This document provides tips and instructions for using a PowerPoint presentation (ppt) on anal cancer: 1. The ppt can be freely downloaded, edited, and modified. It contains blank slides for notes that students can fill in. 2. The instructor should show blank slides, ask students what they know, and then show slides with information to fill gaps in an active learning session repeated three times. 3. The ppt is also useful for self-study with notes and bibliography provided.

1. Tips on using my ppt.
1. You can freely download, edit, modify and put your
name etc.
2. Don’t be concerned about number of slides. Half the
slides are blanks except for the title.
3. First show the blank slides (eg. Aetiology ) > Ask
students what they already know about ethology of
today's topic. > Then show next slide which enumerates
aetiologies.
4. At the end rerun the show – show blank> ask questions >
show next slide.
5. This will be an ACTIVE LEARNING SESSION x
three revisions.
6. Good for self study also.
7. See notes for bibliography.

2. INTRODUCTION

3. INTRODUCTION
• Cancers of the anal region account for 1% to
2% of all large bowel cancers and 4% of all
anorectal carcinomas.
I. squamous cell carcinomas:- 75% - 80%
II. Adenocarcinomas:- 15%
• There is a slight female predominance with 1.
7 cases per 1 00,000 women compared with 1
.4 per 1 00,000 men per year
• Anal canal cancer most commonly develops in
patients 50 to 60 years of age.

4. Etiology
.

5. Etiology
• Risk Factors: >10 sexual partners, history of anal warts,
history of anal intercourse < age 30 or with multiple
partners, history of STD.
• HPV: strongly associated with SCC and may be
requisite for disease formation. High-grade
intraepithelial lesions are precursors.
• In particular HPV-16, 18 as in cervical cancer.
.
• AIDS is associated with anal cancer, likely through an association with
immunodeficiency in the setting of HPV coinfection . Increased risk if
CD4 < 200.

6. Etiology
• Cigarette smoking has also been implicated as a
risk factor for the development of anal cancer in a
number of case-control studies. The risk is
increased fivefold compared with controls.
• An association between anal cancer and benign anal
conditions (e.g., hemorrhoids, anal fissure, or
fistula) has been reported frequently and chronic
irritation or inflammation of the anal tissue has
been assumed to play a role in anal carcinogenesis.

7. Pathology

8. Distinction Above Pectinate line Below Pectinate line
Destination of
lymph
drainage
Internal iliac lymph nodes
(pararectal lymph nodes)
Superficial inguinal lymph nodes
(Below Hilton’s line)
Epithelium Columnar epithelium Stratified squamous epithelium ,
non keratinized
Embryologica
l origin
Endoderm Ecotoderm
Artery Superior rectal artery> Inf.
Meseteric
Middle & inferior rectal arteries>
Internal iliac
Vein Superior rectal vein> Inf.
Meseteric
Middle & inferior rectal veins>
Internal iliac
Hemorrhoids
classification
Internal hemorrhoids (not
painful)
External hemorrhoids (painful)
Nerves Inferior hypogastric plexus
Symp L1,L2 & parasymp
S2,S3,S4
Inferior rectal nerves > pudendal
nerve

9. Malignant tumors

10. Malignant tumors
• Below dentate line : Squamous Cell
Carcinoma
• Above dentate line : basaloid, cloacogenic
or transitional carcinomas.
• Still above Adenocarcinoma

11. PATHOLOGY

12. PATHOLOGY

14. PATHOLOGY
•
I. transitional cell carcinoma,
II. basaloid carcinoma, and
III. mucoepidermoid carcinoma.
These tumors all arise from the anal transition zone and are
often grouped together as cloacogenic carcinoma.

15. PATHOLOGY
• Anal cancers occur between the anal verge and 2 cm
beyond the dentate line; tumors occurring further from the
dentate line are called rectal cancers.
• Adenocarcinomas can arise from anal crypts and should
be treated as a rectal cancer though with a higher risk of
inguinal node spread, given their location and lymphatic
flow compared with rectal adenocarcinomas.

16. CLINICAL PRESENTATION

17. CLINICAL PRESENTATION
• The most common presenting symptoms are
bleeding (45%) and anal pain(30%). Other less
common symptoms include pruritus , palpable mass
,anal swelling and changes in bowel habits are the
main symptoms.
• It is common for patients and their physicians to
attribute such symptoms to hemorrhoids for many
months preceding the diagnosis, underscoring the
importance of performing a simple anorectal
examination for patients with such symptoms.

18. Investigations
•

19. Investigations
•

20. Investigations
• PET imaging is useful in further evaluating the
extent of the primary tumor and the presence of
regional lymph node metastases, and distant
metastases, as well as in evaluating the response to
therapy.
• For patients with HIV risk factors, a determination
of HIV status should be made before the initiation of
therapy.
• Female patients should be subjected to a gynecologic
examination to exclude other HPV-associated
cancers.

21. TREATMENT

22. • Until the late 1970s, the conventional treatment
for anal canal cancer was an APR.
• Combined Modality Therapy
– preoperative treatment with RT
– concurrent fluorouracil (5-FU) and mitomycin-C of
carboplatin, paclitaxel,
– surgery.
TREATMENT

23. SURGERY

24. SURGERY
• Surgery is the principal treatment for anal
intraepithelial neoplasia but retains only a limited
place in the initial management of primary
invasive anal cancer.
• Local excision, preserving anorectal function, is
possible in some patients, small well-
differentiated squamous cell cancers that have not
invaded the sphincter muscles and are located
distal to the dentate line.

25. MANAGEMENT OF
METASTATIC DISEASE
•

26. MANAGEMENT OF
METASTATIC DISEASE
• Systemic chemotherapy for metastatic squamous
cell carcinoma of the anus is generally similar to
other metastatic squamous histology, such as lung
or head and neck cancers.
• Cisplatin and 5-FU have been reported to achieve
an 11 % complete response and 61 % partial
response rate.
•

27. SQUAMOUS CELL CANCER OF
THE ANAL MARGIN
• Anal margin is usually defined as the area extending from the anal
verge to 5 cm out.The onset of the disease is usually in the seventh
and eighth decade with a slight female predominance. In most
cases, these tumors are well differentiated and slow growing and
distant metastases are rare.
• Inguinal lymph nodes are the primarily nodal drainage for anal
margin cancers, and regional nodal metastasis is directly related to
the size of the tumor.
• The treatment of anal margin cancer needs to be individualized based
on the size and location. Wide local excision with a 1 -cm margin is
often sufficient for small and superficial tumors. When the tumor is
advanced, or located close to the anal canal and sufficient surgical
margin cannot be achieved, combined modality treatment or APR
may have to be considered.

28. ADENOCARCINOMA OF
THE ANAL CANAL
• Adenocarcinoma arises from the columnar epithelium of
the anal canal and its incidence is low accounting for less
than 5 % of all anal malignancies.
• Extension of rectal cancer into the anal canal is the more
common presentation. Occasionally, adenocarcinoma
may occur in patients with ulcerative colitis or Crohn
disease who have ileal pouch-anal anastomosis.
• APR should be offered for early-stage disease.
• For locally advanced disease , a multimodality approach
should be considered. Patients treated with APR had
significantly improved 5-year OS than those treated with
radiation alone.

29. MELANOMA OF THE
ANORECTAL REGION
• Anorectal melanoma is rare and accounts for
less than 3 % of all malignant melanomas and
less than 1 % of all anal canal tumors.
• The 5 -year OS rate is generally less than 20 %
. The initial stage at presentation largely
determines OS.
• Local excision of anorectal melanoma if
adequate margins could be achieved.

30. •
• Other Perianal skin and anal margin tumors
besides squamous cell carcinoma, giant
condyloma (verrucous carcinoma), basal cell
carcinoma, Bowen disease, and Paget disease.

31. NEOPLASIA

32. NEOPLASIA
• Carcinoma in Situ

33. AIN:Pathology
•

34. AIN:Pathology
• It is classified according to the degree of
dysplasia
• on biopsy into AIN I, AIN II and AIN III

35. AIN Presentation
• Asymptomatic and the diagnosis is often a
histological surprise.
• Suspicious areas are raised, scaly, white,
erythematous,pigmented or fissured.
• Cytology.

36. AIN: Management
• Local excision
• Wide local excision
• Observation – repeat biopsies.

37. Get this ppt in mobile
1. Download Microsoft
PowerPoint from play
store.
2. Open Google assistant
3. Open Google lens.
4. Scan qr code from
next slide.

40. Get my ppt collection
• https://www.slideshare.net/drpradeeppande/
edit_my_uploads
• https://www.dropbox.com/sh/x600md3cvj8
5woy/AACVMHuQtvHvl_K8ehc3ltkEa?dl
=0
• https://www.facebook.com/doctorpradeeppa
nde/?ref=pages_you_manage