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Anal cancer ppt


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Anal cancer ppt

  2. 2. ANATOMY  Anal Canal= 4 cm mucosa lined region from junction of the puborectalis portion of the levator ani muscle and the external anal sphincter, and extends distally to the anal verge  Transitional zone- from glandular (columnar) to squamous mucosa- at dentate line  Anal Margin- begins at the anal verge. It represents the transition from the squamous mucosa to the epidermis- lined perianal skin. Rectal glandular mucosa Transitional Squamous True Epidermis
  3. 3. ANATOMY  The anal canal is a 4-cm-long structure that passes downward and backward from the rectal ampulla (level of pelvic floor) to the anus (anal verge).  The proximal border of the anal canal clinically corresponds to the anal sphincter at the level of the puborectalis muscle (palpable as the anorectal ring on digital rectal examination). This is where the rectum enters the puborectalis sling, made by fibers from both sides.  The distal end of the anal canal is at the level of the anal verge, where the groove between the internal sphincter and the subcutaneous part of the external sphincter is palpable.  This also is the level of the squamous-mucocutaneous junction and the perianal skin.
  4. 4. Epidemiology and Risk Factors Squamous cell carcinoma of the anus is rare and least prevalent GI malignancy & accounts for only 1 – 2 % of all large bowel malignancy. Ratio of 1:2 for men to women with median age at diagnosis is 60 yrs. Geographical variation- heighest in caucasian female lowest in asian males
  5. 5. Risk Factors - HPV infection. - HIV seropositivity and low CD 4 count (twice) - Cigarette smoking - Anoreceptive intercourse (homosexual male 15 times) - Immune suppresion following transplant - anal warts.
  6. 6. Natural History Most anal cancers are believed to arise from precancerous changes(i.e. AIN) of the anal canal and peri anal skin epithelium High-grade AIN  Squamous cell cancers in most instances. However, it has been estimated that approximately 5% of cases with AIN III progress to invasive cancer over multiyear period. Squamous cell cancers spread.
  7. 7. Clinical Presentation and Workup Rectal bleeding- 45% of patients Pain or sensation of mass- 30% No symptoms- 20% Pruritus ani or bleeding plaques associated with anal margin skin cancers- Paget’s disease. Sensation of mass or fullness and tenesmus Physical exam- perrectal and nodes. Biopsy- used to differentiate squamous cell (anal ca) from adenocarcinoma (rectal ca) .
  8. 8. Vaccine prevention- two vaccines- best long term approach for reducing long term risk. Boys 11-12 yrs Girls 13 to 26 yrs
  9. 9. CT scan EUS or MRI PET scan
  10. 10. It follows that two distinct categories of tumors arise in the anal region. Tumors that develop from mucosa (columnar, transitional, or squamous) are true anal canal cancers tumors that arise from skin at or distal to the squamous- mucocutaneous junction are termed anal margin tumors
  11. 11. WHO Classification of Anal Cancer Anal canal  Squamous cell carcinoma - Keratinizing (below dentate) - Nonkeratinizing (above dentate) - Basaloid (transitional)  Adenocarcinoma - Rectal type - Of anal glands - Within anorectal fistula  Small cell carcinoma  Undifferentiated Anal margin  Squamous cell carcinoma  Giant condyloma  Basal cell carcinoma  Others (Melanoma)  Bowen's disease (SCC in situ)  Paget's disease (Intraepithelial adenocarcinoma)
  12. 12. STAGING  PRIMARY TUMOR (T)  TX Primary tumor cannot be assessed  T0 No evidence of primary tumor  Tis Carcinoma in situ  T1 Tumor =2 cm in greatest dimension  T2 Tumor >2 cm but =5 cm in greatest dimension  T3 Tumor >5 cm in greatest dimension  T4 Tumor of any size invades adjacent organ(s) (e.g., vagina, urethra, bladder)  Direct invasion of the rectal wall, perirectal skin, subcutaneous tissue, or the sphincter muscle(s) is not classified as T4
  13. 13.  REGIONAL LYMPH NODES (N)  NX Regional lymph nodes cannot be assessed  N0 No regional lymph node metastasis  N1 Metastasis in perirectal lymph node(s)  N2 Metastasis in unilateral internal iliac and/or inguinal lymph node(s)  N3 Metastasis in perirectal and inguinal lymph nodes and/or bilateral internal iliac and/or inguinal lymph node
  14. 14. AJCC stage groups  Stage I T1 N0 M0  Stage II T2 N0 M0 T3 N0 M0  Stage IIIA T1 N1 M0 T2 N1 M0 T3 N1 M0 T4 N0 M0  Stage IIIB T4 N1 M0 Any T N3 M0 Any T N2 M0  Stage IV Any T Any N M1
  15. 15. PROGNOSIS 5 y survival-  T1 — 86 percent  T2 — 86 percent  T3 — 60 percent  T4 — 45 percent  N0 — 76 percent  N+ — 54 percent
  16. 16. Prognostic factors Tumor size >5 cm , lymph nodes involvement, male sex are associated with poor prognosis. High expression of p53 associated with decreased DFS. Also local control rates are lower with increased p53 expression. High level of Ki 67 – longer DFS.
  17. 17. Combined-Modality Treatment  Combined-modality therapy was described initially by Nigro and coworkers.  This was a preoperative regimen inspired by reports that 5-fl uorouracil (5-FU) potentiated the effects of radiotherapy on garointestinal tumors.  This regimen consisted of delivering 30 Gy in 15 fractions to the primary tumor and pelvic lymph nodes with concurrent 5- FU (1000 mg/m2 as a 4-day continuous infusion) and mitomycin C (MTC) (15 mg/m2 bolus injection) chemotherapy, and APR 6 weeks after completion of the protocol.
  18. 18.  Promising early results, however, suggested that surgery may not be necessary.  The series of Nigro and colleagues included 31 patients who underwent surgery and 73 who received chemoradiotherapy alone.  Twenty-two of the 31 surgical specimens had no evidence of disease (NED) on histopathologic examination, and on long- term follow-up evaluation, an NED rate of 79% was found for the surgical patients, compared with 82% NED for patients receiving combined-modality treatment.  Overall death rates were 6% in patients with tumors smaller than 4 cm and 26% for those larger than 4 cm
  19. 19.  The trials conducted by the ( combined modality therapy Vs radiation alone ) - United Kingdom Coordinating Committee for Cancer Research (UKCCCR) - European Organization for Research on Treatment of Cancer (EORTC) - Both showed statistically significant advantages in -- the rate of control of the primary cancer -- colostomy-free survival rates
  20. 20. UKCCCR ACT I trial  585 patients with SCC of anal canal & perianal skin were randomized between radiation alone and radiation combined with chemotherapy.  The radiation dose was 45 Gy , with a boost dose of 15 to 20 GY following 6-weeks break, based on response.  5-FU (1,000 mg/m2 per 24 hours for 4 days or 750 mg/m2 per 24 hours for 5 days) by continuous peripheral intravenous infusion in the first and final weeks of radiation treatment, plus mitomycin (12 mg/m2 ) by bolus intravenous injection on day 1 of the first course of chemotherapy.
  21. 21.  3 year local Failure in the primary tumor or regional lymph nodes -(39%) of chemoradiation , (61%) of radiation alone.  Acute toxicity, particularly hematologic, skin, gastrointestinal, and genitourinary, was increased in the combined modality arm .  Late morbidity was comparable in each group.  No statistically significant advantage was seen in terms of overall survival
  22. 22. EORTC STUDY  Included 103 patients with T3-4N0-3 or T1-2N1-3  The radiation dose was 45 Gy , with a boost dose of 15 to 20 GY following 6-weeks break, based on response  Chemotherapy consisted of 5-FU (750 mg/m2 per 24 hours by continuous infusion for 5 days) in the first and fifth week of radiation, and a single bolus injection of mitomycin (15 mg/m2 ) on day 1 of the first course of 5-FU only.  Surgery was reserved for the patients with less than a partial response.  Concurrent CTRT group has higher complete response(80 vs 54%),locoregional control(68 vs 50%),colostomy free (72 vs 40%)  Acute and late toxicity rates were similar
  23. 23. U.S. RTOG–ECOG trial (RTOG 87–04/ ECOG 1289)  The need for MMC in combined-modality therapy of anal cancers was evaluated  This was the first study comparing two methods of chemoradiotherapy in patients with anal cancer. One study arm used 5-FU alone with radiotherapy, and the other arm used 5-FU and MMC with radiotherapy.  showed that colostomy free survival (71 vs 59%) and disease free survival rate(73 vs 51%) were significantly higher in patient receiving MMC and significantly lower colostomy (9 vs 22%) and local failure rate(16 vs 34%)  The investigators concluded that despite the greater toxicity, the use of MTC in a definitive complete response regimen for anal cancer was justified.
  24. 24. ACT II trial  randomized trial of 950 non-HIV infected patients with anal SCC .  Treatment consisted of RT in both arms (50.4 Gy in 28 fractions) with concurrent infusional 5-FU (1000 mg/m2 per day on days 1 to 4 and 29 to 32) and either cisplatin (60 mg/m2 on days 1 and 29) or mitomycin (12 mg/m2 day 1 only).  There was a second randomization to receive or not receive maintenance chemotherapy starting four weeks after chemoradiotherapy (two courses of cisplatin plus 5-FU, administered four weeks apart).
  25. 25. RESULTS  patients receiving mitomycin had more acute grade 3 or 4 hematologic toxicity (25 versus 13 percent), but no higher rates of febrile neutropenia (3.1 versus 3.2 percent) during chemoradiotherapy.  Rates of grade 3 or 4 nonhematologic toxicity were similar (61 versus 65 percent).  The complete response rate at six months (the primary endpoint) was 95 percent with both cisplatin and mitomycin, and  the three-year colostomy rate was not significantly different (13.7 versus 11.3 percent).  Three year RFS was similar with or without the use of maintenance therapy (75 percent for both arms) as was overall survival (84 versus 85 percent).
  26. 26. ACCORD 03 307 patients with stage II and III anal cancers randomized to one of four treatment arms: -Group 1- 5FU & cisplatin f/b EBRT 45 GY+ 5FU & Cisplatin ->rest ->15 GY -Group 2- 5FU & cisplatin f/b EBRT 45 GY+ 5FU & Cisplatin ->rest ->20 -25 GY -Group 3- EBRT 45 GY+ 5FU & Cisplatin ->rest ->15 GY -Group 4- EBRT 45 GY+ 5FU & Cisplatin ->rest ->20 -25 GY
  27. 27. Results-no significant difference in 5 yr colostomy free survival (70 to 82%), no significant differences were seen between the arms in terms of LRF and OS. Conclusion-induction CT does not improve outcomes, with the role of radiation dose escalation remaining uncertain, but the combination of induction CT and radiation dose escalation should be explored further.
  28. 28. Radical resection  For intermediate-stage primary anal canal cancer who - - Cannot tolerate radiation therapy or chemoradiation - Incontinent because of irreversible damage of the sphincters - Anovaginal fistula - Prior pelvic radiation treatment (most frequently for carcinoma of the cervix) - Active inflammatory bowel disease affecting the rectum or anal region - Failure of chemoradiation or radiation and less frequently, complications of the initial treatment.
  29. 29. SALVAGE SURGERY  Salvage Surgery  APR = abdominoperineal resection  Pelvic exenteration = multiviseral resection with urinary and fecal diversion  Salvage surgery is recommended in patient with chronically persistent disease or recurrence.  Salvage APR is associated with five-year survival rates from 30 to 70%,with DFS ranging from 30 to 40%.  Tumor size >5 cm, inguinal lymph node involvement, positive surgical margin, male sex, adjacent organ involvement are the factors associated with poor overall survival after salvage surgery.
  30. 30. Extrapelvic metastases Reported in up to about 10-17% of patients Median survival time - 8 to 12 months The combination studied most extensively, and the most effective, is 5-FU and cisplatin. The usual regimen is a 4- or 5-day continuous infusion of 5- FU (1,000 mg/m2 per 24 hours) plus a bolus infusion of cisplatin (100 mg/m2 ) on day 1 or 2, repeated at 4 weekly intervals as tumor response and toxicity permit.
  31. 31. A patient with metastatic cancer who received 12 cycles of 5-FU and cisplatin had been free of cancer for more than 3 years at the time of reporting. Other combinations, including mitomycin and 5-FU, and bleomycin, vincristine, and high-dose methotrexate produced few responses.
  32. 32. Adenocarcinomas  Comprise about 5% of cancers of the anal canal.  Small female preponderance.  The majority develop in rectal mucosa, which extends below the upper muscular boundary of the canal.  No recognized association with high-risk HPV or immunosuppression.  The most useful prognostic factors are T category and N category.  Overall 5-year survival rates following all treatments have generally been less than 50%.
  33. 33. Locoregional control is problematic. Risk of distant metastases higher than for squamous cell cancers Treated similarly to adenocarcinomas which arise in the rectum with surgery remaining as a cornerstone therapy and neoadjuvant radiation therapy or combined modality therapy generally implimented in patients with T3 or T4 and/or N+ disease
  34. 34. Melanoma of anal canal It’s a rare disease, 1% of all malignant melanoma & 0.5%of all anal malignancy. Bleeding perrectum is most common c/f. Surgery is the cornerstone for the treatment of anal melanoma, traditionally surgeons use more redical approach in form of APR with radical lymphnodes dissection Kiran et al 109 patients , reported no significant difference b/w patient treated by APR or local resection.
  35. 35. Anal Margin Cancers  Anal margin cancers includes the area extending from the anal verge radially 5cm outward on perianal skin.  More common in 7th and 8th decade with slight female preponderance.  Treat similar to skin cancer.  WLE for T1 and N0 can be excised with a 1-cm margin.  T3 and T4 lesions- radiation to both inguinal regions and the pelvis, along with 5-FU and mitomycin C.  APR should be reserved for patients with recurrent disease following CTRT or recurrence not amenable to local excision.
  36. 36.  The regional nodes for the perianal skin are the inguinal nodes.  Perirectal or pelvic node metastases are very uncommon.  The risk of inguinal node metastases is about 10%, associated mainly with category T3 or T4 tumors, or poorly differentiated cancers.  Elective inguinal nodal irradiation has been suggested for those categories only.
  37. 37. Perianal Cancers Bowen's Disease and Paget's Disease About half the cases of anal Paget's disease are associated with a synchronous or metachronous internal malignancy, often a colorectal adenocarcinoma. High local recurrence rate . May become invasive . Wide local excision, with intraoperative microscopic control of margins.
  38. 38.  Local recurrence can often be managed by further local excision.  Other less-established treatments -- Topical chemotherapy -- Topical immune modifiers such as imiquimod -- Photodynamic therapy.  Radiation therapy, or radiation and chemotherapy - reserved for patients with recurrent or invasive disease in whom adequate excision would entail sacrifice of anorectal function.  Abdominoperineal resection may be necessary to control extensive or recurrent disease.
  39. 39. THANK YOU