Anal Margin Tumors Research Articles

Management of small (T1-T2) anal margin squamous cell carcinoma: clinical outcomes following local excision alone.

Squamous cell carcinomas of the anus are normally treated with synchronous chemoradiotherapy (CRT). Small, localized anal margin tumours may be adequately treated by local excision (LE) alone. This study aims to investigate the outcomes of patients with anal margin tumours treated with LE alone, reserving the use of CRT for salvage on local recurrence (LR). Patients with small, localized (stage I/IIA) anal margin tumours treated by LE from October 1999 to September 2018 were identified. The effect of tumour size and resection margin on LR risk was analysed. Outcomes of overall survival and disease-free survival were measured. Fifty-five patients with anal margin tumours were identified. Overall 5-year LR, overall survival and disease-free survival rates were 8%, 86% and 82% respectively. Of the seven LRs, five were successfully salvaged with CRT with no further recurrence and two were not fit for CRT. Resection margins in non-fragmented tumours and tumour size did not significantly influence LR risk. Most small, localized anal margin tumours can be adequately treated by LE alone with low LR rates. Most patients who developed LR were salvaged using CRT, with no cancer-related deaths reported.

So Now My Patient Has Squamous Cell Cancer: Diagnosis, Staging, and Treatment of Squamous Cell Carcinoma of the Anal Canal and Anal Margin.

Squamous cell carcinomas of the anal canal and the anal margin are rare malignancies that are increasing in incidence. Patients with these tumors often experience delayed treatment due to delay in diagnosis or misdiagnosis of the condition. Distinguishing between anal canal and anal margin tumors has implications for staging and treatment. Chemoradiation therapy is the mainstay of treatment for anal canal squamous cell, with abdominoperineal resection reserved for salvage treatment in cases of persistent or recurrent disease. Early anal margin squamous cell carcinoma can be treated with wide local excision, but more advanced tumors require a combination of chemoradiation therapy and surgical excision.

Race Is Associated With Burden of Anal Condyloma and Need for Operative Intervention

BackgroundHuman papillomavirus is a common sexually transmitted infection that may affect the oropharynx, genitalia, or anus. Some strains of this virus may cause bulky growths around the anus known as giant anal condylomas. These can become large, disfiguring, and may cause bleeding, as well as difficulty with defecation and hygiene. Surgical management is usually necessary for large condylomas, whereas office-based procedures are common for smaller lesions. It is unclear why some develop large anal margin tumors, whereas others develop limited disease. The aim of the present study was to evaluate for risk factors that may play a role in the development of extensive disease warranting operative management. Materials and methodsA retrospective chart review of patients seen within the Anal Dysplasia Clinic at the Medical College of Wisconsin was undertaken. Clinic encounters for patients with anogenital condyloma were abstracted for demographic information, operative interventions, Human Immunodeficiency Virus status, and smoking history to determine risk factors that predicted operative intervention for giant anal condylomas. ResultsA total of 239 patients met inclusion criteria; 211 (88.3%) were male and 28 (11.7%) were female. Racial makeup of the cohort included 49% Caucasian, 38.9% African-American, 9.2% Hispanic, and 2.9% were identified as another ethnicity. One hundred forty-three patients (60.1%) were current or past smokers. One hundred ninety-eight (82.8%) patients tested positive for human immunodeficiency virus (HIV), whereas 41 (17.2%) were negative. Multiple linear regression identified only African-American race as predictive of greater disease burden. ConclusionsAfrican-American race was associated with increased size of anal condyloma. As the size of anal condylomas increase, management shifts from topical treatments to operative intervention. This is the first study to correlate race with burden of disease in the general population.

The Development of an Umbrella Trial (PLATO) to Address Radiation Therapy Dose Questions in the Locoregional Management of Squamous Cell Carcinoma of the Anus

Purpose/Objective(s) Randomized controlled trials for patients with squamous cell carcinoma of the anus have been successfully performed, despite the rarity of the disease. The RTOG 9811 and ACT2 trials demonstrated no improvement in cancer outcomes when neoadjuvant or adjuvant cisplatin 5FU chemotherapy was used. To capture as many anal cancer patients as possible in future clinical trials, we developed an umbrella of trials testing efficacy and acceptable morbidity across different loco-regional risk strata. Materials/Methods We formed a network of UK and international multi-disciplinary trialists and identified the following priorities:- i] the need for national consensus guidance for the introduction of intensity modulated radiation therapy (IMRT) based on the successful principles and fractionation used in the ACT2 protocol prior to future trials; ii] to evaluate a strategy using selective chemoradiation therapy (CRT) after local excision of anal margin tumors; iii] to evaluate reduced dose CRT to the primary tumor in order to limit late effects whilst maintaining elective nodal irradiation in early stage disease; iv] to evaluate dose escalated CRT in locally advanced T3/4 and N+ stage disease. Results The PLATO (personalizing radiotherapy dose in anal cancer) umbrella trial comprising of the ACT3, 4 and 5 trials is funded by Cancer Research UK and is due to commence recruitment in Q3 2016.The ACT 3 trial (n = 90) is a non-randomized phase II study that will evaluate a strategy of local excision for T1N0 anal margin tumors with selective postoperative involved field CRT using 41.4 Gy in 23 fractions (F) and concurrent capecitabine reserved for patients with margins <=1mm. An exact single-stage A’Hern design is used. The ACT4 trial (n = 162) is a randomized phase II trial (2:1) comparing reduced dose CRT with 41.4 Gy in 23F to GTV with 50.4 Gy in 28F using concurrent capecitabine for T1-2(<4cm)N0 disease. An exact single-stage A’Hern design is used. The ACT5 trial (n = 677) is a seamless pilot (n = 60)/phase II (n = 140)/phase III trial (n = 672 total) that will compare 53.2 Gy with 58.8 Gy and 61.6 Gy using 28 fractions to GTV with either 5FU or capecitabine in T3/4 N1-3 disease. Only one of the dose escalated experimental arms will be evaluated for the phase III component. The primary end point for each trial is 3 year locoregional failure. Conclusion The PLATO trial concept allows different research questions across the locoregional disease spectrum to be addressed efficiently using a single protocol and clinical trial funding application. This type of trial design is increasingly important in the era of personalized medicine and the need for clinical studies to address different research questions within the same disease. Sharing the details of this concept should assist other investigators to develop similar future studies.

Tumors and Tumorlike Conditions of the Anal Canal and Perianal Region: MR Imaging Findings.

Tumors and tumorlike conditions of the anus and perianal region originate from the anal canal and anal margin or result from direct extension of tumors from adjacent organs. The anatomy of the anal canal is complex, and its different histologic characteristics can lead to diverse pathologic conditions. The anal canal extends from the anorectal junction to the anal verge. The World Health Organization classification of anal canal tumors includes (a) anal intraepithelial neoplasia, the precursor of squamous cell carcinoma (SCC), and (b) invasive tumors. Invasive tumors are further classified on the basis of cell type as epithelial tumors (SCC, adenocarcinoma, mucinous adenocarcinoma, small cell carcinoma, and undifferentiated carcinoma), nonepithelial tumors, carcinoid tumors, melanoma, and secondary tumors (direct spread from rectal, cervical, or prostate carcinoma). The anal margin, or perianal skin, lies outside the anal verge and encompasses a radius of 5 cm from the anal verge. Tumors in the anal margin are classified according to the World Health Organization classification of skin tumors. Anal margin tumors include SCC, anal intraepithelial neoplasia, also known as Bowen disease, adenocarcinoma and its precursor Paget disease, basal cell carcinoma, and verrucous carcinoma (Buschke-Löwenstein tumor), which is a rare variant of SCC. Imaging plays an important role in the evaluation, staging, and follow-up of patients with anal and perianal tumors. However, because of the overlap in imaging features among these diverse entities, a definitive diagnosis is best established at histopathologic examination. Nevertheless, familiarity with the pathogenesis, imaging features, and treatment of these tumors can aid radiologic diagnosis and guide appropriate patient treatment. (©)RSNA, 2016.

Chemoradiotherapy with Brachytherapy or Electron Therapy Boost for Locally Advanced Squamous Cell Carcinoma of the Anus\u2014Reducing the Colostomy Rate

PurposeThe aim of this study is to determine overall survival, disease-specific survival and stoma-free survival after treatment of squamous cell carcinoma of the anus with chemoradiotherapy followed by brachytherapy or electron boost in a recent cohort of patients.MethodsFifty-two patients (median age 62 years) were treated with radical chemoradiotherapy (mitomycin C, infusional 5-fluorouracil concurrently with conformal radical radiotherapy 45 Gy in 25 fractions over 5 weeks) followed by a radiotherapy boost between 1 December 2000 and 30 April 2011. Follow-up was to 30 November 2014. Thirty-six patients received a boost (15–20 Gy) over 2 days with 192Ir needle brachytherapy for anal canal tumours, and 16 patients received electron beam therapy (20 Gy in 10 fractions in 2 weeks) for anal margin tumours. A defunctioning stoma was only created prior to chemoradiotherapy for fistula or severe anal pain.ResultsThe overall survival for the 36 patients treated with chemoradiotherapy followed by brachytherapy was 75 % (95 % CI, 61–89) at 5 years, the disease-specific survival was 91 % (95 % CI, 81–101 %), and the stoma-free survival was 97 % (95 % CI, 91–103 %) all at 5 years. For the 16 patients treated with an electron boost for anal margin tumours, the 5-year overall survival, disease-specific survival and stoma-free survival were 68 % (95 % CI, 44–92 %), 78 % (95 % CI, 56–100 %) and 80 % (95 % CI, 60–100 %), respectively.ConclusionsA very low stoma formation rate can be obtained with radical chemoradiotherapy followed by a brachytherapy boost for squamous cell carcinoma of the anal canal but not with an electron boost for anal margin tumours.

PTU-213 Oncological outcomes following local excision with and without (chemo)-radiotherapy for anal margin squamous cell carcinoma

Introduction The mainstay of treatment for anal squamous cell carcinoma (ASCC) is chemo-radiotherapy (CRT). Less than 5% of initial presentations are confined to the anal margin and amenable to local excision (LE) with or without post-operative (C)RT. However, treatment is poorly defined and outcome is understudied. Method PLATO is the next UK anal cancer trial; a three-part umbrella trial where the first stream (ACT 3) is a phase II study to assess the use of LE, for T1N0 anal margin tumours, combined with low-dose post-operative CRT (41.4Gy in 23 fractions) for close margins (≤ 1 mm), evaluated against a minimally tolerated loco-regional actuarial relapse rate of 10%. To inform this trial, we report the characteristics, treatment and outcomes of patients treated through a large anal cancer MDT (2004 to 2013), supplemented by a literature review. Results From 446 patients with new ASSC, there were 20 (4%) anal margin tumours treated by LE. Thirteen (65%) were T1; 7 (35%) were T2. All were N0 and M0. The lateral and deep margins were close (≤ 1 mm) in seven patients (35%). Five patients had additional therapy: 2 RT; 3 CRT. With a median follow-up of 38.6 months, there were no primary site recurrences; 3 patients developed nodal relapses (3-year loco-regional relapse = 11%). Three patients died attributed to their disease – the 3-year disease-free survival rate was 89%. The literature search identified six studies – there was a near total paucity of data on tumour characteristics, excision margin status, and the impact of these on subsequent treatment or outcome. Conclusion There is a need for a contemporaneous prospective study of this sub-population of patients with anal cancer, through centralisation of patients to anal cancer MDTs with pro-active identification and recruitment of these patients for the ACT3 trial. Disclosure of interest None Declared.

Squamous cell carcinoma of the anal margin

Squamous cell carcinoma of the anal margin is a rare disease. Accurate clinical staging with physical exam and imaging is important and determines the treatment. Evidence-based management is challenging because there is a paucity of randomized controlled trials and existing literature seldom distinguishes between anal canal and margin tumors. In this article, we review the anatomy, presentation, classification, and clinical management of squamous cell carcinoma of the anal margin.

In vivo quality assurance of volumetric modulated arc therapy for ano-rectal cancer with thermoluminescent dosimetry and image-guidance

ObjectiveTo assess in vivo dose distribution using cone-beam computed tomography scans (CBCTs) and thermoluminescent dosimeters (TLDs) in patients with anal or rectal cancer treated with volumetric modulated arc therapy (VMAT). MethodsIntracavitary (IC) in vivo dosimetry (IVD) was performed in 11 patients using adapted endorectal probes containing TLDs, with extra measurements at the perianal skin (PS) for anal margin tumors. Measured doses were compared to calculated ones obtained from image fusion of CBCT with CT treatments plans. ResultsA total of 55 IC and 6 PS measurements were analyzed. IC TLD median planned and measured doses were 1.81Gy (range, 0.25–2.02Gy) and 1.82Gy (range, 0.19–2.12Gy), respectively. In comparison to the planned doses all IC TLD dose measurements differed by a median dose of 0.02Gy (range, −0.11/+0.19Gy, p=0.102) (median difference of 1.1%, range −6.1%/+10.6%). Overall, 95% of IC measurements were within ±7.7% of the expected percentage doses and only 1 value was above +10%. For PS measurements, only one was not within ±7.7% of expected values (i.e., −8.9%). ConclusionsImage guidance using CBCT for IVD with TLDs is helpful to validate the delivered doses in patients treated with VMAT for ano-rectal tumors.

Four decades of anal cancer in Tasmania, Australia: what do the case data tell us?

Anal cancer is a rare cancer analogous to cervical cancer, largely caused by exposure to oncogenic human papillomavirus. We have sought to study this disease in the epidemiologically distinct population of Tasmania. Medical records at all tertiary and secondary referral centres in Tasmania were audited for records with corresponding International Classification of Diseases (ICD)-10 codes. Statistical significances of trends were evaluated using Fisher's exact test, logistic regression or linear regression. Of ~1350 screening records, 170 cases of anal cancer were found with patient presentation during 1973-2010, corresponding to 132 patients. This cohort was mostly female (66.7%), with squamous cell histology (81.8%) and anal canal primaries (72.0%). Most cases were detected at Stage II or below and the majority remained disease-free after treatment. Relatively few cases had documentation of typical risk factors for anal cancer, such as HIV seropositivity, a history of cancer or smoking. After 2000, there was a trend towards a lower stage at presentation, correlating with an increased 5-year survival. After 2000, no anal margin tumours presented beyond Stage II; nearly half were detected in situ and none were fatal. For anal canal tumours, there was virtually no change in the mean stage at detection or in survival. This is the first case series of anal cancer in Tasmania. We find that in many ways, including symptoms and pathology at presentation, epidemiology is typical. However, our cohort is distinct in its paucity of known risk groups, including HIV-positive people, those with a history of cancer and smokers.

Long-Term Outcome after Combined Radiochemotherapy for Anal Cancer – Retrospective Analysis of Efficacy, Prognostic Factors, and Toxicity

Background: This retrospective study evaluated the efficacy, prognostic factors, and toxicity of combined radiochemotherapy for anal cancer. Patients and Methods: Data of 90 patients treated with radiochemotherapy between 1990 and 2006 were analyzed. Mean follow-up was 30 months (range: 2–129 months). Endpoints were disease-specific survival, local control, freedom from metastasis, and colostomy-free survival. Tumor stage, nodal status, age, sex, tumor site, tumor resection, and radiation dose were analyzed for prognostic value. Acute toxicity was scored according to the RTOG/EORTC scale, late toxicity according to the LENT/ SOMA scale. Results: Disease-specific survival was 86%, local control 79%, freedom from metastasis 92%, and colostomy-free survival 83%. Higher T category was associated with inferior prognosis for colostomy-free survival (p = 0.000), male sex for local control (p = 0.004) and diseasespecific survival (p = 0.002), and tumor site at the anal margin for local control (p = 0.03). 4 of 7 patients with recurrent anal margin tumors had human papillomavirus (HPV)-related disease. 49% of patients suffered from ≧ grade 3 acute toxicity. 3 patients had late toxicity of grade 3 concerning sphincter control. Conclusion: Combined radiochemotherapy for anal cancer is a highly effective therapy with pronounced acute and minor late toxicity. In the case of higher T stage, male sex, and cancer at the anal margin, treatment intensification should be considered.

The results of surgery for epidermoid carcinoma of the anus.

A series of 89 cases of anal carcinoma presenting over a 20-year period is reviewed. The majority were epidermoid carcinomas, 57 arising in the anal canal and 13 at the anal margin. The remainder were melanomas and basal cell carcinomas, and these were not considered further. The main presenting symptoms of epidermoid anal carcinomas were bleeding and pain. Tumours arising in the anal canal were commoner in women whilst those at the margin were more frequent in men. The majority (51/70) had a clinical diagnosis of malignancy made but in 19 cases this was not considered initially. The necessity for routine early histological diagnosis is stressed. Treatment was mainly surgical, either abdominoperineal resection (37 canal, 2 margin) or wide excision (8 canal, 11 margin). The 5 year survival of patients with anal margin tumours was better than those with canal lesions (50 per cent compared with 36 per cent).

Malignant anal tumours.

Anal tumours represent 5 per cent of anorectal cancers and exist as two clinical entities: tumours of the anal canal and those of the anal margin. Smoking and sexual behaviour, particularly homosexual anal intercourse, are important aetiological factors. This association is related to anal warts and human papillomavirus infection, notably type 16, which is found in around 70 per cent of warts. Symptoms are non-specific and are frequently attributed to benign conditions. Rectal examination reveals a characteristically infiltrating lesion and any suspicious anal area should be biopsied. There are two histological types. Squamous carcinoma comprises approximately 95 per cent of anal tumours and includes the 35 per cent of tumours derived from the anal transition zone (cloacogenic tumours), containing a mixture of squamous and mucinous elements. The remaining 5 per cent of anal tumours are adenocarcinoma. Squamous cell tumours of the anal canal are probably best treated using radiotherapy (with chemotherapy) as complete response rates, 5-year survival rates, and incidences of normal sphincter function and significant toxicity are around 80, 70, 75 and 20 per cent respectively. Treatment failures may be salvaged by surgery. The 5-year survival and local recurrence rates for radical surgery are around 60 and 25 per cent respectively; there are few indications for local excision. In contrast, 60 per cent of anal margin tumours are suitable for local excision, the 5-year survival rate being in excess of 80 per cent. Combining radiotherapy with surgery may give additional benefit. Current randomized controlled trials should further clarify the relative merits and demerits of the treatment options.

The management of anal carcinoma.

In a 20-year survey of anal carcinoma at Groote Schuur Hospital 55 cases were studied retrospectively. Patients of mixed race with anal margin carcinoma had a median age 29 years below that of Whites with anal margin carcinoma. Patients in these two groups with anal canal carcinoma had the same median age. Anal margin tumours were smaller than anal canal tumours at presentation and had a substantially better 5-year survival rate. The approach to treatment of these conditions is outlined.

Tumor Site Predicts Outcome After Radiochemotherapy in Squamous-Cell Carcinoma of the Anal Region: Long-Term Results of 101 Patients

This study was designed to assess the long-term results following radiochemotherapy in patients with anal squamous-cell carcinoma and to evaluate the impact of tumor location on response, survival, and colostomy-free survival. Between 1985 and 2001, a total of 101 patients with anal carcinoma were registered for curative treatment, of whom 77 had involvement of the anal canal alone, 10 cases had extension into the perianal skin, and 14 patients had pure anal margin tumors. Small tumors of the anal margin were not included since they were treated by surgical excision only. Among the 101 patients were 74 women and 27 men with a median age of 62 (range, 26-84) years. T categories (International Union against Cancer) were T1 (15), T2 (36), T3 (34), and T4 (16). Seventy-one patients had no evidence of nodal disease, whereas 30 presented with involved regional nodes. Radiation treatment was directed to the primary tumor region and to the inguinal, perirectal, and internal iliac nodes using a three-field to four-field box technique with 10MV photons up to a total dose of 5040 cGy. Lesions greater than 5 cm received an additional boost by interstitial or external radiation depending on circumferential extension of the residual tumor. All patients were scheduled for simultaneous chemotherapy with two cycles of 5-fluorouracil at a dose of 1000 mg/m (2)/day as 120 hours of continuous intravenous infusion on Days 1 to 5 and 29 to 33 and mitomycin C at 10 mg/m (2)/day on Days 1 and 29. Median follow-up time was was 7.5 (range, 1-16) years. Overall survival and colostomy-free survival rates for patients with anal canal cancer were 75 percent and 87 percent at five years, respectively. Patients with anal margin cancer had a less favorable outcome with five-year-overall and colostomy-free survival rates of 54 percent and 69 percent, respectively. After correction for imbalance between anal canal and anal margin tumors, i.e., exclusion of T1 tumors of the anal canal, difference in overall survival remained significant (73 percent vs. 54 percent, P = 0.01). Following multivariate analysis, tumor location (anal canal vs. anal margin, P = 0.02), age (P = 0.003), and dose intensity of chemotherapy (< or =75 percent vs. >75 percent, P = 0.03) remained independent significant factors for overall survival. Initial tumor response at six weeks (P = 0.03) was predictive for colostomy-free survival. With colostomy-free survival rates around 85 percent, long-term treatment results for anal canal carcinoma have reached a satisfactory level. However, patients with larger lesions of the perianal skin are at high risk for locoregional recurrence and possible treatment intensification in this subgroup seems desirable.

Conservative treatment by irradiation of epidermoid carcinomas of the anal margin

Purpose : Few series have described treatment results of anal margin tumors as defined in the UICC 87 classification. The purpose of this article is to describe experience with an uncommon condition in a single cancer center. Methods and Materials : From 1971 to 1995, 32 patients with carcinoma of the anal margin were irradiated with a curative intent, and 31 were followed-up for more than 6 months (mean = 4.5 years). There were 9 T1, 15 T2, 7 T3, and 1 T4 (vulvar), with 26 N0 and 6 N1. There was a minor invasion of the lower canal in 17 patients. The histological types were 24 squamous cell and 7 basocellular carcinomas, and 1 Paget's disease. The treatment was a combined External Beam Irradiation (EBI) and Brachytherapy (BT) in 16 patients, an exclusive BT in12 patients, and an exclusive EBI in 4 patients. No prophylactic inguinal irradiation was delivered. Results : The 5-year actuarial restults are as follows: overall survival = 67%, specific survival = 89%. The only prognostic factor was nodal involvement ( p < 0.001). T-stage, T-size, age, sex, and treatment schedule were not significant. The overall local control was 77%, and 93.5%after salvage. Two N0 patients relapsed in inguinal areas (one was salvaged). Twenty-six percent presented a Grade 3 or 4 late complication, necessitating a temporary colostomy in only one patient. The sphincter conservation reached 84% for the whole series, 80% for patients followed-up 5 years or more, and 89% for cured patients. Conclusion : Results are similar to other series, and seem better than for anal canal cancer. We recommended exclusive irradiation. There is no data recommending concomitant chemotherapy. Depending on the tumor size and localization, the tumor boost can be applied by EBI or BT. Surgery is reserved for small tumors far from the canal or for salvage. An inguinal prophylactic bilateral irradiation should be recommended for N0, with tumors over 4 cm.

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.

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.

Squamous-cell carcinoma of the anus.

Seventy-six cases of squamous-cell carcinoma of the anus are reviewed—11 of these were classified as anal-margin tumors and 65 as anal-canal carcinomas. Fifty-nine of these were available for five-year follow-up, ten having been treated within the last five years, and seven were lost to follow-up. The five-year survival rate for nine patients with neoplasms arising at the anal margin was 67 per cent (six survivors) and for 50 patients with anal-canal neoplasms, 32 per cent (16 survivors). Radiotherapy proved unsatisfactory, and radical excision was the only method of treatment which carried reasonable prospects of cure.