Organ-preserving multimodality management of squamous cell carcinoma of anal canal.

AIM: To study the efficacy of an organ-preserving, sequential chemoradiation therapy for squamous cell carcinoma of the anal canal, and of salvage surgery in those in whom this treatment fails. METHODS: Forty biopsy-proven untreated patients (28 men) with squamous cell carcinoma of the anal canal received two cycles of chemotherapy using cisplatin and methotrexate, followed by 45 to 60 (median 50) Gy external beam radiotherapy. Salvage surgery was offered to those in whom this treatment failed. Overall survival, disease-free survival and colostomy-free survival were analyzed. RESULTS: Most patients (n=35; 87%) had T3 or T4 lesions and 5 (12.5%) had involvement of inguinal nodes. Thirty-one patients (77.5%) had complete response after chemoradiation. Only three patients (7.5%) developed chemotherapy-related grade 3 mucositis and myelosuppression. Radiotherapy-related toxicity included grade III cystitis in one patient and grade III proctitis in three patients. Three patients had post-treatment anal stenosis requiring repeated dilatation and two had chronic non-healing ulcers at the anal verge. Nine patients had failure of chemoradiation or disease recurrence; of these, only 5 could undergo salvage surgery. After a median follow up of 60 months, overall survival, disease-free survival and colostomy-free survival were 80%, 77.5% and 72.5%, respectively. CONCLUSION: Chemoradiation is effective in the treatment of squamous cell anal cancer and has acceptable toxicity. Surgical salvage may be useful in those with failure of this treatment.     

Human papillomavirus-related squamous cell carcinoma of the anal canal with papillary features

Human papillomavirus(HPV)related squamous cell carcinoma(SCC)involving the anal canal is a well-known carcinoma associated with high-risk types of HPV.HPVrelated SCC with papillary morphology(papillary SCC)has been described in the oropharynx.We describe,for the first time,a case of anal HPV-related squamous carcinoma with papillary morphology.The tumor arose from the anal mucosa.The biopsies revealed a superficially invasive SCCwith prominent papillary features and associated in situ carcinoma.The tumor cells were positive for p16 and were also positive for high-risk types of HPV using chromogenic in situ hybridization.The findings are consistent with a HPV-related SCC of the anal canal with papillary features.This tumor shows histologic features similar to a papillary HPV-related SCC of the oropharynx.Additional studies are needed to characterize these lesions.     

The prospect of endoscopic submucosal dissection for early anal canal squamous cell carcinoma

Squamous cell carcinoma (SCC) of the anal canal is seldom diagnosed at an early stage. Chemoradiation therapy is a standard in Europe and the United States, though in squamous cell carcinoma there is no evidence-based therapy. In Japan, endoscopic submucosal dissection (ESD) is the standard minimally invasive treatment for early stage cancer of the digestive tract, including the colorectum. Therefore, if the lesion is diagnosed at an early stage, ESD may be selected for anal canal lesions. We experienced two cases of early stage anal canal cancer in which the diagnosis and the extent of the lesions were confirmed using magnifying endoscopy with narrow-band imaging (NBI), as well as performing ESD. Pathological examination showed the resected specimen to be SCC in situ; the horizontal and vertical margins were free of tumor; and in one case there was no lymphovascular invasion. In the other case it showed the tumor was contained within the epithelium; horizontal and vertical margins were free of tumor; The follow-up period is not long enough to assert that ESD for anal canal squamous cell carcinoma may be an option of minimally invasive therapy. However, if there is a possibility of lymphatic invasion as in one of our cases, we need to give serious consideration to ESD for these lesions, and careful follow-up is necessary even if the lesion is in situ.     

Squamous cell carcinoma of the canal anal

BACKGROUND: Anal cancer is an uncommon malignancy accounting for only a small (4%) percentage of intestinal cancer. The authors described the clinical aspects and the treatment of the patients with squamous cell carcinoma of the canal anal. PATIENTS: Eleven patients with squamous cell carcinoma treated among 1995 and 1999, were analyzed retrospectively. Nine were women and two were men. The mean age was 57.6 years old (range 35-82 years old). RESULTS: The most common symptoms were rectal bleeding, local tumor and pain. Six of them had previous anal benign disease and two had metastases at the diagnosis. All were submitted to systemic chemotherapy with 5-fluorouracil and mitomycin and radiotherapy with 4500 cGy. Four patients had residual disease after chemo radiation and salvage surgery with abdominoperineal resection was done. Three patients had recurrence and four died from the disease. CONCLUSION: Most of our patients were women. The chemo radiation can be a curable treatment in patients with local disease; conversely in patients with residual disease, abdominoperineal resection must be done. Although anal cancer is an often curable disease, four patients died because the diagnosis was done in advanced stage.     

Adenocarcinoma of a colostomy following abdominoperineal resection for squamous cell carcinoma of the anal canal: a case study

Malignant neoplasms presenting on a stoma, as well as the development of colorectal adenocarcinoma after previous treatment for squamous cell carcinoma (SCC) of the anal canal, are rare. The unique case is presented of an 81-year-old woman with parastomal bleeding and ulceration found to have a primary colorectal adenocarcinoma arising de novo on a colostomy, formed after salvage abdominoperineal resection (APR) 3 years earlier for recurrent anal SCC. This is the first reported case of a colonic adenocarcinoma on a colostomy formed after an APR for anal SCC. Although stomal neoplasia is rare, the appearance of a friable bleeding lesion on the stoma should be investigated to exclude metastatic cancer or a second primary malignancy.     

Elevated anal squamous cell carcinoma risk associated with benign inflammatory anal lesions

BACKGROUND: The association between benign anal lesions and anal cancer is still unclear. Few data from large cohort studies are available. METHODS: We conducted a register based retrospective cohort study including 45,186 patients hospitalised for inflammatory anal lesions (anal fissures, fistulas, and perianal abscesses) as well as 79,808 haemorrhoid patients, from 1965 to 2002. Multiple record linkages identified all incident anal (squamous cell carcinoma only) and colorectal cancers through to 2002. Relative risk was estimated by standardised incidence ratio (SIR), the ratio of observed number of cases divided by that expected in the age, sex, and calendar year-matched general Swedish population. RESULTS: There was a distinct incidence peak in the first three years of follow up among patients with inflammatory lesions. SIR then levelled off at around 3 and remained at this level throughout follow up (SIR during years 3-37 of follow up was 3.3 (95% confidence interval 1.8-5.7)). A similar initial incidence peak was observed among haemorrhoid patients but was confined to the first year; SIR was 2.8 in the second year, and then it decreased further and was close to unity in the following years (SIR during years 3-37 was 1.3 (95% confidence interval 0.7-2.1)). Among inflammatory lesion and haemorrhoid patients, a significantly increased risk of colorectal cancer was observed only in the first year after hospitalisation. CONCLUSIONS: Inflammatory benign anal lesions are associated with a significantly increased long term risk of anal cancer. In contrast, haemorrhoids appear not to be a risk factor for this malignancy.     

Squamous cell carcinoma of the anal canal following multiple hemorrhoidectomies

Summary and Conclusions A case of squamous cell carcinoma of the anal canal which developed following multiple hemorrhoidectomies is presented. A review of the literature reveals the prevalence of previous anorectal operations before diagnosis of the condition was made. The indifference of the general population to anal lesions is an important contributory factor to the delay of diagnosis. Clinically, the lesion may mimic many common benign anorectal diseases. It is re-emphasized that all specimens removed from the anorectum should be submitted for microscopic examination, and wherever possible the surgeon should point out to the pathologist the area of suspicion. We believe that these tumors, regardless of their size, should be treated by radical surgery with extended lymphadenectomy. Read at the meeting of the Pennsylvania Proctologic Society, Philadelphia, Pennsylvania, October 7, 1959.     

HPV in anal squamous cell carcinoma and anal intraepithelial neoplasia (AIN)

Background and aims Majority of cases of anal squamous cell carcinoma are human papilloma virus (HPV)-induced and result from anal intraepithelial neoplasia (AIN). This study was conducted to examine methods which may enable the routine diagnosis of HPV-induced changes in the anal rim and the consequences of such detection especially in view of a more sensitive diagnosis of AIN. Results were clinically correlated.Methods The study included biopsy samples from 87 patients who had been diagnosed with the following disease patterns: 47 invasive anal carcinoma, 33 AIN of varying severity and seven condylomatous lesions. In 52 of these cases, a tumour was clinically suspected. All biopsies were retrospectively examined for microscopic indications of HPV infection. After microdissection, additional HPV analysis via PCR was carried out.Results In 38 of 47 cases of anal carcinoma, HPV DNA could be detected via PCR (80.9%), the majority of which were HPV 16 (33/38=86.8%). In 29 of the 33 cases of AIN, HPV DNA was detected (87.9%), most of these in AIN III (15/16=93.8%). Histological markers of HPV infection were detected in all 87 cases.Discussion In our series, the clinical diagnosis of the invasive anal carcinoma had a high sensitivity of 93.6%, with a specificity of 80%. The positive predictive value was 84.6%, and the negative predictive value 91.4%. In contrast, AIN had been detected clinically in none of the cases. In this situation, especially with high-risk patients, our findings recommend anal HPV screening in combination with anal cytology and anoscopy.Conclusion Based on our results, we urgently recommend for any histological report on excision of anal lesions to include a statement whether histological markers of HPV infection were detected. In individual cases, validation via HPV PCR must be considered.     

Assessment of “squamous cell carcinoma antigen” (SCC) as a marker of epidermoid carcinoma of the anal canal

We measured squamous cell carcinoma antigen (SCC) in epidermoid carcinoma of the anal canal in 66 patients. Samples were taken at diagnosis, before treatment, and during follow-up; 353 samples were analyzed. The positive threshold was taken as 2 ng/ml. At diagnosis, the sensitivity of the marker was 44 percent and its specificity 92 percent. In our series, the pretherapeutic level of SCC does not correlate with T as in Papillons' Clinical Staging System, but it does correlate with nodal invasion (P<0.05). It is of no prognostic value at the time of diagnosis. During follow-up, at relapse the level of SCC is 20.3 ±43 ng/ml. This increase is significant (P<0.01); the sensitivity of the marker is 77 percent. In patients who have relapsed, development of the illness correlates with the level of SCC, which is of prognostic value (P<0.01). In conclusion, the level of SCC should be associated with the clinical follow-up of patients with epidermoid carcinoma of the anal canal.