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Johnsson M, Alkner S, Johnsson A, Nilsson M. Impact of the risk-adapted Nordic anal cancer group consensus guidelines on the contouring of the elective clinical target volume in anal cancer. Acta Oncol 2025; 64:708-714. [PMID: 40420400 DOI: 10.2340/1651-226x.2025.42723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2025] [Accepted: 05/07/2025] [Indexed: 05/28/2025]
Abstract
BACKGROUND AND PURPOSE The recently published Nordic anal cancer group (NOAC) contouring guidelines aim for improved oncological outcomes and reduced toxicity in anal cancer patients treated with radiotherapy. The present work describes how the elective clinical target volume (CTVe) would change when applying the NOAC guidelines instead of the previous Australasian standard. According to the Australasian guidelines, the cranial border of the CTVe is at the common iliac bifurcation for all patients, and the external iliac region as well as the ischiorectal fossa are always included. MATERIALS AND METHODS Retrospectively, 166 anal cancer patients treated with curative radiotherapy according to Australasian guidelines between 2009 and 2017 were studied in a single-center analysis. Pretherapeutic scans, and clinical information were used to categorize patients according to the NOAC guidelines for a comparison with the Australasian guidelines. RESULTS Applying the risk-adapted alternative of the NOAC guidelines had the external iliac region omitted in 41.0% of the patients. The cranial border was lowered from the common iliac bifurcation in 27.7% and elevated in 12.7% of the patients. Elderly patients (≥70 years) more often had the external iliac region omitted than younger patients (60.9% vs. 33.3%; p = 0.001). The entire ischiorectal fossa was included in 23.7% of the patients due to tumor extension beyond the levator ani muscles or external sphincter. INTERPRETATION Contouring according to the NOAC risk-adapted guidelines changed, and mainly reduced, the CTVe in about half of all patients. Prospective follow-up is needed to determine if this is clinically beneficial.
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Affiliation(s)
- Marcus Johnsson
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.
| | - Sara Alkner
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Anders Johnsson
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Martin Nilsson
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
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Sodergren SC, Edwards R, Krishnatry R, Guren MG, Dennis K, Franco P, de Felice F, Darlington AS, Vassiliou V. Improving our understanding of the quality of life of patients with metastatic or recurrent/persistent anal cancer: a systematic review. Support Care Cancer 2025; 33:475. [PMID: 40372578 DOI: 10.1007/s00520-025-09520-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2024] [Accepted: 05/03/2025] [Indexed: 05/16/2025]
Abstract
PURPOSE Chemoradiation (CRT) is used to treat anal carcinomas which, for most patients with loco-regional disease, results in a cure but is associated with acute and chronic complications impairing quality of life (QoL). Patients with metastatic disease or recurrence are likely to experience additional QoL concerns. This paper identifies the QoL issues of these patients and determines whether the EORTC QLQ-ANL27 (QLQ-ANL27), a measure of QoL of patients treated with CRT for anal cancer used alongside the core EORTC QLQ-C30 (QLQ-C30), is suitable or needs adapting. METHODS A systematic review was conducted of studies published between 2014 and 2024 reporting QoL of patients with metastatic or recurrent/persistent anal cancer or follow-up data of patients treated with CRT for anal cancer. RESULTS This review included 23 papers, only three focused exclusively on metastatic and/or recurrent anal cancer. Most of the 53 reported symptoms related to bowel, urinary, and sexual functioning, with 60% covered by the QLQ-ANL27 or the QLQ-C30. Issues not captured include, for example, neuropathy, hair loss, musculoskeletal problems, urinary incontinence, and embarrassment. CONCLUSION There is a paucity of research looking specifically at QoL outcomes of patients with metastatic or recurrent anal cancer. Whilst the QLQ-ANL27 captures most QoL issues affecting these patients, it might require adapting to improve its sensitivity.
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Affiliation(s)
| | | | - Rahul Krishnatry
- Tata Memorial Centre, Homi Bhabha National Institute University, Mumbai, India
| | - Marianne G Guren
- Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | | | - Pierfrancesco Franco
- University Hospital 'Maggiore della Carità', Novara, Italy
- University of Eastern Piedmont, Novara, Italy
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Jirkovská M, Stankušová H, Kindlová A, Jirkovský D, Lohynská R. Interstitial HDR brachytherapy for anal cancer-results and quality of life. Strahlenther Onkol 2024:10.1007/s00066-024-02316-5. [PMID: 39542884 DOI: 10.1007/s00066-024-02316-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 10/02/2024] [Indexed: 11/17/2024]
Abstract
PURPOSE While anal cancer is a very rare oncological diagnosis representing less than 2% of lower gastrointestinal tract cancers, the incidence has doubled in the past 20 years. Radical radiochemotherapy with sequential or simultaneous boost is now the standard treatment modality. Interstitial HDR brachytherapy is one of the boost application options. Implementation of new radiotherapy techniques has resulted in improved therapeutic outcomes; however, it is still associated with acute and especially late toxicity. Gastrointestinal disorders and sexual dysfunction are the most frequent factors affecting the long-term quality of cured patients' lives. METHODS A total of 96 patients consecutively treated between 2000 and 2022 with external beam radio-/chemotherapy and an interstitial brachytherapy boost for histologically verified nonmetastatic anal squamous cell carcinoma were evaluated. The median follow-up time was 15.4 years (range 13.4-17.3 years). The primary objective of the study was to assess local control (LC) and quality of life (QoL). The Czech versions of internationally validated EORTC questionnaires were used to evaluate life quality-the basic EORTC QOL-C30 v.3 and the specific QOL-ANL 27 questionnaire. RESULTS Local control was 85.5% at 5 years, 83.4% at 10 years, 83.4% at 15 years, and 83.4% at 20 years, and there was no dependence on clinical stage. The most common forms of acute toxicity were cutaneous and hematological but were gastrointestinal for late toxicities. In the evaluation of quality of life, 80.5% of patients alive at the time participated. In the EORTC quality of life questionnaire C30 v.3, patients rated the functional scale score as 86.2 points (standard deviation [SD] = 12.6) and the symptom score as 15.5 points (SD = 12.5). The global health score achieved 68.4 points (SD = 23.6). The most common symptoms were fatigue with 25.6 points (SD = 20.2) and diarrhea with 19.0 points (SD = 27.8). In the QOL-ANL 27 questionnaire, symptom scales assessing bowel symptoms were scored 27.5 points (SD = 19) in non-stoma patients and 11.9 points (SD = 17.2) in stoma patients. In the single-item symptom scales, the highest scores were rated for frequency of urination with 26.4 points (SD = 30.8), need to be close to a toilet with 22.4 points (SD = 27.3), and self-cleaning more often with 25.3 points (SD = 31.8). In the functional scales assessing sex life and interest, men and women reported scores of 45.2 (SD = 23) and 45.5 points (SD = 19), respectively. CONCLUSION Boost with interstitial HDR brachytherapy is an established safe method of anal cancer treatment, with excellent results and limited late toxicity. Functioning scales were rated relatively highly in QoL questionnaires, and the overall global health score was comparable to published data. Gastrointestinal difficulties, fatigue, and sexual dysfunction dominated the symptom scales in our cohort.
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Affiliation(s)
- Michaela Jirkovská
- Department of Oncology, Second Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, 150 06, Prague, Czech Republic.
| | - Hana Stankušová
- Department of Oncology, Second Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, 150 06, Prague, Czech Republic
| | - Anna Kindlová
- Department of Oncology, Second Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, 150 06, Prague, Czech Republic
| | - Daniel Jirkovský
- Second Faculty of Medicine, Charles University in Prague, V Úvalu 84, 150 06, Prague, Czech Republic
| | - Radka Lohynská
- Department of Oncology, First Faculty of Medicine, Charles University and Thomayer University Hospital in Prague, Vídeňská 800, 140 59, Prague, Czech Republic
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Storm KS, Åström LM, Sibolt P, Behrens CP, Persson GF, Serup-Hansen E. ROAR-A: re-optimization based Online Adaptive Radiotherapy of anal cancer, a prospective phase II trial protocol. BMC Cancer 2024; 24:374. [PMID: 38528456 DOI: 10.1186/s12885-024-12111-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/12/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Chemo-radiotherapy with curative intent for anal cancer has high complete remission rates, but acute treatment-related gastrointestinal (GI) toxicity is significant. Toxicity occurs due to irradiation of surrounding normal tissue. Current radiotherapy requires the addition of large planning margins to the radiation field to ensure target coverage regardless of the considerable organ motion in the pelvic region. This increases the irradiated volume and radiation dose to the surrounding normal tissue and thereby toxicity. Online adaptive radiotherapy uses artificial intelligence to adjust the treatment to the anatomy of the day. This allows for the reduction of planning margins, minimizing the irradiated volume and thereby radiation to the surrounding normal tissue.This study examines if cone beam computed tomography (CBCT)-guided oART with daily automated treatment re-planning can reduce acute gastrointestinal toxicity in patients with anal cancer. METHODS/DESIGN The study is a prospective, single-arm, phase II trial conducted at Copenhagen University Hospital, Herlev and Gentofte, Denmark. 205 patients with local only or locally advanced anal cancer, referred for radiotherapy with or without chemotherapy with curative intent, are planned for inclusion. Toxicity and quality of life are reported with Common Terminology Criteria of Adverse Events and patient-reported outcome questionnaires, before, during, and after treatment. The primary endpoint is a reduction in the incidence of acute treatment-related grade ≥ 2 diarrhea from 36 to 25% after daily online adaptive radiotherapy compared to standard radiotherapy. Secondary endpoints include all acute and late toxicity, overall survival, and reduction in treatment interruptions. RESULTS Accrual began in January 2022 and is expected to finish in January 2026. Primary endpoint results are expected to be available in April 2026. DISCUSSION This is the first study utilizing online adaptive radiotherapy to treat anal cancer. We hope to determine whether there is a clinical benefit for the patients, with significant reductions in acute GI toxicity without compromising treatment efficacy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05438836. Danish Ethical Committee: H-21028093.
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Affiliation(s)
- Katrine Smedegaard Storm
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark.
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, København, Denmark.
| | - Lina M Åström
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Department of Health Technology, Technical University of Denmark, Roskilde, Denmark
| | - Patrik Sibolt
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Claus P Behrens
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Department of Health Technology, Technical University of Denmark, Roskilde, Denmark
| | - Gitte F Persson
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, København, Denmark
| | - Eva Serup-Hansen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
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Parkin E, Kallipershad S, Nasser A, Al-Mudhaffer M, Rosero D, Haston J, Williamson D, Mitchell P. Predictors of recurrence following local excision for early-stage anal squamous cell carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107093. [PMID: 37801832 DOI: 10.1016/j.ejso.2023.107093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/01/2023] [Accepted: 09/20/2023] [Indexed: 10/08/2023]
Abstract
INTRODUCTION There is increasing use of local excision (LE) for definitive treatment of early-stage anal squamous cell carcinoma (ASCC) to avoid the morbidity associated with chemoradiotherapy (CRT). However, the importance of different histological variables on risk of recurrence is poorly understood. METHODS A detailed analysis of patient characteristics, histology results, recurrence patterns and salvage treatment was conducted in consecutive T1/T2N0 ASCC patients treated by LE 2010-2021 across a UK regional cancer network multi-disciplinary team (MDT). Associations between potential predictors of disease recurrence were explored using chi-squared and Kruskal-Wallis tests for categorical and continuous variables respectively. RESULTS Of 621 ASCC patients discussed in the network MDT, 164 had early-stage disease (T1/T2 N0). Of these, 36 (22%) were deemed suitable for LE (median age 61 years, female to male ratio 2:1). Twenty-two LE tumours were T1; 14 were T2. There were 12 well-differentiated tumours, 21 moderate and 3 poorly-differentiated. Seven out of 36 LE patients (19.4%) developed recurrence, all of whom went on to have salvage treatment with CRT (n = 4), re-excision (n = 2) or radiotherapy (n = 1). Predictors of disease recurrence following LE were: tumour differentiation (p = 0.024), tumour depth (p = 0.033) and R1 resection margin (p = 0.034). Tumour stage and site (margin/canal) were non-significant. CONCLUSION LE for T1/T2 N0 ASCC of the margin or canal is a viable treatment strategy to avoid the morbidity associated with CRT and salvage treatments are still available for patients that develop recurrence. Tumour differentiation, depth and margin status are all important factors to consider when discussing management of early-stage ASCC.
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Affiliation(s)
- E Parkin
- Department of Colorectal Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom.
| | - S Kallipershad
- Department of Colorectal Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - A Nasser
- Department of Colorectal Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - M Al-Mudhaffer
- Department of Histopathology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - D Rosero
- Department of Histopathology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - J Haston
- Department of Clinical Oncology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - D Williamson
- Department of Clinical Oncology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - P Mitchell
- Department of Colorectal Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
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Zhang R, Luo W, Qiu Y, Chen F, Luo D, Yang Y, He W, Li Q, Li X. Clinical Management of Low Anterior Resection Syndrome: Review of the Current Diagnosis and Treatment. Cancers (Basel) 2023; 15:5011. [PMID: 37894378 PMCID: PMC10605930 DOI: 10.3390/cancers15205011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Low anterior resection syndrome (LARS) is a series of bowel dysfunction symptoms, including altered bowel frequency, irregular bowel rhythms, fecal incontinence, and constipation. LARS occurs in 80% of patients undergoing sphincter-preserving surgery, affecting patients' quality of life along with social avoidance. Different measurements and treatments have been raised to deal with LARS, but no systematic standard has been developed. OBJECTIVE AND METHODS To promote the standardization of clinical trials and clinical management of LARS, this review summarizes the latest findings up until 2023 regarding the diagnostic criteria, assessment protocols, and treatment modalities for postoperative LARS in rectal cancer. RESULTS The diagnostic criteria for LARS need to be updated to the definition proposed by the LARS International Collaborative Group, replacing the current application of the LARS score. In both clinical trials and clinical treatment, the severity of LARS should be assessed using at least one symptom assessment questionnaire, the LARS score or MSKCC BFI, and at least one scale related to quality of life. Anorectal manometry, fecoflowmetry, endoscopic ultrasonography, and pelvic floor muscle strength testing are recommended to be adopted only in clinical trials. After analysis of the latest literature on LARS treatment, a stepwise classification model is established for the standardized clinical management of LARS. Patients with minor LARS can start with first-line treatment, including management of self-behavior with an emphasis on diet modification and medication. Lamosetron, colesevelam hydrochloride, and loperamide are common antidiarrheal agents. Second-line management indicates multi-mode pelvic floor rehabilitation and transanal irrigation. Patients with major LARS should select single or several treatments in second-line management. Refractory LARS can choose antegrade enema, neuromodulation, or colostomy. CONCLUSIONS In clinical trials of LARS treatment between 2020 and 2022, the eligibility criteria and evaluation system have been variable. Therefore, it is urgent to create a standard for the diagnosis, assessment, and treatment of LARS. Failure to set placebos and differentiate subgroups are limitations of many current LARS studies. Randomized controlled trials comparing diverse therapies and long-term outcomes are absent, as well. Moreover, a new scale needs to be developed to incorporate the patient's perspective and facilitate outpatient follow-up. Though the establishment of a stepwise classification model for LARS treatment here is indispensable, the refinement of the guidelines may be improved by more standardized studies.
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Affiliation(s)
- Ruijia Zhang
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Wenqin Luo
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yulin Qiu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Fan Chen
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Dakui Luo
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yufei Yang
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weijing He
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qingguo Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xinxiang Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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Joseph K, Balushi MA, Ghosh S, Stenson T, Abraham A, Elangovan A, Warkentin H, Paulson K, Tankel K, Usmani N, Severin D, Schiller D, Wong C, Mulder K, Doll C, King K, Nijjar T. Long-Term Patient-Reported Quality of Life of Anal Cancer Survivors Treated With Intensity Modulated Radiation Therapy and Concurrent Chemotherapy: Results From a Prospective Phase II Trial. Int J Radiat Oncol Biol Phys 2023; 117:434-445. [PMID: 37148982 DOI: 10.1016/j.ijrobp.2023.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/12/2023] [Accepted: 04/18/2023] [Indexed: 05/08/2023]
Abstract
PURPOSE Intensity modulated radiation therapy (IMRT) has confirmed its superiority in improving acute treatment-related toxicities in anal cancer, without compromising tumor control. However, the effect of IMRT on long-term quality of life (QOL) is poorly documented. The study prospectively evaluated the long-term patient-reported QOL after IMRT-based chemoradiation in anal cancer. METHODS AND MATERIALS Fifty-eight patients treated with IMRT and concurrent 5 fluorouracil/mitomycin-C were enrolled in the study. A prespecified secondary endpoint was prospective evaluation of long-term QOL. Fifty-four patients underwent QOL evaluation at baseline, after treatment, and during follow-up until 60 months, with European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) scales and the Colorectal Cancer-Specific Quality Of Life Questionnaire (QLQ-CR29) scales. The QOL scores at baseline and posttreatment periods were compared. RESULTS For QLQ-C30, at 60 months, the mean scores of global health status, all functional scales, and all symptoms except diarrhea had improved, indicating normalization of QOL. Clinically and statistically significant improvements in the global health status (15.4; P = .003), role functioning (19.3; P = .0017), emotional functioning (18.9; P = .008), and social functioning (29.8; P ≤ .001) were observed. Diarrhea persisted as a concern over the years (P = .172). For European Organization for Research and Treatment of Cancer QLQ-CR29, rectal pain (-38.6; P = .001), mucous or blood discharge per rectum (-22.8; P = .005), and perianal soreness (-37.3; P ≤ .001) were improved both clinically and statistically. Clinically significant fecal leakage was reported by 16% of patients (5.6; P = .421). Volumes receiving 45 and 54 Gy were independent predictors for fecal incontinence. Clinically and statistically significant urinary incontinence occurred in 21% of patients (17.5; P = .014). Deterioration of dyspareunia was clinically significant (26.7; P = .099) at 60 months. CONCLUSIONS Compared with historical data, IMRT is associated with reduced long-term effects on QOL. The majority of patients treated with IMRT experienced clinically significant recovery of function and improvement in QOL over 5 years after completion of treatment. Specific toxicities such as chronic diarrhea, fecal incontinence, and urinary and sexual dysfunction were primarily responsible for deterioration of the long-term QOL. Future research aimed at reducing such toxicities is needed to further improve long-term QOL in anal cancer.
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Affiliation(s)
- Kurian Joseph
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada.
| | - Mustafa Al Balushi
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Sunita Ghosh
- Division of Medical Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Trevor Stenson
- Alberta Cancer Clinical Trials, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Aswin Abraham
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Arun Elangovan
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Heather Warkentin
- Alberta Cancer Clinical Trials, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Kim Paulson
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Keith Tankel
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Nawaid Usmani
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Diane Severin
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Dan Schiller
- Division of Medical Physics, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Clarence Wong
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, Canada; Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Karen Mulder
- Division of Medical Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Corinne Doll
- Division of Radiation Oncology, Department of Oncology, University of Calgary & Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Karen King
- Division of Medical Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Tirath Nijjar
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
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8
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Nilsson MP, Undseth C, Albertsson P, Eidem M, Havelund BM, Johannsson J, Johnsson A, Radu C, Serup-Hansen E, Spindler KL, Zakrisson B, Guren MG, Kronborg C. Nordic anal cancer (NOAC) group consensus guidelines for risk-adapted delineation of the elective clinical target volume in anal cancer. Acta Oncol 2023; 62:897-906. [PMID: 37504978 DOI: 10.1080/0284186x.2023.2240490] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023]
Abstract
Background: To date, anal cancer patients are treated with radiotherapy to similar volumes despite a marked difference in risk profile based on tumor location and stage. A more individualized approach to delineation of the elective clinical target volume (CTVe) could potentially provide better oncological outcomes as well as improved quality of life. The aim of the present work was to establish Nordic Anal Cancer (NOAC) group guidelines for delineation of the CTVe in anal cancer.Methods: First, 12 radiation oncologists reviewed the literature in one of the following four areas: (1) previous delineation guidelines; (2) patterns of recurrence; (3) anatomical studies; (4) common iliac and para-aortic recurrences and delineation guidelines. Second, areas of controversy were identified and discussed with the aim of reaching consensus.Results: We present consensus-based recommendations for CTVe delineation in anal cancer regarding (a) which regions to include, and (b) how the regions should be delineated. Some of our recommendations deviate from current international guidelines. For instance, the posterolateral part of the inguinal region is excluded, decreasing the volume of irradiated normal tissue. For the external iliac region and the cranial border of the CTVe, we agreed on specifying two different recommendations, both considered acceptable. One of these recommendations is novel and risk-adapted; the external iliac region is omitted for low-risk patients, and several different cranial borders are used depending on the individual level of risk.Conclusion: We present NOAC consensus guidelines for delineation of the CTVe in anal cancer, including a risk-adapted strategy.
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Affiliation(s)
- Martin P Nilsson
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | | | - Per Albertsson
- Department of Oncology, Sahlgrenska University Hospital, Region Västra Götaland, and Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Monika Eidem
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Norway
| | - Birgitte Mayland Havelund
- Department of Oncology, University Hospital of Southern Denmark, Lillebaelt Hospital, Vejle, Denmark
| | - Jakob Johannsson
- Department of Radiation Oncology, Landspitali University Hospital, Reykjavik, Iceland
| | - Anders Johnsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Calin Radu
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | - Eva Serup-Hansen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | | | - Björn Zakrisson
- Department of radiation sciences - oncology, Umeå University
| | - Marianne G Guren
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Camilla Kronborg
- Danish, Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark. Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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9
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Liu F, Guo P, Wang Q, Chen F, Wu W, Su X, Wang G, Yu Z, Jiang J, Liang F, Diao D, Chen Z, Liu Y, Meng F, Ning N, Ye Y. Excessive bowel volume loss during anus-preserving surgery for rectal cancer affects the bowel function after operation: A prospective observational cohort study (Bas-1611). Heliyon 2023; 9:e17630. [PMID: 37483691 PMCID: PMC10362271 DOI: 10.1016/j.heliyon.2023.e17630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 07/25/2023] Open
Abstract
Background Bowel volume loss during anus-preserving surgery (APS) may result in low anterior resection syndrome (LARS). We conducted this prospective observational cohort study to measure the incidence of LARS after surgery and evaluate the relationship between bowel volume loss and bowel function. Methods Patients with R0 resectable rectal cancer who consented to several bowel function surveys through telephone interviews after the operation were included. Enrolled patients underwent standard APS for rectal cancer, and three length indexes, viz. length of excised bowel, length of the distal margin and length of the proximal margin (LPM) of fresh bowel specimens, were measured in vitro. Results The three measured variables of the specimens showed a positively skewed distribution. Patient interviews revealed a trend of gradual improvement in bowel function. Univariate analyses revealed that longer LPM was associated with a significantly negative impact on bowel function at all time points. In multivariate analysis, LPM was found to be a significant risk factorstatistically significant, but its impact was not as strong as that of radiotherapy and low-middle tumour. Furthermore, there was no significant difference in the lymph node detection rate between <10-cm and ≥10-cm LPM groups. Conclusion In APS for rectal cancer, bowel volume loss is an important factor causing postoperative bowel dysfunction. Controlling LPM to <10 cm may help improve postoperative bowel function.
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Affiliation(s)
- Fan Liu
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, China
| | - Peng Guo
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, China
| | - Quan Wang
- Department of Gastrointestinal Surgery, The First Hospital of Jilin University, Changchun, China
| | - Fujun Chen
- Department of Colorectal Surgery, The First Affiliated Hospital of Jiamusi Medical University, Jiamusi, China
| | - Wenyong Wu
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Hefei, China
| | - Xiangqian Su
- Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital, Beijing, China
- Key Laboratory of Carcinogenesis and Translational Research, Peking University Cancer Hospital, Beijing, China
| | - Guiying Wang
- Department of General Surgery, 3rd Hospital of Hebei Medical University, Shijiazhuang, China
- 2nd Department of General Surgery, 4th Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhouman Yu
- Department of Gastroenterological Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Jianlong Jiang
- Department of General Surgery, Changshu Hospital Affiliated to Soochow University, First People's Hospital of Changshu City, Changshu, China
| | - Feng Liang
- Department of General Surgery, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Dechang Diao
- Department of Gastrointestinal (Tumor) Surgery, Guangdong Province Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhikang Chen
- Department of Colorectal and Anal Surgery, Xiangya Hospital of Central South University, Changsha, China
| | - Yuanting Liu
- Department of Gastroenterological Surgery, Tangshan People's Hospital, Tangshan, China
| | - Fanqiang Meng
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Ning Ning
- Department of Gastrointestinal Surgery, Peking University International Hospital, Beijing, China
| | - Yingjiang Ye
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, China
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10
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Sodergren SC, Johnson CD, Gilbert A, Darlington AS, Cocks K, Guren MG, Rivin Del Campo E, Brannan C, Christensen P, Chu W, Chung H, Dennis K, Desideri I, Gilbert DC, Glynne-Jones R, Jefford M, Johansson M, Johnsson A, Juul T, Kardamakis D, Lai-Kwon J, McFarlane V, Miguel IMC, Nugent K, Peters F, Riechelmann RP, Turhal NS, Wong S, Vassiliou V. International Validation of the EORTC QLQ-ANL27, a Field Study to Test the Anal Cancer-Specific Health-Related Quality-of-Life Questionnaire. Int J Radiat Oncol Biol Phys 2023; 115:1155-1164. [PMID: 36402360 DOI: 10.1016/j.ijrobp.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE The European Organisation for Research and Treatment of Cancer (EORTC) health-related quality of life questionnaire for anal cancer (QLQ-ANL27) supplements the EORTC cancer generic measure (QLQ-C30) to measure concerns specific to people with anal cancer treated with chemoradiotherapy. This study tested the psychometric properties and acceptability of the QLQ-ANL27. METHODS AND MATERIALS People with anal cancer were recruited from 15 countries to complete the QLQ-C30 and QLQ-ANL27 and provide feedback on the QLQ-ANL27. Item responses, scale structure (multitrait scaling, factor analysis), reliability (internal consistency and reproducibility) and sensitivity (known group comparisons and responsiveness to change) of the QLQ-ANL27 were evaluated. RESULTS Data from 382 people were included in the analyses. The EORTC QLQ-ANL27 was acceptable, comprehensive, and easy to complete, taking an average 8 minutes to complete. Psychometric analyses supported the EORTC QLQ-ANL27 items and reliability (Cronbach's α ranging from 0.71-0.93 and test-retest coefficients above 0.7) and validity of the scales (particularly nonstoma bowel symptoms and pain/discomfort). Most scales distinguished people according to treatment phase and performance status. Bowel (nonstoma), pain/discomfort, and vaginal symptoms were sensitive to deteriorations over time. The stoma-related scales remained untested because of low numbers of people with a stoma. Revisions to the scoring and question ordering of the sexual items were proposed. CONCLUSIONS The QLQ-ANL27 has good psychometric properties and is available in 16 languages for people treated with chemoradiotherapy for anal cancer. It is used in clinical trials and has a potential role in clinical practice.
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Affiliation(s)
| | | | - Alexandra Gilbert
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | | | - Kim Cocks
- KCStats Consultancy, Cheshire, United Kingdom
| | - Marianne G Guren
- Department of Oncology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eleonor Rivin Del Campo
- Department of Radiation Oncology, Tenon University Hospital, Sorbonne University, Paris, France
| | | | | | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Hans Chung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Kristopher Dennis
- The Ottawa Hospital Cancer Centre, Ottawa, Canada; Department of Radiology, University of Ottawa, Ottawa, Canada
| | - Isacco Desideri
- Radiotherapy Department, University of Florence, Florence, Italy
| | - Duncan C Gilbert
- Sussex Cancer Centre, Royal Sussex County Hospital, Eastern Road, Brighton, United Kingdom
| | | | - Michael Jefford
- Departments of Medical Oncology and Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Mia Johansson
- Department of Oncology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Department of Oncology, University of Gothenburg, Gothenburg, Sweden
| | - Anders Johnsson
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Therese Juul
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Dimitrios Kardamakis
- Department of Radiation Oncology, University of Patras Medical School, Patras, Greece
| | - Julia Lai-Kwon
- Departments of Medical Oncology and Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Vicky McFarlane
- University Hospital Southampton, Southampton, United Kingdom
| | | | - Karen Nugent
- University Hospital Southampton, Southampton, United Kingdom
| | - Femke Peters
- Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | | | - Shun Wong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Vassilios Vassiliou
- Department of Radiation Oncology, Bank of Cyprus Oncology Center, Nicosia, Cyprus
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11
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Influence of radiation treatment technique (IMRT vs. 3D-RT) on acute toxicity and prognostic factors for survival for anal cancer. Sci Rep 2022; 12:19914. [PMID: 36402828 PMCID: PMC9675840 DOI: 10.1038/s41598-022-24362-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 11/14/2022] [Indexed: 11/21/2022] Open
Abstract
We compared our institutional experience with intensity-modulated radiotherapy (IMRT) and 3D-conformal radiotherapy (3D-RT) for definitive treatment of primary anal cancer. We performed a single-institution retrospective review of all patients with anal squamous cell carcinoma treated with definitive (chemo) radiotherapy with curative intent from 2004 through 2018. We assessed several prognostic factors in respect to relevant survival endpoints. In addition, acute toxicities were determined and compared between IMRT and 3D-RT patients. This study included 94 patients (58 IMRT, 36 3D-RT). Mean follow up for all patients, for IMRT and 3D-RT patients was 61 months (range 6-176), 46 months (range 6-118), and 85 months (range 6-176), respectively. 5-year overall survival (OS) was 86%, disease-free survival (DFS) was 72%, and colostomy-free survival (CFS) was 75% in the IMRT cohort. In the 3D-RT cohort, OS was 87%, DFS was 71%, and CFS was 81% (all p > 0.05). Male gender and Karnofsky Index (KI) were revealed as independent prognostic factors for 5-year OS (p = 0.017; p = 0.023). UICC stage was an independent prognostic factor for DFS and CFS (p = 0.023; p = 0.042). In addition, the pre-treatment leukocyte count was an independent prognostic factor for CFS (p = 0.042). Acute grade ≥ 3 toxicity was not significantly different between IMRT and 3D-RT patients, but the IMRT cohort had favorable outcomes. This study confirmed IMRT as the primary definitive treatment of anal cancer. With similar survival rates, IMRT had the potential to reduce acute toxicity by sparing organs at risk. Promising prognostic factors such as BMI, KI, and leucocyte and hemoglobin levels should be further investigated.
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12
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van Dongen J, de Heus E, Eickholt L, Schrieks M, Zantingh I, Brouwer OR, Oonk MHM, Grotenhuis BA, Ezendam NPM, Duijts SFA. Challenges and controversies patients and (health care) professionals experience in managing vaginal, vulvar, penile or anal cancer: The SILENCE study. Eur J Cancer Care (Engl) 2022; 31:e13676. [PMID: 35938519 PMCID: PMC9787908 DOI: 10.1111/ecc.13676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/23/2022] [Accepted: 07/28/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Patients with vaginal, vulvar, penile or anal cancer experience deteriorated psychosocial functioning and decreased Quality of Life (QoL). The aims of this study were to explore (1) the challenges and controversies patients experience in managing vaginal, vulvar, penile or anal cancer; their unmet needs; and how this affects their psychosocial functioning and (2) the gaps health care professionals (HCPs) experience in providing psychosocial support and potential improvements in care. METHODS Semi-structured interviews with patients with vaginal, vulvar, penile or anal cancer and with HCPs were conducted. All interviews were transcribed verbatim and thematically analysed. RESULTS Fourteen patients (86% female; mean age 55.5) and 12 HCPs (75% female; mean age 46.4) participated. Four themes were identified: (1) recognisable symptoms but unfamiliar diagnosis, (2) 'double hit' has severe impact on psychosocial functioning, (3) personal and tailored information is important but not guaranteed and (4) all-encompassing care to improve psychosocial functioning and QoL. CONCLUSION Patients with vaginal, vulvar, penile or anal cancer encounter a lack of awareness and knowledge about their rare cancer type, difficulties regarding communication and long-term changes in body image and sexuality. Awareness of symptoms should be raised and psychosocial care should be offered on a structural basis.
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Affiliation(s)
- Jessy van Dongen
- Department of Research and DevelopmentNetherlands Comprehensive Cancer Organisation (Integraal Kankercentrum Nederland, IKNL)UtrechtNetherlands
| | - Eline de Heus
- Department of Research and DevelopmentNetherlands Comprehensive Cancer Organisation (Integraal Kankercentrum Nederland, IKNL)UtrechtNetherlands,Department of Medical OncologyRadboud University Medical CenterNijmegenNetherlands
| | - Lauren Eickholt
- Department of Research and DevelopmentNetherlands Comprehensive Cancer Organisation (Integraal Kankercentrum Nederland, IKNL)UtrechtNetherlands
| | - Marga Schrieks
- Dutch Federation of Cancer Patients Organisations (Nederlandse Federatie van Kankerpatiëntenorganisaties, NFK)UtrechtNetherlands
| | - Ilaniek Zantingh
- Center for Quality of LifeThe Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital (NKI‐AvL)AmsterdamThe Netherlands
| | - Oscar R. Brouwer
- Department of UrologyThe Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital (NKI‐AvL)AmsterdamNetherlands
| | - Maaike H. M. Oonk
- Department of Obstetrics and GynecologyUniversity Medical Center GroningenGroningenNetherlands
| | - Brechtje A. Grotenhuis
- Department of Surgical OncologyThe Netherlands Cancer Institute – Antoni van Leeuwenhoek (NKI‐AvL)AmsterdamNetherlands
| | - Nicole P. M. Ezendam
- Department of Research and DevelopmentNetherlands Comprehensive Cancer Organisation (Integraal Kankercentrum Nederland, IKNL)UtrechtNetherlands,Department of Medical and Clinical Psychology, Center of Research on Psychology in Somatic diseasesTilburg UniversityTilburgNetherlands
| | - Saskia F. A. Duijts
- Department of Research and DevelopmentNetherlands Comprehensive Cancer Organisation (Integraal Kankercentrum Nederland, IKNL)UtrechtNetherlands,Department of Medical Psychology, Cancer Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamNetherlands
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13
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De B, Corrigan KL, Rooney MK, Ludmir EB, Das P, Smith GL, Taniguchi CM, Minsky BD, Koay EJ, Koong A, Morris VK, Messick CA, You YN, Chang GJ, Westney OL, Nogueras Gonzalez GM, Holliday EB. Patient-Reported Bowel and Urinary Function in Long-Term Survivors of Squamous Cell Carcinoma of the Anus Treated With Definitive Intensity Modulated Radiation Therapy And Concurrent Chemotherapy. Int J Radiat Oncol Biol Phys 2022; 114:78-88. [PMID: 35589011 DOI: 10.1016/j.ijrobp.2022.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/30/2022] [Accepted: 05/07/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE Definitive radiation therapy with concurrent chemotherapy is curative for nonmetastatic squamous cell carcinoma of the anus (SCCA). However, the true effect of chemoradiation on long-term functional outcomes is poorly understood owing to limited follow-up and patient-reported outcomes (PROs). METHODS AND MATERIALS We conducted a cross-sectional survey of 248 patients with SCCA treated with definitive intensity modulated radiation and concurrent chemotherapy from 2010 to 2018 who were alive and without recurrence. PRO measures were collected, including Functional Assessment of Cancer Therapy-General (FACT-G7), Fecal Incontinence Quality of Life (FIQoL), Low Anterior Resection Syndrome (LARS), and International Consultation on Incontinence Questionnaires (ICIQ). Models were used to determine the association between demographic, tumor, treatment, and dosimetric data with PROs. RESULTS One hundred twelve (45%) patients completed PROs. Median [interquartile range (IQR)] time from radiation completion to survey was 51 [37-85] months. The median scores [IQR] for FACT-G7, FIQoL, and LARS were 21 [15-24], 14 [11-16], and 32 [25-37], respectively. For men, median subscores [IQR] for ICIQ voiding and incontinence subscores were 5 [2-6] and 1 [1-3], respectively. For women, median subscores [IQR] for ICIQ voiding, incontinence, and filling were 1 [1-3], 5 [3-8], and 4 [2-5], respectively. Higher (better) FIQoL scores were associated with higher (better) FACT-G7 scores (β = 0.83; 95% confidence interval, 0.58-1.09; P < .001), and higher (worse) LARS scores were associated with lower (worse) FACT-G7 scores (β = -0.22; 95% confidence interval, -0.31 to -0.13; P < .001). A separate multivariable analysis revealed higher bowel bag D1% was associated with lower (worse) FIQoL (P = .001) and higher (worse) LARS (P = .003) scores. Higher bladder V40 Gy was associated with increased (worse) ICIQ voiding subscore (P = .001). CONCLUSIONS Patients treated with modern chemoradiation for SCCA experience significant long-term bowel toxic effects with considerable effect on quality of life. Minimizing bowel hotspots and bladder V40 Gy may improve bowel and urinary function. Other interventions to reduce long-term toxic effects and improve quality of life are needed.
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Affiliation(s)
- Brian De
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology
| | - Kelsey L Corrigan
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology
| | - Michael K Rooney
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology
| | - Ethan B Ludmir
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology; Department of Biostatistics
| | - Prajnan Das
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology
| | - Grace L Smith
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology; Department of Health Services Research
| | - Cullen M Taniguchi
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology
| | - Bruce D Minsky
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology
| | - Eugene J Koay
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology
| | - Albert Koong
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology
| | - Van K Morris
- Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine
| | | | - Y Nancy You
- Department of Colon and Rectal Surgery, Division of Surgery
| | - George J Chang
- Department of Health Services Research; Department of Colon and Rectal Surgery, Division of Surgery
| | - O Lenaine Westney
- Department of Urology, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Emma B Holliday
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology.
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14
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Goffredo P, Klemen ND, Hassan I. Prevention of Anal Cancer. N Engl J Med 2022; 387:666-667. [PMID: 36070724 DOI: 10.1056/nejmc2209237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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15
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Principe DR, Cataneo JL, Timbers KE, Koch RM, Valyi-Nagy K, Mellgren A, Rana A, Gantt G. Leukocyte subtyping predicts for treatment failure and poor survival in anal squamous cell carcinoma. BMC Cancer 2022; 22:697. [PMID: 35751111 PMCID: PMC9229146 DOI: 10.1186/s12885-022-09742-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background Anal squamous cell carcinoma (SCC) generally carries a favorable prognosis, as most tumors are highly sensitive to standard of care chemoradiation. However, outcomes are poor for the 20–30% of patients who are refractory to this approach, and many will require additional invasive procedures with no guarantee of disease resolution. Methods To identify the patients who are unlikely to respond to the current standard of care chemoradiation protocol, we explored a variety of objective clinical findings as a potential predictor of treatment failure and/or mortality in a single center retrospective study of 42 patients with anal SCC. Results Patients with an increase in total peripheral white blood cells (WBC) and/or neutrophils (ANC) had comparatively poor clinical outcomes, with increased rates of death and treatment failure, respectively. Using pre-treatment biopsies from 27 patients, tumors with an inflamed, neutrophil dominant stroma also had poor therapeutic responses, as well as reduced overall and disease-specific survival. Following chemoradiation, we observed uniform reductions in nearly all peripheral blood leukocyte subtypes, and no association between peripheral white blood cells and/or neutrophils and clinical outcomes. Additionally, post-treatment biopsies were available from 13 patients. In post-treatment specimens, patients with an inflamed tumor stroma now demonstrated improved overall and disease-specific survival, particularly those with robust T-cell infiltration. Conclusions Combined, these results suggest that routinely performed leukocyte subtyping may have utility in risk stratifying patients for treatment failure in anal SCC. Specifically, pre-treatment patients with a high WBC, ANC, and/or a neutrophil-dense tumor stroma may be less likely to achieve complete response using the standard of care chemoradiation regimen, and may benefit from the addition of a subsequent line of therapy. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09742-7.
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Affiliation(s)
- Daniel R Principe
- Medical Scientist Training Program, University of Illinois College of Medicine, Chicago, IL, USA.,Department of Surgery, University of Illinois at Chicago, IL, Chicago, USA
| | - Jose L Cataneo
- Department of Surgery, University of Illinois at Chicago, IL, Chicago, USA
| | - Kaytlin E Timbers
- Department of Surgery, University of Illinois at Chicago, IL, Chicago, USA
| | - Regina M Koch
- Department of Surgery, University of Illinois at Chicago, IL, Chicago, USA
| | - Klara Valyi-Nagy
- Department of Pathology, University of Illinois at Chicago, IL, Chicago, USA
| | - Anders Mellgren
- Department of Surgery, Division of Colorectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Ajay Rana
- Department of Surgery, University of Illinois at Chicago, IL, Chicago, USA.,Jesse Brown VA Medical Center, Chicago, IL, USA
| | - Gerald Gantt
- Department of Surgery, Division of Colorectal Surgery, University of Illinois at Chicago, Chicago, IL, USA.
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16
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Sauter C, Peeken JC, Borm K, Diehl C, Münch S, Combs SE, Dapper H. Quality of life in patients treated with radiochemotherapy for primary diagnosis of anal cancer. Sci Rep 2022; 12:4416. [PMID: 35292732 PMCID: PMC8924204 DOI: 10.1038/s41598-022-08525-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/04/2022] [Indexed: 11/12/2022] Open
Abstract
Anal cancer and the related treatment are generally known to affect patients’ quality of life. The aim of this study was to assess self-reported quality of life (QoL) of anal cancer patients after combined radiation and chemotherapy, and to identify patient-, disease-, and therapy-related factors associated with QoL. A total of 94 patients treated with definitive chemoradiation for anal cancer at our institution in the period from 2004 to 2018 were identified from our database. QoL was assessed in the remaining 52 patients using the EORTC QLQ-C30 questionnaire (cancer-specific QoL) and the newly developed anal cancer module QLQ-ANL27 (site-specific QoL). Differences in QoL between anal cancer patients and a German age and sex adjusted reference population were examined. The median follow-up was 71 months (range, 7–176). In the cancer-specific QoL module, the anal cancer cohort presented with significantly lower scores in role (− 12.2 points), emotional (− 6.6 points), and social functioning (− 6.8 points), but higher scores in diarrhea (+ 36.3 points) and constipation (+ 13.3 points) than the German reference population. There were no significant differences in disease- or therapy-related factors, but age greater than 70 years and a follow-up time greater than 71 months had a negative impact on global QoL. As for the site-specific QoL, patients with a tumor relapse showed significantly higher symptom scores than patients with a complete clinical remission in all scales except of micturition frequency. Compared to 3D conformal radiotherapy, IMRT treatment seemed to improve non-stoma bowel function (+ 23.3 points), female sexual functioning (+ 24.2 points), and came along with less scores in the symptom scales pain (− 35.9 points), toilet proximity (− 28.6 points), and cleanliness (− 26.2 points). Most of the functional scores of anal cancer patients were lower compared to the general German population, but did not seem to affect the general QoL. Fatigue, physical, and role functioning had the strongest impact on global QoL causing psychological symptoms as important as physical.
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Affiliation(s)
- Christina Sauter
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Jan C Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.,Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany
| | - Kai Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christian Diehl
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.,Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
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17
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Axelsson A, Johansson M, Bock D, Haglind E, de la Croix H, Nilsson PJ, Angenete E. Patient-reported QoL in anal cancer survivors 3 and 6 years after treatment—results from the Swedish national ANCA study. Support Care Cancer 2022; 30:4169-4178. [PMID: 35079906 PMCID: PMC8942973 DOI: 10.1007/s00520-021-06769-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022]
Abstract
Purpose The impact of anal cancer treatment for the patients is best evaluated by the patients themselves. The purpose of this study was to investigate quality of life (QoL) in patients with anal cancer at 3 and 6 years after treatment. Methods A Swedish national cross-sectional prospective cohort study with patients diagnosed with anal cancer between 2011 and 2013. Patients were invited to respond to a QoL questionnaire at 3 and 6 years, with focus on bowel, urinary and sexual function, social and mental function, co-morbidity, lifestyle, daily activities, personal characteristics, and perceived QoL. It also contained questions on the severity of the symptoms regarding occurrence, frequency, and duration and the level of “bother” experienced related to functional symptoms. QoL and prevalence of bother with urinary, sexual, bowel dysfunction, and anal pain were described. The prevalence of impaired QoL was compared with a healthy reference population. The association between QoL and experiencing bother was quantified by regression models. Results From an original cohort of 464 patients with anal cancer, 264 (57%) were alive and contacted at 3 years and 230 (50%) at 6 years. One hundred ninety-five (74%) patients responded to the 3-year and 152 (66%) to the 6-year questionnaire. Sixty percent reported low QoL at both 3 and 6 years. Impaired QoL was more prevalent among patients with major bother due to bowel dysfunction (at 3 years RR 1.42, 95% CI (1.06–1.9) p-value 0.020, at 6 years RR 1.52, 95% CI (1.03–2.24) p-value 0.034) and urinary dysfunction (at 6 years RR 1.44, 95% CI (1.08–1.91) p-value 0.013). There was a tendency to a positive relationship between the number of bodily functions causing bother and risk for impaired QoL. Conclusion Patients treated for anal cancer reported bother regarding several bodily functions as well as poor QoL both at 3 and 6 years without much improvement. Bother was also associated with low QoL indicating that function-related bother should be addressed.
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Haas S, Mikkelsen AH, Kronborg C, Oggesen BT, Faaborg PM, Serup-Hansen E, Spindler KLG, Christensen P. Management of late adverse effects after chemoradiation for anal cancer. Acta Oncol 2021; 60:1688-1701. [PMID: 34845967 DOI: 10.1080/0284186x.2021.1983208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE Significant improvements in the treatment of anal cancer have produced a growing population of anal cancer survivors. These patients often experience late adverse effects related to their treatment. Research has revealed substantial unmet needs because of long-term symptoms and functional impairments after treatment that may negatively affect health-related quality of life. The purpose of the present guidelines is to review the scientific evidence for the management of late adverse effects after (chemo)radiotherapy ([C]RT) for anal cancer and to extrapolate knowledge from other pelvic malignancies treated with pelvic (C)RT so that they may guide the clinical management of late adverse effects. MATERIALS AND METHODS Relevant studies were systematically searched in four databases from their inception to June 2020 (no language limitation) and guidelines were searched in 16 databases, focussing on bowel dysfunction, psychosocial aspects, pain, and sexual and urinary dysfunction. The guidelines were developed by a panel of experts using the Oxford Centre for Evidence-based Medicine, levels of evidence, and grades of recommendations. SCIENTIFIC EVIDENCE Late adverse effects after (C)RT for anal cancer are associated with a low overall quality of life among survivors. The most pronounced late adverse effects are bowel dysfunction (present in up to 78%), urinary dysfunction (present in up to 45%), and sexual dysfunction (present in up to 90% of men and up to 100% of women). Only indirect data on adequate treatment options of these late adverse effects for anal cancer are available. CONCLUSION Quality of life and late adverse effects should be monitored systematically following treatment for anal cancer to identify patients who require further specialist evaluation or support. Increased awareness of the extent of the problem may serve to stimulate and facilitate multidisciplinary collaboration, which is often required.
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Affiliation(s)
- Susanne Haas
- Danish Cancer Society, National Research Centre for Survivorship and Late Adverse Effects following Pelvic Organ Cancer, Department of Surgery, Aarhus University Hospital, Aalborg, Denmark
| | | | - Camilla Kronborg
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Pia Moeller Faaborg
- Department of Surgery, Vejle Hospital, Danish Colorectal Cancer Centre South, Vejle, Denmark
| | | | | | - Peter Christensen
- Danish Cancer Society, National Research Centre for Survivorship and Late Adverse Effects following Pelvic Organ Cancer, Department of Surgery, Aarhus University Hospital, Aalborg, Denmark
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Nilsson MP, Gunnlaugsson A, Johnsson A, Scherman J. Dosimetric and Clinical Predictors for Acute and Late Gastrointestinal Toxicity Following Chemoradiotherapy of Locally Advanced Anal Cancer. Clin Oncol (R Coll Radiol) 2021; 34:e35-e44. [PMID: 34598844 DOI: 10.1016/j.clon.2021.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/04/2021] [Accepted: 09/16/2021] [Indexed: 11/03/2022]
Abstract
AIMS To analyse dosimetric and clinical predictors for acute and late gastrointestinal toxicity following chemoradiotherapy of anal cancer. MATERIALS AND METHODS Consecutive patients with locally advanced (T2 ≥4 cm - T4 or N+) anal cancer were selected from an institutional database (n = 114). All received intensity-modulated radiotherapy with concomitant 5-fluorouracil and mitomycin C. Gastrointestinal toxicity was retrospectively graded according to Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 and bowel cavity, small bowel and large bowel were contoured. Dosimetric and clinical variables were tested for associations with acute grade ≥3 gastrointestinal toxicity and late grade ≥2 gastrointestinal toxicity using the Mann-Whitney test, area under receiver operating characteristic curve (AUC) and logistic regression. RESULTS The median follow-up was 40 months. Acute grade ≥3 gastrointestinal toxicity was seen in 51 (44.7%) of the patients; late grade ≥2 gastrointestinal toxicity was seen in 36 of the patients (39.6% of 91 patients with >1 year recurrence-free follow-up). Bowel cavity V30Gy was the best dosimetric predictor for acute gastrointestinal toxicity (AUC 0.633; P = 0.02). Large bowel V20Gy was the best dosimetric predictor for late gastrointestinal toxicity (AUC 0.698; P = 0.001) but showed no association with acute gastrointestinal toxicity. In multivariate logistic regression, increasing age was significantly associated with acute gastrointestinal toxicity; smoking and large bowel V20Gy were significantly associated with late gastrointestinal toxicity. Patients who experienced acute grade ≥3 gastrointestinal toxicity were not at an increased risk of late grade ≥2 gastrointestinal toxicity (odds ratio 1.3; P = 0.55). CONCLUSIONS Factors of importance for acute and late gastrointestinal toxicity were not the same. Bowel cavity V30Gy is a good metric to use for the prediction of acute gastrointestinal toxicity, but the results of our study indicate that individual large and small bowel loops need to be contoured for better prediction of late gastrointestinal toxicity. The role of the large bowel as an important organ at risk for late gastrointestinal toxicity merits further research.
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Affiliation(s)
- M P Nilsson
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.
| | - A Gunnlaugsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - A Johnsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - J Scherman
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
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20
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Possiel J, Ammon HE, Guhlich M, Conradi LC, Ghadimi M, Wolff HA, Schirmer MA, Samel S, Mügge M, Rieken S, Leu M, Dröge LH. Volumetric Modulated Arc Therapy Improves Outcomes in Definitive Radiochemotherapy for Anal Cancer Whilst Reducing Acute Toxicities and Increasing Treatment Compliance. Cancers (Basel) 2021; 13:cancers13112533. [PMID: 34064061 PMCID: PMC8196749 DOI: 10.3390/cancers13112533] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 05/16/2021] [Accepted: 05/19/2021] [Indexed: 01/13/2023] Open
Abstract
Simple Summary Intensity-modulated radiotherapy (IMRT) is the standard of care in definitive chemoradiotherapy (CRT) for anal cancer. Only a limited number of studies have analyzed the clinical results with VMAT (volumetric modulated arc therapy, the advanced form of IMRT). We conducted a retrospective study on patients treated at our institution. We compared the outcomes of VMAT-treated and 3DCRT (3D conformal radiotherapy)-treated patients. VMAT reduced acute toxicities (i.e., primarily dermatitis and enteritis) to a great extent. Additionally, VMAT relevantly improved treatment compliance (i.e., less CRT interruptions/delays, shorter overall treatment time, and higher absolute 5-fluorouracil dose applied). Finally, we found improved cancer-specific survival and distant control in VMAT-treated patients. The present study underlines the great progress that has been achieved with IMRT/VMAT in the CRT of anal cancer. Our study is the first to demonstrate an improvement in treatment compliance and outcomes with VMAT. Future studies could address whether VMAT is advantageous when compared to conventional IMRT. Abstract Background: Intensity-modulated radiotherapy (IMRT) is the standard of care in chemoradiotherapy (CRT) for anal cancer. Until now, only a limited number of studies have analyzed the results with VMAT (volumetric modulated arc therapy). We conducted a retrospective study on patients treated at our institution. Patients and Methods: We included patients who received curative CRT for anal cancer. We compared VMAT-treated and 3DCRT (3D conformal radiotherapy)-treated patients. We analyzed toxicities (acute: CTCAE criteria; late: LENT/SOMA criteria), treatment compliance, overall survival, cancer-specific survival (CSS), distant control (DC), and locoregional control. Results: A total of 149 patients (3DCRT: n = 87, VMAT: n = 62) were included. The median follow-up was longer in 3DCRT-treated patients (3DCRT: 61.3 months; VMAT: 39.1 months; p < 0.05). VMAT-treated patients had more G3 tumors (3DCRT: 12/87 (13.8%); VMAT: 18/62 (29.0%), p < 0.001). VMAT reduced acute toxicities ≥grade 3 (3DCRT: n = 48/87 (55.2%); VMAT: n = 11/62 (17.7%), p < 0.001). VMAT improved treatment compliance (less interruptions/delays) (3DCRT: 37/87, 42.5%; VMAT: 4/62, 6.5%; p < 0.001), provided a shorter median overall treatment time (3DCRT: 41 days; VMAT: 38 days; p = 0.02), and gave a higher median absolute 5-fluorouracil dose (3DCRT: 13,700 mg; VMAT: 14,400 mg; p = 0.001). Finally, we found improved CSS (p = 0.02; 3DCRT: 81.9% at 3 years; VMAT: 94.1% at 3 years) and DC (p = 0.01; 3DCRT: 89.4% at 3 years; VMAT: 100.0% at 3 years) with VMAT. Summary: Our study is the first to demonstrate improved treatment compliance and outcomes with VMAT for anal cancer. Previous studies have indicated that organs at risk sparing might be more improved with the use of VMAT vs. with conventional IMRT. Future studies should address whether these advantages lead to a further reduction in CRT-associated morbidity.
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Affiliation(s)
- Jacqueline Possiel
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (J.P.); (H.E.A.); (M.G.); (M.A.S.); (S.R.); (M.L.)
| | - Hanne Elisabeth Ammon
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (J.P.); (H.E.A.); (M.G.); (M.A.S.); (S.R.); (M.L.)
| | - Manuel Guhlich
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (J.P.); (H.E.A.); (M.G.); (M.A.S.); (S.R.); (M.L.)
| | - Lena-Christin Conradi
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (L.-C.C.); (M.G.)
| | - Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (L.-C.C.); (M.G.)
| | - Hendrik Andreas Wolff
- University Medical Center Göttingen, 37075 Göttingen, Germany;
- Department of Radiology, Nuclear Medicine and Radiotherapy, Radiology Munich, 80333 Munich, Germany
- Department of Radiotherapy and Radiation Oncology, University Medical Center Regensburg, 93053 Regensburg, Germany
| | - Markus Anton Schirmer
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (J.P.); (H.E.A.); (M.G.); (M.A.S.); (S.R.); (M.L.)
| | - Stephan Samel
- Praxis für Koloproktologie und chirurgische Endoskopie, Waldweg 1, 37073 Göttingen, Germany; (S.S.); (M.M.)
| | - Michael Mügge
- Praxis für Koloproktologie und chirurgische Endoskopie, Waldweg 1, 37073 Göttingen, Germany; (S.S.); (M.M.)
| | - Stefan Rieken
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (J.P.); (H.E.A.); (M.G.); (M.A.S.); (S.R.); (M.L.)
| | - Martin Leu
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (J.P.); (H.E.A.); (M.G.); (M.A.S.); (S.R.); (M.L.)
| | - Leif Hendrik Dröge
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (J.P.); (H.E.A.); (M.G.); (M.A.S.); (S.R.); (M.L.)
- Correspondence: ; Tel.: +49-551-398-866
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21
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Local excision and chemoradiation for clinical node-negative anal adenocarcinoma. Surg Oncol 2021; 37:101551. [PMID: 33819849 DOI: 10.1016/j.suronc.2021.101551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 03/04/2021] [Accepted: 03/26/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Given the lack of consensus in the surgical treatment of anal adenocarcinoma, practice-patterns demonstrate utilization of organ-preserving techniques. The adequacy of local excision compared to abdominoperineal resection (APR) as a surgical approach for stage II disease is unknown. Our study examines the utilization of local excision in the treatment of stage II anal adenocarcinoma, rates of R0 resection, and differences in overall survival compared to APR. MATERIALS AND METHODS Using the National Cancer Database (2004-2016), we retrospectively analyzed patients diagnosed with clinical stage II anal adenocarcinoma who received chemoradiation and surgery. Patient cohorts were assigned based on the surgical procedure they received. Propensity score matching was used to offset selection bias and confounding factors. Treatment approach, pathologic margin status, and overall survival were assessed. RESULTS Overall, 359 patients underwent resection of clinical stage II anal adenocarcinoma and received chemoradiation therapy. Of these patients, 87 (24%) underwent local excision, whereas 272 (76%) received an abdominoperineal resection. In a propensity score-matched cohort, patients who underwent local excision were less likely to achieve an R0 resection (40% vs 90%), and more likely to receive adjuvant instead of neoadjuvant chemoradiation. Overall survival was not significantly different between the propensity-matched groups. Surgical approach and pathologic margin status were not independently associated with overall survival. CONCLUSIONS Among patients with clinical stage II anal adenocarcinoma who received chemotherapy and radiation, complete resection was significantly less likely with local excision compared to abdominoperineal resection, however, overall survival was not affected. Prospective studies of neoadjuvant chemoradiation followed by local excision are warranted.
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22
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Liu F, Guo P, Su X, Cui M, Jiang J, Wang S, Yu Z, Zhou R, Ye Y. A Novel Remote Follow-Up Tool Based on an Instant Messaging/Social Media App for the Management of Patients With Low Anterior Resection Syndrome: Pilot Prospective Self-Control Study. JMIR Mhealth Uhealth 2021; 9:e22647. [PMID: 33739295 PMCID: PMC8078008 DOI: 10.2196/22647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 01/13/2021] [Accepted: 01/30/2021] [Indexed: 01/30/2023] Open
Abstract
Background Low anterior resection syndrome (LARS) is a common functional disorder that develops after patients with rectal cancer undergo anal preservation surgery. Common approaches to assess the symptoms of patients with LARS are often complex and time-consuming. Instant messaging/social media has great application potential in LARS follow-up, but has been underdeveloped. Objective The aim of this study was to compare data between a novel instant messaging/social media follow-up system and a telephone interview in patients with LARS and to analyze the consistency of the instant messaging/social media platform. Methods Patients with R0 resectable rectal cancer who accepted several defecation function visits via the instant messaging/social media platform and agreed to a telephone interview after the operation using the same questionnaire including subjective questions and LARS scores were included. Differences between the 2 methods were analyzed in pairs and the diagnostic consistency of instant messaging/social media was calculated based on telephone interview results. Results In total, 21 questionnaires from 15 patients were included. The positive rates of defecation dissatisfaction, life restriction, and medication use were 10/21 (48%), 11/21 (52%), and 8/21 (38%) for telephone interview and 10/21 (48%), 13/21 (62%), and 5/21 (24%) for instant messaging/social media, respectively. No statistically significant difference was observed between instant messaging/social media and telephone interview in terms of total LARS score (mean 22.4 [SD 11.9] vs mean 24.7 [SD 10.7], P<.21) and LARS categories (Z=–0.264, P=.79); however, instant messaging/social media showed a more negative tendency. The kappa values of 3 subjective questions were 0.618, 0.430, and 0.674, respectively. The total LARS scores were consistent between both groups (Pearson coefficient 0.760, P<.001; category correlation coefficient 0.570, P=.005). Patients with major LARS had highly consistent results, with sensitivity, specificity, kappa value, and P value of 77.8%, 91.7%, 0.704, and .001, respectively. Conclusions Instant messaging/social media can be a major LARS screening method. However, further research on information accuracy and user acceptance is needed before implementing a mature system. Trial Registration ClinicalTrials.gov NCT03009747; https://clinicaltrials.gov/ct2/show/NCT03009747
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Affiliation(s)
- Fan Liu
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Beijing, China
| | - Peng Guo
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Beijing, China
| | - Xiangqian Su
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, China
| | - Ming Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, China
| | - Jianlong Jiang
- Department of General Surgery, Changshu Hospital Affiliated to Soochow University, First People's Hospital of Changshu City, Changshu, China
| | - Suo Wang
- Department of General Surgery, Changshu Hospital Affiliated to Soochow University, First People's Hospital of Changshu City, Changshu, China
| | - Zhouman Yu
- Department of General Surgery, QiLu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Runhe Zhou
- Department of General Surgery, QiLu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Yingjiang Ye
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Beijing, China
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Kronborg CJS, Christensen P, Pedersen BG, Spindler KLG. Anorectal function and radiation dose to pelvic floor muscles after primary treatment for anal cancer. Radiother Oncol 2021; 157:141-146. [PMID: 33545256 DOI: 10.1016/j.radonc.2021.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/05/2021] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Chemoradiotherapy is the primary treatment for localized anal cancer (AC). This treatment offers high rates of cure and organ preservation. Radiotherapy can however, result in late persisting anorectal dysfunction, with anal incontinence, urge and clustering. Correlation of radiation doses to pelvic substructures and functional outcome is not well described in AC. We correlated patient reported anorectal function to radiation doses to sphincters and pelvic floor muscles. MATERIALS AND METHODS Patients treated with (chemo)radiotherapy for AC were asked to fill out LARS (lower anterior resection syndrome) questionnaires at follow-up. We compared patients with no LARS (score 0-19) and patients with major LARS (30-42) as well as individual LARS questions to specific radiation doses to sphincters, levators and puborectal muscles. RESULTS Thirty-six patients were included, 18 with no LARS and 18 with major LARS. Gender, age, TNM stage, PTV, chemotherapy, time to LARS score (mean 660 and 749 days) were comparable between the two groups. LARS symptoms, occurring at least once per week, were reported between 25-55.7%, and poorer LARS outcome was associated to worse quality of life. Dose to sphincter complex (Dmean, V50Gy and D90%) differed significantly between patients with no and major LARS (p = 0.048, 0.035 and 0.02 respectively). Further, D90% to the sphincter complex was significantly higher in patients who had accidental leakage of stool, (p = 0.044). CONCLUSION Patients treated with (chemo)radiotherapy for AC show high frequency of patient reported anorectal dysfunction. Specific doses to the sphincters could become a useful predictor of anal incontinence and major LARS and incorporated into future radiotherapy planning studies.
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Evaluation of PD-L1 Expression and HPV Genotyping in Anal Squamous Cell Carcinoma. Cancers (Basel) 2020; 12:cancers12092516. [PMID: 32899762 PMCID: PMC7564961 DOI: 10.3390/cancers12092516] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/07/2020] [Accepted: 08/31/2020] [Indexed: 12/15/2022] Open
Abstract
Anal squamous cell carcinoma (SCC) is a rare cancer with increasing incidence. Infection with high-risk human papillomavirus (HPV) subtypes is the major cause for its development. We retrospectively analyzed tumor samples from 54 anal SCC patients for infection with a panel of 32 HPV subtypes in a PCR-based approach, determined the PD-L1 expression status, and correlated the findings with the clinical data and the survival of the patients. Forty-two patients (77.8%) were HPV-positive and harbored at least one carcinogenic HPV subtype. HPV16 was the most frequently detected (n = 39, 72.2%). Four patients were infected with multiple HPV subtypes. HPV infection was significantly more often detected in female than in male patients (90.3% vs. 60.9%, p = 0.018). Patients with PD-L1 positive tumors showed a significantly better median overall survival (OS) compared with patients with PD-L1 negative tumors (69.3 vs. 28.3 months, p = 0.006). The median OS was significantly different among the distinct tumor stages (p = 0.029). Sex, grade of differentiation, and HPV infection status did not influence the median OS. Furthermore, HPV infection status and PD-L1 expression were not correlated. A multivariate Cox regression analysis revealed that PD-L1 expression status was an independent prognostic marker for survival (p = 0.012).
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25
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Lum C, Prenen H, Body A, Lam M, Segelov E. A 2020 update of anal cancer: the increasing problem in women and expanding treatment landscape. Expert Rev Gastroenterol Hepatol 2020; 14:665-680. [PMID: 32458709 DOI: 10.1080/17474124.2020.1775583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Anal cancer is a rare malignancy with increasing incidence, notably in women. This disease is highly associated with HPV infection and its incidence and mortality are currently rising. Most patients present with localized disease which has a high survival after definitive treatment with chemoradiation. For patients who develop metastatic disease or present with this de novo, survival is poor. AREAS COVERED This review provides a summary of current literature on anal cancer. With a focus on women, this includes current epidemiological trends, role of HPV, and the current and future treatment landscape, including HPV vaccination and immunotherapy. Screening currently focusses on HIV-positive men, missing most female cases. In curative disease, trials are investigating treatment de-intensification in good prognostic groups. Immunotherapy is showing early promise in the advanced disease setting. EXPERT OPINION Similar to cervical cancer, anal cancer is strongly associated with HPV, and therefore, broader implementation of screening programs may reduce its incidence. HPV vaccination is expected to reduce the development of (pre)malignant anal lesions. The emergence of biomarkers will assist patient treatment selection, allowing optimal balance of treatment efficacy and morbidity. It is hoped that new treatment approaches, including immunotherapy, will improve outcomes. International collaboration is needed.
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Affiliation(s)
- Caroline Lum
- Medical Oncology, Monash Medical Centre , Clayton, Australia
| | - Hans Prenen
- Medical Oncology, Monash Medical Centre , Clayton, Australia.,Oncology Department, University Hospital Antwerp , Antwerp, Belgium
| | - Amy Body
- Medical Oncology, Monash Medical Centre , Clayton, Australia
| | - Marissa Lam
- Medical Oncology, Monash Medical Centre , Clayton, Australia
| | - Eva Segelov
- Medical Oncology, Monash Medical Centre , Clayton, Australia.,School of Clinical Sciences, Monash University , Clayton, Australia
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Kouzy R, Abi Jaoude J, Lin D, El Alam MB, Minsky BD, Koay EJ, Das P, Holliday EB, Klopp AH, Colbert LE, Taniguchi CM. Patient-Reported GI Outcomes in Patients With Anal Cancer Receiving Modern Chemoradiation. JCO Oncol Pract 2020; 16:e1524-e1531. [PMID: 32609585 DOI: 10.1200/op.20.00122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Among patients with anal cancer, chemoradiotherapy is often associated with toxicities that diminish quality of life. We describe the GI-related patient-reported outcomes (PROs) of patients with anal cancer receiving chemoradiotherapy to improve patient-physician communication. METHODS We prospectively followed patients with nonmetastatic squamous cell carcinoma of the anal canal who received definitive chemoradiotherapy. Patients completed the bowel subdomain of the Expanded Prostate Cancer Index Composite (EPIC) questionnaire before treatment and at 4 subsequent timepoints. We used the paired Wilcoxon test to compare EPIC scores at different times. RESULTS The study included 21 patients; median age was 57 years. Most patients (52%) had T2 and either N0 or N1 disease (81%). Most patients (91%) received chemotherapy with cisplatin-fluorouracil and either intensity-modulated radiotherapy or volumetric modulated arc therapy. Compared with the patients' median overall summary score at baseline (66), their median score at 1 week (82) was higher (P = .009), whereas their median score at 5 weeks (54) was lower (P = .025). The patients' median overall summary score at baseline and at 3 months did not differ (P = .919). Three months after radiotherapy, most patients reported minimal adverse effects compared with baseline. CONCLUSION The GI-related PROs of patients with anal cancer tend to fluctuate during radiotherapy but return to baseline by 3 months, at which time most patients report few or no residual adverse effects. We provide a clear timeline of GI acute toxicity using sequential PRO measurements that will improve patient-physician communication regarding expectations for cancer treatment.
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Affiliation(s)
- Ramez Kouzy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joseph Abi Jaoude
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Molly B El Alam
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Emma B Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lauren E Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cullen M Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Nilsson MP, Nilsson ED, Johnsson A, Leon O, Gunnlaugsson A, Scherman J. Patterns of recurrence in anal cancer: a detailed analysis. Radiat Oncol 2020; 15:125. [PMID: 32460785 PMCID: PMC7251738 DOI: 10.1186/s13014-020-01567-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 05/12/2020] [Indexed: 12/23/2022] Open
Abstract
Background Anal cancer is a rare disease, which might be the reason for the “one size fits all” approach still used for radiotherapy target contouring. To refine and individualize future guidelines, detailed and contemporary pattern of recurrence studies are needed. Methods Consecutive anal cancer patients, all treated with curative intent intensity-modulated radiotherapy (IMRT), were retrospectively studied (n = 170). Data was extracted from medical records and radiological images. Radiotherapy planning CT’s and treatment plans were reviewed, and recurrences were mapped and categorized according to radiation dose. Results The mean dose to the primary tumor was 59.0 Gy. With a median follow-up of 50 months (range 14–117 months), 5-year anal cancer specific survival was 86.1%. Only 1 of 20 local recurrences was located outside the high dose (CTVT) volume. More patients experienced a distant recurrence (n = 34; 20.0%) than a locoregional recurrence (n = 24; 14.1%). Seven patients (4.2%) had a common iliac and/or para-aortic (CI/PA) recurrence. External iliac lymph node involvement (P = 0.04), and metastases in ≥3 inguinal or pelvic lymph node regions (P = 0.02) were associated with a 15–18% risk of CI/PA recurrence. Following chemoradiotherapy, 6 patients with recurrent or primary metastatic CI/PA lymph nodes were free of recurrence at last follow-up. The overall rate of ano-inguinal lymphatic drainage (AILD) recurrence was 2 of 170 (1.2%), and among patients with inguinal metastases at initial diagnosis it was 2 of 65 (3.1%). Conclusions We conclude that other measures than increased margins around the primary tumor are needed to improve local control. Furthermore, metastatic CI/PA lymph nodes, either at initial diagnosis or in the recurrent setting, should be considered potentially curable. Patients with certain patterns of metastatic pelvic lymph nodes might be at an increased risk of harboring tumor cells also in the CI/PA lymph nodes.
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Affiliation(s)
- Martin P Nilsson
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden. .,Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.
| | - Erik D Nilsson
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Anders Johnsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Otilia Leon
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Adalsteinn Gunnlaugsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Jonas Scherman
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
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