Anal canal cancer
| Classification according to ICD-10 | |
|---|---|
| C21.0 | Malignant neoplasm of the anus and anal canal: anus |
| C21.1 | Malignant neoplasm of the anus and anal canal: anal canal |
| C21.2 | Malignant neoplasm of the anus and anal canal: cloacal region |
| C21.8 | Malignant neoplasm of the anus and anal canal: rectum, anus and anal canal, several areas overlapping |
| ICD-10 online (WHO version 2019) | |
The anal canal carcinoma is a malignant tumor in the anal canal, the junction between the rectum and the anus . It can arise from wart-like growths ( condylomas ) triggered by human papilloma viruses (HPV 16) or as a result of sexually transmitted diseases such as AIDS . Anal canal carcinoma is often mistakenly perceived by those affected as ' hemorrhoids ', which is why many patients only visit a proctologist very late and thus significantly reduce their chances of recovery. Other proctological diseases, such as anal fissures , can cause similar symptoms. Risk factors for anal canal carcinoma are chronic inflammatory bowel diseases such as Crohn's disease or ulcerative colitis , as well as nicotine abuse and frequent anal intercourse .
The anal canal carcinoma belongs together with the anal margin carcinoma to the anal carcinoma . While anal canal carcinoma occurs by definition between the dentate line and the anocutaneous line , one speaks of an anal margin carcinoma in the case of malignant tumors that lie below (distal) the anocutaneous line and 5 cm around it.
In clinical parlance, there is usually no linguistic distinction between anal canal and anal margin carcinoma, only anal carcinoma is spoken of. As a rule, the term “anal carcinoma” refers to an anal canal carcinoma.
frequency
The anal canal carcinoma accounts for about 1% of all colorectal carcinomas . The incidence is 0.5 to 1.5 per 100,000 inhabitants per year. Cancer has two main risk groups: homosexual men and women over 70.
Symptoms and diagnosis
Blood deposits on the stool and pain when defecating combined with enlarged inguinal lymph nodes , as well as faecal incontinence and weight loss are mostly the long-term consequences of anal canal cancer.
If there is justified suspicion, the doctor will perform a palpation examination with the finger and, if necessary, a reflection ( endoscopy ) of the rectum ( rectoscopy ), usually under anesthesia . Other diagnostic options include taking biopsies , endoanal ultrasound ( sonography ), computed tomography of the abdomen, and a chest X-ray to search for possible lung metastases .
An FDG-PET-CT examination is not one of the standard examinations, but can be used in the case of unclear lymph node enlargement (reactive or physiological enlargement of the lymph nodes) or if distant metastases are suspected.
Spreading pattern
Anal canal carcinomas show local growth in the rectum and perineum with infiltration of the neighboring organs. They tend to premature lymphogenic metastasis along the large vessels and later via the bloodstream (hematogenous) in the liver and lungs .
Staging and histology
| T status | Definition (extent of tumor) |
|---|---|
| TX | Primary tumor cannot be assessed |
| T0 | No evidence of primary tumor |
| Tis | Carcinoma in situ , Bowen's disease , highly squamous intraepithelial lesion (HISL), anal intraepithelial neoplasia |
| T1 | Tumor ≤ 2 cm in greatest extent |
| T2 | Tumor> 2 cm; ≤ 5 cm in the largest dimension |
| T3 | Tumor> 5 cm in greatest extent |
| T4 | Tumors of any size with infiltration into adjacent organs, e.g. B. vagina , urethra or urinary bladder |
| N status | Definition (lymph node involvement) |
| Nx | Lymph node status cannot be assessed |
| N1 | affected lymph nodes perirectally |
| N2 | Affected lymph nodes on one side of the internal iliac artery
and / or inguinally unilateral |
| N3 | perirectal and inguinal
and / or bilateral inguinal and / or bilateral internal iliac |
| M status | Definition (distant metastasis) |
| M0 | No distant metastases detectable |
| Mx | Distant metastases cannot be assessed |
| M1 | Presence of a distant metastasis |
UICC stadiums (7th edition, valid from 2010) |
|
| I. | T1 N0 M0 |
| II | T2-3 N0 M0 |
| IIIA |
T1-3 N1 M0
T4, N0 M0 |
| IIIB |
T4 N1 M0
T1-4 N2-3 M0 |
| IV | every T every N M1 |
Histologically, anal canal carcinomas are mostly squamous cell carcinomas (in 75–90% of cases). Adenocarcinomas in the anal canal are rather rare (around 15%) and mostly rectal carcinomas that have grown into the anal canal secondarily. They are treated like rectal cancer. Other rare malignancies in the anal canal are malignant melanomas , malignant lymphomas, and metastases from other carcinomas. The TNM staging is shown in the table below.
treatment
In 1974, Norman Nigro and colleagues at Wayne State University in Detroit ( Michigan ) were able to show for the first time in a small study that (squamous) anal canal carcinomas can be cured with chemoradiotherapy . Your study was originally designed so that the administered chemoradiation should be given as neoadjuvant therapy , ie to reduce the size of the tumor before a planned operation. Ultimately, the chemoradiotherapy proved to be incredibly effective and in the first 6 patients who were operated on as planned, no residual tumor was detectable in the surgical specimen. Therefore, the other patients in the study did not undergo surgery in the event of complete remission. Subsequent therapeutic studies confirmed the effectiveness and equivalence of chemoradiotherapy compared to surgery in the treatment of anal canal carcinoma.
Today, simultaneous chemoradiotherapy is the standard therapy for squamous cell anal canal cancer. An operation is only necessary if a residual tumor is still detectable after radiochemotherapy. The advantage of chemoradiotherapy compared to previous surgical therapy lies primarily in the preservation of the natural intestinal outlet and its function. In surgical therapy, an artificial anus ( colostomy ) is always created.
With radiation therapy , both the tumor area and the lymph nodes in the pelvis and groin are irradiated. The radiation through the skin (transcutaneous) takes place with a total dose of 45-50.4 Gy , which is administered in single doses of 1.8 Gy daily on weekdays. This results in a total exposure time of 5 weeks. For larger tumors (≥T2 stage), a small-volume dose saturation ( boost ) of the tumor region or, if necessary, of pathological lymph nodes of a further 5.4–9 Gy is recommended, which results in a further 3 to 5 days of radiation. The entire irradiation takes 5 to 6 weeks.
Chemotherapy, which conventionally consists of 5-fluorouracil (5-FU) and mitomycin C , takes place at the same time as the radiation . Cisplatin and 5-FU combinations gave poorer results. A common therapy regimen is:
| 5-FU 1000 mg / m² / 24h iv | Day 1-4, day 29-32 |
| Mitomycin C 10 mg / m² iv | Day 1, day 29 |
Since 5-FU is administered as a continuous infusion over two 4 days (96 hours), a port catheter must first be implanted in the patient . For this reason, it is relatively common practice not to give 5-FU, but rather its orally administered prodrug capecitabine (analogous to the situation with rectal cancer) and thus avoid port catheter implantation:
| Capecitabine 825 mg / m² twice a day po | during the duration of the irradiation |
| Mitomycin C 10 mg / m² iv | Day 1, day 29 |
Strictly speaking, there are no major therapy studies for this that have shown the equivalence of the two methods.
Remission control after chemoradiation should take place at the earliest 6 to 12 weeks after the end of it, since tumor regression in anal cancer is often delayed. The examination is carried out using proctorectoscopy . A routine biopsy is not recommended and should only be performed if the finding is suspect.
forecast
When combined chemoradiation was established as the standard procedure, 5-year survival rates of 80–90% compared with 47–71% after radical surgery were achieved. As with most cancers, the earlier the disease is detected, the higher the chances of recovery. The 5-year survival rate for distal, well-differentiated tumors that are smaller than 5 cm is up to 85%. In the case of locally removable tumors in the proximal anal canal, it is around 50%. After performing chemoradiation, the average 5-year survival rate for stage I: 77% -90%, stage II: 67% -75%, stage IIIA: 58% -64%, stage IIIB: 51-58 %% and stage IV 5-15%.
literature
- PN Khalil et al: The hemorrhoid ointment was useless here! In: MMWonline of February 4, 2010
- Rolf Sauer : Radiation Therapy and Oncology. Urban & Fischer at Elsevier, 2009, ISBN 978-3-437-47501-6 (textbook)
- MW Trammer: Anal canal carcinoma. (PDF; 214 kB) Dissertation, University of Bonn, 2007
Web links
- Anal cancer (University of Bonn)
- National Comprehensive Cancer Network → Guidelines
Individual evidence
- ↑ a b c d e Hartmut Köppen: Gastroenterology for the practice. Georg Thieme Verlag, 2010, ISBN 3-131-54401-5 , p. 280. Restricted preview in the Google book search
- ↑ Andreas Hirner, Kuno Weise: Surgery: cut by cut. Georg Thieme Verlag, 2004, ISBN 3-131-30841-9 , p. 640. Restricted preview in the Google book search
- ↑ Clinical Cancer Register Coding Aid - as of August 2014. University Medical Center Freiburg, accessed on April 29, 2018 .
- ↑ a b c I. Fraunholz, G. Woeste, R.-D. Hofheinz: Therapy of anal carcinoma . In: The oncologist . tape 20 , 2014, p. 173-182 , doi : 10.1007 / s00761-013-2622-x .
- ^ Nigro ND, Vaitkevicius VK, Considine B Jr .: Combined therapy for cancer of the anal canal: a preliminary report . In: Dis Colon Rectum . tape 17 , no. 3 , June 1974, p. 354-6 , doi : 10.1007 / BF02586980 , PMID 4830803 (English).
- ↑ IN MEMORIAM: Norman D. Nigro, MD, 1912 - 2009. (pdf) (No longer available online.) ASCRS News, 2010, archived from the original on May 10, 2017 ; accessed on April 29, 2018 (English). Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.
- ↑ A. Schmieder, J. Claßen, R. Metzer: Interdisciplinary Recommendations for Therapy 2016/17 . Ed .: Preiß, Honecker, Claßen, Dornoff. Chapter A 1. Anal cancer, p. 311-326 .
- ↑ Nutz V: Colostomy system only as a last resort. Anal cancer: chemoradiotherapy is standard of treatment. In focus oncology 2009; 7-8: 1-10.
- ↑ Becker HD, Hohenberger W, Junginger T, Schlag PM: Tumors of the anal region. In: Surgical Oncology. Stuttgart, New York: Thieme 2002; 485-493.
- ^ [1] Jamie Pawlowski; William E. Jones III., Radiation Therapy For Anal Cancer, StatPearls Publishing, Last Update: January 23, 2020.
- ^ R. Glynne-Jones et al, Anal cancer: ESMO – ESSO – ESTRO clinical practice guidelines for diagnosis, treatment and follow-up. Radiotherapy and Oncology 111 (2014) 330-339.
- ↑ Leonard L. Gunderson, Jennifer Moughan, Jaffer A. Ajani et al., Anal Carcinoma: Impact of TN Category of Disease on Survival, Disease Relapse, and Colostomy Failure in US Gastrointestinal Intergroup RTOG 98-11 Phase 3 Trial. Int J Radiation Oncol Biol Phys, 2013, vol. 87, no. 4, pp. 638-645.
