Anal cancer

Question 1

RF’s

Answer 1

HPV (most are HPV related)

Anal intercourse, STD’s, HIV/immunosuppression, smoking

Question 2

How screening for anal cancer is performed in high risk pts

Answer 2

Rectal exam and cytological smear of anus (anal pap smear).

Question 3

most common anal carcinoma histology

Answer 3

Squamous cell carcinoma

Question 4

Initial work up of anal mass concerning for cancer

Answer 4

Digital rectal exam, exam inguinal lymph nodes.
HIV ab/ag, RPR, hepatitis panel
CT chest, abdomen, pelvis
Anoscopy with biopsy or FNA
IF female → cervical cancer screening

Question 5

Management of locoregional anal SCC and why

Answer 5

Typically mitomycin/5-FU + concurrent radiation (possible to cure without surgery)

Question 6

Role for surgery in anal SCC

Answer 6

Salvage for persistent disease at 26 weeks after chemoradiotherapy

Question 7

conventional chemo regimen for locoregional anal cancer

Answer 7

5-FU and mitomycin C

Question 8

Treatment strategy in HIV patients

Answer 8

The same, regardless of CD4 count

Question 9

Management of locoregional failure

Answer 9

Salvage APR

Question 10

Most common sites of distant metastatic disease

Answer 10

Liver, lungs, extrapelvic LNs

Question 11

Management of oligometastatic disease to the liver or para-aortic LN

Answer 11

IF isolated liver mets, can do surgery

Question 12

Surgery used for locoregional failure

Answer 12

Abdominoperineal resection (APR)

Question 13

Presentation

Answer 13

anal bleeding (45%), sensation of mass or pain (30%).

Question 14

Role for IO?

Answer 14

second line (high TMB despite being microsatelite stable)

Question 15

Preferred Management of metastatic disease

Answer 15

carboplatin/paclitaxel

Question 16

management of inguinal node recurrence

Answer 16

groin dissection with or without APR depending on if recurrence is also in anus

Question 17

First step if suspected progressive disease

Answer 17

biopsy

Question 18

2 categories of anal cancer

Answer 18

anal cancer vs. perianal cancer

Question 19

Preferred regimens for second line

Answer 19

Nivo, pembro (never repeat platinum based therapy if progressed on platinum based)

Question 20

Guideline recommendation for screening

Answer 20

Most don’t suggest screening, even in high risk groups

Question 21

Prognosis of locally advanced disease.

Answer 21

Good survival rates if locoregional. Highly sensitive to CRT.

Question 22

Presentation

Answer 22

anal bleeding (45%), sensation of mass or pain (30%).

Question 23

Use of PET/CT

Answer 23

Verify staging before treatment

Question 24

Mets

Answer 24

Liver, lung, extrapelvic lymph nodes

Question 25

Surveillance and when to consider APR

Answer 25

Guideline is 26 weeks, but studies have shown that it may regress after 26 weeks, and thus it may be appropriate to monitor patients who have not achieved CR for up to 6 months in order to delay surgery

Question 26

Response assessment

Answer 26

physical exam per NCCN (confirm)

Question 27

Reported late complications of chemoRT for anal cancer

Answer 27

increased frequency and urgency of defecation, chronic perianal dermatitis, dyspareunia, impotence

Question 28

T1-T4 or Node positive disease management + regimen

Answer 28

Chemoradiation with mitomycin-5-Fu

Question 29

Type of surgery done for locally recurrent disease

Answer 29

Abdominoperineal resection (APR)

Question 30

What is resected with an APR?

Answer 30

Anus, rectum and sigmoid colon are removed.

Question 31

Management of persistent disease after chemoRT in someone who has responded well

Answer 31

Serial exams (may continue to regress and could save patient APR, which has substantial morbidity)
*persistent disease at 3 months may continue to diminish

Question 32

Surveillance for locally advanced anal cancer in remission

Answer 32

• DRE
• anoscopy
• annual CT scans

Question 33

Management of recurrent locally advanced disease

Answer 33

• salvage surgery w/ APR

Question 34

NCCN preferred first line systemic therapy for Stage IV anal

Answer 34

Cisplatin/5-Fu
Carbo/taxol (preferred)

Question 35

management of anal adenocarcinoma

Answer 35

concurrent chemoRT, followed by surgery (anal adenocarcinoma is rare and more aggressive, requiring surgery)

Question 36

Second line for metastatic anal

Answer 36

Aunt liz + soccer player on platform above car and footabll team/Given PD-L1 >1%, pembro vs. nivo (Phase II data - 15-24% ORR)

Question 37

Management of residual disease in anal cancer

Answer 37

IF persistent disease 8-12 weeks after completing CRT AND no evidence of progression, reevaluate in 4 weeks and continue surveillance for up to 6 months (ACT-II - regression of anal cancer noted to continue for up to 26 weeks)

Question 38

Management of progression with CRT

Answer 38

Salvage APR

Question 39

Role of HPV in anal cancer

Answer 39

Associated with more than 90% of anal cancer