Cell Carcinoma Of Anal Canal Research Articles

Small Cell Carcinoma of Anal Canal: A Rare Case Report from a Tertiary Cancer Centre

Extrapulmonary small cell carcinoma (EPSCC) is very rare with an incidence of 0.1 to 0.4% in the United states and the exact incidence in other regions is unknown. Anal canal involvement is extremely rare contributing to < 1% of all EPSCC. Inspite of its rarity, it is of clinical importance due to its aggressive nature. Most of the patients present with lungs and liver metastasis at diagnosis even in early stage tumors. It has a dismal survival rate of 58% at 6-month and 6% at 5-years in contrast to squamous cell carcinoma of anal canal. Exact ethiopathogenesis is unknown. Association with HIV has been seen like squamous cell carcinoma of anal canal. There is very little literature evidence and management is not clear like that of squamous cell carcinoma anal canal. Here we present the case of a 63 year old HIV positive male who presented with small cell carcinoma of anal canal to our institute and the challenges we faced in diagnosis and management.

The Versicolour Gyre-Squamous Cell Carcinoma-Anal Canal: A Mini Review

Squamous Cell Carcinoma (SCC) of anal canal is a frequently discerned malignant neoplasm confined to the anal tract. Thus denominated by World Health Organization (WHO), the neoplasm exemplifies primary squamous cell carcinoma of anus. Basaloid variant of squamous cell carcinoma is additionally designated as cloacogenic or transitional cell carcinoma of anal canal. Besides, mucoepidermoid carcinoma of anal canal denominates neoplasms delineating prominent features of mucinous transition.

Impact of IMRT- and VMAT technologies on selection of total dose of radiation therapy in patients with squamous cell carcinoma of anal canal

Accurate determination of the tumor with the use of modern diagnostic methods which make the maximum exposure to the tumor and the identified affected lymph nodes possible lead to careful attitude to healthy tissues and critical structures. During the period 2000-2015 301 patients with squamous cell carcinoma of the anal canal stage T1-4N0-3M0-1 completed complex treatment which consisted of radiation therapy in a conventional or conformal mode, including the use of modern technologies - radiation therapy with intensity modulation - IMRT and arch volume-modulated radiation therapy - VMAT. The use of IMRT andVMAT in comparison with conformal radiation therapy allowed to reduce the frequency of unplanned interruptions up to 48 % (p = 0.005), which led to increase in 5-year rates of local regional control - 83.7 % compared with the group where the interruption was applied - 74.2 % (p = 0.049); also increased the frequency of complete responses in the range of the total dose of 50-54 Gy to 28.5 %, 56-58 Gy to 44.3 % and 60-64 Gy to 26.1 %. The achievement of a complete response led to a significant increase in the 92.1 % 5-year locoregional control compared to the group with the absence of a complete response - 76.5 % (p = 0.001). Modern conservative treatment is based on continuous radiation exposure with the absence of intervals between courses, which is the radiobiologically considered the most effective treatment regimen.

SO-14 Baseline diffusion-weighted magnetic resonance imaging features to predict recurrence of anal squamous cell carcinoma following chemoradiotherapy

The aim of this study was to investigate the added value of baseline diffusion-weighted MRI (DWI) imaging features to predict response to chemoradiotherapy (CRT) in patients with primary squamous cell carcinoma of anal canal.

Baseline Diffusion Weighted Magnetic Resonance Imaging to Predict Recurrence of Anal Squamous Cell Carcinoma (ASCC) Following Chemoradiotherapy

The aim of this study was to investigate the added value of baseline diffusion weighted MRI (DWI) heterogeneity analysis to predict response to chemoradiotherapy (CRT) in patients with primary squamous cell carcinoma of anal canal. We have previously demonstrated that MRI heterogeneity features may have an added value in response prediction in ASCC, here, we present the effect of DWI texture features on disease free survival in an expanded patient cohort. An IRB waiver was obtained for retrospective analysis of standard of care MRI including diffusion weighted sequences from consecutive patients with ASCC undergoing CRT treatment between 2010 and 2016. Whole tumor 3D volume of interest (VOI) was manually delineated on apparent diffusion coefficient (APC) parametric maps with reference to T2 & diffusion weighted imaging by two experienced readers in consensus generating 76 imaging features/VOI. Primary endpoint was disease recurrence (local or metastatic). Patients were censored either at time of event or last follow up. Kaplan Meier survival curves with log rank p-values were calculated for clinic-pathological variables. Most predictive univariate imaging features were selected based on their highest permutation based importance using Random Forest algorithm for survival. 65 patients were included in the current analysis (42 female, 23 male, median age 60 (range 37-85)). 33/65 patients had T3 or T4 disease and 48/65 were node positive. 43 patients achieved a complete response (CR) on re-staging MRI at 10-12 weeks post CRT. Median follow-up was 36 months (2-102). Recurrence occurred in 20/65 patients. Higher T stage (T3/T4), node positivity, gender and presence of CR alone were not significantly associated with improved disease free survival (p=0.52, 0.84, 0.28 and 0.3, respectively). Five baseline DWI imaging features with highest importance were found to be significantly associated with recurrence free survival: ADC maximum, ADC standard deviation, ADC CoV, ADC Log Entropy 1.5, ADC Range (HR>1, p < 0.001). Baseline ADC may have a role in predicting long term outcome in patients with ASCC undergoing CRT treatment and warrants further investigation in prospective trials.

Cancer du canal anal : personnalisation de la dose, du volume et du fractionnement

The conservative treatment of squamous cell carcinoma of anal canal by irradiation is recommended as first indication. Despite its rarity, significant improvements were obtained by retrospective or prospective clinical studies these 20 past years, evaluating concomitant chemotherapy and IMRT. Nevertheless, the individualisation of the treatment, over dose distribution, has poor data available. Fractionation remains classic (1.8-2.0Gy/Fr), but the optimal dose level remains under discussion. The strategy concerning the volumes and doses for the prophylactic volumes remains under discussion. This paper will describe the data published, and the recommendations of working Groups, and the main options under evaluation. To conclude, today only the absence of gap is recommended, the benefit of a one-step schedule reducing the treatment time, then increasing local control and survival, but personalised schedules remain under investigation.

The prognostic role of hemoglobin levels in patients undergoing concurrent chemo-radiation for anal cancer

BackgroundConcurrent chemo-radiation (CT-RT) is a standard therapy for squamous cell carcinoma of anal canal. Different clinical and biological factors may potentially affect outcome. We investigated the prognostic role of baseline hemoglobin (Hb) in a cohort of anal cancer patients submitted to CT-RT with 5-fluorouracil and mitomycin C.MethodsUp to 161 patients with clinical stage T1-T4/N0-N3/M0 were treated. Response was assessed at 6 weeks and thereafter at 3, 6 and 12 months. Two different approaches were used:a)simultaneous integrated boost following RTOG 05-29 indications;b)first sequence of 45Gy/25 fractions to the pelvis followed by 9–14.4 Gy/5–8 fractions to the macroscopic disease. Primary endpoints were progression-free survival (PFS) and overall survival (OS).ResultsOn multivariate analysis, pre-treatment Hb level had a significant correlation to OS (HR:0.53;95% CI:0.33–0.87; p = 0.001), but not to PFS (HR:0.78;95% CI:0.53–1.15; p = 0.12) Patients with pre-treatment Hb ≥ 12 g/dl had 5-year PFS and OS of 82.2%, compared to 29.3% and 32.8% for those below the threshold. The likelihood to achieve a complete remission increased by 5.6% for every single-unit (g/dl) increase in baseline Hb level over 11 g/dl. On multivariate analysis, response to treatment had a significant correlation to PFS (incomplete vs complete response – HR:5.43;95% CI:2.75–10.7; p < 0.0001) and OS (HR: 6.96;95% CI:2.96–16.5; p < 0.0001).ConclusionsWe showed that baseline Hb level is a strong indicator for poor response to RT-CT in anal cancer patients. A close clinical monitoring for incomplete response to treatment should be advised in patients with low pre-treatment Hb. The hypothesis that the preservation of adequate Hb level during treatment may lead to a better outcome needs prospective evaluation.

Anal canal squamous carcinoma

BackgroundAnal canal carcinoma is a rare neoplasm, representing 2% of the digestive tumors, and the most common is squamous cell carcinoma, with an increasing incidence. ObjectiveThe study aims to elucidate the pathogenesis of an increasingly prevalent disease, as well as to update treatment and prognosis. MethodsA literature search in Pubmed database, including articles from 2005 to 2015 and cross-research articles with the initial research. ResultsSeveral studies prove the role of HPV as a major risk factor in the development of squamous cell carcinoma of anal canal, as well as a greater prevalence of this neoplasia in HIV-positive people and in those who practice receptive anal intercourse. In the last two decades chemoradiotherapy remains the treatment of choice, and abdominoperineal resection is reserved for those cases of treatment failure or recurrence. Evidence advances in order to adapt the treatment to each patient, taking into account individual prognostic factors and biological tumor characteristics. ConclusionsSquamous cell carcinoma of the anal canal is a neoplasm associated with HPV; therefore, screening and vaccination programs of male individuals, by way of prevention, should be started. Many studies are needed in order to achieve development in the treatment as well as in the evaluation of the biological characteristics of the tumor.

Atypical Granular Cell Tumor with Intranuclear Inclusions: A Case Report

Atypical and malignant granular cell tumors are relatively uncommon constituting 1-2% of all granular cell tumors. We present a case of 57 year old man known to have squamous cell carcinoma of anal canal in 2008, now presenting with a chest wall nodule of 2 months duration. Fine needle aspiration of the chest wall nodule yielded atypical pleomorphic cells with abundant granular cytoplasm and vesicular nuclei with prominent nucleoli and intranuclear inclusions. A biopsy was advised and tru cut biopsy proved it to be atypical granular cell tumor, positive forS100 and KP1. We present this case to increase the awareness of this uncommon entity presenting as a subcutaneous nodule.

The impact of anaemia on treatment outcome in patients with squamous cell carcinoma of anal canal and anal margin.

BackgroundRadiochemotherapy is the main treatment for patients with squamous cell carcinoma of the anal canal. Anaemia is reported to have adverse effect on survival in cancer patients. The aim of the study was to evaluate the influence of anaemia on radiochemotherapy treatment outcome in patients with squamous cell carcinoma of the anal canal.Patients and methodsOne hundred consecutive patients with histologically confirmed squamous cell carcinoma of the anal canal were treated radically with 3-dimensional conformal or intensity-modulated radiation therapy followed by brachytherapy or external beam radiotherapy boost and with concurrent mitomycin C and 5-fluorouracil. The influence on survival of pre-treatment, mean on-treatment and end-of-treatment haemoglobin (Hb) concentrations was studied.ResultsThe 5-year locoregional control, disease free survival, disease specific survival and overall survival rates for all patients were 72%, 71%, 77% and 62%, respectively. In univariate analysis, patients with pre-treatment and end-of-treatment Hb > 120 g/L survived statistically significantly better compared to patients with Hb ≤ 120 g/L. Patients with mean on-treatment Hb > 120 g/L only had statistically significant better locoregional control and overall survival than patients with Hb ≤ 120 g/L. In multivariate analysis, independent prognostic factors were pre-treatment Hb (> 120 g/L vs. ≤ 120 g/L) for overall survival (hazard ratio [HR] = 0.419, 95% confidence interval [CI] = 0.190–0.927, p = 0.032) and stage (I & II vs. III) for disease specific (HR = 3.523, 95% CI = 1.375–9.026, p = 0.009) and overall survival (HR = 2.230, 95% CI = 1.167–4.264, p = 0.015).ConclusionsThe pre-treatment, mean on-treatment and end-of-treatment Hb concentration > 120 g/L carried better prognosis for patients for with squamous cell carcinoma of the anal canal treated with radiochemotherapy. The pre-treatment Hb > 120 g/L was an independent prognostic factor for overall survival of patients with anal canal cancer.

Urethral dose sparing in squamous cell carcinoma of anal canal using proton therapy matching electrons with prior brachytherapy for prostate cancer: A case study

The purpose of this case study is to communicate a technique on treating the re-irradiation of squamous cell carcinoma (SCC) of anal canal with proton fields matched with electron fields to spare prostatic urethra. A 76-year old male presented with a secondary radiation-induced malignancy as a result of prostate brachytherapy seeds irradiation 10 years prior. A rectal examination revealed a bulky tumor at the top of the anal canal involving the left superior-most aspect of the anal canal extending superiorly into the rectum. The inferior extent was palpable approximately 3cm from the anal verge and the superior extent of the mass measured greater than 5cm in the superior-inferior dimension. Chemoradiation was suggested since the patient was opposed to abdominoperineal resection (APR) and colostomy. The use of proton therapy matching with electron fields in the re-irradiation setting could help reduce the complications. A 2 lateral proton beams were designed to treat the bulky tumor volume with 2 electron beams treating the nodal volumes. This complication of treatment fields helped spare the prostatic urethra and reduced the risk of urinary obstruction in the future.

P-152 Impact of anemia on treatment outcome in patients with squamous cell carcinoma of anal canal and anal margin

P-152 Impact of anemia on treatment outcome in patients with squamous cell carcinoma of anal canal and anal margin

Impact of radiation dose on locoregional control and survival on squamous cell carcinoma of anal canal

Purpose To perform a systematic analysis of clinical data of presentation, treatment, outcome, toxicity, survival and other associated prognostic factors of the patients of anal canal who received treatment at our hospital. Methods and materials The medical records of 257 patients treated with radiotherapy with or without chemotherapy from the year 1985 to 2005 were studied. Results Median follow-up was 36 months. Complete clinical response after radiotherapy was 74.4% in the whole group. The 5 years overall (OAS) and disease-free (DFS) survival for the whole group was 71.5% and 61%, respectively. Patients with T1–2 tumors which received the radiation dose between 55 and 60 Gy had superior locoregional control, DFS and OAS. Similarly T3–4 tumors receiving radiation dose more than 60 Gy independently improved the locoregional control, DFS and OAS irrespective of the nodal status and addition of chemotherapy. Conclusions Radiation dose of 56–60 Gy for T1 and T2 and 65 Gy for T3 and T4 tumors along with concurrent chemotherapy is required to achieve better local control, disease-free survival and overall survival, with acceptable toxicity.

High Dose Rate Brachytherapy Boost with Newly Made Surface Applicator in Anal Canal Cancers: Our Experience

Purpose/Objective(s): Conservative treatment of cancer of anal canal is a better alternative to radical surgery. We have made a simplesurface applicatorforthe treatmentofcarcinomaof analcanal. Ouraimwasto evaluate therole ofthis newlymadesurface applicator for intraluminal brachytherapy following chemoradiotherapy in carcinoma of anal canal patients. Materials/Methods: In our study, we included 20 patients with squamous cell carcinoma of anal canal treated with combined chemoradiotherapy.AllpatientsweregivenMitomycinC+5FluorouracilonDay1to5,followedbyexternalbeamradiotherapyfrom Day 6. The dose of external beam radiotherapy was 50 Gy in 25 #. Chemotherapy was repeated every 28 days for 2 more cycles. In ourstudy,wehavedonebrachytherapywithsurfaceapplicatordesignedbyus.Theapplicatorwasfabricatedfromaclearcastacrylic cylindricalrodof10cmslengthand2/2.5cmindiameter.Itscentralportionwasdrilledandametallicrodwasfixedinitbyascrew mechanism to act as a handle. Five grooves were drilled on the surface of the applicator along its length in such a manner that the distance between each parallel groove was 1 cm. The grooves were wide enough for steel needles of 6 F diameter provided for interstitialbrachytherapyonmicroSelectronHDRofNucletron.Theneedleswereinsertedthroughthelowerendandupperendswere blind. The brachytherapy was given 7-10 days after external radiotherapy. Total of 15 Gy were given in 2 # at 1 week intervals, on microSelectron HDR with Iridium 192. The brachytherapy was given selectively to the involved wall of anal canal. Results: The treatment was well tolerated. We didn’t face any problems in insertion of the applicator. Follow-up of these patients ranged from 6 to 40 months. The 2-year locoregional control (LRC), disease free survival (DFS). and overall survival (OS) were 80%, 85%. and 90%, respectively. None of the patients developed any serious complications. Only 2 patients developed bleeding per rectum and were managed conservatively. Conclusions: Brachytherapy with the newly designed surface applicator is simple and inexpensive. With this new applicator we can selectively treat the wall of anal canal having the disease and sparing the rest of the normal wall. It is a good alternative to interstitial brachytherapy in superficial cancers of anal canal. Author Disclosure: R.K. Vyas, None; K.R. Jani, None; S. Unnikrishnan, None; D.C. Bhavsar, None; A. Kumar, None.

Squamous cell carcinoma of the anal canal at The Queen Elizabeth Hospital: A local experience

AbstractAim: Concurrent chemoradiotherapy is the standard treatment for squamous cell carcinoma of anal canal. We describe our experience of treating such patients at our center.Methods: Patients with anal squamous cell carcinoma were treated with a uniform sphincter preserving protocol at The Queen Elizabeth Hospital, South Australia. Standard radiotherapy along with 5‐fluorouracil (750 mg/m2 on days 1–5 and days 29–32) and mitomycin C (12 mg/m2 on day 1 only) was given to eligible patients.Results: Of the 34 patients included in this study, nearly 60% were women. Most (89.3%) had T1‐2 disease. One‐third had nodal involvement. Twenty‐seven had chemoradiotherapy, six had local excision alone and one had radiotherapy alone. Among those who had chemoradiation, 71.5% had a complete response and remained colostomy free until the last follow‐up. Most completed the treatment without major side‐effects. The 3 and 5‐year disease free survival rate was 62% and 53%, respectively. All patients who failed chemoradiation underwent salvage surgery with a median survival time of 32.5 months.Conclusion: Sphincter preservation is the goal for anal cancers. Chemoradiotherapy is an important modality to achieve this goal.

A retrospective review of anal squamous cell carcinoma in HIV positive and HIV negative patients

4153 Background: The incidence of invasive anal cancer is 120 times higher in the HIV infected patients than in the general population. The outcome of anal cancer in HIV infected patients has not been evaluated in prospective trials and the published literature is limited to small retrospective case series. The aim of this study is to describe the outcome, tolerability, event free survival, and overall survival in patients with squamous cell carcinoma of anal canal (SCCAC) with and without HIV infection treated at Karmanos Cancer Institute/Wayne State University from 1991 to 2005. Methods: We performed a retrospective chart review. Patients were identified using the SEER database. We collected data regarding HIV status, demographics (age, gender, race), stage at diagnosis, treatment, response to treatment, toxicity and survival. Results: Forty patients with SCCAC were identified, of which 13 were HIV positive and 27 were HIV negative. The HIV-positive and HIV-negative groups differed by mean age (44 vs. 55 years), male gender (100 vs. 37 percent), and African American race (92 vs. 59 percent). There were no differences in stage at diagnosis, type of chemotherapy received. HIV positive population received reduced chemotherapy (67 vs. 8 percent), and RT (22 vs. 7 percent) dosage. The major toxicities observed in HIV positive and negative patients were mucositis (23% vs. 29%), neutropenia (8% vs. 33%) and skin toxicity (46% vs. 55%) secondary to radiotherapy. Only 61 percent of HIV-positive patients were disease free vs. 60 percent of HIV-negative patients. Conclusions: We found that HIV positive patients received lower doses of chemo-radiotherapy. Patients with HIV tolerated the lower dose chemoradiotherapy and had a similar toxicity profile to the HIV negative patients. No major difference in the risk of recurrence between HIV positive and negative patients was observed. No significant financial relationships to disclose.

The bottom line: Outcomes after conservation treatment in anal cancer

At the Department of Radiation Oncology, Westmead Hospital, between 1980 and 2000, 60 patients with squamous cell carcinoma of anal canal or margin (including 15 with Stage IIIA or IIIB) were treated radically; 55 received chemoradiation (89% were prescribed mitomycin C and 5-fluorouracil). Five-year overall survival was 64% (95% confidence interval (CI): 48-79%), with a median survival of 9.75 years (median follow up 5.6 years, range 5 months to 22.5 years). Ten patients have died of disease. At 2 years the local control rate was 86%, and colostomy-free survival was 83%. Relapse after 2 years was uncommon. Tumour size was the main factor driving outcomes, especially survival. Patients with larger tumours (T > 4 cm) had a hazard ratio for survival of 5.7 (95% CI: 1.8-17). Fourteen (24%) patients experienced treatment interruptions as a result of acute toxicity, including one death from neutropenic sepsis. Seven (12%) patients, in total, experienced one or more late toxicities, grade 3 or above, including four women (all postmenopausal) who developed a radiation-induced bone injury. Most patients with anal cancer can expect to retain a functional sphincter after chemoradiation/radiation. Further studies are in progress to determine the optimal chemoradiation protocol.

Squamous cell carcinoma of the anal canal at the Queen Elizabeth Hospital: A local experience

6126 Background: Abdominal-perineal resection (APR) with or without chemo radiation (CRT) was a standard treatment for squamous cell carcinoma of anal canal. Subsequently a series of clinical trials have clearly demonstrated that CRT as primary treatment results in improvement in local regional control, colostomy free survival and disease-free survival. The aims of this study are to determine what is the local practice and outcomes in a single centre. Methods: All patients with squamous cell carcinoma of the anus treated in TQEH over 6-year period (1998–2004) were identified. A standardised chemoradiotherapy protocol was used - 36 Gy in 20 fractions to the pelvis using a 3–4 field technique followed by a dose of 14.4 -18.0 Gy, in 8–10 fractions, to macroscopic disease (primary and nodes) combined with mitomycin C/CVI 5fluorouracil. Baseline data were collected prospectively. Results: A total of 35 patients were reviewed during the study period: 14 men and 21 women with a median age of 64 years. After diagnosis 77% of patients had chemo radiotherapy as first line treatment. 23% local recurrence rates were found and all had salvage abdominal-perineal resection. The 3 and 5 year overall survival for all patients was 75% & 53%. For patients undergoing primary CRT, the 3 and 5 year disease free survival (DFS) was 62% & 53%. The median survival has not been reached. For patients undergoing primary surgery - 3 year DFS is 62%. The median survival for those patients undergoing salvage surgery was 41.5 months, with a 3 year DFS of 50%. One patient with local recurrence subsequently underwent hepatic resection for an isolated metastasis 10 months out from diagnosis and is disease free 5 months post resection. CRT was generally well tolerated although there was one unexplained death at the completion of CRT. Conclusions: This series demonstrates combined chemo radiotherapy is used as first line treatment in the majority of patients with similar outcomes to those reported in other trials. Furthermore this series confirms that salvage surgery achieves prolonged survival. Despite these results, nearly 50% of patients still die of this disease by 5 years and further research assessing the impact of newer chemotherapy agents or targeted drugs is warranted. No significant financial relationships to disclose.