Sphincter preservation in anal cancer: A brief review

Abstract

Management of anal cancer is a challenge. The goal of treatment is to eradicate tumor without sacrificing the anal sphincters. The idea of organ preservation emerged following the discovery of a high complete response rate from preoperative combined chemoradiation (CRT) prior to abdominoperineal resection. CRT is widely accepted as the standard therapy for treating anal squamous cell cancer. The combination of external beam radiotherapy with interstitial brachytherapy increases the dose to the tumor volume and decreases dose to normal tissues. The current goal is to avoid colostomy, and surgery has become a salvage or secondary therapy. In this article, we review the non-surgical management of anal cancer with special emphasis on CRT, role of intensity modulated radiation therapy and brachytherapy.

Chemoradiotherapy in Cancer Treatment: Rationale and Clinical Applications

“…Today, CRT with 5-fluorouracil plus mitomycin C is offered as mainstay curative treatment for anal squamous cell carcinomas with the intent of organ preservation after having repeatedly been shown to be a superior treatment in large-scale clinical trials (8)(9)(10)(11)(12). Abdominoperineal resection surgery with formation of end colostomy is reserved for salvage or secondary therapy after disease progression following CRT (13). Furthermore, highdose irradiation with brachytherapy in patients with residual disease after CRT achieves higher rates of local disease control, and although this has been criticised for increased risk of adverse events, these remain statistically insignificant (13)(14)(15).…”

“…Abdominoperineal resection surgery with formation of end colostomy is reserved for salvage or secondary therapy after disease progression following CRT (13). Furthermore, highdose irradiation with brachytherapy in patients with residual disease after CRT achieves higher rates of local disease control, and although this has been criticised for increased risk of adverse events, these remain statistically insignificant (13)(14)(15). Finally, intensity-modulated radiation therapy, provides a means of delivering curative radiotherapy in CRT without treatment gaps.…”

“…Finally, intensity-modulated radiation therapy, provides a means of delivering curative radiotherapy in CRT without treatment gaps. Intensity-modulated radiation therapy facilitates dose escalation, reduces dosing to surrounding normal critical structures, and maintains excellent targeted tumour coverage (13,(16)(17)(18). Nevertheless, these benefits from intensity-modulated radiation therapy do not necessarily correlate to an improved overall survival (OS) (16).…”

Anal Carcinoma: A Series of Cases with a Literature Review

“…The anal preservation rate was 61% and the five-year survival rate was 65%. In more than 90% of the surviving patients, normal anal function could be preserved (35).Today, brachytherapy is used for small tumours or as the main dose for residual or big tumors after CRT (36).…”

“…Lymph node involvement in diagnosis is observed in 30% -40% of cases, while systemic spread is uncommon with distant extra-pelvic metastasis recorded in 5% -8% at onset, and rates of metastatic progression after primary treatment between 10% and Acta facultatis medicae Naissensis 2016;33(4):295-306 (25). The inguinal area radiation in the dose of [30][31][32][33][34][35][36] Gy is applied in case of positive lymph nodes in the inguinal region (13). The sentinel lymph node biopsy (SLNB) can also be applied in case of recurrence after the CRT (13).…”