Anal cancer Flashcards
RF’s
HPV (most are HPV related)
Anal intercourse, STD’s, HIV/immunosuppression, smoking
How screening for anal cancer is performed in high risk pts
Rectal exam and cytological smear of anus (anal pap smear).
most common anal carcinoma histology
Squamous cell carcinoma
Initial work up of anal mass concerning for cancer
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
Management of locoregional anal SCC and why
Typically mitomycin/5-FU + concurrent radiation (possible to cure without surgery)
Role for surgery in anal SCC
Salvage for persistent disease at 26 weeks after chemoradiotherapy
conventional chemo regimen for locoregional anal cancer
5-FU and mitomycin C
Treatment strategy in HIV patients
The same, regardless of CD4 count
Management of locoregional failure
Salvage APR
Most common sites of distant metastatic disease
Liver, lungs, extrapelvic LNs
Management of oligometastatic disease to the liver or para-aortic LN
IF isolated liver mets, can do surgery
Surgery used for locoregional failure
Abdominoperineal resection (APR)
Presentation
anal bleeding (45%), sensation of mass or pain (30%).
Role for IO?
second line (high TMB despite being microsatelite stable)
Preferred Management of metastatic disease
carboplatin/paclitaxel
management of inguinal node recurrence
groin dissection with or without APR depending on if recurrence is also in anus
First step if suspected progressive disease
biopsy
2 categories of anal cancer
anal cancer vs. perianal cancer
Preferred regimens for second line
Nivo, pembro (never repeat platinum based therapy if progressed on platinum based)
Guideline recommendation for screening
Most don’t suggest screening, even in high risk groups
Prognosis of locally advanced disease.
Good survival rates if locoregional. Highly sensitive to CRT.
Presentation
anal bleeding (45%), sensation of mass or pain (30%).
Use of PET/CT
Verify staging before treatment
Mets
Liver, lung, extrapelvic lymph nodes
Surveillance and when to consider APR
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
Response assessment
physical exam per NCCN (confirm)
Reported late complications of chemoRT for anal cancer
increased frequency and urgency of defecation, chronic perianal dermatitis, dyspareunia, impotence
T1-T4 or Node positive disease management + regimen
Chemoradiation with mitomycin-5-Fu
Type of surgery done for locally recurrent disease
Abdominoperineal resection (APR)
What is resected with an APR?
Anus, rectum and sigmoid colon are removed.
Management of persistent disease after chemoRT in someone who has responded well
Serial exams (may continue to regress and could save patient APR, which has substantial morbidity) *persistent disease at 3 months may continue to diminish
Surveillance for locally advanced anal cancer in remission
- DRE
- anoscopy
- annual CT scans
Management of recurrent locally advanced disease
- salvage surgery w/ APR
NCCN preferred first line systemic therapy for Stage IV anal
Cisplatin/5-Fu
Carbo/taxol (preferred)
management of anal adenocarcinoma
concurrent chemoRT, followed by surgery (anal adenocarcinoma is rare and more aggressive, requiring surgery)
Second line for metastatic anal
Aunt liz + soccer player on platform above car and footabll team/Given PD-L1 >1%, pembro vs. nivo (Phase II data - 15-24% ORR)
Management of residual disease in anal cancer
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)
Management of progression with CRT
Salvage APR
Role of HPV in anal cancer
Associated with more than 90% of anal cancer
