Grand round

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Grand round
9th November 2004
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SURGICAL GRAND ROUND

• GASTROINTESTINAL SURGERY DIVISION

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MANAGEMENT OF ANAL CARCINOMA

• AN OVERVIEW

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Presenters

• Dr. D. V. OZIGA
• Dr. T. OSISANYA
• Dr. A. DONGO
• Supervising Consultants
• Dr. D.O. IRABOR
• Dr. J. K. LADIPO

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Case presentation 1

• Name O.W.
• Hospital No 1059203
• Age 55 years
• Sex Female
• Address Ibadan
• Occupation Trading
• Marital status Married
• Religion Christianity
• Tribe Yoruba

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Presenting complaints

• Anal mass X 11 months
• Anal bleeding

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History of presenting complaints

• Anal mass progressively increasing in size
• later ulcerated
• Associated haematochezia,anal pain,
• faecal incontinence, weight loss,
• feeling of incomplete bowel emptying
• No cough, chest pain, abdominal distension,
  jaundice or vomiting

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History of presenting complaints

• No history of STI,perianal growth or anal
  intercourse
• Had incisional biopsy at mission hospital -
  histology ( in UCH ) Squamous cell carcinoma

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History continued

• Known hypertensive controlled on drugs
• Allergy none
• Family and social history-
• No history of gastrointestinal cancers

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Examination

• Chronically ill looking
• Afebrile,anicteric,not pale
• Solitary 3 2 cm right inguinal lymphadenopathy
• No pedal oedema

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Examination

• Chest
• respiratory rate 24/min
• clinically clear
• Cardiovascular
• pulse 74/min,regular,good volume
• B.P. 140/90 mmHg
• normal heart sounds

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Examination

• Abdomen
• flat,soft,moved with respiration
• no tenderness
• liver,spleen not enlarged
• kidneys not ballotable

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Examination

• Rectal (inspection only)
• circumferential, ulcerated anal mass extending
  up to the posterior fourchette,
• right ischiorectal fossa involvement,
• mass bled slightly on contact,
• anal canal could not admit a finger

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Diagnosis

• Locally advanced anal carcinoma with right
  inguinal metastasis
• ( T3N2M0)

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Management

• Had diverting loop colostomy
• Chemotherapy 5 Fluorouracil
• Mitomycin C
• Discharged to radiotherapy unit
• Day prior to commencement of RTH,
• Had Cerebrovascular accident
• On medical ward.

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Case presentation 2

• Name I.T.
• Hospital No 1055359
• Age 16 years
• Sex Female
• Address Ibadan
• Occupation Schooling (SS 2)
• Marital status Single
• Religion Islam
• Tribe Yoruba

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Presenting complaints

• Anal mass
• Bloody mucoid diarrhoea 18 months
• Faecal incontinence x 14 months

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History of presenting complaints

• Painful anal mass
• progressive enlargement
• associated low grade fever and weight loss
• Developed faecal incontinence 4 months later
• No history of cough, chest pain, jaundice or
  genitourinary symptoms

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History continued

• Not sexually active
• Past medical history
• not contributory
• Drug and allergy history
• not of note
• Family and social history
• no family history of similar illness
• does not smoke cigarettes

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Examination

• Chronically ill looking,
• Cachectic,afebrile,anicteric,pale (18),
• Bilateral inguinal lymphadenopathy,
• No pedal oedema

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Examination

• Chest
• respiratory rate 28/min
• clinically clear
• Cardiovascular
• normal
• Abdomen
• no mass
• no tenderness

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Examination

• Rectal ( inspection only)
• exophytic circumferential cauliflower pigmented
  mass almost occluding anal orifice,
• mass was hard, tender,
• anal canal could not admit a finger

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Diagnosis

• Anal carcinoma ( T3N3M0)

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Management

• Had wedge biopsy of anal mass histology
  invasive mucinous adenocarcinoma
• Chemotherapy 5 Fluorouracil
• Loop colostomy
• Discharged to radiotherapy unit
• Awaiting definitive surgery

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Anatomy of anal canal

• Last 4 cm of the gut
• Develops from anorectal canal and proctodeum
• Tubular muscle with circular fibres
• Consists of mucous membrane, internal and
  external sphincters
• External sphincter skeletal (voluntary)
• Internal sphincter visceral (involuntary)

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Anatomy of anal canal
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Anatomy of anal canal

• External sphincter continuous with levator ani
  and has 3 parts
• rectal end (deep part)
• middle (superficial part)
• subcutaneous part
• Internal sphincter thickened downward
  continuation of inner circular muscle of the
  rectum

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Anatomy of anal canal

• Mucous membrane 3 regions
• upper 1/3 12 longitudinal ridges(anal
  columns/columns of Morgagni)
• pink in colour
• anal valves join adjacent anal columns forming
  pockets (anal sinuses)
• sinuses contains openings of 10 mucous secreting
  glands

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Anatomy of anal canal

• Lining is columnar epithelium
• middle portion pecten (anal margin)
• smooth surfaced, pale
• extends from dentate line to intersphincteric
  groove. Sometimes called anal skin.
• lining is stratified squamous epithelium non
  keratinising,no hair follicles, sebaceous or
  sweat gland

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Anatomy of anal canal

• Anal verge between groove and anal
  orifice(anus)
• truly cutaneous
• lining stratified squamous keratinising
  epithelium
• has hair follicles, sebaceous and sweat glands
• Note just above pectinate line is anal
  transition zone (ATZ) of variable epithelial
  structure, thus no abrupt line of change

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Anatomy of anal canal

• Blood supply
• superior rectal artery upper part
• middle rectal artery middle
• median sacral artery - middle
• inferior rectal artery lower part
• Venous drainage
• correspond to arteries

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Anatomy of anal canal

• Upper part - inferior mesenteric
• Middle part inferior mesenteric
• Lower part internal iliac vein
• Lymphatic drainage
• upper canal internal iliac nodes
• lower canal superficial inguinal/femoral nodes

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Anatomy of anal canal

• Nerve supply
• inferior rectal branches of pudendal nerves
  external sphincter
• sensory to lower canal
• autonomic nerves- internal sphincter and upper
  canal

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Risk factors

• Human papilloma virus (types 16,18)
• Human immunodeficiency virus
• Anoreceptive intercourse
• incidence in heterosexual males in general
  population 0.9/100,000
• in HIV negative homosexual males 35/100,000
• in HIV positive homosexual males 60-70/100,000

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Risk factors

• Premalignant anal lesions
• Bowens disease
• anal condylomata
• Pagets disease
• Chronic immunosuppression
• renal transplant patients
• long term steroid therapy for medical conditions
• Smoking

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Risk factors

• Cervical cancer
• Multiple sexual partners
• Crohns disease

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Clinical presentation

• 75 of anal cancers initially misdiagnosed as
  benign lesions
• Rectal bleeding in 45
• Anal pain or sensation of anal mass in 20
• Tenesmus
• 70 of patients sphincteric involvement at
  presentation causing faecal incontinence
• Rectovaginal fistulae in neglected tumours

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Clinical presentation

• On examination
• Chronically ill looking
• Digital rectal
• mass in anal canal or verge
• fleshy
• fungating ulcer
• Inguinal lymphadenopathy suggests local spread

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Investigations

• Proctoscopy
• Sigmoidoscopy
• Barium enema
• Endoluminal ultrasonography
• Rectal EUA and biopsy
• - most useful staging investigation

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Investigations

• CT scan / MRI to asses pelvic spread
• Monometry and electromyography to asses the
  length, resting tone and contractility of anal
  sphincter
• Defaecating proctography
• Dynamic integrated proctography
• Abdominal ultrasound scan for spread to distant
  sites

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Investigations

• Chest radiograph
• Full blood count
• Electrolytes, urea and creatinine infiltration
  of bladder and ureters may cause obstructive
  uropathy and impaired renal function

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Histology of anal carcinoma

• ANAL MARGIN
• Squamous epithelium
• Eccrine glands
• Apocrine glands

• Squamous cell carcinoma
• Basal cell carcinoma
• Bowens disease ( CIS)
• Perianal Pagets disease

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Histology of anal carcinoma

• ANAL TRANSITION ZONE
• Columnar cells
• Squamous cells
• Neuroendocrine cells
• Melanocytes
• Anal glandular cells

• Malignant melanoma
• (pigmented or amelanotic)
• Sessile or pigmented
• Carcinoid tumour

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Histology of anal carcinoma

• ANAL CANAL
• Columnar cells

• Adenocarcinoma

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TNM Definition (AJCC IUCC)

• TX
• T0
• TIS
• T1 lt 2 cm
• T2 gt 2 cm lt 5 cm
• T3 gt 5 cm
• T4 any size invading adjacent organs (not
  sphincters)

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TNM Definition (AJCC IUCC)

• NX
• N0
• N1 perirectal lymph nodes
• N2 unilateral internal iliac or inguinal lymph
  nodes
• N3 perirectal and inguinal lymph nodes
• bilateral internal iliac / inguinal lymph
  nodes

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TNM Definition (AJCC IUCC)

• MX
• M0 none
• M1 distant

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Stage grouping

• Stage 0 carcinoma in situ
• TISN0M0
• Stage I 2cm or less , no spread
• T1N0M0
• Stage II gt 2cm
• T2N0M0 , T3N0M0
• Stage IIIA
• T1N1M0 , T2N1M0 , T3N1M0 , T4N0M0

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Stage grouping

• Stage IIIB
• T4N1M0
• Any T,N2M0
• Any T,N3M0
• Stage IV
• Any T, Any N,M1

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Treatment options for Squamous Cell Carcinoma

• Previously
• Abdominoperineal resection
• with permanent colostomy

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Treatment for Stages I and II

• No sphincter involvement
• local resection
• Sphincter involvement
• external beam radiation therapy chemotherapy

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Treatment for Stages I and II contd.

• Chemotherapy
• mitomycin C
• 5 fluorouracil (5FU)
• Moertel CG et al, mitomycin C therapy in advanced
  gastrointestinal cancer JAMA 20410451968.
• Nigro ND et al, combined therapy for cancer of
  anal canal a prelim. report, Dis colon rectum
  17 3541974
• UKCCCR anal cancer trial working party, Lancet
  348(9034)1049 10541996

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Treatment for Stages I and II contd.

• Radical resection is reserved for residual or
  recurrent Ca
• Trial with 5FU and Cisplatin
• Doci R et al, Primary chemoradiation therapy with
  fluorouracil and cisplatin for cancer of the anus
  results in 35 patients, J.Clin.Oncology
  1996143121 3125
• Interstitial iridium 192 after external beam
• Sandhu et al , 10yr experience with interstitial
  iridium implantation, Int.J.of Rad Onc and Bio
  Phys 4(3) 575 581 ,1998

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Treatment for Stage IIIA

• Endorectal ultrasound will confirm stage
• As for stages I and II , using radiation therapy
  and chemotherapy
• Abdominoperineal resection
• radical lymphadenectomy and postoperative
  radiation
• Sichy B et al, Definitive irradiation and
  chemotherapy for radiosensitisation

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Treatment for Stage IIIB

• Cure is not possible
• chemoradiation
• local or AP resection
• radical lymphadenectomy

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Treatment for Stage IV

• No standard chemotherapy for metastatic disease
• Palliative surgery
• Palliative irradiation
• Palliative combined chemotherapy and irradiation
  therapy
• Clinical trials

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Recurrent anal cancer

• Alternate treatment
• resection after radiation and vice versa
• Longo NE et al , Recurrent squamous cell
  carcinoma of the anal canal predictors of
  initial treatment failure and results of salvage
  therapy, Annals of Surgery 220(1)40 49,1994

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AdenocarcinomaColorectal type

• Stage I
• tumours moderately/well differentiated
• not involving dentate line
• Local excision/Electrocoagulation
• Sphincter involvement
• Abdominoperineal resection

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Anal gland type

• Abdominoperineal resection
• Preoperative radiotherapy to groin nodes

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Prognosis

• Size gt 2cm
• Degree of differentiation
• Lymph node involvement
• DNA ploidy
• Depth of tumour penetration

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HIV and anal cancer

• Problems with tolerance
• If CD4 lt 200 - modify therapy

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Local experience

• August 2002 date
• No of cases of colorectal and anal carcinoma
  115
• No of cases of ? anorectal carcinoma 14
• Anal carcinoma 12.2 of total

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Local experience - gender distribution

• Male 6
• Female 8
• Total 14
• MF 11.33

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Local experience - age
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Local experience - histology

• Adenocarcinoma 9 cases (90)
• Squamous cell carcinoma 1 case (10)