Download Surgery for Anal Cancer

Surgery for Anal Cancer
Peter Sagar
The General Infirmary at Leeds
Where is the anal canal?
• Perianal cancer
• Anal canal cancer
Anal canal
Perianal neoplasms
• Perianal skin – junction of the hair-bearing
skin and anoderm of the anal canal
Perianal neoplasms
•
•
•
•
Squamous cell carcinoma
Basal cell carcinoma
Bowen’s disease
Perianal Paget’s disease
Squamous cell carcinoma
•
•
•
•
•
Rolled everted edges
Central ulceration
Late diagnosis
30% misdiagnosed
Spread to lymph
nodes
Perianal squamous cell carcinoma
- treatment
• Wide local excision – well differentiated,
up to 3 cm
• Less favourable lesions- chemoradiation
(40-70 Gy)
Perianal basal cell carcinoma
•
•
•
•
•
•
Uncommon
1-2 cm
Rarely metastasize
Misdiagnosed in 33%
Delayed diagnosis
Rx – local excision
with adequate
margins
Bowen’s disease
• Intraepidermal
squamous cell
carcinoma
• Associated with
primary internal
malignancies (5%)
• Discrete scaly or
crusted plaques
Bowen’s disease
- mapping biopsies
Bowen’s disease
- excise deep to subcutaneous fat
Perianal Paget’s disease
• Extramammary
Paget’s found in axilla
and anogenital region
• Uncommon
• Eczematous lesions
• Visceral carcinomas
in 50%
Perianal Paget’s disease
- biopsy & identify Paget’s cells
Perianal Paget’s disease
-
Excise deep to subcutaneous fat &
up to dentate line
Outline of flaps
Arrowhead flaps
Flaps sutured to anal canal
Y shaped flaps at completion
Squamous cell carcinoma of the
anal canal
• Long h/o minor
perianal symptoms
• 33% misdiagnosed
• Assess primary lesion
• Examine groins
• Proctoscopy
• Endoanal ultrasound
• MRI
Squamous cell carcinoma of the
anal canal
• Spread determined by
dentate line
• 20% nodal
involvement at
presentation
• Extensive Ca may
invade muscular/bony
walls of the pelvis
Squamous cell cancer
- treatment
• Local excision
• CHEMORADIATION
• Abdominoperineal
resection
Inguinal lymph node
• No indication for prophylactic groin
dissection
• Ominous sign if present at presentation
• Rx chemoradiation to groin nodes
Patient Numbers
Total Number of Patients
188
Not treated with XRT
Treated with XRT
13
175
50Gy
110
49.9-30.1Gy
9
30Gy
<30Gy
39
17
Clinical Stage - primary
50
45
40
35
30
No 25
20
15
10
5
0
T1
T2
T3
Stage
T4
Clinical stage - nodes
80
70
60
50
No 40
30
20
10
0
N0-1
N2-3
Nodal stage
Patterns of failure
14
12
10
8
6
4
2
0
Local
Distant
Both
TIME TO LOCAL FAILURE
14
12
10
8
6
4
2
0
3/12 - 6/12
6/12 - 12/12
> 1YR
Local control
1,1
1,0
,9
Local control
,8
,7
,6
,5
,4
,3
,2
,1
0,0
0
20
40
60
Time (months)
80
100
Overall survival
1,1
1,0
,9
,8
,7
,6
,5
,4
,3
,2
,1
0,0
0
20
40
60
Time (months)
80
100
Overall survival by stage
1,2
T1
1,0
,8
T2
T3
,6
T4
,4
,2
0,0
0
20
40
60
Time (months)
80
100
Local control by stage
1,1
1,0
,9
,8
,7
,6
,5
T4
,4
,3
,2
,1
0,0
0
20
40
60
Time (months)
80
100
Salvage Surgery
Treated to 50Gy
110
Local recurrence
23
Number had
salvage surgery
13/23
Alive and well
5
Dead disease
6
Dead other
2
Patterns of failure
• Anal area or regional lymph nodes
• APER for residual or recurrent carcinoma
• Fixed disease at time of Rx failure, median
survival = 8 mths
APER for local failure of treatment
• Not easy
Technical tips
• Fill the hole
• Tackle pelvic side wall involvement
• Sacral invasion
Rectus abdominus flap
Sidewall vessel involvement
vessels
Pelvic side wall
• BLEEDING
•
•
•
•
Suture
Fibrillar surgicell
Argon beamer
Be prepared to pack
Direct invasion of the sacrum
• Choose level of sacrectomy carefully
• Frozen section
• Beware bleeding from pre-sacral veins
APR+S vs TPE+S
Summary
• High index of suspicion
• Mapping biopsies (4 or 12 quadrants)
• Excision biopsy
• Failure of local treatment = referral to specialist
centre
Anorectal melanoma
• Depressing
• Third most common
site
• Confused with
thrombosed
haemorrhoid
• Spread submucosally
WLE vs APER
• 428 patients
• WLE n=90, APER n=189
• Free of disease at 5yrs:
– WLE = 8%
– APE = 13%