Anal Cancer Flashcards
Lymphatic drainage above vs below dentate line
Above - perirectal drainage below - superficial inguinal
must confirm that it is what histology?
squamous cell ca
Clinically node negative
still have 10% chance of perirectal or superficial inguinal nodes
best way to follow the response?
DRE
what % will have a synchronous primary with HPV cervial cancer?
5%! make sure to do a bimanual exam
DRE follow-up
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
T Staging
T1: < 2 cm T2: 2-5 cm T3: >5 cm T4: Invasion into adjacent organs
N Staging
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
What does an APR not take out? How does this impact survival in somebody does not want radiation?
They will have a colostomy. It won’t be good because it won’t address the inguinal nodes.
Study paradigm
RTOG 9811 design
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
RTOG 9811 5 year results
There was a survival detriment with cisplatin
RTOG 0529
- 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
RTOG 0529
- IMRT associated with significant sparing of acute G2+ and G3+ dermatologic and GI toxicity
- Provides CT-based planning guideline
What are the AE of MMC?
long term renal, pulmonary and bone marrow toxicity
Common to have myelosuppression, dermatitis
Pulmonary fibrosis
Hemolytic uremic syndrome
MDS
ACT II UK Phase III study
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)
ACCORD 03 trial
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
How many will have persistent disease?
about 10%
Evolution of doses
Ongoing trials
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
ACT I looked at…
RT Alone
EORTC 22861 looked at…
RT Alone
RTOG 87-04 asked…
Can we remove MMC?
ChemoRT (5FU + MMC) vs 5FU alone
