Terminology: anal canal cancer. Terminology: Anal margin cancer. Treatment Epidermoid
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1 Terminology: anal canal cancer Epidermoid Below dentate line squamous CC At and above dentate line «basaloid», «cloacogenic», or «transi6onal» = non kera6nizing types of squamous cell carcinoma same =t Nicolas Demartines, MD, FACS, Professor and Chairman University Hospital CHUV Lausanne, Switzerland Terminology: Anal margin cancer Anal margin cancer Anal canal cancer Anal Cancer Prognosis (Mul6- modal treatment +/- surgery) Stage : 5 year overal survival: Other histology Adenocarcinoma (= rectum cancer) Melanoma, Lymphoma Merkel carcinoma Sarcoma other =t T1: ( 2cm) 68.5% T2: (2-5 cm) 58.9% T3: (>5 cm) 43.1% T4: (adj. organ invasion) 34.3% Bilimoria KY, Bentrem DJ, Rock CE, Stewart AK, Ko CY, Halverson A. Outcomes and prognosbc factors for squamous cell carcinoma of the anal canal: analysis of pabents from the NaBonal Cancer Database. Dis Colon Rectum 2009;52: Anal Cancer Prognosis (Mul6- modal treatment +/- surgery) Treatment Stage : 5 year overall survival: T1: ( 2cm) 68.5% T2: (2-5 cm) 58.9% T3: (>5 cm) 43.1% T4: (adj. organ invasion) 34.3% N0: 62.9% N+: 37.4% M0: 59.4% M+: 18.7% Bilimoria KY, Bentrem DJ, Rock CE, Stewart AK, Ko CY, Halverson A. Outcomes and prognosbc factors for squamous cell carcinoma of the anal canal: analysis of pabents from the NaBonal Cancer Database. Dis Colon Rectum 2009;52: Anal Margin T1 No : Primary surgery ( anal canal) All other: ChemoradiaSon Gy during 5 weeks, including inguinal areas Combined with 5- FU and Mitomycin C during week 1 and 5 1
2 Assessment of response to ChemoradiaSon First assessment at 6-8 weeks Clinical (DRE, inguinal), (+/- biopsies: controversial) PET CT: predicts long term outcome MRI: tends to overessmate disease Assessment of response to ChemoradiaSon First assessment at 6-8 weeks Clinical (DRE, inguinal), (+/- biopsies: controversial) PET CT: predicts long term outcome MRI: tends to overes6mate disease 60-85%: complete clinical response (CR) 5-30%: >50% CR: follow*, +/- boost crx^ 10%: <50% CR: immediate salvage surgery (*SCC con6nue to decrease in size for 3 to 12 weeks following therapy) IndicaSons to surgery: local failure of (chemo- )radiason A. progression or <50% response at 6-8 weeks B. residual disease at final assessment and aber boost/ salvage radiason C. recurrence aber inisal complete clinical response IndicaSons to surgery: local failure of (chemo- )radiason A. progression or <50% response at 6-8 weeks B. residual disease at final assessment and aher boost/salvage radia6on C. recurrence aher ini6al complete clinical response Renehan AG et al., BJS 2004 Renehan AG et al., BJS 2004 Salvage surgery & survival Salvage surgery & survival Renehan AG et al., BJS 2004 Renehan AG et al., BJS
3 Outcomes of salvage surgery Predictors of successful salvage Renehan AG et al.(nhs UK), BJS 2004 Akbari R et al. (MSKCC), DCR 2004 Predictors of successful salvage R0 Recurrent > residual N0 Female gender Low Charlson comorbidity score Size of resected tumor <4cm Renehan AG et al.(nhs UK), BJS 2004 Akbari R et al. (MSKCC), DCR
4 Low Stapled (High Anal) Manual Transanal (Low Anal) Amputation (APR) APR ISR Importance in Laparoscopic Approach! Rullier E Ann Chir 2002; 127: The Holy Plane of rectal surgery TME: Total Mesorectal Excision APR: Abdomino Perineal ResecSon Richard John Bill Heald The Pope Heald RJ J R Soc Med 1988; 81: Anatomical landmarks Presacral plane Hypogastric nerves Denonvilliers fascia & Prostate Seminal vesicles Pelvic plexus Levator ani muscles Double fascia of Denonvilliers Anterior leaflet of the fascia is related to the prostate Posterior leaflet is related to the rectum Space of Proust between anterior and posterior leaflet It is not always easy to find the passage between wind and water" Healey JE Jr, Hodge J. Surgical Anatomy (2nd ed). Toronto: BC Decker, 1990, p
5 Denonvilliers Charles-Pierre French anatomist and surgeon Paris Skandalakis s Surgical Anatomy 2006,Mc Graw Hill s Access Surgery Perineal Wound Complication (23% - 80%) Risk factors Diabetes, obesity, smoke Radiotherapy : Wound complication: From 23% to 47% Primary Flap Pelvic abcess 46% 12% Primary wound healing 33% 63% Wiatrek,, Clin colon rectal Surg, 2008, 21:76-85 Bullard, Dis Colon rectum 2005, 48: Khoo, Surgery 2001, 130:463-9 Wiatrek,, Clin colon rectal Surg, 2008, 21:76-85 Bullard, Dis Colon rectum 2005, 48: Khoo, Surgery 2001, 130:
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xvm. Subject Index Cancer of the Rectum Accessibility 98 Age 6 Astler-Coller classification 17 Bleeding 80 CEAlevel 29 Clinical staging 41 Colloid carcinoma 8 Conservative irradiation 63 Conservative procedures
Rectal cancer management: a team sport The role of radiology and the multidisciplinary conference
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