour-, and treatment-factors were tested for influence on survival and local control using Cox multivariate analysis.

RESULTS

Median age was 67 years (n=129), the UICC stage distribution was 15%, 58%, and 27% for stages I, II, and III, respectively. With median follow-up of 8.0 years for surviving patients (3.9 years including deceased patients), five-year overall survival and disease-free-survival were 57% and 51%, respectively. Local control at 5 years was 87%. Stage and age were significant factors for overall and colostomy-free-survival, N-stage for disease-free-survival. Shorter overall treatment time favoured local control in stage T1-2 (p=.015), higher total radiation dose and female gender were associated with improved local control in T3-4 tumours (p=.021).

CONCLUSIONS

These results support potential improvement of anal cancer treatment by studying advanced technology such as IMRT, making it possible to tailor high-dose regions.

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.

Combined multimodal approach to the treatment of metastatic anal carcinoma: report of a case and review of the literature

BACKGROUND

We report on a patient with squamous cell anal carcinoma and liver metastases, who underwent multimodal treatment for cure, consisting of repeated partial hepatectomy in combination with chemoradiotherapy.

PATIENTS AND METHODS

A 54-year-old woman presented with squamous cell anal carcinoma and liver metastases. She was treated with a combination of chemoradiotherapy for the primary tumor and then underwent surgery for liver metastases. 2 and 5 years after presentation, the patient underwent repeated partial hepatectomies for recurrent liver disease. At present, 5 months after completing therapy and 71 months after the initial diagnosis, she is in good health with no evidence of disease.

RESULTS

Repeated partial hepatectomy led to prolonged survival in a patient with squamous cell anal carcinoma metastatic to the liver.

CONCLUSIONS

This is the first report of aggressive partial hepatectomy for recurrent liver metastases resulting from anal cancer. Based on our experience, we suggest that in selected patients repeated hepatectomy should be part of an aggressive multimodal treatment program with curative intent.

Anal screening cytology

This issue of CytoJournal contains an article on screening for anal intraepithelial neoplasia in high-risk male patients. This accompanying Editorial focuses on current understanding of this relatively new disease entity, with insights as to the potential role of screening cytopathology in the epidemiology, pathophysiology and clinical management of this HIV and HPV related anal lesion, which predominates in male patients living long-term with AIDS. Mention is made of techniques of obtaining samples, methods of preparation, and morphologic classification. Issues of anoscopic confirmation, as well as topical and surgical management are emphasized. The similarity of initial experiences in anal screening to problems encountered early in cervical cancer screening programs several decades ago, are highlighted.

Anal cancer incidence and survival: the surveillance, epidemiology, and end results experience, 1973-2000

BACKGROUND

Anal cancer is a rare malignancy of the anogenital tract that historically has affected women at a greater rate than men.

METHODS

The authors analyzed changing trends in incidence rates and 5-year relative survival percentages for patients with anal cancer. The publicly available data used in the current study were obtained from the Surveillance, Epidemiology, and End Results (SEER) Program, a system of population-based tumor registries in the United States.

RESULTS

The incidence of anal cancer was similar for men and women between 1994 and 2000 (2.04 per 100,000 and 2.06 per 100,000, respectively), the most recent period for which data were available, whereas men had lower rates than did women between 1973 and 1979 (1.06 per 100,000, compared with 1.39 per 100,000), the earliest period for which data were available. In addition, recently, black men had higher incidence rates than did other race-specific and gender-specific groups (2.71 per 100,000). From the earliest period for which data were available to the most recent period, relative 5-year survival improved from 59% to 73% among women, was unchanged among men ( approximately 60%), and decreased from 45% to 27% among black men. Eighteen percent of patients who had distant disease were alive at 5 years, compared with 78% of patients who had localized disease.

CONCLUSIONS

The incidence of anal cancer in the United States increased between 1973 and 2000, particularly among men. There were higher incidence rates and lower survival rates for black men compared with other race-specific and gender-specific groups. Later disease stage was inversely associated with the survival rate, indicating that earlier detection may improve the survival of patients with anal cancer.

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.

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.