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Anal cancer video


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Treatment of cancer of the anal canal

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Anal cancer video

  1. 1. Anal Canal CancerRobert Miller
  2. 2. Incidence of new cases in2013Site Men WomenColon 50,090 52,390Rectum 23,590 16,750Anus 2,630 4,430Anal cancer is uncommon. It comprisesonly 2.4 percent of all digestive systemmalignancies in the United States
  3. 3. Age and Anal CancerUS Data 2005 - 2009• Median age at diagnosis allcancers was 66 for Anus was60• Median age at death was 72 forall cancers and for anus was 64In 2013 estimated 7,060 new cases and 880 deaths so crude deathrate was only 12%
  4. 4. Anal Cancer• This is usually squamous cancer(HPV infection) and is treated withchemo-radiation.• Rectal cancer is adenocarcinoma(from a polyp) and is treated withsurgery +/- chemoradiation
  5. 5. Anal CancerRectal bleeding is the most common initialsymptom of squamous-cell carcinoma of theanus, occurring in 45 percent of patients.Bleeding from a mass lesion just above the analsphincter may be ascribed erroneously to thepresence of hemorrhoids. Thirty percent ofpatients have either pain or the sensation of arectal mass, whereas 20 percent have no rectalsymptoms whatsoever
  6. 6. Histology (what type of cancerfrom the biopsy and pathologyreport)Cellular Classification of Anal CancerSquamous cell (epidermoid) carcinomas make up themajority of all primary cancers of the anus. The importantsubset of cloacogenic (basaloid transitional cell, non-keratinizing) tumors constitutes the remainder. (about25%). These two histologic variants are associated withhuman papillomavirus infection.Adenocarcinomas from anal glands or fistulae formationand melanomas are rare
  7. 7. HistologyTreatment forkeratinizingsquamous cancers isthe same as non-keratinizing (basaloidor cloacogenic
  8. 8. HPV CancersCancers PercentCervix > 99%Anus 84%Vagina 70%Penis 47%Vulva 44%Oropharynx 36%Oral Cavity 24%JCO May 2011;29:1785
  9. 9. HPV Cancers 2004-2008Cancer All Cases HPV CausedCervix 11,967 11,500Vulva 3,136 1,600Vagina 729 500Penis 1,046 400Anus (female)Anus (male)2,9001,6782,7001,600Oropharynx (female) 2,370 1,500Oropharynx (male) 9,356 5,900
  10. 10. HPV Types
  11. 11. Prevalence of High Risk HPVinfection found in biopsyAnus cancer: 84%Rectal cancer: 0 %N Eng J Med 1997;337:1350
  12. 12. The proximal end of the anal canalbegins anatomically at the junction ofthe puborectalis portion of the levatorani muscle and the external analsphincter, and extends distally to theanal verge, a distance ofapproximately 4 cm. The anal canal isdivided by the dentate line, whichoverlies the transition from glandular(columnar) to squamous mucosa thatis often referred to as the transitionalzone.Anal Canal lower 4cmtumors are classified as rectal cancers if their epicenter is locatedmore than 2 cm proximal to the dentate line or proximal to theanorectal ring on digital examination, and as anal canal cancers if theirepicenter is 2 cm or less from the dentate line
  13. 13. Anal Canal and Anal Margin
  14. 14. Anal Canal Anatomy
  15. 15. Pelvic Anatomy (female)colonAnal canalboweluterusrectumbladder
  16. 16. Pelvic Anatomy (male)Anal canal
  17. 17. Lymph Nodes at Risk in Anal Cancer• Cancers from thedistal region (belowdentate line) go tosuperficial groin(inguinal) nodes• Cancers that arise ateor proximal (above)the dentate line aredirected to anorectal,perirectal,paravetebral and
  18. 18. para-aorticperi-rectalinguinalpelvicinguinalLymph Nodes at Risk in Anal Cancer
  19. 19. StageStart with Tumor (T) stage
  20. 20. StageThen Nodes (N) or Metastases (M)
  21. 21. StageThen combine T, N, M
  22. 22. Cancer Imaging for Anal Cancerin a study of 61 patients with anal cancer the sensitivity for nodalregional disease by PET versus conventional imaging (CT and/or MRI)was 89 and 62 percent, respectively
  23. 23. CT scan = large anal cancer
  24. 24. Since cancers use more glucose than normalcells (hypermetabolic) they will ‘light up’ on aPET Scan
  25. 25. CT and PET Imaging for Anal Cancer
  26. 26. PET scan showing small anal cancer
  27. 27. PET and Lymph NodeMetastases
  28. 28. PET and Lymph NodeMetastases
  29. 29. Moreadvancedcase of analcancer thathas spread onPET scan topara- aorticlymph nodesPET and Lymph NodeMetastases
  30. 30. Treatment of Anal Cancer• Anal canal Stages I – III : radiation+ chemotherapy (5FU + Mitomycin)• Anal margin Stage I : wide localexcision• Anal margin Stage II – III: radiation+ chemotherapy (5FU + Mitomycin)• Stage IV: Cisplatin basedchemotherapy +/- radiation
  31. 31. CT scan is obtained at thetime of simulationCT images are thenimported into thetreatment planningcomputer
  32. 32. In thesimulationprocess theCT and PETscan imagesare used tocreate acomputerplan
  33. 33. Computer generatedimages of anal cancer
  34. 34. Tomotherapy forAnal Cancer
  35. 35. Tomotherapy for anal cancer, high dose to anusand groin nodes, while avoiding the bladderand femurs
  36. 36. Radiation Dose andTechnique• Radiation is daily, Monday through Friday for5 to 6 weeks• Radiation works best when combined withchemotherapy• Minimal dose of 45Gy (1.8Gy X 25) up to 54to 59Gy for more advanced cancers• The radiation should include the lymph noderegions for at least part of the treatment
  37. 37. Target Volumes for Anal Carcinoma For RTOG 0529RadiationDose andTechnique
  38. 38. RTOG 0529: A Phase 2 Evaluation of Dose-Painted IntensityModulated Radiation Therapy in Combination With 5-Fluorouracil andMitomycin-C for the Reduction of Acute Morbidity in Carcinoma of theAnal CanalDP-IMRT was associated with significant sparing of acute grade2+ hematologic and grade 3+ dermatologic and gastrointestinaltoxicity.IJROBP 2013;86:27Anus cancerNodesHigh RiskNode
  39. 39. Side Effects of PelvicRadiationRadiation fieldsRadiation may hit thesmall bowel causingsome cramps, diarrheaand fatigueHigh dosearea
  40. 40. Side Effects of PelvicRadiationRadiation fieldsRadiation may hit the bladderand rectum causing urinaryburning or frequency and ano-rectal irritation and skin burningHigh dose areaIn pre-menopausal women, radiation is likely toeffect ovarian function and should not be used ifthe woman is pregnant
  41. 41. Results with combined chemo-radiation for anal cancer• Local failure rates of 14 to 37percent• Five-year overall survival rates of72 to 89 percent• Five-year colostomy-free survivalrates of 70 to 86 percent
  42. 42. Long-Term Update of US GI Intergroup RTOG 98-11 Phase III Trial forAnal CarcinomaJCO December 10, 2012 vol. 30 no. 35 4344-4351Survival78%71%
  43. 43. 5 Year Survival with AnalCancerStage Squamous Non-squamousI 71.4 59.2II 63.5 52.9IIIA 48.1 37.7IIIB 43.2 24.4IV 20.9 7.4NCDB 1998-99, n = 3598
  44. 44. 5 Year Survival with AnalCancerNCDB 1985 - 2000Stage SurvivalI 70%II 59%III 41%IV 19%
  45. 45. 5 Year Survival with AnalCancer (SEER Data Base)SEER 1999-2006Stage Incidence SurvivalLocal 50% 80%Regional 29% 60%Distant 12% 30.5%
  46. 46. Fluorouracil, mitomycin, and radiotherapy vs fluorouracil, cisplatin,and radiotherapy for carcinoma of the anal canal: a randomizedcontrolled trial. US Gastrointestinal Intergroup trial RTOG 98-11,The 5-year overall survival rate was 75% in themitomycin-based group and 70% in the cisplatin-based group.The 5-year local-regional recurrence and distantmetastasis rates were 25% and 15%, respectively, formitomycin-based treatment and 33% and 19%,respectively, for cisplatin-based treatment.The cumulative rate of colostomy was significantlybetter for mitomycin-based than cisplatin-basedtreatment (10% vs 19%)JAMA. 2008 Apr 23;299(16):1914-21.
  47. 47. Survival by Stage in a series of270 patients with anal cancer5 Year Survival by StageT1: 86% N0: 76%T2: 86% N1: 54%T3: 60%T4: 45%
  48. 48. Odds of Requiring aColostomy• In large series the odds were 10 to 30%• 235 patients diagnosed with anal cancer between 1995 and 2003the five-year cumulative incidences of tumor-related andtreatment related colostomy were 26 and 8 percent, respectively.Large tumor size (>6 cm) was associated with a higher risk oftumor-related colostomy, while a history of prior excision was arisk factor for therapy-related colostomy.• RTOG trial 98-11 five-year colostomy rates among patientstreated initially with Chemoradiotherapy were 9 percent for thosewith node-positive disease, and 19 percent for tumors >5 cm indiameter, regardless of nodal status. Overall, 78 percent of thecolostomies were performed for persistent or recurrent disease.
  49. 49. Anal CancerRobert Miller