Anal Canal Tumors Research Articles

The Swedish National Care Programme for Anal Carcinoma: Implementation and Overall Results

The Swedish National Care Programme for Anal Carcinoma (SNCPAC) was instituted in order to create a uniform handling policy for anal cancer and thus to accrue a population-based material allowing unbiased analyses. This study evaluates the degree of implementation of the SNCPAC guidelines, and presents overall treatment results in a total of 356 patients with epidermoid cancer of the anus and the perianal region diagnosed in Sweden between 1985 and 1989. Primary treatment according to the guidelines was irradiation up to 40 Gy. Bleomycin was administered intramuscularly before the first 18 fractions. After a 3-week pause, radiotherapy was to be continued up to a dose of 60-64 Gy, if at least an almost complete response was achieved. Otherwise, the patient was recommended surgery within a week. The guidelines were applied in 90% of cases where such treatment was possible. The 5-year tumour-specific survival rate was 72%. The survival rate was more favourable in perianal tumours (90%) than in anal canal tumours (68%, p<0.01). The 5-year probability of having a preserved anus was 64% (anal canal/perianal 58%/91%, p<0.001). Bleomycin did not appear to have any effect on treatment results. The care programme has had a rapid and almost complete nation-wide penetration, and h as created the desired uniformity allowing proper analyses. The treatment results also appear comparable with specialised referral centres.

Correlation between human papillomavirus infection and clinicopathological parameters in anal canal carcinoma

We evaluated human papillomavirus (HPV) DNA in 17 anal canal tumors and its correlation with symptomatology, tumor extension and prognosis. Five squamous carcinomas and 4 cloacogenic tumors resulted HPV+. Statistical analysis showed no correlation between HPV infection and tumor morphology, lymph node involvement or prognosis, and no significant difference in the duration of symptoms between HPV+ and HPV- patients. HPV are involved in the pathogenesis of the tumors, but are not responsible for an increased neoplastic malignancy. Anoscopy with brushing or biopsy is a suitable screening method to identify HPV.

Anal canal cancer diagnosis: usefulness of serum tumor markers

Only a few Authors have evaluated the importance of serum markers in the diagnosis of anal canal tumors. The ideal tumor marker must be specifically produced by neoplastic cells; it must be easily detectable in the biological fluids by means of simple and cheap techniques; it must be produced in known concentration by normal tissues; it must offer extreme sensitivity in the identification of a minimum number of neoplastic cells. The aim of this study is to identify a specific and sensitive marker, useful in the diagnosis of anal canal tumors.

ANORECTAL DISORDERS

Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.

Successful treatment of anal tumors with CO2 laser in elderly, high-risk patients.

The central issue in elderly surgery remains the operative risk, which is usually a direct factor of age, ASA classification, and other pathologies, especially cardiovascular diseases. It is the surgeon's role to define properly the risks involved with a patient and to anticipate the involved operative mortality. Based on this, we performed CO2 laser fulguration of anal canal tumors in 10 patients suffering from either squamous cell or adenocarcinoma localized up to 4 cm from the anus. The rationale was to avoid prohibitive operative and anesthetic risk, achieve local control of disease and improve quality of life by avoiding surgical convalescence and an otherwise certain colostomy. All patients underwent fulguration (25-30 W) every 3-4 months. Complications included minor pain and bleeding. Three patients required operation (Hartman's pouch) within 2 1/2 years due to continuous tumor bleeding and stricture of the anal canal. The remaining 7 patients were treated regularly and satisfactorily by fulguration and the mean survival in this group was 8 years (in all cases the causes of death were unrelated to the procedure or the tumor). We conclude that CO2 laser fulguration of anal canal tumors in elderly, high-risk patients represents an invaluable option of treatment, while avoiding major operative risk, controlling the local spread of disease, maintaining physiological bowel function, and avoiding colostomy. Most importantly, the main dividends of the study are patient satisfaction and maintenance of good quality of life.

Squamous Cell Carcinoma of the Anal Region at the King Faisal Specialist Hospital and Research Centre

This study documents the epidemiological aspects of squamous cell carcinoma of the anus and anal canal as it has presented to the King Faisal Specialist Hospital and Research Centre (KFSH&RC). Thirty-eight (33 Saudis) patients, 24 males and 14 females were studied. They ranged in age from 32 to 100 years. Twenty-four had anal canal tumors and 12 had anal margin cancers. Riyadh, the Eastern Province or Medina provided most patients and the majority presented with bleeding, a lump or pain. Symptom duration ranged from one month to more than two years. Fourteen had previous anal problems. There was an almost equal distribution of lesions between the anterior and posterior halves of the anus. Nineteen had clinically normal inguinal nodes. Thirty had squamous cell carcinoma (epidermoid) and eight had cloacogenic/basiloid tumors. Most tumors were either moderately or poorly differentiated. Twenty-eight presented with T3 or T4 tumors and only ten presented with T1 or T2 tumors. Five had evidence of metastases at initial presentation. Eight were treated by abdominoperinal resection of the rectum. A diversion colostomy was performed in six. Fifteen received radiotherapy alone but only three were treated by chemotherapy alone. Combination chemotherapy and radiotherapy was given to 14. More males than females had both anal canal and anal margin tumors. Patients with anal margin tumors were on average ten years older. There were twice as many with anal canal as anal margin tumors. There were more node-positive patients with anal margin tumors. Anal canal tumors were less well-differentiated. Follow-up was inadequate.

Precancerous changes in the anal canal epithelium in resection specimens.

Systematic histological examination for precancerous changes was carried out on 139 anal canals resected for anal or colo-rectal tumours or for inflammatory bowel disease. Severe squamous dysplasia or carcinoma in situ were found in 13 of 16 anal canals harbouring variants of squamous carcinoma but not in others. The lesions were mainly or totally located to the anal transitional zone (ATZ) in 11 cases and only in 2 cases exclusively to the squamous zone below the dentate line. Dysplastic areas separate from the tumour were found in 6 of the 13 cases. Junctional melanocytic activity and atypical melanocytic hyperplasia located in the ATZ as well as the squamous zone were present in 1 of 3 cases of malignant melanoma. The findings underline the close relationship between dysplasia and invasive carcinoma in the anal canal. Further they support the concept that basaloid, mucoepidermoid and some ordinary squamous carcinomas arise in the ATZ, and that this may also be the point of origin for malignant melanoma. A search for precancerous changes for anal canal tumours should therefore include the whole ATZ, i.e. in some cases up to 2 cm above the dentate line and it should be borne in mind that the lesions may be spotty.

Carcinoma of the anus in Nigerians.

In the 18-year period between 1960 and 1978, only 20 cases of carcinoma of the anus were recorded in the Cancer Registry of the University College Hospital, Ibadan, Nigeria; of these 18 were treated in the hospital. This paper is an analysis of the clinicopathologic features and outcome of treatment of ten patients whose records could be traced. There was a slight female predominance, with anal canal tumours being more common than anal margin tumors. Most cases were advanced when first seen and the commonest manifestations were passage of mucoid stool, with blood and anal pain. The tumors tended to grow circumferentially and could be confused with anorectal tuberculosis, schistosomiasis, and lymphogranuloma venereum. Prognosis was better with anal margin tumors.

Definitive treatment of anal canal tumors by means of radiation therapy and chemotherapy

Definitive treatment of anal canal tumors by means of radiation therapy and chemotherapy