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FRCR2 > Anal cancer > Flashcards

Anal cancer Flashcards

1
Q

How are anal cancers categorised anatomically

A

Anal canal - majority.

Anal verge - Lower end of anal canal

Anal margin - 5cm of perianal skin, to lower limit of anal canal

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2
Q

What is the lymphatic drainage of anal tumours

A

Low tumours of the anal margin and verge drain to the peri rectal nodes, inguinal & femoral nodes, iliac and para-aortic

Mid and upper tumours drain to internal pudendal nodes, obturator, pre-sacral and internal iliac nodes

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3
Q

What proportion of cancers are node positive at presentation

A

12% are node positive at presentation

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4
Q

What are the risk factors for anal cancer

A

HPV - 16 & 18
Multiple sexual partners, ano-receptive intercourse
Cervical CIN & cancer, vaginal/vulval VIN & SCC
Smoking
Immunosuppression & HIV

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5
Q

What proportion of AIN progresses to anal cancer after 5yrs

A

10%

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6
Q

How does anal cancer tend to present

A

Bleeding, pain, itching, discharge
Faecal incontinence and frequency
Palpable mass in <25% of pts

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7
Q

Does HPV predict for response to CRT

A

No - carry worse prognosis (opposite to H&N)

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8
Q

What are the negative prognostic factors for anal cancer

A

Increasing stage
Size (>5cm)
Nodal involvement
Mets

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9
Q

How is anal cancer investigated

A

History and examination incl genital examination and EUA
Speculum examination to assess vulva/vagina/cervix
Assess for presence of fistula (and consider defunctioning stoma)
FNA of positive nodes
Imaging - MRI pelvis
PET if >T2

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10
Q

What should an MRI comment on for a potential anal cancer

A

Relationship between inferior aspect of tumour and anal margin
Depth of invasion
Length and quadrant of involvement
Evidence of adjacent organ involvement

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11
Q

When is a PET scan indicated for investigation of anal cancer

A

> T2 stage

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12
Q

How is nodal disease defined for anal cancer

A

N1a - internal iliac, mesorectal or inguinal nodal involvement only

N1b - external iliac node involvement only

N1c - external iliac node AND mesorectal / inguinal / int iliac nodal involvement

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13
Q

What are the aims of treatment of anal cancer

A

Achieve cure with locoregional control
Preservation of anal sphincter function
QOL

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14
Q

When is local excision indicated for anal cancer

A

Anal margin tumours - <1cm, well differentiated, and if macroscopically clear margins are possible (>5-10mm) without sphincter damage, to allow histological clear margin of >1mm

If tumour >1cm -> primary CRT

Surgery contraindicated for anal canal tumours

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15
Q

When is an APER indicated for anal cancer
What doesn’t an APER treat

A

APER indicated if radical CRT is contraindicated:
-Prev RT
- adenocarcinoma or adenosquamous carcinoma histology (less likely to respond to CRT)
- transplated kidney in pelvis
- IBD
- wish to preserve fertility

Doesn’t treat pelvic LNs

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16
Q

When is CRT standard of care for anal cancer

A

Anal canal tumour
Anal margin tumours >1cm

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17
Q

What category treatments are anal SCC

A

Cat 1

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18
Q

When is a defunctioning stoma indicated for anal cancer

A

Bulky tumours - Obstruction
Faecal incontinence
Risk of fistulation
Significant pain

19
Q

What is the RT dose, for a T1-2 N0 tumour and what stage is this

A

T1-2 N0 (stage I-IIA): 50.4Gy/28# with 40Gy/28# electively to pelvic nodes

20
Q

What is the RT dose, for a T3-4 N0 tumour, or any node positive tumour
and what stage is this

A

Dose to primary tumour (and nodes >3cm) - 53.2Gy/28#
Dose to positive nodes - 50.4Gy/28#
Dose to elective nodal volume - 40Gy/28#

T3N0 = stage IIB
node positive = IIIA and above

21
Q

What chemotherapy regimen is given alongside anal RT?

A

Concurrent chemotherapy
Mitomycin C + capecitabine is SOC
MMC given IV day 1 - 12mg/m2, to max dose 20mg
capecitabine 825mg/m2 bd, on days of RT (M-F) only

Can give 5FU instead of cape - days 1-4 & 29-32 ie wks 1&5 - 1000mg/m2 over 24hrs via pump

MMC only given if GFR >50

22
Q

When is mitomycin C omitted

A

GFR <50 - risk of thrombocytopenia

23
Q

For chemoRT, what chemotherapy dose is given if elderly / poor PS

A

Mitomycin C, at dose 8mg/m2
AND 5FU at 750mg/m2

24
Q

What are the indications for adjuvant CRT for anal cancer

A

Positive margins (<1mm) and further surgery not possible
Where completeness of excision cannot be guaranteed
Those at risk of pelvic nodal involvement

25
Q

What is the adjuvant dose for anal CRT?

A

41.4Gy/23# - scar + margin, with MMC + capecitabine
30Gy/15# - scar + margin, with MMC+5FU for wk1 only

26
Q

What volumes are margins are used for a T1 anal tumour treated with primary CRT

A

GTV - Gross primary anal tumour
CTV - GTV + 1cm
Cover Anal canal, verge, internal and external anal sphincters.
Edit from bone & muscle.
PTV - CTV + 1cm

27
Q

What volumes are margins are used for a T2N0 anal tumour treated with primary CRT

A

GTV-P
CTV - GTV +1cm
Cover Anal canal, verge, internal and external anal sphincters.

Elective nodal volume - inguinal, femoral, int & ext iliac, obturator, pre-sacral
Start 2cm above SI-joint or 1.5cm above GTV
If node negative, include lower 5cm of mesorectum
If node positive, include whole mesorectum in CTV

PTV = CTV +0.5cm (for tumour volume) and +1cm (for elective volume)

28
Q

What volumes and margins are used for a large T2, or T3-4 or node positive anal tumour treated with primary CRT

A

GTV-P
CTV-P = GTV +1.5cm
Cover Anal canal, verge, internal and external anal sphincters.
PTV = CTV +1cm (for tumour volume)

GTV-N
CTV-N = GTV-N +0.5cm

Elective nodal volume - inguinal, femoral, int & ext iliac, obturator, pre-sacral
Start 2cm above SI-joint or 1.5cm above GTV
If node negative, include lower 5cm of mesorectum
If node positive, include whole mesorectum in CTV

PTV-N = CTV +0.5cm (GTV-N & elective nodal volume)

29
Q

What OARs would be planned for anal CRT

A

Bladder, rectum and small bowel, perineum & genitalia, femoral heads

30
Q

What is the follow up after completion of primary CRT for anal cancer

A

6mth MRI

31
Q

What is the local recurrence rate after primary CRT

A

20%, typically within first 18mths

32
Q

How is recurrent disease managed after primary CRT

A

Workup of recurrence: Biopsy, MRI, PET-CT to exclude distant mets

Local recurrence within RT volume - salvage surgery (APER / exenteration), or if not suitable for surgery / sufficient interval, reirradiation

Para-aortic LN - SABR

Isolated Inguinal node - surgery (block dissection)

33
Q

What is the first line management of metastatic anal SCC?
Based on what trial
What is the prognosis for this regimen

A

Carboplatin/paclitaxel
InterAAct phase II study (carbo/taxol vs cisplatin/5FU)
mOS 20mths

34
Q

How can CRT be used in the palliative setting

A

30Gy in 15# over 3 weeks
Primary & Nodes + 3 cm margin
Concurrent 5FU week 1 only

35
Q

What must be included in RT volume if tumour extends into the rectum

A

all of the mesorectum in elective volume

36
Q

where does anal cancer tend to metastasise to

A

Liver, very rarely brain

37
Q

What numbers are important for anal cancer T staging
And for N staging

A

2, 5

t1 = ≤2cm
T2 = 2-5
t3 = >5cm
t4 = local inasion (not sphincters)

N1a - inguinal, mesorectal, int iliac
N1b - ext iliac
N1c - both

38
Q

when does staging change management for an anal cancer CRT

A

stage IIA and below ie T1-2N0, treat with lower dose RT (50.4/28 & 40/28 to elective volume)

stage IIB and above (T3N0 or node positive) - treat with higher dose RT - 53.2/28 and 40/28 to elective volume

39
Q

what margin is needed for surgery

A

> 1mm
If ≤1mm, given adjuvant CRT

40
Q

For an early anal cancer, what is the GTV, GTV-CTV margin, CTV, and CTV-PTV margin

What else is included for a larger tumour (>4cm)

A

GTV - gross tumour
GTV-CTV margin 1cm
CTV - GTV +1cm, also including anal canal, verge, int & ext sphincters, edited off bone and muscle
CTV-PTV margin - 1cm

T1N0 - tumour only, no elective nodal volume
T2N0 - include elective nodal volume, starting 2cm above SI joints, with.
CTVe-PTV margin of 0.5cm

41
Q

For an advanced anal cancer, what is the GTV, GTV-CTV margin, CTV, and CTV-PTV margin

A

For T3+ or node positive:

GTv-CTVp margin now 1.5cm, also including anal canal, verge, int & ext sphincters, edited off bone and muscle
CTV-PTV margin - 0.5cm

elective nodal volume, starting 2cm above SI joints
GTV-N -> CTV-N 0.5cm
CTV-PTV margin - 0.5cm

42
Q

When would surgery (APER, not local excision) be considered for anal cancer

A

Prev pelvic EBRT
Transplanted kidney in the pelvis & early disease
To preserve fertility
IBD - radiosensitivity

43
Q

what is the outcome after radical chemoRT

A

Local control 60%, 5yr survival 30-60%

44
Q

What is the response rate to primary CRT for anal SCC

A

Complete tumour regression in 80-90%

FRCR2 (38 decks)

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