Early stage anal margin cancer: towards evidence‐based management

Renehan, Andrew G.; Muirhead, R.; Berkman, Lindy; McParland, Lucy; Sebag‐Montefiore, David

doi:10.1111/codi.14571

Cited by 14 publications

(17 citation statements)

References 23 publications

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“…Pre-treatment risk modelling in ASCC is important; a current platform of three anal cancer trials (PLATO) is testing radiotherapy dose alteration in ASCC [23, 31]. In early-stage tumours, dose de-escalation is being evaluated (ACT4) and in locally advanced tumours does escalation (ACT5).…”

Section: Discussionmentioning

confidence: 99%

Prediction of outcome in anal squamous cell carcinoma using radiomic feature analysis of pre-treatment FDG PET-CT

Brown

Zhong

Frood

et al. 2019

Eur J Nucl Med Mol Imaging

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Purpose Incidence of anal squamous cell carcinoma (ASCC) is increasing, with curative chemoradiotherapy (CRT) as the primary treatment of non-metastatic disease. A significant proportion of patients have locoregional treatment failure (LRF), but distant relapse is uncommon. Accurate prognostication of progression-free survival (PFS) would help personalisation of CRT regimens. The study aim was to evaluate novel imaging pre-treatment features, to prognosticate for PFS in ASCC. Methods Consecutive patients with ASCC treated with curative intent at a large tertiary referral centre who underwent pretreatment FDG-PET/CT were included. Radiomic feature extraction was performed using LIFEx software on baseline FDG-PET/ CT. Outcome data (PFS) was collated from electronic patient records. Elastic net regularisation and feature selection were used for logistic regression model generation on a randomly selected training cohort and applied to a validation cohort using TRIPOD guidelines. ROC-AUC analysis was used to compare performance of a regression model encompassing standard clinical prognostic factors (age, sex, tumour and nodal stage-model A), a radiomic feature model (model B) and a combined radiomic/ clinical model (model C). Results A total of 189 patients were included in the study, with 145 in the training cohort and 44 in the validation cohort. Median follow-up was 35.1 and 37. 9 months, respectively for each cohort, with 70.3% and 68.2% reaching this time-point with PFS. GLCM entropy (a measure of randomness of distribution of co-occurring pixel grey-levels), NGLDM busyness (a measure of spatial frequency of changes in intensity between nearby voxels of different grey-level), minimum CT value (lowest HU within the lesion) and SMTV (a standardized version of MTV) were selected for inclusion in the prognostic model, alongside tumour and nodal stage. AUCs for performance of model A (clinical), B (radiomic) and C (radiomic/clinical) were 0.6355, 0.7403, 0.7412 in the training cohort and 0.6024, 0.6595, 0.7381 in the validation cohort. Conclusion Radiomic features extracted from pre-treatment FDG-PET/CT in patients with ASCC may provide better PFS prognosis than conventional staging parameters. With external validation, this might be useful to help personalise CRT regimens in the future.

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Section: Discussionmentioning

confidence: 99%

Prediction of outcome in anal squamous cell carcinoma using radiomic feature analysis of pre-treatment FDG PET-CT

Brown

Zhong

Frood

et al. 2019

Eur J Nucl Med Mol Imaging

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“…In accordance with the guidelines and expert opinion, it is safe to say that T1N0 tumors < 1 cm, located in the anal margin, are good candidates for LE [34,35]. This will probably account for only 4% of all anal cancers [72]. If pathological examination of the surgical specimen reveals that the resection is not radical, some form of additional treatment is warranted and should be discussed in a multidisciplinary team.…”

Section: Curative Local Excisionmentioning

confidence: 97%

Evolving Concepts toward Individualized Treatment of Squamous Cell Carcinoma of the Anus

Dewit¹,

Cats²,

Beets³

2020

Squamous Cell Carcinoma - Hallmark and Treatment Modalities

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Treatment of squamous cell carcinoma of the anus has evolved over the last 5 decades from radical surgery to combined chemoradiation therapy. Radiation treatment techniques have dramatically improved with the development of more powerful computers, algorithms and treatment machines. The clinical impact of the modern radiation treatment techniques, such as intensity-modulated radiotherapy and volumetric modulated arc therapy, is discussed. The standard-of-care regimen still is concurrent Mitomycin C, 5-fluorouracil and high-dose radiation, as was conceived 45 years ago. Variants of this schedule are discussed in this chapter. International guidelines have been generated and implemented. Whereas concurrent chemoradiation therapy is the treatment of choice for locally advanced tumors, early tumors are probably adequately controlled with either reduced dose chemoradiation therapy or radiation therapy alone. Prognostic factors, such as high-risk human papillomavirus, epidermal growth factor receptor and immune response, will be highlighted. The role of surgery in primary care is limited to local excision of T1N0 tumors ≤ 1 cm of the anal margin. Salvage radical surgery is limited to locoregional recurrent, non-metastasized and resectable tumors after chemoradiation therapy. In addition, new treatment modalities, such as targeted therapy and immunotherapy, will be discussed. Current research aims at refining prognostic subgroups to further individualize treatment strategy, implementing quality assurance protocols in international trials and investigating the molecular profile of squamous cell carcinoma of the anus, in order to identify new treatment avenues. This will hopefully change the landscape of anal cancer treatment in the future.

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“…ACT 3 is a nonrandomized phase II study evaluating local excision with selective postoperative CRT for patients with T1 N0 anal margin tumors. Patients with surgical margins >1 mm will receive no additional treatment, while those with margins ≤1 mm receive additional CRT with reduced doses (41.4 Gy in 23 fractions with single dose MMC and concurrent capecitabine) [ 68 ]. ACT 4 is a randomized phase II trial comparing reduced-dose (41.4 Gy in 23 fractions) to standard-dose (50.4 Gy in 28 fractions) CRT for patients with T1–2 (<4 cm) N0 SCCA with the goal of decreasing toxicity while maintaining high rates of LRC [ 69 ].…”

Section: Current Prospective Trialsmentioning

confidence: 99%

De-Escalation of Therapy for Patients with Early-Stage Squamous Cell Carcinoma of the Anus

Miller

Bazan

2021

Cancers

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The incidence of squamous cell carcinoma of the anus (SCCA) is increasing, particularly in the elderly, with increased mortality in this age group. While the current standard of care for localized SCCA remains chemoradiation (CRT), completion of this treatment can be challenging with risks for severe acute and late toxicity. It remains unclear if full course CRT is required for the management of early-stage SCCA or if de-escalation of treatment is possible without compromising patient outcomes. Alternative therapies include radiation therapy alone or local excision for appropriate patients. Modifying standard CRT may also reduce toxicity including the routine use of intensity-modulated radiation therapy for treatment delivery, modification of treatment volumes, and selection and dosing of concurrent systemic therapy agents. Finally, we provide an overview of currently accruing prospective trials focused on defining the role of de-escalation of therapy in patients with early-stage SCCA.

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Early stage anal margin cancer: towards evidence‐based management

Cited by 14 publications

References 23 publications

Prediction of outcome in anal squamous cell carcinoma using radiomic feature analysis of pre-treatment FDG PET-CT

Prediction of outcome in anal squamous cell carcinoma using radiomic feature analysis of pre-treatment FDG PET-CT

Evolving Concepts toward Individualized Treatment of Squamous Cell Carcinoma of the Anus

De-Escalation of Therapy for Patients with Early-Stage Squamous Cell Carcinoma of the Anus

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