1
|
Rosen R, Quezada-Diaz FF, Gönen M, Karagkounis G, Widmar M, Wei IH, Smith JJ, Nash GM, Weiser MR, Paty PB, Cercek A, Romesser PB, Sanchez-Vega F, Adileh M, Roth O’Brien D, Hajj C, Williams VM, Shcherba M, Gu P, Crane C, Saltz LB, Garcia Aguilar J, Pappou E. Oncologic Outcomes of Salvage Abdominoperineal Resection for Anal Squamous Cell Carcinoma Initially Managed with Chemoradiation. J Clin Med 2024; 13:2156. [PMID: 38673429 PMCID: PMC11050212 DOI: 10.3390/jcm13082156] [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: 02/24/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Abdominoperineal resection (APR) has been advocated for persistent or recurrent disease after failure of chemoradiation (CRT) for anal squamous cell cancer (SCC). Treatment with salvage APR can potentially achieve a cure. This study aimed to analyze oncological outcomes for salvage APR in a recent time period at a comprehensive cancer center. Methods: A retrospective review of all patients who underwent APR for biopsy-proven persistent or recurrent anal SCC between 1 January 2007 and 31 December 2020 was performed. Patients with stage IV disease at the time of initial diagnosis and patients with missing data were excluded. Univariate analysis was used with a chi-square test for categorical variables, and non-parametric tests were used for continuous variables. Kaplan-Meier survival analysis was performed to evaluate disease-specific (DSS), post-APR local recurrence-free (RFS), and disease-free survival (DFS). Results: A total of 96 patients were included in the analysis: 39 (41%) with persistent disease and 57 (59%) with recurrent SCC after chemoradiation had been completed. The median follow-up was 22 months (IQR 11-47). Forty-nine patients (51%) underwent extended APR and/or pelvic exenteration. Eight (8%) patients developed local recurrence, 30 (31%) developed local and distant recurrences, and 16 (17%) developed distant recurrences alone. The 3-year DSS, post-APR local recurrence-free survival, and disease-free survival were 53.8% (95% CI 43.5-66.5%), 54.5% (95% CI 44.4-66.8%), and 26.8% (95% CI 18.6-38.7%), respectively. In multivariate logistic regression analysis, positive microscopic margin (OR 10.0, 95% CI 2.16-46.12, p = 0.003), positive nodes in the surgical specimen (OR 9.19, 95% CI 1.99-42.52, p = 0.005), and lymphovascular invasion (OR 2.61 95% CI 1.05-6.51, p = 0.04) were associated with recurrence of disease. Gender, indication for APR (recurrent vs. persistent disease), HIV status, extent of surgery, or type of reconstruction did not influence survival outcomes. Twenty patients had targeted tumor-sequencing data available. Nine patients had PIK3CA mutations, seven of whom experienced a recurrence. Conclusions: Salvage APR for anal SCC after failed CRT was associated with poor disease-specific survival and low recurrence-free survival. Anal SCC patients undergoing salvage APR should be counseled that microscopic positive margins, positive lymph nodes, or the presence of lymphovascular invasion in the APR specimen are prognosticators for disease relapse. Our results accentuate the necessity for additional treatment strategies for the ongoing treatment challenge of persistent or recurrent anal SCC after failed CRT.
Collapse
Affiliation(s)
- Roni Rosen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Felipe F. Quezada-Diaz
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Georgios Karagkounis
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Maria Widmar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Iris H. Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - J. Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Garrett M. Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Martin R. Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Philip B. Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (P.G.)
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.B.R.)
| | - Francisco Sanchez-Vega
- Department of Computational Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Mohammad Adileh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Diana Roth O’Brien
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.B.R.)
| | - Carla Hajj
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.B.R.)
| | - Vonetta M. Williams
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.B.R.)
| | - Marina Shcherba
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (P.G.)
| | - Ping Gu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (P.G.)
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.B.R.)
| | - Leonard B. Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (P.G.)
| | - Julio Garcia Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Emmanouil Pappou
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| |
Collapse
|
2
|
Damron EP, McDonald J, Rooney MK, Das P, Ludmir EB, Minsky BD, Messick C, Chang GJ, Morris VK, Holliday EB. Salvage Treatment of Recurrent or Persistent Anal Squamous Cell Carcinoma: The Role of Multi-modality Therapy. Clin Colorectal Cancer 2024; 23:85-94. [PMID: 38216367 DOI: 10.1016/j.clcc.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/07/2023] [Accepted: 12/10/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND The standard treatment for recurrent or persistent anal squamous cell carcinoma is surgical salvage, but disease control and survival are suboptimal. PATIENTS/METHODS Patients treated for recurrent or persistent anal squamous cell carcinoma at our institution from 2002 to 2022 were included. Patients were classified by type of salvage treatment received: surgery alone vs. reirradiation followed by surgery and by whether they received intraoperative radiation at the time of surgery. Clinical and pathologic variables were collected and assessed for association with risk of second local recurrence and death from any cause. RESULTS Sixty four patients were included; 55(85.9%) were treated with surgery alone and 9 (14.1%) were treated with reirradiation followed by surgery. Median (IQR) follow up from the time of salvage treatment was 40.0 (20.3-68.0) months. The 3-year cumulative incidence of second local recurrence (95% CI) after salvage surgery was 36% (24%-48%); 39% (26%-52%) for patients treated with surgery alone and 15% (0.46%-51%) for patients treated with reirradiation followed by surgery. Factors associated with increased second local recurrence after salvage surgery included a locoregional recurrence, lymphovascular space invasion and positive surgical margins. The 3-year overall survival (95% CI) after salvage surgery was 70% (59%-83%); 68% (7%-56%) after surgery alone and 89% (10.5%-70.6%) after reirradiation followed by surgery. Factors associated with worse overall survival included male sex, a larger recurrent tumor and positive surgical margins. CONCLUSIONS Approximately 60% of patients achieved pelvic control after salvage therapy for recurrent or persistent anal squamous cell carcinoma. Although receipt of reirradiation and intraoperative radiation were not associated with improved second local recurrence or overall survival in our cohort, patients with positive surgical margins and lymphovascular space invasion on surgical pathology had higher rates of pelvic recurrence after salvage surgery and may benefit from escalated salvage therapy.
Collapse
Affiliation(s)
- Ethan P Damron
- University of Texas McGovern Medical School, Houston, TX
| | - Jordan McDonald
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Prajnan Das
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ethan B Ludmir
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bruce D Minsky
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Craig Messick
- Department of Colorectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George J Chang
- Department of Colorectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Van K Morris
- Deparment of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Emma B Holliday
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| |
Collapse
|
3
|
Temperley HC, O'Sullivan NJ, Waters C, Corr A, Mehigan BJ, O'Kane G, McCormick P, Gillham C, Rausa E, Larkin JO, Meaney JF, Brennan I, Kelly ME. Radiomics; Contemporary Applications in the Management of Anal Cancer; A Systematic Review. Am Surg 2024; 90:445-454. [PMID: 37972216 DOI: 10.1177/00031348231216494] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
INTRODUCTION The management of anal cancer relies on clinical and histopathological features for treatment decisions. In recent years, the field of radiomics, which involves the extraction and analysis of quantitative imaging features, has shown promise in improving management of pelvic cancers. The aim of this study was to evaluate the current application of radiomics in the management of anal cancer. METHODS A systematic search was conducted in Medline, EMBASE, and Web of Science databases. Inclusion criteria encompassed randomized and non-randomized trials investigating the use of radiomics to predict post-operative recurrence in anal cancer. Study quality was assessed using the QUADAS-2 and Radiomics Quality Score tools. RESULTS The systematic review identified a total of nine studies, with 589 patients examined. There were three main outcomes assessed in included studies: recurrence (6 studies), progression-free survival (2 studies), and prediction of human papillomavirus (HPV) status (1 study). Radiomics-based risk stratification models were found to provide valuable insights into treatment response and patient outcomes, with all developed signatures demonstrating at least modest accuracy (range: .68-1.0) in predicting their primary outcome. CONCLUSION Radiomics has emerged as a promising tool in the management of anal cancer. It offers the potential for improved risk stratification, treatment planning, and response assessment, thereby guiding personalized therapeutic approaches.
Collapse
Affiliation(s)
- Hugo C Temperley
- Department of Radiology, St. James's Hospital, Dublin, Ireland
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | | | - Caitlin Waters
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | - Alison Corr
- Department of Radiology, St. James's Hospital, Dublin, Ireland
| | - Brian J Mehigan
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | - Grainne O'Kane
- St Luke's Radiation Oncology Network, Dublin, Ireland
- Department of Radiation Oncology, St. James's Hospital, Dublin, Ireland
| | - Paul McCormick
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | - Charles Gillham
- St Luke's Radiation Oncology Network, Dublin, Ireland
- Department of Radiation Oncology, St. James's Hospital, Dublin, Ireland
| | - Emanuele Rausa
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - John O Larkin
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | - James F Meaney
- Department of Radiology, St. James's Hospital, Dublin, Ireland
| | - Ian Brennan
- Department of Radiology, St. James's Hospital, Dublin, Ireland
| | - Michael E Kelly
- Department of Surgery, St. James's Hospital, Dublin, Ireland
- Trinity St James's Cancer Institute, Dublin, Ireland
| |
Collapse
|
4
|
Borg J, Garm Spindler KL, Havelund BM, Sørensen MM, Funder JA. Risk factors and outcome following salvage surgery for squamous cell carcinoma of the anus. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107050. [PMID: 37657174 DOI: 10.1016/j.ejso.2023.107050] [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: 04/20/2023] [Revised: 07/08/2023] [Accepted: 08/28/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Chemoradiotherapy is the primary treatment for anal cancer. 15-33% of patients will have persistent or recurrent disease after treatment requiring salvage surgery. Relapse after surgery, postoperative complications, and mortality as well as possible risk factors are not fully understood due to the rareness of the disease. The aim of the study was to report outcomes after salvage surgery as well as evaluate risk factors for postoperative complications, cancer relapse and survival. METHODS Data were retrospectively collected from electronical patients charts and pathology reports from all patients undergoing salvage surgery from July 1st, 2011 to July 1st, 2021 at the Department of Surgery, Aarhus University Hospital, Denmark. RESULTS A total of 98 patients were included in the study. The 5-year overall survival was 61.8%. Relapse after surgery occurred in 36.7% of patients and was significantly associated with R1-resection (HR = 4.4) and preoperative nodal metastases (HR = 4.5). Negative prognostic factors for survival were found to be R1-resection (HR = 3.2), preoperative nodal metastases (HR = 2.9), and male gender (HR = 0.5). There was no association found between complications and survival (HR 1.2). None of the possible risk factors were associated with major postoperative complications. CONCLUSIONS An acceptable overall survival after surgery was found. Survival and relapse-free survival was negatively associated with R1 resections and positive preoperative lymph nodes. Complications did not influence long-term survival.
Collapse
Affiliation(s)
- Julie Borg
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Karen-Lise Garm Spindler
- Department of Oncology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Birgitte Mayland Havelund
- Department of Oncology, University Hospital of Southern Denmark, Lillebaelt Hospital, Beriderbakken 4, 7100, Vejle, Denmark.
| | - Mette Møller Sørensen
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Jonas Amstrup Funder
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| |
Collapse
|
5
|
Kitaguchi D, Tsukada Y, Ito M, Horasawa S, Bando H, Yoshino T, Yamada K, Ajioka Y, Sugihara K. Survival outcomes following salvage abdominoperineal resection for recurrent and persistent anal squamous cell carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106929. [PMID: 37210274 DOI: 10.1016/j.ejso.2023.05.004] [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: 11/30/2022] [Revised: 04/03/2023] [Accepted: 05/03/2023] [Indexed: 05/22/2023]
Abstract
INTRODUCTION The primary treatment for locoregional failure following chemoradiotherapy for squamous cell carcinoma of the anus (SCCA) is salvage abdominoperineal resection (APR). However, it is necessary to distinguish between recurrent and persistent diseases because of their varied pathologies. We aimed to clarify the survival outcomes following salvage APR for recurrent and persistent diseases and investigate the significance of salvage APR. MATERIALS AND METHODS This multicentre retrospective cohort study used clinical data from 47 hospitals. All patients were diagnosed with SCCA and underwent definitive radiotherapy as the primary treatment between 1991 and 2015. Overall survival (OS) was compared between the following cohorts: salvage APR for recurrence, salvage APR for persistence, non-salvage APR for recurrence, and non-salvage APR for persistence. RESULTS Five-year OS of salvage APR for recurrence, salvage APR for persistence, non-salvage APR for recurrence, and non-salvage APR for persistence were 75% (46%-90%), 36% (21%-51%), 42% (21%-61%), and 47% (33%-60%), respectively. OS of salvage APR for the recurrent disease was significantly higher than that for persistent disease (p = 0.00597). For recurrent disease, OS following salvage APR was significantly higher than that following non-salvage APR (p = 0.0204); however, for persistent disease, there was no significant difference between salvage and non-salvage APR (p = 0.928). CONCLUSION Survival outcomes following salvage APR for persistent disease were significantly worse than that for recurrent disease. Salvage APR did not improve survival outcomes for persistent disease compared to non-salvage APR. These results will elicit a review of persistent disease treatment strategies.
Collapse
Affiliation(s)
- Daichi Kitaguchi
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Satoshi Horasawa
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Hideaki Bando
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Takayuki Yoshino
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Kazutaka Yamada
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55, Oe, Chuo-ku, Kumamoto, 862-0971, Japan.
| | - Yoichi Ajioka
- Division of Molecular and Diagnostic Pathology, Niigata University Graduate School of Medical and Dental Sciences, 8050 Ikarashi 2-no-cho, Nishi-ku, Niigata, 950-2181, Japan.
| | - Kenichi Sugihara
- Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| |
Collapse
|
6
|
El Homsi M, Sheedy SP, Rauch GM, Ganeshan DM, Ernst RD, Golia Pernicka JS. Follow-up imaging of anal cancer after treatment. Abdom Radiol (NY) 2023; 48:2888-2897. [PMID: 37024606 DOI: 10.1007/s00261-023-03895-0] [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: 12/22/2022] [Revised: 03/21/2023] [Accepted: 03/21/2023] [Indexed: 04/08/2023]
Abstract
Anal cancer treatment response assessment can be challenging with both magnetic resonance imaging (MRI) and clinical evaluation considered essential. MRI, in particular, has shown to be useful for the assessment of treatment response, the detection of recurrent disease in follow up and surveillance, and the evaluation of possible post-treatment complications as well as complications from the tumor itself. In this review, we focus on the role of imaging, mainly MRI, in anal cancer treatment response assessment. We also describe the treatment complications that can occur, and the imaging findings associated with those complications.
Collapse
Affiliation(s)
- Maria El Homsi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | | | - Gaiane M Rauch
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dhakshina M Ganeshan
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Randy D Ernst
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer S Golia Pernicka
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| |
Collapse
|
7
|
Chen KA, Goffredo P, Hu D, Joisa CU, Guillem JG, Gomez SM, Kapadia MR. Estimating Risk of Locoregional Failure and Overall Survival in Anal Cancer Following Chemoradiation: A Machine Learning Approach. J Gastrointest Surg 2023; 27:1925-1935. [PMID: 37407899 PMCID: PMC10528925 DOI: 10.1007/s11605-023-05755-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/03/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Optimal treatment of anal squamous cell carcinoma (ASCC) is definitive chemoradiation. Patients with persistent or recurrent disease require abdominoperineal resection (APR). Current models for predicting need for APR and overall survival are limited by low accuracy or small datasets. This study sought to use machine learning (ML) to develop more accurate models for locoregional failure and overall survival for ASCC. METHODS This study used the National Cancer Database from 2004-2018, divided into training, validation, and test sets. We included patients with stage I-III ASCC who underwent chemoradiation. Our primary outcomes were need for APR and 3-year overall survival. Random forest (RF), gradient boosting (XGB), and neural network (NN) ML-based models were developed and compared with logistic regression (LR). Accuracy was assessed using area under the receiver operating characteristic curve (AUROC). RESULTS APR was required in 5.3% (1,015/18,978) of patients. XGB performed best with AUROC of 0.813, compared with 0.691 for LR. Tumor size, lymphovascular invasion, and tumor grade showed the strongest influence on model predictions. Mortality was 23.6% (7,988/33,834). AUROC for XGB and LR were similar at 0.766 and 0.748, respectively. For this model, age, radiation dose, sex, and insurance status were the most influential variables. CONCLUSIONS We developed and internally validated machine learning-based models for predicting outcomes in ASCC and showed higher accuracy versus LR for locoregional failure, but not overall survival. After external validation, these models may assist clinicians with identifying patients with ASCC at high risk of treatment failure.
Collapse
Affiliation(s)
- Kevin A Chen
- Divison of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 100 Manning Drive, 4038 Burnett Womack Building, CB #7050, Chapel Hill, NC, 27599, USA
| | - Paolo Goffredo
- Division of Colon & Rectal Surgery, Department of Surgery, University of Minnesota, 420 Delaware St SE, MN, 55455, Minneapolis, USA
| | - David Hu
- Department of Biostatistics, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 3101 McGavran-Greenberg Hall, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Chinmaya U Joisa
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, 10202C Mary Ellen Jones Building, Chapel Hill, NC, 27599, USA
| | - Jose G Guillem
- Divison of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 100 Manning Drive, 4038 Burnett Womack Building, CB #7050, Chapel Hill, NC, 27599, USA
| | - Shawn M Gomez
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, 10202C Mary Ellen Jones Building, Chapel Hill, NC, 27599, USA
| | - Muneera R Kapadia
- Divison of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 100 Manning Drive, 4038 Burnett Womack Building, CB #7050, Chapel Hill, NC, 27599, USA.
| |
Collapse
|
8
|
de Paiva ACM, Nahas SC, Kimura CMS, Moniz CMV, Marques CFS, Júnior UR, Nahas CSR. Salvage Surgery for Anal Squamous Cell Carcinoma: Still a Difficult Challenge. J Gastrointest Surg 2022:10.1007/s11605-022-05486-8. [PMID: 36509896 DOI: 10.1007/s11605-022-05486-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/20/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Aline Costa Mendes de Paiva
- Division of Gastrointestinal Surgery, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil
| | - Sergio Carlos Nahas
- Division of Gastrointestinal Surgery, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil
| | - Cintia M S Kimura
- Division of Gastrointestinal Surgery, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil
| | - Camila Motta Venchiarutti Moniz
- Division of Clinical Oncology, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil
| | - Carlos Frederico Sparapan Marques
- Division of Gastrointestinal Surgery, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil
| | - Ulysses Ribeiro Júnior
- Division of Gastrointestinal Surgery, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil
| | - Caio Sergio Rizkallah Nahas
- Division of Gastrointestinal Surgery, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil.
| |
Collapse
|
9
|
Jaraudias C, Saint LMA, Schiappa R, Baron D, Marie L, Benezery K, Scouarnec C, François É, Evesque L. Failure of Initial Curative Treatment for Non-Metastatic Anal Squamous Cell Carcinoma: From Prognostic Factors Analysis to Stratified Treatment. Clin Colorectal Cancer 2022; 21:362-370. [PMID: 35934635 DOI: 10.1016/j.clcc.2022.07.001] [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: 10/24/2021] [Revised: 03/14/2022] [Accepted: 07/03/2022] [Indexed: 01/26/2023]
Abstract
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.
Collapse
Affiliation(s)
- Claire Jaraudias
- Department of Medical Oncology, Centre Antoine Lacassagne, 33 Avenue Valombrose 06100 Nice, France.
| | | | - Renaud Schiappa
- Department of Epidemiology, Biostatistics and Health Data, Centre Antoine Lacassagne, 33 Avenue Valombrose 06100 Nice, France
| | - David Baron
- Department of Radiotherapy, Centre Antoine Lacassagne, 33 Avenue Valombrose 06100 Nice, France
| | - Léa Marie
- Department of Medical Oncology, Centre Antoine Lacassagne, 33 Avenue Valombrose 06100 Nice, France
| | - Karen Benezery
- Department of Radiotherapy, Centre Antoine Lacassagne, 33 Avenue Valombrose 06100 Nice, France
| | - Cyrielle Scouarnec
- Department of Radiotherapy, Centre Antoine Lacassagne, 33 Avenue Valombrose 06100 Nice, France
| | - Éric François
- Department of Medical Oncology, Centre Antoine Lacassagne, 33 Avenue Valombrose 06100 Nice, France
| | - Ludovic Evesque
- Department of Medical Oncology, Centre Antoine Lacassagne, 33 Avenue Valombrose 06100 Nice, France
| |
Collapse
|
10
|
Mesorectal failure after chemoradiotherapy for squamous cell carcinoma of the anus: is sphincter-saving surgery reasonable? Tech Coloproctol 2022; 27:379-388. [PMID: 36127625 DOI: 10.1007/s10151-022-02698-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/01/2022] [Indexed: 12/24/2022]
Abstract
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.
Collapse
|
11
|
Eng C, Ciombor KK, Cho M, Dorth JA, Rajdev LN, Horowitz DP, Gollub MJ, Jácome AA, Lockney NA, Muldoon RL, Washington MK, O'Brian BA, Benny A, Lebeck Lee CM, Benson AB, Goodman KA, Morris VK. Anal Cancer: Emerging Standards in a Rare Rare Disease. J Clin Oncol 2022; 40:2774-2788. [PMID: 35649196 DOI: 10.1200/jco.21.02566] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The social stigma surrounding an anal cancer diagnosis has traditionally prevented open discussions about this disease. However, as recent treatment options and an increasing rate of diagnoses are made worldwide, awareness is growing. In the United States alone, 9,090 individuals were expected to be diagnosed with anal cancer in 2021. The US annual incidence of squamous cell carcinoma of the anus continues to increase by 2.7% yearly, whereas the mortality rate increases by 3.1%. The main risk factor for anal cancer is a human papillomavirus infection; those with chronic immunosuppression are also at risk. Patients with HIV are 19 times more likely to develop anal cancer compared with the general population. In this review, we have provided an overview of the carcinoma of the anal canal, the role of screening, advancements in radiation therapy, and current trials investigating acute and chronic treatment-related toxicities. This article is a comprehensive approach to presenting the existing data in an effort to encourage continuous international interest in anal cancer.
Collapse
Affiliation(s)
- Cathy Eng
- Division of Hematology and Oncology, Department of Internal Medicine, Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Kristen K Ciombor
- Division of Hematology and Oncology, Department of Internal Medicine, Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - May Cho
- Division of Hematology and Oncology, Department of Medicine, University of California- Irvine School of Medicine, Irvine, CA
| | - Jennifer A Dorth
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Lakshmi N Rajdev
- Division for Hematology and Oncology, Department of Medicine, Northwell Health/Lenox Hill Hospital, New York, NY
| | - David P Horowitz
- Department of Radiation Oncology, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Alexandre A Jácome
- OncoBio Comprehensive Cancer Center, Department of Gastrointestinal Medical Oncology, Nova Lima, Brazil
| | - Natalie A Lockney
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Roberta L Muldoon
- Division of Colon and Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Mary Kay Washington
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Brittany A O'Brian
- Division of Hematology and Oncology, Department of Internal Medicine, Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Amala Benny
- Division of Hematology and Oncology, Department of Internal Medicine, Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Cody M Lebeck Lee
- VA Tennessee Valley Healthcare System, Department of Internal Medicine, Nashville, TN
| | - Al B Benson
- Division of Hematology-Oncology, Northwestern University, Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Van Karlyle Morris
- Division of Cancer Medicine, Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
12
|
Martinez-Cannon BA, Perez ACT, Hincapie-Echeverri J, Roy M, Marinho J, Buerba GA, Akagunduz B, Li D, Soto-Perez-de-Celis E. Anal cancer in older adults: A Young International Society of Geriatric Oncology review paper. J Geriatr Oncol 2022; 13:914-923. [DOI: 10.1016/j.jgo.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/06/2022] [Accepted: 04/06/2022] [Indexed: 02/07/2023]
|
13
|
Johansson M, Axelsson A, Haglind E, Bock D, Angenete E. Long-term survival after treatment for primary anal cancer- results from the Swedish national ANCA cohort study. Acta Oncol 2022; 61:478-483. [PMID: 35098862 DOI: 10.1080/0284186x.2022.2033314] [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: 11/01/2022]
Abstract
BACKGROUND Squamous cell carcinoma of the anus is increasing in incidence but remains a rare disease with good 3- and 5-year recurrence free and overall survival rates of 63%-86%. The treatment includes chemoradiotherapy, mainly with 5-fluoruracil (5FU) and mitomycin. The aim of this study was to describe long-term (up to 9 years after treatment) oncological outcome and the types of treatments given, in a Swedish national cohort of patients diagnosed with anal cancer between 2011 and 2013. METHOD Patients were identified in the Swedish Cancer Registry. Patients still alive were contacted and asked for consent. Clinical data were retrieved from National Patient Register at the Swedish National Board of Health and Welfare and from medical records. Unadjusted and adjusted analyses were performed for overall survival. RESULTS Three hundred and eighty-eight patients were included in the study of which 338 patients (87%) received treatment with a curative intent. Follow up was 85 months (0-113 months) for patients treated with curative intent (information missing in one patient) 7.5 months (0-55) for patients with treated with a palliative intent. Curative treatment varied and consisted of both chemoradiotherapy and radiotherapy (46-64 Gy) alone. 5-FU, mitomycin and cisplatin were the most used chemotherapy agents. Five-year overall survival for patients treated with curative intent was 73%. In an adjusted analysis 5-FU and mitomycin is associated with a lower mortality than 5-FU and cisplatin but the association was weaker (HR 1.61 (95% CI: 0.904; 2.85) than in the unadjusted analysis. CONCLUSIONS In this national cohort overall five-year survival was 73% for patients treated with curative intent. As reported by others our results indicate that 5-FU and mitomycin C should be the preferred chemotherapy in treatment for cure.
Collapse
Affiliation(s)
- Mia Johansson
- Department of Oncology, Region Västra Götaland, Sahlgrenska University Hospital/Sahlgrenska, Gothenburg, Sweden
| | - Anna Axelsson
- Department of Surgery, SSORG-Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Haglind
- Institute of Clinical Science, Sahlgrenska University Hospital, Göteborg, Sweden
| | - David Bock
- Department of Surgery, SSORG-Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Angenete
- Department of Surgery, SSORG-Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
14
|
Tchelebi LT, Eng C, Messick CA, Hong TS, Ludmir EB, Kachnic LA, Zaorsky NG. Current treatment and future directions in the management of anal cancer. CA Cancer J Clin 2022; 72:183-195. [PMID: 34847242 DOI: 10.3322/caac.21712] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/15/2021] [Accepted: 10/18/2021] [Indexed: 12/18/2022] Open
Abstract
Although rare, the rate of squamous cell carcinoma of the anus (SCCA) is rising globally. Most patients present with nonmetastatic disease and are curable with appropriate treatment, which has evolved significantly over the last several decades. Before the 1970s, SCCA was managed with radical surgery, resulting in a permanent colostomy. Researchers found that preoperative treatment with chemotherapy and concurrent radiation could achieve a pathologic complete response. After this observation, definitive therapy shifted from radical surgery to sphincter-preserving chemoradiation. Investigations into the necessity of chemotherapy and the optimal regimen found that chemotherapy with mitomycin-C and 5-fluorouracil is required for cure. Further studies evaluating the addition of induction or maintenance chemotherapy, monoclonal antibody therapy, or higher radiation doses have demonstrated no significant benefit to disease control. Advanced radiation delivery with intensity-modulated radiotherapy techniques is now considered the standard of care because of its prospectively determined, favorable acute toxicity profile compared with 3-dimensional conformal radiation. It is important to note that chemoradiation treatment response may be slow (up to 26 weeks) and should be assessed through serial clinical examinations. Today, surgical management of SCCA is reserved only for the lowest risk, early stage tumors or for recurrent/persistent disease. Current studies are evaluating radiation dose de-escalation in early stage disease and radiation dose escalation and the addition of immune checkpoint inhibitors in locally advanced cancers. In reviewing how and why modern-day treatment of SCCA was established, the objective of this report is to reenforce adherence to current treatment paradigms to assure the best possible outcomes for patients.
Collapse
Affiliation(s)
- Leila T Tchelebi
- Department of Radiation Medicine, Zucker School of Medicine, Hempstead, New York
- Department of Radiation Medicine, Northwell Health Cancer Institute, Mount Kisco, New York
| | - Cathy Eng
- Department of Hematology and Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Craig A Messick
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve School of Medicine, Cleveland, Ohio
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| |
Collapse
|
15
|
The role of haematological parameters in predicting the response to radical chemoradiotherapy in patients with anal squamous cell cancer. Radiol Oncol 2021; 55:449-458. [PMID: 34626531 PMCID: PMC8647797 DOI: 10.2478/raon-2021-0039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/16/2021] [Indexed: 12/24/2022] Open
Abstract
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.
Collapse
|
16
|
Role of 18F-FDG PET-derived parameters for predicting complete response to chemoradiotherapy in squamous cell anal carcinoma. Nucl Med Commun 2021; 41:1089-1094. [PMID: 32732599 DOI: 10.1097/mnm.0000000000001260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We aimed to evaluate the accuracy of metabolic parameters, calculated on pretreatment positron emission computed tomography (PET/CT) with fluorodeoxyglucose (F-FDG), for predicting complete response to chemoradiotherapy (CRT) of patients affected by squamous cell anal carcinoma (SCAC). PATIENTS AND METHODS Clinical records of 20 patients affected by SCAC and treated with CRT were retrospectively evaluated. F-FDG PET/CT was performed at time 0 (baseline) and time 1 (12 weeks after CRT). The following parameters were extracted from PET at time 0: standardized uptake values (SUVmax and SUVmean), metabolic tumor volume (MTV) and total lesion glycolysis (TLG). Response was assessed according to PET response criteria in solid tumors and classified as complete metabolic response (CMR), partial metabolic response (PMR) and progressive metabolic disease (PMD). Receiver operating characteristic analysis was performed to analyze the predictive value of each PET-derived parameter on CMR. RESULTS Sixteen patients were finally enrolled. All presented increased F-FDG uptake in the primary tumor and 11 (68.7%) also showed metastatic lymph nodes. At PET/CT performed at time 1, 11 subjects (68.7%) presented CMR, three (18.7%) had PMR and the remaining two (12.5%) showed PMD (i.e. hepatic metastases). Among baseline PET-derived parameters, both MTV and TLG efficiently predicted response to CRT with an area under the curve of 0.9 (cutoff 62.3 cm, sensitivity 80%, specificity 100%, P = <0.0001) and 0.87 (cutoff 654.1 g, sensitivity 80%, specificity 100%, P = 0.004), respectively. CONCLUSION Among PET-derived parameters, both MTV and TLG presented a high predictive value on subjects' outcome after CRT.
Collapse
|
17
|
|
18
|
Dee EC, Byrne JD, Wo JY. Evolution of the Role of Radiotherapy for Anal Cancer. Cancers (Basel) 2021; 13:1208. [PMID: 33801992 PMCID: PMC8001637 DOI: 10.3390/cancers13061208] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/05/2021] [Accepted: 03/06/2021] [Indexed: 12/11/2022] Open
Abstract
Prior to the 1980s, the primary management of localized anal cancer was surgical resection. Dr. Norman Nigro and colleagues introduced neoadjuvant chemoradiotherapy prior to abdominoperineal resection. Chemoradiotherapy 5-fluorouracil and mitomycin C afforded patients complete pathologic response and obviated the need for upfront surgery. More recent studies have attempted to alter or exclude chemotherapy used in the Nigro regimen to mitigate toxicity, often with worse outcomes. Reductions in acute adverse effects have been associated with marked advancements in radiotherapy delivery using intensity-modulated radiation therapy (IMRT) and image-guidance radiation delivery, resulting in increased tolerance to greater radiation doses. Ongoing trials are attempting to improve IMRT-based treatment of locally advanced disease with efforts to increase personalized treatment. Studies are also examining the role of newer treatment modalities such as proton therapy in treating anal cancer. Here we review the evolution of radiotherapy for anal cancer and describe recent advances. We also elaborate on radiotherapy's role in locally persistent or recurrent anal cancer.
Collapse
Affiliation(s)
| | - James D. Byrne
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA 02115, USA;
| | - Jennifer Y. Wo
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA;
- Department of Radiation Oncology, Massachusetts General Hospital, 100 Blossom St., Boston, MA 02114, USA
| |
Collapse
|
19
|
Park IJ, Chang G. Survival and Operative Outcomes After Salvage Surgery for Recurrent or Persistent Anal Cancer. Ann Coloproctol 2020; 36:361-373. [PMID: 33486907 PMCID: PMC7837391 DOI: 10.3393/ac.2020.12.29] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/29/2020] [Indexed: 12/24/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- In Ja Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine Seoul, Korea
| | - George Chang
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
20
|
Bogach J, Fenech D, Chu W, Ashamalla S, Ung Y, Taggar AS, Chan KKW, Earle CC, Wong CS. Salvage surgery for locally recurrent anal cancer after intensity modulated radiation therapy with concurrent chemotherapy. Cancer Treat Res Commun 2020; 26:100287. [PMID: 33360327 DOI: 10.1016/j.ctarc.2020.100287] [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: 09/29/2020] [Revised: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Chemoradiation (CRT) with intensity modulated radiation treatment (IMRT) has become the standard for anal cancer. In patients who fail this treatment modality, salvage surgery with abdominal perineal resection can result in long term cancer control. We aimed to evaluate a single centre's experience of salvage surgery for local recurrence since the introduction of IMRT. MATERIALS AND METHODS A retrospective chart review was performed of all patients who underwent definitive CRT for anal carcinoma at a single tertiary referral center since IMRT became standard in 2009. Patients with recurrent or persistent disease after treatment who underwent salvage surgery were included. Details of CRT, salvage surgery and surgical complications, patterns of recurrence after surgery, and survival data were collected and described. RESULTS Between 2009-2018, 181 patients underwent definitive treatment using IMRT for anal carcinoma. Of 26 patients who had locoregional recurrent or persistent disease, 14 underwent salvage surgery. Nine had multi-visceral resection and 8 required autologous flap reconstruction. Twelve patients had resections with clear margins and 2 had microscopic positive margins. Twelve patients (86%) experienced post-operative complications, and eight (57%) had perineal wound complications. After salvage, four patients (29%) recurred locally. None of the 8 patients with rpT2 disease recurred. After salvage surgery, 5-year disease free survival was 68.4% and 5-year overall survival was 75%. CONCLUSION Following IMRT based chemoradiation, salvage surgery has high rates of surgical complications; however disease free and overall survival results are excellent particularly for small recurrences.
Collapse
Affiliation(s)
- Jessica Bogach
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Darlene Fenech
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - William Chu
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Shady Ashamalla
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Yee Ung
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Amandeep S Taggar
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Kelvin K W Chan
- Division of Medical Oncology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Craig C Earle
- Division of Medical Oncology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - C Shun Wong
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.
| |
Collapse
|
21
|
Pravong V, Brind'Amour A, Sidéris L, Dubé P, Tremblay JF. A rare case of recurrent epidermoid anal cancer treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy-case report. World J Surg Oncol 2020; 18:152. [PMID: 32622361 PMCID: PMC7335445 DOI: 10.1186/s12957-020-01935-3] [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: 04/02/2020] [Accepted: 06/24/2020] [Indexed: 11/24/2022] Open
Abstract
Background Anal cancer is a rare cancer with chemoradiation being the mainstay of treatment for locoregional presentation. In North America, the most common subtype is anal squamous cell carcinoma (epidermoid). A surgical approach is considered for persistent or recurrent anal disease and systemic chemotherapy for metastatic disease. We are presenting a unique case of recurrent anal cancer with isolated peritoneal malignancy, an oligometastatic state which is rare in itself. It was treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. There are currently no clear guidelines for the aforementioned presentation. The discussion drew on the feasibility and safety of this approach. Case presentation A 68-year-old woman diagnosed with an epidermoid anal cancer (stage 3B) was initially treated with chemoradiation therapy (Standard Nigro Protocol) in 2014. At the 5-year mark post-treatment, she was diagnosed with a recurrent anal epidermoid cancer in the form of isolated peritoneal carcinomatosis proven by biopsy. After declining systemic chemotherapy, she underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy with Mitomycin-C©. Peritoneal carcinomatosis index was evaluated at 10, and intraoperative frozen sections were positive for carcinoma of epidermoid origin compatible with anal cancer. A completeness of cytoreduction score of 0 was achieved during the cytoreductive surgery, and her hospital course was unremarkable. She remains disease-free 12 months later. Conclusions To our knowledge, this is the first case reporting the disease presentation of anal cancer with oligometastatic dissemination to the peritoneum. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were performed. Thus far, this approach seems to be a safe and feasible option for short-term control of the disease.
Collapse
Affiliation(s)
- Vera Pravong
- Department of General Surgery, University of Montreal, Montreal, Quebec, Canada.,The Centre de Recherche de l'Hôpital Maisonneuve-Rosemont, Université de Montréal, 5415 boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada
| | - Alexandre Brind'Amour
- The Centre de Recherche de l'Hôpital Maisonneuve-Rosemont, Université de Montréal, 5415 boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada.,Division of Surgical Oncology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| | - Lucas Sidéris
- The Centre de Recherche de l'Hôpital Maisonneuve-Rosemont, Université de Montréal, 5415 boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada.,Division of Surgical Oncology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| | - Pierre Dubé
- The Centre de Recherche de l'Hôpital Maisonneuve-Rosemont, Université de Montréal, 5415 boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada.,Division of Surgical Oncology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| | - Jean-François Tremblay
- The Centre de Recherche de l'Hôpital Maisonneuve-Rosemont, Université de Montréal, 5415 boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada. .,Division of Colorectal Surgery, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada.
| |
Collapse
|
22
|
Pessia B, Romano L, Giuliani A, Lazzarin G, Carlei F, Schietroma M. Squamous cell anal cancer: Management and therapeutic options. Ann Med Surg (Lond) 2020; 55:36-46. [PMID: 32461801 PMCID: PMC7240186 DOI: 10.1016/j.amsu.2020.04.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 04/02/2020] [Accepted: 04/19/2020] [Indexed: 02/06/2023] Open
Abstract
The incidence of anal cancer has increased during the second half of the 20th century, with an incidence rate over 2.9% greater than in the decade of 1992-2001. Yet, it still constitutes a small percentage, about 4%, of all anorectal tumours. Its risk factors are human papillomavirus infection, a history of sexually transmitted diseases, a history of vulvar or cervical carcinoma, immunosuppression related to human immunodeficiency virus infection or after organ transplantation, haematological or immunological disorders, and smoking. The most frequent symptom is rectal bleeding (45%), followed by anal pain, and sensation of a rectal mass. The diagnosis requires clinical examination, palpation of the inguinal lymph nodes, high resolution anoscopy followed by fine-needle aspiration biopsy or core biopsy. Subsequent histologic diagnosis is necessary, as well as computed tomography or magnetic resonance imaging evaluation of the pelvic lymph nodes. Since 1980, patients with a diagnosis of anal cancer have shown a significant improvement in survival. In Europe during the years 1983-1994, 1-year survival increased from 78% to 81%, and the improvement over 5 years was between 48% and 54%. Prior to 1974, patients with invasive cancer were routinely scheduled for abdominoperineal amputation, after which it was demonstrated that treatment with 5-fluorouracil and radiotherapy associated with mitomycin or capecitabine could be adequate to treat the tumour without surgery. Today, numerous studies have confirmed that combined multimodal treatment is effective and sufficient.
Collapse
Affiliation(s)
- Beatrice Pessia
- Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Lucia Romano
- Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Antonio Giuliani
- Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Gianni Lazzarin
- Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Francesco Carlei
- Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Mario Schietroma
- Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila, Italy
| |
Collapse
|
23
|
Nichols DS, Satteson E, Harbor P, DeFranzo A, David L, Thompson JT. Factors associated with the use of vertical rectus abdominus myocutaneous flap reconstruction following abdominoperineal resection for anorectal cancer. J Surg Oncol 2020; 122:923-927. [PMID: 32596855 DOI: 10.1002/jso.26086] [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: 04/16/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Following abdominoperineal resection (APR), primary closure of the perineal defect is often possible. Some patients, however, require flap reconstruction. Identifying these patients preoperatively is critical to facilitate comprehensive patient counseling and optimize surgical efficacy. METHODS A retrospective review of patients undergoing APR over a 10-year period was performed to identify predictive factors for patients requiring reconstruction with a vertical rectus abdominis myocutaneous (VRAM) flap as opposed to primary closure. Student's t and Fisher's exact tests were utilized for statistical analysis. RESULTS A total of 158 patients underwent APR, 29 of whom (18%) required a VRAM flap. A higher average skin resection area was seen among those requiring flap reconstruction (P < .0001). Flap reconstruction was also associated with current smoking status (P = .0197), anal tumor location (P < .0001), and neoadjuvant radiation (P = .0457). Although not statistically significant, average tumor diameter was larger in the VRAM flap group compared with the primary closure group. CONCLUSIONS While the appropriate method of closure for those undergoing APR should be considered on an individual case basis, patients who smoke, have a tumor located at the anus, or require large skin resection are more likely to need flap reconstruction.
Collapse
Affiliation(s)
- David S Nichols
- University of Florida College of Medicine, Gainesville, Florida
| | - Ellen Satteson
- University of Florida College of Medicine, Gainesville, Florida.,Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida, Gainesville, Florida
| | - Patrick Harbor
- Department of Plastic Surgery, Georgetown University Hospital, Washington, District of Columbia
| | - Anthony DeFranzo
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Lisa David
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - James T Thompson
- Section of Plastic and Reconstructive Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| |
Collapse
|
24
|
Martínez-Gómez C, Angeles MA, Martinez A, Meresse T, Gangloff D, Ferron G. Perineal resection and anorectal amputation with perforator flap reconstruction by a dorsal approach in prone Jackknife position. Int J Gynecol Cancer 2020; 30:1082-1083. [PMID: 32513663 DOI: 10.1136/ijgc-2020-001423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Carlos Martínez-Gómez
- Department of Surgical Oncology, Institut Universitaire de Cancer de Toulouse, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France.,CRCT Team 1 - Tumor Immunology and Immunotherapy, INSERM, Toulouse, France
| | - Martina Aida Angeles
- Department of Surgical Oncology, Institut Universitaire de Cancer de Toulouse, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Alejandra Martinez
- Department of Surgical Oncology, Institut Universitaire de Cancer de Toulouse, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France.,CRCT Team 1 - Tumor Immunology and Immunotherapy, INSERM, Toulouse, France
| | - Thomas Meresse
- Plastic and Reconstructive Surgery, Institut Universitaire du Cancer de Toulouse, Toulouse, France
| | - Dimitri Gangloff
- Plastic and Reconstructive Surgery, Institut Universitaire du Cancer de Toulouse, Toulouse, France
| | - Gwenael Ferron
- Department of Surgical Oncology, Institut Universitaire de Cancer de Toulouse, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France .,CRCT 19 - Oncosarc - Oncogenesis of Sarcomas, INSERM, Toulouse, France
| |
Collapse
|
25
|
Salvage Abdominoperineal Resection for Anal Squamous Cell Carcinoma: Use, Risk Factors, and Outcomes in a Canadian Population. Dis Colon Rectum 2020; 63:748-757. [PMID: 32384405 DOI: 10.1097/dcr.0000000000001630] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Previous studies have reported that 30% to 40% of patients with squamous cell carcinoma of the anus will require salvage abdominoperineal resection after chemoradiotherapy. OBJECTIVE The purpose of this study was to identify the use, risk factors, and impact on survival of salvage abdominal perineal resection for squamous cell carcinoma of the anus. DESIGN This was a retrospective, population-based cohort study. SETTINGS Patients treated in Ontario, Canada through a single-payer universal healthcare system, were included. PATIENTS Patients included all incident cases of squamous cell anal cancer who underwent curative intent radiotherapy from 2007 to 2015. MAIN OUTCOME MEASURES Risk of salvage abdominoperineal resection, factors associated with salvage abdominoperineal resection, and survival were measured. RESULTS A total of 1125 patients were treated with curative intent radiotherapy for squamous cell cancer of the anus. Within this cohort, salvage surgery was performed in 8% (93/1125), whereas 14% (156/1125) required a permanent colostomy. In log-binomial regression, younger age was associated with salvage surgery, whereas sex, cancer stage, socioeconomic status, and HIV were not. There was a suggested lower risk of salvage surgery in those who completed chemoradiation (relative risk = 0.67 (95% CI, 0.43-1.03)). Crude 5-year overall survival rate was 73% (95% CI, 70%-76%) in those not requiring salvage surgery and 48% (95% CI, 37%-58%) in those who did. In Cox models, mortality was higher in patients requiring salvage surgery compared with those who did not (adjusted HR = 2.20 (95% CI, 1.65-2.94), whereas improved survival was seen in those who completed chemoradiation (HR = 0.65 (95% CI, 0.42-0.82)) LIMITATIONS:: The study was limited by its potential residual confounding by indication for salvage surgery. CONCLUSIONS In this large, contemporary cohort of patients with squamous cell carcinoma of the anus, the proportion of patients undergoing salvage surgery was considerably lower than previous reports. Younger age was associated with salvage surgery, and there was a suggestion of lower risk of salvage surgery with completion of chemoradiation. Patients requiring salvage surgery had poor 5-year overall survival. See Video Abstract at http://links.lww.com/DCR/B205. RAP DE RESCATE PARA EL CARCINOMA ANAL DE CéLULAS ESCAMOSAS: USO, FACTORES DE RIESGO Y RESULTADOS EN UNA POBLACIóN CANADIENSE: Estudios anteriores han reportado que 30-40% de los pacientes con carcinoma de células escamosas del ano requerirán una resección abdominoperineal de rescate después de la quimiorradioterapia.Identificar la utilización, los factores de riesgo y el impacto en la supervivencia de la resección abdominoperineal de rescate para el carcinoma de células escamosas del ano.Estudio de cohorte retrospectivo, basado en la población.Todos los casos incidentes de cáncer anal de células escamosas que se sometieron a radioterapia con fines curativos de 2007 a 2015.Pacientes tratados en Ontario, Canadá, un sistema de salud universal de un solo pagador.Riesgo de resección abdominoperineal de rescate, factores asociados con la resección abdominoperineal de rescate y la supervivencia.1125 pacientes fueron tratados con radioterapia de intención curativa para el cáncer de células escamosas del ano. Dentro de esta cohorte, la cirugía de rescate se realizó en el 8% (93/1125), mientras que el 14% (156/1125) requirió una colostomía permanente. En la regresión log-binomial, la edad más joven se asoció con la cirugía de rescate, mientras que el sexo, la etapa del cáncer, el estado socioeconómico y el VIH no. Se sugirió un menor riesgo de cirugía de rescate en aquellos que completaron la quimiorradiación (RR 0,67; IC del 95%: 0,43 a 1,03). La tasa de supervivencia global bruta a 5 años fue del 73% (IC del 95%: 70-76%) en aquellos que no requirieron cirugía de rescate y del 48% (IC del 95%: 37-58%) en los que sí lo requirieron. En los modelos de Cox, la mortalidad fue mayor en los pacientes que requirieron cirugía de rescate en comparación con aquellos que no lo requirieron (HR ajustado 2.20, IC 95%: 1.65 - 2.94), mientras que se observó una mejor supervivencia en aquellos que completaron la quimiorradiación (HR 0.65, IC 95% 0.42 - 0,82).Posible confusión residual por indicación de cirugía de rescate.En esta gran cohorte contemporánea de pacientes con carcinoma de células escamosas del ano, la proporción de pacientes sometidos a cirugía de rescate fue considerablemente menor que los informes anteriores. La edad más temprana se asoció con la cirugía de rescate, y se sugirió un menor riesgo de cirugía de rescate con la finalización de la quimiorradiación. Los pacientes que requirieron cirugía de rescate tuvieron una deficiente supervivencia general de 5 años. Consulte Video Resumen en http://links.lww.com/DCR/B205. (Traducción-Dr Gonzalo Hagerman).
Collapse
|
26
|
Lee JY, Cutts RJ, White I, Augustin Y, Garcia-Murillas I, Fenwick K, Matthews N, Turner NC, Harrington K, Gilbert DC, Bhide S. Next Generation Sequencing Assay for Detection of Circulating HPV DNA (cHPV-DNA) in Patients Undergoing Radical (Chemo)Radiotherapy in Anal Squamous Cell Carcinoma (ASCC). Front Oncol 2020; 10:505. [PMID: 32363162 PMCID: PMC7180612 DOI: 10.3389/fonc.2020.00505] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/20/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Following chemo-radiotherapy (CRT) for human papilloma virus positive (HPV+) anal squamous cell carcinoma (ASCC), detection of residual/recurrent disease is challenging. Patients frequently undergo unnecessary repeated biopsies for abnormal MRI/clinical findings. In a pilot study we assessed the role of circulating HPV-DNA in identifying "true" residual disease. Methods: We prospectively collected plasma samples at baseline (n = 21) and 12 weeks post-CRT (n = 17). Circulating HPV-DNA (cHPV DNA) was measured using a novel next generation sequencing (NGS) assay, panHPV-detect, comprising of two primer pools covering distinct regions of eight high-risk HPV genomes (16, 18, 31, 33, 35, 45, 52, and 58) to detect circulating HPV-DNA (cHPV DNA). cHPV-DNA levels post-CRT were correlated to disease response. Results: In pre-CRT samples, panHPV-detect demonstrated 100% sensitivity and specificity for HPV associated ASCC. PanHPV-detect was able to demonstrate cHPV-DNA in 100% (9/9) patients with T1/T2N0 cancers. cHPV-DNA was detectable 12 weeks post CRT in just 2/17 patients, both of whom relapsed. 1/16 patients who had a clinical complete response (CR) at 3 months post-CRT but relapsed at 9 months and 1/1 patient with a partial response (PR). PanHPV-detect demonstrated 100% sensitivity and specificity in predicting response to CRT. Conclusion: We demonstrate that panHPV-detect, an NSG assay is a highly sensitive and specific test for the identification of cHPV-DNA in plasma at diagnosis. cHPV-DNA post-treatment may predict clinical response to CRT.
Collapse
Affiliation(s)
- Jen Y. Lee
- Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Rosalind J. Cutts
- Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Ingrid White
- Department of Clinical Oncology, The Royal Marsden Hospital, London, United Kingdom
| | - Yolanda Augustin
- Department of Clinical Oncology, St. Georges Hospital NHS Trust, London, United Kingdom
| | | | - Kerry Fenwick
- Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Nik Matthews
- Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Nicholas C. Turner
- Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
- Department of Clinical Oncology, The Royal Marsden Hospital, London, United Kingdom
| | - Kevin Harrington
- Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
- Department of Clinical Oncology, The Royal Marsden Hospital, London, United Kingdom
| | - Duncan C. Gilbert
- Department of Clinical Oncology, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
- MRC Clinical Trials Unit at UCL, London, United Kingdom
| | - Shreerang Bhide
- Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
- Department of Clinical Oncology, The Royal Marsden Hospital, London, United Kingdom
| |
Collapse
|
27
|
Bingmer K, Kondray V, Ofshteyn A, Bliggenstorfer JT, Dietz DW, Charles R, Stein SL, Paspulati R, Steinhagen E. Sarcopenia is associated with worse overall survival in patients with anal squamous cell cancer. J Surg Oncol 2020; 121:1148-1153. [PMID: 32133665 DOI: 10.1002/jso.25887] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/24/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Sarcopenia is associated with poor long-term outcomes in many gastrointestinal cancers, but its role in anal squamous cell carcinoma (ASCC) is not defined. We hypothesized that patients with sarcopenic ASCC experience worse long-term outcomes. METHODS A retrospective review of patients with ASCC treated at an academic medical center from 2006 to 2017 was performed. Of 104 patients with ASCC, 64 underwent PET/computed tomography before chemoradiation and were included in the analysis. The skeletal muscle index was calculated as total L3 skeletal muscle divided by height squared. Sarcopenia thresholds were 52.4 cm2 /m2 for men and 38.5 cm2 /m2 for women. Cox regression analysis was performed to assess overall and progression-free survival. RESULTS Twenty-five percent of the patients were sarcopenic (n = 16). Demographics were similar between groups. There was no difference in the clinical stage or comorbidities between groups. On multivariate analysis, factors associated with worse overall survival were male gender (hazard ratio [HR] 3.7, P = .022) and sarcopenia (HR 3.6, P = .019). Male gender was associated with worse progression-free survival (HR 2.6, P = .016). CONCLUSIONS Sarcopenia is associated with worse overall survival in patients with anal cancer. Further studies are indicated to determine if survival can be improved with increased attention to nutritional status in sarcopenic patients.
Collapse
Affiliation(s)
- Katherine Bingmer
- Department of Surgery, Research in Surgical Outcomes and Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Victor Kondray
- Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Asya Ofshteyn
- Department of Surgery, Research in Surgical Outcomes and Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jonathan T Bliggenstorfer
- Department of Surgery, Research in Surgical Outcomes and Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - David W Dietz
- Department of Surgery, Research in Surgical Outcomes and Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Ronald Charles
- Department of Surgery, Research in Surgical Outcomes and Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Sharon L Stein
- Department of Surgery, Research in Surgical Outcomes and Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Raj Paspulati
- Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Emily Steinhagen
- Department of Surgery, Research in Surgical Outcomes and Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| |
Collapse
|
28
|
Local Therapy Options for Recurrent Rectal and Anal Cancer: Current Strategies and New Directions. CURRENT COLORECTAL CANCER REPORTS 2019. [DOI: 10.1007/s11888-019-00445-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
29
|
Russo S, Anker CJ, Abdel-Wahab M, Azad N, Bianchi N, Das P, Dragovic J, Goodman KA, Jones W, Kennedy T, Kumar R, Lee P, Sharma N, Small W, Suh WW, Jabbour SK. Executive Summary of the American Radium Society Appropriate Use Criteria for Treatment of Anal Cancer. Int J Radiat Oncol Biol Phys 2019; 105:591-605. [PMID: 31288054 PMCID: PMC11101015 DOI: 10.1016/j.ijrobp.2019.06.2544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Suzanne Russo
- Case Western Reserve University School of Medicine and University Hospitals, Cleveland Ohio
| | | | - May Abdel-Wahab
- International Atomic Energy Agency, Division of Human Health, New York City, New York
| | - Nilofer Azad
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nancy Bianchi
- University of Vermont Cancer Center, Burlington, Vermont
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - William Jones
- UT Health Cancer Center, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Rachit Kumar
- Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Percy Lee
- University of California, Los Angeles, Jonsson Comprehensive Cancer Center, Los Angeles, California
| | - Navesh Sharma
- Milton S. Hershey Cancer Institute, Hershey, Pennsylvania
| | | | - W Warren Suh
- Ridley-Tree Cancer Center, Sansum Clinic, Santa Barbara, California
| | - Salma K Jabbour
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
| |
Collapse
|
30
|
Ko G, Sarkaria A, Merchant SJ, Booth CM, Patel SV. A systematic review of outcomes after salvage abdominoperineal resection for persistent or recurrent anal squamous cell cancer. Colorectal Dis 2019; 21:632-650. [PMID: 30689272 DOI: 10.1111/codi.14569] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 01/12/2019] [Indexed: 02/08/2023]
Abstract
AIM Up to 30% of patients with squamous cell cancer of the anus (SCCA) will require a salvage abdominoperineal resection (APR) for either persistent or recurrent disease. The objective of this study was to assess cancer-related outcomes in patients with (i) persistent or (ii) recurrent SCCA. METHOD Embase and MEDLINE were searched. Publications were included if they assessed overall survival (OS), disease-free survival (DFS) and locoregional recurrence or metastatic disease after salvage APR for persistent or recurrent SCCA. RESULTS A total of 28 retrospective case series (study size ranged from nine to 111) met our inclusion criteria. The median time to salvage APR was 2.6 months [interquartile range (IQR) 2.6-5.0 months, six studies] for persistent disease and 27.6 months (IQR 15.0-32.7 months, five studies) for recurrent disease. The median 5-year OS from the time of salvage APR was 45.0% (IQR 32.0%-52.3%, 10 studies) for persistent disease and 51.0% (IQR 36.0%-60.9%, 11 studies) for recurrent disease. The median 5-year DFS following salvage APR was 44.0% (IQR 29.5%-53.0%, 10 studies) for all patients. Following salvage APR, the median locoregional recurrence rate was 23.5% (IQR 15.8%- 46.9%, 19 studies) and 9.0% (IQR 6.4%-13.3%, 16 studies) of patients developed metastatic disease after salvage APR. CONCLUSION Our review characterizes the best evidence for outcomes following salvage APR for patients with persistent or recurrent SCCA. The evidence is limited by the quality of included studies, as many were single centre case series.
Collapse
Affiliation(s)
- G Ko
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - A Sarkaria
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - S J Merchant
- Department of Surgery, Queen's University, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - C M Booth
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - S V Patel
- Department of Surgery, Queen's University, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
31
|
Hagemans JAW. ASO Author Reflections: Salvage Surgery for Anal Cancer. Ann Surg Oncol 2018; 25:852-853. [PMID: 30414037 PMCID: PMC6329720 DOI: 10.1245/s10434-018-7025-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Indexed: 11/18/2022]
Affiliation(s)
- J A W Hagemans
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| |
Collapse
|