Malignant tumors of the anal canal]

Results of treatment of 381 cases of various malignancies of the anal canal were analysed. The above tumors were classified according to clinical course, histology and stage. Various treatment modalities, peculiarities of early diagnosis, causes of tumor advancement and end results of treatment of cancer of the anal canal are discussed.     

Malignant parotid tumors: presentation, clinical/pathologic prognostic factors, and treatment outcomes

PURPOSE: To determine the important clinical/pathologic prognostic factors and optimal treatment of malignant parotid tumors. METHODS AND MATERIALS: This study was a retrospective chart review of 163 patients treated for malignant parotid tumors at two institutions. Of the 163 patients, 91 were treated with surgical resection and radiotherapy (RT), 56 were treated with surgery alone, and 13 were treated with RT alone. The median follow-up was 5.1 years (range, 0-37 years). RESULTS: Locoregional recurrence occurred in 37% of surgery-only, 11% of surgery plus RT, and 15% of RT-only patients (p = 0.001, Pearson's chi-square test). Cox proportional hazard multivariate analysis revealed that increasing age and higher stage were each statistically significantly (p < 0.05) associated with a poorer overall 5-year survival and cause-specific survival. Only increasing age and the absence of adjuvant RT were shown in Cox proportional hazard multivariate analysis to impact negatively on local failure-free survival. CONCLUSION: In Cox proportional hazards multivariate analysis, only increasing age and stage were statistically significant prognostic factors for survival. The addition of RT to surgery did not improve overall survival but did reduce locoregional recurrence and improve local failure-free survival.     

Preneoplastic anal lesions and anal canal carcinoma

Anal canal cancer rate is relatively high among HIV-positive patients, particularly in homosexual men, where it is twice that of HIV-negative homosexual men. As for uterine cervix cancer, it is possible that anal canal cancer is linked to human papillomaviruses (HPV): in fact, its oncogenic serotypes are found in 60% of tumours. Most of anal mucosa in HIV-positive patients is infected by HPV. It causes Anal Squamous Intraepithelial Lesions (ASTI): low grade and high grade squamous intraepithelial lesions, which can probably progress to invasive anal cancer. In the anal mucosa, HPV induces clinically flat condylomata. They generally are invisible and revealed only by acetic acid application. Sixty percent of seropositive gay men and 26% of seropositive women have anal ASTI. This rate is higher than in the general population. A decreasing of systemic and local immunity and so probable interactions between HPV and HIV could explain the frequency of anal ASTI among seropositive patients. Introduction of highly active antiretroviral therapy does not really influence the evolution of anal dysplasia. Screening of preneoplastic lesion is possible with anal Pap smear, and when it is positive, patients must undergo high resolution anuscopy. Cost effectiveness analyses indicate that only the highest risk group (HIV-positive gay men) should have anal screening. Only high grade squamous intraepithelial lesions have to he systematically treated, low grade squamous intraepithelial lesions could he simply followed up. The best treatment of anal dysplasia is surgical excision, with careful follow-up, because of high recurrence rate among seropositive patients.     

Squamous cell carcinoma of the anal canal and anal margin

Squamous cell carcinomas of the anal canal and margin are relatively uncommon neoplasms of the distal gastrointestinal tract and surrounding skin. The major risk factors for tumor development have been defined through various epidemiologic studies. Randomized, phase III trials have defined the standard of care for anal cancer tumors to be a combined modality approach of radiation therapy and chemotherapy. This nonsurgical, organ-sparing regimen results in good anal sphincter function in the majority of patients, and treatment efficacy is favorable when compared with historic surgical series. Anal margin tumors are staged and treated as skin cancers, with a more favorable prognosis.     

Carcinoma of the anal canal

There are around 5,000 new cases of anal canal cancer each year in the United States. It is of particular risk in HIV-positive populations. Many cases are related to persistent infection with human papillomavirus (HPV). The treatment of anal cancer has progressed from abdominoperineal resection mandating permanent colostomy in the 1940s through the 1970s to modern chemoradiation with sphincter preservation in around 80% of patients, even with locally advanced disease. The evolution of the treatment paradigm of this disease is a model for the treatment of malignant disease with organ preservation. Multiple randomized trials have been conducted to guide this evolution. Technological developments in the delivery of radiotherapy and anti-cancer pharmaceuticals harbor hope for further improvements in outcomes with possible reductions in toxicity and increases in tumor control. Perhaps most inspiring is the recent development of HPV vaccines that may significantly decrease the incidence of this cancer.     

Cancer of the anal canal

Anal cancer is an uncommon tumour that represents 4% of all cancers of the lower gastrointestinal tract. Its pathogenesis and treatment have undergone substantial reassessment over the past two decades, and this is likely to continue. Anal cancer can be cured by synchronous chemoradiotherapy, a treatment that both enables anal continence to be retained and reserves abdominoperineal resection of the rectum and anal canal (with formation of a permanent colostomy) for recurrent or residual disease after primary chemoradiotherapy. Overall, survival from anal cancer is now around 70-80% at 5 years. Future challenges will be influenced by an increasing incidence due to human papillomavirus and HIV infection, more accurate characterisation and treatment of early (in situ) disease, and optimisation of chemoradiation regimens.     

Adenocarcinoma of the anal canal

Adenocarcinoma of the anal canal is a rare pattern accounting for 1.5% of rectal malignancies. Mucinous and poorly-differentiated carcinomas are predominant. The said tumors are highly pernicious, with prognosis being poor even in radically--operated cases. Long-term treatment results are extremely unsatisfactory.     

Squamous cell carcinoma of the anal canal: treatment by external beam irradiation

External beam radiation therapy alone or in combination with curietherapy is the recommended treatment for anal canal carcinoma in some countries. In others, surgery is the sole accepted treatment. The results for 64 patients treated by external radiotherapy alone show excellent survival for stage T1T2 tumors but results are poor for large tumors (stage T4). The overall 5 year crude survival rate is 46%. The 5-year results are better for stage T1T2 (72%) than for stage T3T4 (35%). The presence of inguinal node involvement at first examination is a very poor prognostic sign. Local recurrences and metastases are infrequent for stage T1T2, but are more common for stage T3 and T4. Complications follow radiotherapy more frequently in those with stage T3 and T4 tumors. The analysis of local recurrences, complications and survival shows that radiation therapy may be sufficient treatment for stage T1 and T2 and for some stage T3 tumors. The importance of anal sphincter involvement and the poor quality of life for patients who are cured but develop complications, shows the need for combined treatment with surgery and perhaps with chemotherapy. For small tumors the results obtained by external radiotherapy alone are comparable with those obtained by external radiotherapy and curietherapy in terms of survival and complications.     

Disease profile and treatment results of anal canal SCC: Experience from AIIMS, New Delhi

Introduction: Anal Canal squamous cell carcinoma (SCC) accounts for nearly 2% of all cancers of the alimentary tract. Over the past few years, the management of anal canal cancer has changed from primary surgery to primary chemo-radiotherapy (CRT). Methods: A total of 83 patients' (pts) records (62 males, 21 females) were retrospectively reviewed. Length of disease was <5 cm in 44 pts and confined to primary in 46 pts. Ten pts have anti-cancer therapy outside. We delivered radiotherapy (RT) alone to 16 pts, chemotherapy (CT) alone to 4 pts, CRT in 51 pts and pre-operative (pre-op) RT in 2 pts. RT dose was up to 30 Gray (Gy) =16; 30-50 Gy=12 and >50 Gy=41 pts. Results: RT compliance was optimal in 64/69, grade (Gr) ≤ 2 toxicity in 56/69 and Gr ≥ 2 in 13/69 pts. Thirteen pts (18.84%) were hospitalized during RT. No response (NR) was found in 4/83, <50% in 18/83, >50-<100% in 39/83 and complete response (CR) in 22/83 pts. Recurrence at primary site was seen in 7 and loco-regional in 2 pts. Salvage therapy was done in all 9 pts (surgery=8 and CT=1). Status at last follow up, alive without disease = 22/83 and with disease = 61/83 pts. Conclusion: This retrospective analysis revealed that the advanced disease was in 47%, the optimal anti-cancer therapy could be delivered to 63.9%. Despite heterogeneity of patient population and management, the overall disease-free survival (DFS) with sphincter-preservation was achieved in 26.5% pts. Key Words: Anal canal, squamous cell carcinoma, chemo-radiotherapy, sphincter preservation, disease free survival.     

Malignant disease: nutritional implications of disease and treatment

Protein-energy malnutrition (PEM) is common in cancer patients and may develop into the syndrome known as cancer cachexia. This is characterised by complex disturbances in carbohydrate, lipid, protein, and electrolyte metabolism. The actiology is equally complex, with host and therapeutic factors contributing to the reduced food intake and effects on host tissues. Anorexia is of prime importance, differing in its cause from one patient to another and often presenting a barrier to successful nutritional support. Further research is necessary to elucidate the interaction of central and peripheral factors that may be involved in the aetiology of anorexia. Because of the interplay of biochemical, physiological, and psychological consequences of cancer, the nutritional support of the patient presents a considerable challenge to the caring professions. Address for offprints: Department of Biochemistry University of Surrey, Guildford, Surrey GU2 5XH, United Kingdom     

The treatment of squamous cell cancer of the anal canal]

Three methods of treatment for squamous-cell cancer of the anal canal, namely abdominoperineal extirpation of the rectum, radiotherapy and thermoradiotherapy were compared. The rate of relapse following thermoradiotherapy was 5.4 times lower than in the radiotherapy alone group and 3.9 times lower than in patients undergoing surgery. Five-year survival rate for thermoradiotherapy (75.1 +/- 9.5%) was significantly higher than for radiotherapy (6.9 +/- 4.0%) and extirpation of the rectum (39.4 +/- 7.7%).     

Gastrointestinal stromal tumors: a spectrum of disease

The majority of gastrointestinal stromal tumors (GIST) express c-kit, a growth factor receptor with tyrosine kinase activity. Mutations in the c-kit proto-oncogene may lead to constitutive ligand-independent activation of c-kit and subsequent neoplastic transformation. Selective tyrosine kinase inhibitors target this property of GIST and have become the standard chemotherapy for metastatic or unresectable tumors. The mainstay of treatment, however, continues to be complete surgical resection. Tyrosine kinase inhibitors may prove expedient for adjuvant therapy, and are currently the focus of clinical trials conducted by the ACOSOG, RTOG, and ACRIN. It is important to distinguish GISTs from other mesenchymal tumors of the GI tract because of differences in natural history, as well as the efficacy of treatments targeting the GIST tyrosine kinase.     

Malignant parotid tumors: natural history and treatment.

Sixty-seven cases of histologically proven malignant parotid tumors are presented. Forty percent of the tumors were differentiated adenocarcinoma, while malignant mixed tumors (or pleomorphic adenocarcinomas) formed 18%. The remaining types of malignant salivary tumors are also represented in the series. The natural history and spread of these tumors are studied in detail, with lymph-node metastasis occurring in 25% of the cases and distant metastasis in 20%. Malignant tumors involve largely the retromandibular portion of the parotid gland in over 40% of the cases and the preauricular portion in about one-fifth of the cases. Both regions are affected in a further fifth of the cases. A combination of surgery and radiotherapy was the method employed for curative therapy, with radiotherapy alone reserved mainly for palliation. While the overall five-year survival was 42%, late recurrences constitute a serious problem with eventual demise of about half of these patients. Various factors affecting the prognosis, including histological type of tumor, method of treatment and response to radiotherapy are discussed.     

Chemoradiotherapy and anal canal cancer

Local control and sphincter preservation are the two challenges of anal canal cancer treatment. These tumors are radio- and chemo-sensitive and treatment moved from surgical approach, with abdominoperineal resection, to definitive radiation therapy with or without concurrent chemotherapy. Randomised trials proved the benefit of combined modality with chemoradiotherapy and of mitomycine C (MMC) compared with radiotherapy alone, with a toxic death rate of about 2%. Indications of chemoradiotherapy are locally advanced tumor T2 > or = 4 cm, T3-4 or N1-3 but the best modalities of combined treatment are still under debate. Standard chemotherapy is 5 flurouracile (5FU) + MMC, but cisplatinum (CDDP) is an effective and well tolerated substitute for MMC. Favourable results with CDDP-containing regimen in term of toxicity and carcinologic control have been reported in phase II and retrospective studies. Total radiation dose, overall duration of radiation therapy, duration of the gap and indications of additional boost are not clear, but it is demonstrated that overall duration of treatment should be as short as possible to improve the therapeutic radio. Phase II and III studies are ongoing, to evaluate the best chemotherapy regimen between 5FU+MMC and 5FU+CDDP, the benefit of neoadjuvant or maintenance chemotherapy and the interest of increased total dose. Next future could be the utilisation of oral 5FU. This article is a review of past randomised trials, phases II and retrospective study on radiochemotherapy of anal canal carcinoma.     

一穴肛原癌

目的　更加全面地了解一穴肛原癌 (cloacogeniccancer)。方法　回顾性分析 195 8年～ 1997年收治的 6例一穴肛原癌的病例资料。结果　一穴肛原癌分别占肛管直肠癌和肛管癌的 0 .3 %和 5 .8% ;女性多见 ,平均发病年龄 5 8.1岁 ;临床和影像学检查无特异性表现 ,组织病理学检查可明确诊断 ;PTNM分期 :Ⅱ期 1例 ,Ⅲ期 3例 ,Ⅳ期 2例 ;以手术加放疗为主的治疗后 1,3 ,5年生存率分别为 83 .3 % ,33 .3 %和 0 %。结论　一穴肛原癌是一少见的肛管癌 ;须靠组织病理学确诊 ;以手术治疗为主的治疗效果不佳 ,早期诊断和以放疗或放疗加手术为主的治疗可获得较好的治疗效果。     

Epidermoid carcinoma of the anal canal

The charts of 67 patients treated for epidermoid carcinoma of the surgical anal canal were reviewed. The clinical presentation, type of surgical procedure performed, lymph node status of the pararectal and inguinal nodes, time of recurrence, site of recurrence, and median survival from the date of primary surgery and from the date of recurrence were determined. There were 55 patients (82%) who had a minimum of 5 years' follow-up since initial treatment. Optimal surgical treatment requires an abdominoperineal resection with wide dissection of the ischiorectal fossa and perineum in all patients, as well as an en bloc excision of the posterior vaginal wall in women. Although excision of the posterior vaginal wall improves the disease-free interval, median survival is not altered, compared with the group without vaginectomy. The predominant sites of local recurrence in men are the pelvis and perineum, and in women, the pelvis and posterior vaginal wall. The status of the pararectal lymph nodes from the operative specimen can give accurate information about the relative risk of recurrence. The presence of inguinal lymph node metastases represents a poor prognosis because of a close association with systemic metastases.