Salvage abdominoperineal resection after failed Nigro protocol: modest success, major morbidity

OBJECTIVE: Chemotherapy and radiation (C-XRT) is the first-line therapy for epidermoid carcinomas of the anal canal (ECAC). Treatment failure occurs in up to 33% of patients. Salvage-abdominoperineal resection (APR) is the treatment of choice for locoregional failure but pre-operative radiation may increase wound complications. The purpose of this study was to evaluate patient survival and wound complications after salvage-APR for C-XRT failure. METHODS: We reviewed the clinical records of all patients who failed initial C-XRT for ECAC diagnosed between 1992 and 2002. We evaluated patient demographics, treatment, tumour characteristics, survival and postoperative complications. RESULTS: Nineteen patients were identified. The mean age at diagnosis was 55 years. Eight (42%) patients had persistent disease; 11 (58%) had tumour recurrence. APR was performed in 15 patients. Perineal wound complications occurred in 12 (80%) patients; half were major complications. Primary flap reconstruction at time of APR was performed in 5 (33%) patients; 2 experienced major wound complications. Overall-survival after salvage APR was 40% (6/15) and disease-free survival was 47% (7/15) at a median follow-up of 14 months (range 2-95 months). Recurrence after salvage-APR occurred in 7 (47%) patients at a median follow-up of 5 months (range 3-19 months). Kaplan-Meier survival analysis showed an advantage for recurrent over persistent disease with 2-year and 5-year survival rates of 75%vs 34% and 28%vs 0%, respectively. CONCLUSIONS: Failure of C-XRT for ECAC is associated with a poor prognosis. Although salvage APR may be curative in some patients, perineal wound complications are frequent and primary flap reconstruction is not reliable.