Anal Cancer

Question 1

Lymphatic drainage above vs below dentate line

Answer 1

Above - perirectal drainage below - superficial inguinal

Question 2

must confirm that it is what histology?

Answer 2

squamous cell ca

Question 3

Clinically node negative

Answer 3

still have 10% chance of perirectal or superficial inguinal nodes

Question 4

best way to follow the response?

Answer 4

DRE

Question 5

what % will have a synchronous primary with HPV cervial cancer?

Answer 5

5%! make sure to do a bimanual exam

Question 6

DRE follow-up

Answer 6

During treatment, no DRE because it can be painful, but look at any exophytic mass. 4-6 weeks after, should be 80% resolved then 3 months If resolved q 3 months, if not, q6weeks

Question 7

T Staging

Answer 7

T1: < 2 cm T2: 2-5 cm T3: >5 cm T4: Invasion into adjacent organs

Question 8

N Staging

Answer 8

N0 - none N1 - regional node(s) N1a (mets in inguinal, mesorectal, and/or internal iliac nodes N1b mets in external iliac nodes N1cmeds in ecternal iliac and in inguinal, mesorectal and/or internal iliac nodes

Question 9

What does an APR not take out? How does this impact survival in somebody does not want radiation?

Answer 9

They will have a colostomy. It won’t be good because it won’t address the inguinal nodes.

Question 10

Study paradigm

Answer 10

Question 11

RTOG 9811 design

Answer 11

Did not ask the the primary question of cisplatin vs mmc, it also asked

• RCT, n = 649
• T2-T4 (35% T3/4), any N (26% cN+)
• RT: Pelvic field to 45 Gy, with 10-14 Gy boost for T3, T4, LN+ or residual disease
• Chemo: Arm 1, n=325: Concurrent CI 5-FU 1000 mg/m2 d1-4 & d29-32 + MMC 10 mg bolus on d1 & d29 + RT.
• Arm 2, n=324: Induction CDDP 75 mg/m2 + CI 5-FU 1000 mg/m2 (2 cycles, q4wk)
• Followed by concurrent 5-FU/CDDP + RT (same doses) starting d57
• Stratification by gender, nodal status, tumor size

Question 12

RTOG 9811 5 year results

Answer 12

There was a survival detriment with cisplatin

Question 13

RTOG 0529

Answer 13

• Phase II trial of Dose-Painted IMRT with 5-FU/MMC
• Low-Risk: T2N0

—42Gy elective nodal + 50.4Gy PTV in 28fx

•High-Risk: T3-4N0-3

—-45Gy elective nodal + 54Gy PTV in 30fx

—-For N+: 50.4Gy/30fx (<3cm)/54Gy/30fx (>3cm)

•CTV = GTV + anal canal + 2.5cm expansion
CTVN = inguinal/external iliac/internal iliac nodes + 1.0cm expansion

•Primary Endpoint: Grade 2+ combined acute GI/GU toxicity

Question 14

RTOG 0529

Answer 14

• IMRT associated with significant sparing of acute G2+ and G3+ dermatologic and GI toxicity
• Provides CT-based planning guideline

Question 15

What are the AE of MMC?

Answer 15

long term renal, pulmonary and bone marrow toxicity

Common to have myelosuppression, dermatitis

Pulmonary fibrosis

Hemolytic uremic syndrome

MDS

Question 16

ACT II UK Phase III study

Answer 16

What came out of this study– how to follow pts. Imaging is not great of the sphincter area

Prior to this study you allowed regression for 3 months, but if still disease at 3 months then they went to APR

this study highlighted that 6 months is better as the cancer can still respond after 3 months

Conclusion – neither cisplatin or maintenance chemo is more effective than standard 5-FU/MMC and RT. Benefit of MMC is fewer cycles of chemo, fewer non-chemo drugs, less chemo time in suite, no risk of neuropathy. There are some times where is it is appropriate to switch to cisplatin (like if they have concurrent H&N cancer)

Question 17

ACCORD 03 trial

Answer 17

induction chemo and dose escalation with a high dose boost

4 arms _/+ boost and +/- induction

-Boost: EBRT or LDR brachy with Ir-192 - •In high-dose arms, 20 Gy if CR or reduction >80%; 25 Gy if <80% PR

Induction: (5-FU/CDDP) x2 cycles

Neither induction or boost had better outcomes

Question 18

How many will have persistent disease?

Answer 18

about 10%

Question 19

Evolution of doses

Answer 19

Question 20

Ongoing trials

Answer 20

Decrease trial – looking to decrease dose for early stage disease (36 Gy for T1)

ECOG - adjuvant nivolumab in patients at a high risk of failure

Question 21

ACT I looked at…

Answer 21

RT Alone

Question 22

EORTC 22861 looked at…

Answer 22

RT Alone

Question 23

RTOG 87-04 asked…

Answer 23

Can we remove MMC?

ChemoRT (5FU + MMC) vs 5FU alone