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

Radiotherapy in the management of rare gastrointestinal cancers: A systematic review

The aim of this analysis is to assess radiotherapy's role and technical aspects in an array of rare gastrointestinal (GI) cancers for adult patients. Collection data pertaining to radiotherapy and digestive rare cancers were sourced from Medline, EMBASE, and Cochrane Library. Preoperative chemoradiotherapy improved outcomes for patients with esophageal undifferentiated carcinoma compared with esophageal salivary gland types of carcinomas. For rare gastric epithelial carcinoma, perioperative chemotherapy is the common treatment. Adjuvant chemoradiotherapy showed no benefice compared with adjuvant chemotherapy for duodenal adenocarcinoma. Small bowel sarcomas respond well to radiotherapy. By analogy to anal squamous cell carcinoma, exclusive chemoradiotherapy provided better outcomes for patients with rectal squamous cell carcinoma. For anal adenocarcinoma, neoadjuvant chemoradiotherapy, followed by radical surgery, was the most effective regimen. For pancreatic neuroendocrine tumors, chemoradiotherapy can be a suitable option as postoperative or exclusive for unresectable/borderline disease. The stereotactic body radiotherapy (SBRT) is a promising approach for hepatobiliary malignancy. Radiotherapy is a valuable option in gastrointestinal stromal tumors (GIST) for palliative intent, tyrosine kinase inhibitors (TKIs) resistant disease, and unresectable or residual disease. Involved field (IF) radiotherapy for digestive lymphoma provides good results, especially for gastric extranodal marginal zone lymphoma (MALT). In conclusion, radiotherapy is not an uncommon indication in this context. A multidisciplinary approach is needed for better management of digestive rare cancers.

Clinical outcomes of neoadjuvant therapy followed by selective inguinal lymph node dissection and total mesorectal excision for metastasized low rectal cancer

PURPOSE

Rectal or anal canal adenocarcinoma with inguinal lymph node metastasis (ILNM) is rare and is associated with poor prognostic outcomes. This study aimed to elucidate the clinical significance of neoadjuvant therapy followed by selective inguinal lymph node dissection and total mesorectal excision for rectal or anal canal adenocarcinoma with clinically suspected ILNM.

METHODS

This study enrolled 15 consecutive patients who underwent neoadjuvant therapy and curative resection for rectal or anal canal adenocarcinoma with clinically suspected ILNM between 2005 and 2019 at a single institution. Inguinal lymph node dissection was selectively performed on the side of suspected metastasis before neoadjuvant therapy. Short- and long-term outcomes were retrospectively reviewed.

RESULTS

Out of the15 patients, 11 were treated with neoadjuvant chemoradiation, three with chemotherapy, and one with chemoradiation followed by chemotherapy. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) scans were performed after neoadjuvant therapy in 14 patients. Five patients had negative FDG accumulation in inguinal lymph nodes on FDG-PET scan, and their inguinal lymph nodes were also pathologically negative for metastasis. Of the nine patients who had positive FDG accumulation, four had pathologically positive inguinal lymph nodes. Seven patients (46.7%) had inguinal seroma postoperatively. Five-year-overall survival was 77.5%, and 5-year-relapse-free survival was 64.2%. No patient had a recurrence in the inguinal region.

CONCLUSION

In patients with rectal or anal canal adenocarcinoma associated with clinical ILNM, radical resection with neoadjuvant therapy provides a good long-term survival.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management and Outcomes in Anal Canal Adenocarcinomas—A Systematic Review

Simple Summary

Anal canal adenocarcinomas are a rare type of bowel cancer. For this reason, it is challenging to perform large studies in order to determine the optimal treatment strategy to achieve the best outcomes. Options for treatment include radiotherapy, chemotherapy and surgery. These treatments may be combined or used alone. Outcomes are regarded as survival after diagnosis and treatment, or the recurrence of the disease. There is no universal gold standard that exists, with wide variability in practice and therefore also in outcomes between institutions. Thus, by reviewing the body of literature on the subject matter, the hope is to establish a management algorithm that may be tested and refined going forward. This is the intention of this systematic review.

Abstract

(1) Background: Anal canal adenocarcinomas constitute 1% of all gastrointestinal tract cancers. There is a current lack of consensus and NICE guidelines in the United Kingdom regarding the management of this disease. The overall objective was to perform a systematic review on the multitude of practice and subsequent outcomes in this group. (2) Methods: The MEDLINE, EMBASE, EMCARE and CINAHL databases were interrogated between 2011 to 2021. PRISMA guidelines were used to select relevant studies. The primary outcome measure was 5-year overall survival (OS). Secondary outcome measures included both local recurrences (LR) and distant metastases (DM). The Newcastle–Ottawa Scale (NOS) was used to assess the quality of studies retrieved. The study was registered on PROSPERO (338286). (3) Results: Fifteen studies were included. Overall, there were 11,967 participants who were demographically matched. There were 2090 subjects in the largest study and five subjects in the smallest study. Treatment modalities varied from neoadjuvant chemoradiotherapy (CRT), CRT and surgery (CRT + S), surgery then CRT (S + CRT) and surgery only (S). Five-year OS ranged from 30.2% to 91% across the literature. LR rates ranged from 22% to 29%; DM ranged from 6% to 60%. Study heterogeneity precluded meta-analysis. (4) Conclusions: Trimodality treatment with neoadjuvant chemoradiotherapy (CRT) followed by radical surgery of abdominoperineal excision of rectum (APER) appeared to be the most effective approach, giving the best survival outcomes according to the current data.

Prognosis of anal canal adenocarcinoma versus lower rectal adenocarcinoma in Japan: a propensity score matching study

PURPOSE

Anal canal adenocarcinoma (AC) is rare and its surgical outcomes and prognostic factors (PFs) are not well understood. The aim of this retrospective study was to identify the characteristics and PFs of AC, using population-based data in Japan.

METHODS

Patients with AC (n = 390) or lower rectal adenocarcinoma (LR) (n = 12,477) diagnosed between1991 and 2006 were enrolled in this study. We compared the clinical- and patient-related factors of the two diseases and then examined propensity score matching, overall survival (OS), and PFs.

RESULTS

AC tended to develop more often in women and in patients of advanced age. Macroscopically, AC was of an unclassified type and microscopically, it was of high-grade histological types such as mucinous adenocarcinoma, poorly differentiated adenocarcinoma (por), or signet-ring cell carcinoma (sig), with a high frequency of inguinal node metastasis (P < 0.05). The 5 year OS rates were 56.9% for AC and 67.9% for LR (P = 0.002). The PFs of AC were a high-grade histological type (por/sig), T, N, and M.

CONCLUSIONS

AC has a significantly worse prognosis than LR. Moreover, the AC lymph node metastatic sites for AC, especially the inguinal nodes, are different from those for LR.

Anal Adenocarcinoma: A Rare Malignancy in Need of Multidisciplinary Management

Adenocarcinoma of the anal canal is an uncommon malignancy, making it challenging to perform randomized controlled clinical trials to define best practices in care. For patients with localized disease, there remains a lack of consensus regarding the optimal management, with some physicians advocating for trimodality therapy (similar to the locally advanced rectal adenocarcinoma paradigm) and others advocating for definitive radiation therapy with concurrent chemotherapy (similar to the management of anal squamous cell carcinoma). The objective of this clinical review is to describe the management and outcomes of patients with anal adenocarcinoma to help inform treatment recommendations.

Recurrent ilioinguinal lymph node metastasis from primary anal adenocarcinoma: what should we do?-A case report and review of literature

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Anal adenocarcinoma is more common in the Asian population than previously thought.

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Treatment of ilioinguinal lymph node metastasis from anal canal squamous cell carcinoma has been well described, but the management for primary adenocarcinoma is less so.

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Groin dissection for recurrent ilioinguinal lymph node metastasis from primary anal adenocarcinoma is a reasonable approach.

Introduction

Anal canal tumors are uncommon amongst gastrointestinal tumors or anorectal tumors. While the majority of them seem to be squamous cell carcinoma in nature, adenocarcinoma may be equally as common amongst the Asian population. Recurrent nodal metastasis from a primary anal malignancy is not a rare occurrence in view of the anatomy of the anal canal.

Case presentation

A 70 year-old patient underwent surgery for synchronous sigmoid and anal adenocarcinoma in 2015. He then re-presented 2 years later with recurrence in the right inguinal lymph nodes. He subsequently underwent a right ilio-inguinal lymph node block dissection with a Sartorius flap creation.

Discussion

As most anal canal tumors are squamous cell carcinomas, the optimal treatment for recurrent ilioinguinal lymph node disease has been well-established. This usually involves groin dissection as surgical treatment, with consideration for adjuvant combined chemoradiotherapy. Such an approach is likely to be beneficial for ilioinguinal lymph node disease from primary anal canal adenocarcinomas as well.

Conclusion

Physicians caring for patients with primary anal adenocarcinoma should be vigilant for possible ilioinguinal lymph node metastasis as this is not a rare occurrence. Surgical treatment appears to be a reasonable approach, with consideration for adjuvant therapy.

What factors are associated with the poor prognosis of anal adenocarcinoma compared with low-lying rectal adenocarcinoma based on a population analysis: A propensity score matching study

PURPOSE

Anal adenocarcinoma (AA) represents a rare condition, and little is known about the predictive factors of the outcomes or the optimal TNM staging system for curable AA. Using population-based data, we preliminarily sought to determine the prognostic factors and evaluate the existing T and N staging criteria of AA.

METHODS

We analyzed the Surveillance, Epidemiology, and End Results 18 database to identify patients 20-80 years old who were diagnosed with AA or rectal adenocarcinoma (RA) and underwent abdominal perineal resection between 2004 and 2012. The difference between Kaplan-Meier survival curves was estimated by a log-rank test. A Cox proportional hazard regression model was used to adjust the effects of other covariates on survival in the propensity score-matched cohort, including age, gender, race, marital status, histology, grade of differentiation, tumor size, number of positive lymph nodes, radiotherapy, and chemotherapy.

RESULTS

Compared to patients with RA, patients with AA had a worse CSS after controlling for other covariates (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.25-3.07; P<0.01). For AA, the increasing tumor size (2-5 cm: HR, 0.62; 95% CI, 0.29-1.32; P>0.05; >5 cm: HR, 1.01; 95% CI, 0.49-2.07; P>0.05) had no significant influence on survival. The number of positive lymph nodes (1-3: HR, 2.93; 95% CI, 1.55-5.53; P<0.01; ≥4: HR, 4.24; 95% CI, 2.08-8.62; P<0.01) significantly influenced survival.

CONCLUSIONS

AA confers a worse prognosis than RA does. The T staging criteria of anal carcinoma, dominated by tumor size, seem to be invalid for AA, while the number of positive lymph nodes is a prognostic factor.

Long-term outcomes after surgical dissection of inguinal lymph node metastasis from rectal or anal canal adenocarcinoma

Background

The 8th edition of the tumor-node-metastasis (TNM) classification classifies inguinal lymph nodes as regional lymph nodes for anal canal carcinoma but non-regional lymph nodes for rectal carcinoma. This difference might reflect the different prognosis of inguinal lymph node metastasis from anal canal carcinoma and rectal carcinoma. However, long-term outcomes of inguinal lymph node metastasis from rectal or anal canal adenocarcinoma are unclear, which we aimed to investigate in this study.

Methods

The study population included 31 consecutive patients with rectal or anal canal adenocarcinoma who underwent inguinal lymph node dissection with curative intent at the National Cancer Center Hospital from 1986 to 2017. Long-term outcomes were assessed and clinicopathologic variables analyzed for prognostic significance.

Results

Of the 31 patients, 12 patients had rectal adenocarcinoma and 19 patients had anal canal adenocarcinoma. Synchronous metastasis were observed in 14 patients and metachronous metastasis in 17 patients. After dissection of inguinal lymph node metastasis with curative intent, the 5-year overall survival rate was 55.2%, with 12 patients surviving for more than 5 years. Median survival time was 66.6 months. Multivariate analyses revealed that location of primary tumor (rectum versus anal canal) was not a prognostic factor, whereas lateral lymph node metastasis and histological findings were independent prognostic factors.

Conclusion

Given the good prognosis, inguinal lymph node metastasis in patients with rectal or anal canal adenocarcinoma appears to be regional rather than distant. If R0 resection can be achieved, inguinal lymph node dissection may be indicated for these patients.