Chemotherapy/chemoradiation in anal cancer: A systematic review

Pelvic Exenteration for Squamous Cell Carcinoma of the Anus: Oncological, Morbidity, and Quality-of-Life Outcomes

BACKGROUND

Salvage surgery is the only potentially curative treatment option for recurrent squamous cell carcinoma of the anus. Where adjacent pelvic viscera, soft tissues, and bone are involved, pelvic exenteration with a wide perineal excision may be required to ensure clear surgical margins and increase the likelihood of long-term survival.

OBJECTIVE

To report oncological, morbidity, and quality-of-life outcomes of pelvic exenteration for anal squamous cell carcinoma.

DESIGN

Cohort study with retrospective analysis of prospectively collected data.

SETTINGS

This study was conducted at a high-volume pelvic exenteration center.

PATIENTS

Those who underwent pelvic exenteration for anal squamous cell carcinoma between 1994 and 2022.

MAIN OUTCOME MEASURES

Local recurrence-free and overall survival, intraoperative and postoperative complication rates, R0 resection rate, and long-term quality-of-life outcomes.

RESULTS

Of 958 patients who underwent pelvic exenteration, 66 (6.9%) had anal squamous cell carcinoma. Thirty-two patients (48.5%) were male and the median age was 57 years (range, 31-79). Ten patients (15%) had primary anal squamous cell carcinoma, 49 (74%) had a recurrent tumor, and 7 (11%) had a re-recurrent tumor. Twenty-two patients (33%) and 16 patients (24%) had a major complication and unplanned return to the operating theater, respectively. Of the 62 patients who underwent pelvic exenteration with curative intent, 50 (81%) had R0 resection, and the 5-year overall and local recurrence-free survival rates were 41% and 37%, respectively. R0 resection was associated with a higher 5-year overall survival (50% vs 8%, p < 0.001). The mental health component scores and several individual quality-of-life domains presented improved trajectories postoperatively (all p values <0.05).

LIMITATIONS

The generalizability of the findings outside specialist pelvic exenteration centers may be limited.

CONCLUSIONS

Morbidity, long-term survival, and quality-of-life outcomes after pelvic exenteration for anal squamous cell carcinoma are comparable to published outcomes of pelvic exenteration for other tumor types.

EXENTERACIN PLVICA POR CARCINOMA EPIDERMOIDE DE ANO RESULTADOS ONCOLGICOS, DE MORBILIDAD Y DE CALIDAD DE VIDA

ANTECEDENTES:La cirugía de rescate es la única opción de tratamiento potencialmente curativa para el carcinoma de células escamosas del ano recurrente. Cuando están involucradas vísceras pélvicas, tejidos blandos y huesos adyacentes, puede ser necesaria una exenteración pélvica con una escisión perineal amplia para asegurar márgenes quirúrgicos claros y aumentar la probabilidad de supervivencia a largo plazo.OBJETIVO:Informar sobre los resultados oncológicos, de morbilidad y de calidad de vida de la exenteración pélvica por carcinoma anal de células escamosas.DISEÑO:Estudio de cohortes con análisis retrospectivo de datos recogidos prospectivamente.ENTORNO CLINICO:Este estudio se realizó en un centro de exenteración pélvica de alto volumen.PACIENTES:Aquellos que se sometieron a exenteración pélvica por carcinoma anal de células escamosas entre 1994 y 2022.PRINCIPALES MEDIDAS DE VALORACIÓN:Supervivencia global y libre de recidiva local, tasas de complicaciones intraoperatorias y posoperatorias, tasa de resección R0 y resultados de calidad de vida a largo plazo.RESULTADOS:De 958 pacientes que se sometieron a exenteración pélvica, 66 (6,9%) tenían carcinoma anal de células escamosas. 32 pacientes (48,5%) eran varones y la mediana de edad fue de 57 años (rango 31-79). 10 pacientes (15%) tenían carcinoma anal primario de células escamosas, 49 (74%) tenían un tumor recurrente y 7 (11%) tenían una segunda recurrencia. 22 (33%) y 16 pacientes (24%) tuvieron una complicación mayor y regreso no planificado al quirófano, respectivamente. De los 62 pacientes que se sometieron a una exenteración pélvica con intención curativa, 50 (81%) tuvieron una resección R0, las tasas de supervivencia global y libre de recidiva local a los 5 años fueron del 41% y el 37%, respectivamente. La resección R0 se asoció con una mayor supervivencia general a los 5 años (50% frente a 8%, p < 0,001). Las puntuaciones del componente de salud mental y varios dominios de calidad de vida individuales presentaron trayectorias mejoradas después de la operación (todos los valores de p < 0,05).LIMITACIONES:La generalización de los hallazgos fuera de los centros especializados en exenteración pélvica puede ser limitada.CONCLUSIONES:Los resultados de morbilidad, supervivencia a largo plazo y calidad de vida después de la EP para el carcinoma anal de células escamosas son comparables a los resultados publicados de la exenteración pélvica para otros tipos de tumores. (Traducción-Dr. Ingrid Melo ).

Failure of Initial Curative Treatment for Non-Metastatic Anal Squamous Cell Carcinoma: From Prognostic Factors Analysis to Stratified Treatment

In squamous cell anal canal neoplasms, persistent disease or recurrence after initial chemoradiotherapy are not the rule, yet their occurrence deserves to be analyzed to better identify prognostics factors. The aim of our study was to describe the patterns of failures of the initial treatment, their subsequent evolution and to identify prognostic factors in these relapsed patients. All patients with non-metastatic anal squamous cell carcinoma initially treated with curative intent at the Centre Antoine Lacassagne between 1999 and 2019, and who presented persistent disease or recurrence were analyzed. The median follow-up was 44 months. Univariate and multivariate analyses were performed to identify prognostic factors. From our database of 528 patients, 77 patients were eligible: 25 with persistent disease and 52 with recurrence after complete response. The median overall survival was 39 months (95% CI: 25.5-52.3 months) from the date of treatment failure. In univariate analysis, prognostic factors were gender, initial lymph node status, type of failure, response to treatment's failure. In multivariate analysis, only female gender remained statistically significant (HR 0.43- P=0.016). 32% of patients with persistent disease had metastatic status. 17.3% and 5.8% of recurrences respectively occurred after three and five years of follow-up. Systematic imaging could be performed after initial treatment because of distant lesions in one third of patients with persistent disease. The follow-up should not be interrupted before five years, given the significant frequency of late recurrences. In multivariate analysis, only female gender was statistically significant. Stratified treatment based on prognostic factors could be envisaged, the details of which remain to be defined.

Mesorectal failure after chemoradiotherapy for squamous cell carcinoma of the anus: is sphincter-saving surgery reasonable?

BACKGROUND

Abdominoperineal resection (APR) is today the standard treatment for improving survival in case of mesorectal failure without anal canal recurrence after chemoradiotherapy (CRT) for squamous cell carcinoma of the anus (SCC). The aim of this study was to assess if a sphincter-saving surgery is a safe alternative to classical salvage APR in these patients.

METHODS

A retrospective study was conducted on all patients who had total mesorectal excision (TME) with sphincter-saving surgery either with coloanal or low colorectal anastomosis, for mesorectal failure after CRT for SCC between 2012 and 2020 at our institution. The main endpoint of our study was oncological results at the end of follow-up. Postoperative morbidity and mortality were secondary endpoints.

RESULTS

There were 10 patients, (8 women, median age 55 years [range 45-61 years]). On TME specimens, R0 resections were noted in five (50%), R1 resection in four (40%) and R2 resection in one (10%). After a median follow-up of 42 months (4-74 months), five patients were alive, and four (40%) were alive at 5-year follow-up. During follow-up, locoregional failure after TME was noted in two patients (20%), distant relapse in three patients (30%) and both locoregional plus distant failure in two patients (20%). Only two patients (20%) had anal recurrence, one in the anal canal, the other in the peri-anastomotic area. Long- term local control was achieved in 2 of the 5 patients (40%) who underwent R0 resection versus only 1/4 patients (25%) with R1 resection.

CONCLUSIONS

Our preliminary study suggested that sphincter-saving surgery could be proposed in selected patients with SCC presenting mesorectal failure after CRT, providing a feasible R0 resection.

The role of haematological parameters in predicting the response to radical chemoradiotherapy in patients with anal squamous cell cancer

Background

Historically, the treatment of choice for anal cancer had been abdominoperineal resection (APR). Radical radiotherapy with concurrent 5-fluorouracil plus mitomycin C chemotherapy was later established as standard therapy, although with a failure rate of 20–30%. The aim of this study was to evaluate the outcomes after radical chemoradiotherapy (CRT), prognostic and predictive factors and patterns of failure.

Patients and methods

This study included 47 patients treated with radical CRT for patohistologicaly confirmed anal squamous cell carcinoma. Analysed haematological parameters included: neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and haemoglobin level. The final logistic regression model included treatment break period. Tumour response was assessed at 24 weeks from CRT completion. Follow-up was performed every 3 months during the first two years, and every 6 months thereafter.

Results

A complete clinical response (CR) was detected in 30 patients (63.8%). Patients who did not achieve a 6-months CR and those who had a CR after 6 months but then relapsed were referred to surgical treatment. With combined CRT and surgical salvage treatment the CR rate was 80.9%. Patients with CR after 6 months had significantly longer disease-free survival (DFS), progression-free survival (PFS), and overall survival (OS). A significant effect on the 6-month response was confirmed for PLR (p = 0.03).

Conclusions

Important prognostic factors associated with CR were baseline haemoglobin level and period of treatment interruptions. Potential haematological prognostic factors could be PLR and NLR, which can be routinely determined by low-cost and minimally invasive methods.

Survival and Operative Outcomes After Salvage Surgery for Recurrent or Persistent Anal Cancer

Anal squamous cell carcinoma (SCC) is a relatively rare cancer comprising less than 2.5% of all gastrointestinal malignancies. The standard treatment for anal SCC is primary chemoradiation therapy which can result in complete regression. After successful treatment, the 5-year survival is approximately 80%. However, up to 30% of patients experience recurrent persistent or recurrent disease. The role of surgery in the treatment of anal cancer, therefore, is limited to the management of recurrent or persistent disease with abdominoperineal resection and/or en bloc adjacent organ excision. Salvage surgery after irradiated anal cancer can be technically demanding in terms of acquisition of oncologically safe surgical margins and minimization of postoperative morbidity. In addition, 5-year survival outcomes after salvage resection have been reported to vary from 23% to 69%. Positive resection margins are generally regarded as the important risk factor associated with poor survival outcome. Perineal wound complications are the most common major postoperative morbidity. Because of the challenges of primary wound closure after salvage abdominoperineal resection, myocutaneous flap reconstruction has been performed to reduce the severity of perianal would complications. We, therefore, descriptively reviewed contemporary published evidence describing the treatment and outcomes after salvage surgery for persistent or recurrent anal SCC.

Hellenic society of medical oncology (HESMO) guidelines for the management of anal cancer

Despite considerable improvement in the management of anal cancer, there is a great deal of variation in the outcomes among European countries, and in particular among different hospital centres in Greece and Cyprus. The aim was to elaborate a consensus on the multidisciplinary management of anal cancer, based on European guidelines (European Society of Medical Oncologists-ESMO), considering local special characteristics of our healthcare system. Following discussion and online communication among members of an executive team, a consensus was developed. Guidelines are proposed along with algorithms of diagnosis and treatment. The importance of centralisation, care by a multidisciplinary team (MDT) and adherence to guidelines are emphasised.

Pooled Analysis of external-beam RADiotherapy parameters in phase II and phase III trials in radiochemotherapy in Anal Cancer (PARADAC)

PURPOSE

Concomitant external-beam radiochemotherapy (5-fluorouracil-mitomycin C) has become the standard of care in anal cancer since the '90s. A pooled analysis of individual patient data from 7 major trials was performed quantifying the effect of radiation therapy (RT)-related parameters on the outcome of patients with anal cancer.

MATERIALS AND METHODS

Pooling databases from combined modality trials, the impact of RT parameters (total dose, gap duration, OTT: overall treatment time) on outcome including locoregional failure (LRF), 5-year progression free survival (PFS) and toxicities were investigated. Individual patient data were received for 10/13 identified published studies conducted from 1987 to 2008 (n = 3031). A Cox regression model was used (landmark = 3 months after RT for first follow-up).

RESULTS

After data inspection indicating severe heterogeneity between trials, only 1343 patients from 7/10 studies received were analysed (the most recent ones, since 1994; median follow-up = 4.1 years). A higher overall 5-year LRF rate [22.8% (95% confidence interval [CI] 22.3-27.3%)] significantly correlated with longer OTT (p = 0.03), larger tumour size (p < 0.001) and male gender (p = 0.045). Although significant differences were not observed, subset analyses for LRF (dose range: 50.4-59 Gy) seemed to favour lower doses (p = 0.412), and when comparing a 2-week gap versus 3 (dose: 59.4 Gy), results suggested 3 weeks might be detrimental (p = 0.245). For a 2-week gap versus none (dose range: 55-59.4 Gy), no difference was observed (p = 0.89). Five-year PFS was 65.7% (95% CI: 62.8-68.5%). Higher PFS rates were observed in women (p < 0.001), smaller tumour sizes (p < 0.001) and shorter OTT (p = 0.025). Five-year overall survival [76.7% (95% CI: 73.9%-79.3%)] correlated positively with female gender (p < 0.001), small tumour size (p = 0.027) and short OTT (p = 0.026). Descriptive toxicity data are presented.

CONCLUSION

For patients receiving concurrent external-beam doublet chemoradiation, a longer OTT seems detrimental to outcome. Further trials involving modern techniques may better define optimal OTT and total dose.

[Refusal of treatments by an adult cancer patient]

INTRODUCTION

Refusal of treatment questions the treatment's adequacy as well as the quality of the care relationship. A rigorous analysis of these situations is necessary in order to respect the patient's fundamental right to decide for him/herself while preventing a potential loss of chance. This paper proposes practical guidelines for assessment and management of the refusal of treatment by adult cancer patients.

METHODS

The French Association for Supportive Care in Cancer and the French Society for Psycho-Oncology formed a task force that applied a consensus methodology to draft guidelines.

RESULTS

We propose five guidelines: (1) be informed of the conditions most often associated with refusal of treatment so as to reinforce adequate support measures; (2) understand the complexity of the process of refusal and accurately identify what is precisely refused; (3) apply an approach of systematic analysis to refusal, to try and increase the possibilities of finding an agreement while reinforcing the respect of the patient's position; (4) establish a legal procedure to address refusal of treatment that safeguards the stakeholders when no accord can be found; and (5) know the indications for ethical collective decision-making.

CONCLUSION

A systematic assessment procedure of treatment refusal is necessary in order to ensure that all the physical, psychological and contextual aspects of it are taken into account, and to provide patients with the best treatment possible. The setting of good care relationship, the improvement of communication skills training and of comprehensive multidisciplinary care are all crucial elements in the prevention of these situations.

Anal cancer: French Intergroup Clinical Practice Guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, SNFCP)

INTRODUCTION

This document is a summary of the French Intergroup guidelines regarding the management of anal carcinomas, published in November 2016.

METHODS

It is a collaborative work produced under the auspices of the majority of the French medical societies involved in the management of anal cancer. It is based on the previous guidelines published in 2010. Recommendations are graded in three categories, according to the amount of evidence found in the literature.

RESULTS

Non-metastatic anal carcinomas can be divided into two risk groups, according to magnetic resonance imaging (MRI) or endorectal-ultrasonograpy. Localized small cancers (T1N0) are mainly treated by exclusive radiation therapy in the case of cancers of the anal canal, or by surgery in the case of cancers of the anal margin. The recommended treatment of locally advanced tumours (T2-T4, N0-N2) is definitive concomitant radio-chemotherapy. Salvage surgery should be reserved for patients with poor response, tumour progression or local relapse after radio-chemotherapy, or in cases of persistent vaginal fistula or total anal incontinence after the cessation of radio-chemotherapy. In the case of metastatic tumours, current therapeutic recommendations are based on less robust evidence; with chemotherapy playing a major role.

CONCLUSION

These recommendations are permanently being reviewed, and each individual case must be discussed inside a multidisciplinary team.

Clinical practice guidelines of the French Association for Supportive Care in Cancer and the French Society for Psycho-oncology: refusal of treatment by adults afflicted with cancer

PURPOSE

The study's purpose was to develop practical guidelines for assessment and management of refusal of treatment by adults afflicted with cancer.

METHODS

The French Association for Supportive Care in Cancer and the French Society for Psycho-oncology gathered a task force that applied a consensus methodology to draft guidelines studied predisposing situations, the diagnosis, regulatory aspects, and the management of refusal of treatment by adults afflicted with cancer.

RESULTS

We propose five guidelines: (1) be aware of the conditions/profiles of patients most often associated with refusal of treatment so as to adequately underpin the care and support measures; (2) understand the complexity of the process of refusal and knowing how to accurately identify the type and the modalities of the refused treatments; (3) apply a way to systematically analyze refusal, thereby promoting progression from a situation of disaccord toward a consensual decision; (4) devise procedures, according to the legal context, to address refusal of treatment that safeguards the stakeholders in situations of sustained disaccord; and (5) know the indications for ethical collective decision-making.

CONCLUSION

The quality of the relationship between patients and health professionals, and the communication between them are essential components involved in reaching a point of consent or refusal of treatment. A process of systematic analysis of refusal is recommended as the only way to ensure that all of the physiological, psychological, and contextual elements that are potentially involved are taken into account.

Trends in incidence and survival for anal cancer in New South Wales, Australia, 1972-2009

INTRODUCTION

Little is known about the incidence and survival of anal cancer in New South Wales (NSW), Australia, as anal cancer cases are often grouped together with other colorectal cancers in descriptive epidemiological analyses.

METHODS

We studied patterns and trends in the incidence and survival of people diagnosed with anal cancer in NSW, Australia, 1972-2009 (n=2724). We also predicted anal cancer incidence in NSW during 2010-2032. Given the human papilloma virus-associated aetiology for most anal cancers, we quantified these changes over time in incidence and survival by histological subtype: anal squamous cell carcinoma (ASCC); and anal adenocarcinoma (AAC).

RESULTS

There was a linear increase in incident anal cancer cases in NSW with an average annual percentage change (AAPC) of 1.6 (95% CI 1.1-2.0) such that, in combination with age-period-cohort modelling, we predict there will be 198 cases of anal cancer in the 2032 calendar year (95% CI 169-236). Almost all of these anal cancer cases are projected to be ASCC (94%). Survival improved over time regardless of histological subtype. However, five-year relative survival was substantially higher for people with ASCC (70% (95% CI 66-74%)) compared to AAC (51% (95% CI 43-59%)), a 37% difference. Survival was also greater for women (69% (95% CI 64-73%)) with ASCC compared to men (55% (95% CI 50-60%)). It was not possible to estimate survival by stage at diagnosis particularly given that 8% of all cases were recorded as having distant stage and 22% had missing stage data.

INTERPRETATION

Aetiological explanations, namely exposure to oncogenic types of human papillomavirus, along with demographic changes most likely explain the actual and projected increase in ASCC case numbers. Survival differences by gender and histological subtype point to areas where further research is warranted to improve treatment and outcomes for all anal cancer patients.

Radiochemotherapy in Anal Cancer: cCR, clinical outcomes and quality of life using two different treatment schedules

AIM

Main endpoint was a response rate to therapy; secondary endpoints were disease-free survival, overall survival, acute and late toxicities, specially in terms of anorectal and urinary continence.

BACKGROUND

Radiochemotherapy for anal cancer achieves a good clinical response, locoregional control, anal function preservation. However, oncologic outcomes can differ using radiotherapy plus fluorouracil and mytomicin vs. cisplatin and fluorouracil.

METHODS

Between 2000 and 2012, 27 anal cancer patients receiving radiotherapy combined with two different radiochemotherapy schedules, fluorouracil and mytomicin (group A) and cisplatin plus fluorouracil (group B). The Kaplan-Meier method was also used to estimate local control, overall survival and disease free survival. Statistical significance between curves was evaluated using the Log-rank test.

RESULTS

Complete pathological response was found in 85.2% of patients, with higher rates of response in the group A (100% vs. 63.6%, p = 0.039). No significantly difference was found between the two groups for the other endpoints. Low rates of both acute and late toxicities were recorded.

CONCLUSION

Radiotherapy plus fluorouracil and mytomicin provide a better complete pathological response than radiotherapy plus cisplatin and fluorouracil and a greater rate of anal sphincter function preservation. Globally, radiochemotherapy of the anal cancer provides excellent clinical outcomes with a good profile of acute and late toxicity, without difference between the two groups studied.

Chemoradiotherapy for squamous cell cancer of the anal canal: a systematic review

Squamous cell cancer of the anal canal is a rare tumour for which there remains uncertainty regarding optimal therapy. A systematic review was conducted to summarise the evidence examining concurrent chemotherapy and radiotherapy or different chemotherapy regimens in combination with radiotherapy. MEDLINE, EMBASE and conference proceedings were searched for relevant randomised controlled trials. Outcomes of interest were colostomy rate, local failure, overall survival, disease-free survival, adverse effects and quality of life. Six randomised controlled trials were identified. Two trials reported lower colostomy and local failure rates for concurrent 5-fluorouracil (5-FU) plus mitomycin C (MMC) and radiotherapy compared with radiotherapy alone. The omission of MMC from this regimen resulted in higher colostomy and local failure rates and lower disease-free survival. Induction chemotherapy followed by concurrent 5-FU plus cisplatin and radiotherapy resulted in a higher colostomy rate than concurrent 5-FU plus MMC and radiotherapy. Haematological toxicity rates were lower in patients who received radiotherapy with 5-FU alone or 5-FU plus cisplatin compared with 5-FU plus MMC. No benefit was seen for the addition of induction or maintenance chemotherapy to concurrent chemoradiotherapy. The available evidence continues to support the use of radiotherapy with concurrent 5-FU and MMC as standard treatment for cancer of the anal canal to decrease colostomy and local failure rates.

MRI of anal cancer: assessing response to definitive chemoradiotherapy

Anal cancer is an uncommon malignancy of the gastrointestinal tract but has a relatively good prognosis with an 80% 5-year overall survival. In this article, we review the role of MRI for assessing treatment response in anal cancer after completion of definitive chemoradiotherapy. New generation MRI scanners with optimal-phased array body coils, resulting in better signal to noise and improved contrast and spatial resolution, have contributed to high-resolution imaging in clinical practice enabling visualization of relevant anatomy including the sphincter complex, adjacent structures, mesorectal and pelvic lymph nodes with a diameter down to 2 mm. Multiplanar, high-resolution T2-weighted and diffusion-weighted sequences have a role in initial locoregional staging of anal SCC, assisting radiotherapy planning, as well as in assessing response to treatment and treatment-related complications.

A novel biomarker-based analysis reliably predicts nodal metastases in anal carcinoma: preliminary evidence of therapeutic impact

AIM

Routine prophylactic inguinal irradiation in anal cancer may cause significant toxicity associated with overtreatment bias. The aim of this study was to determine the risk of regional node metastases in anal carcinoma by identifying predictive molecular biomarkers.

METHOD

Clinicohistopathological data from 50 pretreatment anal carcinoma biopsies were collected. Immunohistochemical analyses with antibodies against Ki67, p53, epidermal growth factor receptor (EGFR) and YKL-40 were performed. Statistical correlations between biomarkers and clinicopathological features and outcomes were studied. Sentinel lymph node biopsy was performed in a subset of 36 patients.

RESULTS

All patients had undergone synchronous radiochemotherapy; tumour recurrence had developed in 26%, and 16% had died. YKL-40 tumour expression correlated with lymph node metastasis, whereas no inguinal node metastases were found in any of the (14%) patients presenting with a YKL-40/EGFR-negative tumour. YKL-40 expression and node metastasis were both significantly associated with shorter overall and disease-free survival. Tumour grade significantly correlated with disease-free survival only. HIV, tumour histological type, Ki67, p53 and EGFR were not associated with outcome.

CONCLUSION

YKL-40 expression in anal carcinoma is correlated with a poor outcome and can predict lymph node metastases. The combined absence of YKL-40 and EGFR expression in a first biopsy of anal carcinoma reliably selects a subset of patients without inguinal metastases. Such patients could be spared sentinel lymph node biopsy and/or inguinal radiotherapy.

A systematic review of anal squamous cell carcinoma in inflammatory bowel disease

AIM

The aim of this systematic review was to determine the incidence, aetiology and clinical characteristics of anal squamous cell carcinomas (SCC) presenting in patients with inflammatory bowel disease.

METHOD

A systematic review of the literature was undertaken using Medline, Embase, Cochrane and Web of Science.

RESULTS

A total of 33 cases of anal SCC were described, 7 in ulcerative colitis (UC) and 26 in Crohn's disease (CD). The annual incidence of anal SCCs was 0.9/100,000 and 2.0/100,000 in patients with UC and CD respectively. The gender ratio in CD was 3M:17F with a median age of 42 years, the main presenting symptom was anal pain and 85% of CD cases had peri-anal disease. No studies described anal intra-epithelial neoplasia. The human papilloma virus was found to be positive in 2 out of 5 (40%) cases. The majority of patients (73%) with CD received radical surgery as their first line treatment. The cumulative overall and disease free survival in CD was 37 per cent at five years.

CONCLUSION

The findings of this review when contrasted with the data from cancer registries suggests that there is a higher incidence of anal SCC, an earlier age of presentation and poorer outcomes in patients with Crohn's disease compared to the general population implying a more aggressive neoplastic process. This review supports the hypothesis that peri-anal disease plays a contributing role in anal SCCs and as such targeted surveillance in patients with longstanding peri-anal disease should be considered.

Simultaneous integrated boost-intensity modulated radiation therapy with concomitant capecitabine and mitomycin C for locally advanced anal carcinoma: a phase 1 study

PURPOSE

Newer radiation techniques, and the application of continuous 5-FU exposure during radiation therapy using oral capecitabine may improve the treatment of anal cancer. This phase 1, dose-finding study assessed the feasibility and efficacy of simultaneous integrated boost-intensity modulated radiation therapy (SIB-IMRT) with concomitant capecitabine and mitomycin C in locally advanced anal cancer, including pharmacokinetic and pharmacogenetic analyses.

METHODS AND MATERIALS

Patients with locally advanced anal carcinoma were treated with SIB-IMRT in 33 daily fractions of 1.8 Gy to the primary tumor and macroscopically involved lymph nodes and 33 fractions of 1.5 Gy electively to the bilateral iliac and inguinal lymph node areas. Patients received a sequential radiation boost dose of 3 × 1.8 Gy on macroscopic residual tumor if this was still present in week 5 of treatment. Mitomycin C 10 mg/m(2) (maximum 15 mg) was administered intravenously on day 1, and capecitabine was given orally in a dose-escalated fashion (500-825 mg/m(2) b.i.d.) on irradiation days, until dose-limiting toxicity emerged in ≥2 of maximally 6 patients. An additional 8 patients were treated at the maximum tolerated dose (MTD).

RESULTS

A total of 18 patients were included. The MTD of capecitabine was determined to be 825 mg/m(2) b.i.d. The predominant acute grade ≥3 toxicities included radiation dermatitis (50%), fatigue (22%), and pain (6%). Fifteen patients (83% [95%-CI: 66%-101%]) achieved a complete response, and 3 (17%) patients a partial response. With a median follow-up of 28 months, none of the complete responders, and 2 partial responders had relapsed.

CONCLUSIONS

SIB-IMRT with concomitant single dose mitomycin C and capecitabine 825 mg/m(2) b.i.d. on irradiation days resulted in an acceptable safety profile, and proved to be a tolerable and effective treatment regimen for locally advanced anal cancer.

MRI and CT of anal carcinoma: a pictorial review

BACKGROUND

Squamocellular anal carcinoma is increasingly diagnosed in patients with risk factors.

METHODS

State-of-the-art imaging with magnetic resonance imaging (MRI) using phased-array coils and volumetric multidetector computed tomography (CT) provides detailed visualisation of anal disorders, identification and extent assessment of neoplastic tissue, detection and characterisation of nodal and visceral metastases. MRI has been recommended by the European Society for Medical Oncology (ESMO) as the preferred modality of choice to stage anal cancer, taking into account the maximum tumour diameter, invasion of adjacent structures and regional lymph node involvement.

RESULTS

Cross-sectional imaging techniques allow the identification of coexisting complications, and differentiation from other perineal abnormalities.

CONCLUSION

Cross-sectional imaging is useful for planning radiotherapy, surgical drainage or salvage abdomino-perineal resection. After chemo-radiotherapy, MRI follow-up provides confident reassessment of therapeutic response, persistent or recurrent disease. TEACHING POINTS : • Anal carcinoma is increasingly diagnosed in patients with human immunodeficiency virus (HIV), anoreceptive intercourse, chronic inflammatory bowel disease. • An established association exists with human papillomavirus (HPV) infection and premalignant intra-epithelial dysplasia. • Phased-array MRI is recommended as the preferred imaging modality for regional staging. • Imaging allows detection of infectious complications, planning of radiotherapy or salvage surgery. • Follow-up MRI allows reliable assessment of therapeutic response after chemo-radiotherapy.

New approach to anal cancer: Individualized therapy based on sentinel lymph node biopsy

Oncological treatment is currently directed toward a tailored therapy concept. Squamous cell carcinoma of the anal canal could be considered a suitable platform to test new therapeutic strategies to minimize treatment morbidity. Standard of care for patients with anal canal cancer consists of a combination of radiotherapy and chemotherapy. This treatment has led to a high rate of local control and a 60% cure rate with preservation of the anal sphincter, thus replacing surgical abdominoperineal resection. Lymph node metastases represent a critical independent prognostic factor for local recurrence and survival. Mesorectal and iliac lymph nodes are usually included in the radiation field, whereas the inclusion of inguinal regions still remains controversial because of the subsequent adverse side effects. Sentinel lymph node biopsies could clearly identify inguinal node-positive patients eligible for therapeutic groin irradiation. A sentinel lymph node navigation procedure is reported here to be a feasible and effective method for establishing the true inguinal node status in patients suffering from anal canal cancer. Based on the results of sentinel node biopsies, a selective approach could be proposed where node-positive patients could be selected for inguinal node irradiation while node-negative patients could take advantage of inguinal sparing irradiation, thus avoiding toxic side effects.

EGFR and K-ras gene mutation status in squamous cell anal carcinoma: a role for concurrent radiation and EGFR inhibitors?

BACKGROUND

There is a growing appreciation for radio-sensitiser use in multi-modal cancer treatment models. Squamous cell anal carcinoma (SCAC) is a rare gastrointestinal tumour traditionally treated with concurrent chemotherapy and radiation. Cetuximab, an epidermal growth factor receptor (EGFR) inhibitor, has demonstrated significant efficacy when combined with radiation in squamous cell carcinoma of the head and neck (SccH&N). We wanted to assess EGFR and Kirsten-ras (K-ras) status in SCAC to see whether it compares with SccH&N.

METHODS

Over 90 SCAC paraffin-embedded biopsies were mounted onto a tissue microarray and were assessed for EGFR expression by immunohistochemistry. These samples were also assessed for the most frequently mutated K-ras and EGFR exons by high-resolution melting analysis.

RESULTS

The EGFR was present in over 90% of samples tested. The K-ras and EGFR mutations were absent in all samples tested, although a synonymous single-nucleotide polymorphism was found in 3 out of 89 samples tested for EGFR exon 19.

CONCLUSION

The low rate of K-ras and EGFR mutations, coupled with the high surface expression of EGFR, suggests similarity in the EGFR signalling pathway between SCAC and SccH&N, and thus a potential role for EGFR inhibitors in SCAC. To our knowledge this is the largest cohort of invasive SCAC samples investigated for EGFR and K-ras mutations reported to date.

Progress in rectal cancer treatment

The dramatic improvement in local control of rectal cancer observed during the last decades is to be attributed to attention to surgical technique and to the introduction of neoadjuvant therapy regimens. Nevertheless, systemic relapse remains frequent and is currently insufficiently addressed. Intensification of neoadjuvant therapy by incorporating chemotherapy with or without targeted agents before the start of (chemo)radiation or during the waiting period to surgery may present an opportunity to improve overall survival. An increasing number of patients can nowadays undergo sphincter preserving surgery. In selected patients, local excision or even a "wait and see" approach may be feasible following active neoadjuvant therapy. Molecular and genetic biomarkers as well as innovative imaging techniques may in the future allow better selection of patients for this treatment option. Controversy persists concerning the selection of patients for adjuvant chemotherapy and/or targeted therapy after neoadjuvant regimens. The currently available evidence suggests that in complete pathological responders long-term outcome is excellent and adjuvant therapy may be omitted. The results of ongoing trials will help to establish the ideal tailored approach in resectable rectal cancer.