T1N0 anal canal carcinoma

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Kroll2013

Kroll2013

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Dear friends, i have a 27 yo patient that has undergone hemorroidectomy.

The final pathology showed a moderately differentiated invasive squamous carcinoma.
Re biopsy of the scar showed no residual dz.
pelvic CT with IV contrast showed no enlarged LNs.
What should be done next ?
1- observation
2- adjuvant RT only ( to the Tumor bed with no Regional Rt to the LNs)
3- adjuvant CRT ( ACT II protocol) ( RT to TB and pelvico-inguinal nodes ) + ovarian relocation
4- adjuvant CRT ( Focal RT to tumor bed )


Tx



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Size and margins on initial pathology?

A question is going to be whether this is an anal margin cancer or did it arise from the canal/verge. Maybe the surgeon can help with this.

Prefer PET/CT in this setting to help rule out additional disease. Anal SCC tends to be very avid.
 
Kroll2013 said:
Dear friends, i have a 27 yo patient that has undergone hemorroidectomy.

The final pathology showed a moderately differentiated invasive squamous carcinoma.
Re biopsy of the scar showed no residual dz.
pelvic CT with IV contrast showed no enlarged LNs.
What should be done next ?
1- observation
2- adjuvant RT only ( to the Tumor bed with no Regional Rt to the LNs)
3- adjuvant CRT ( ACT II protocol) ( RT to TB and pelvico-inguinal nodes ) + ovarian relocation
4- adjuvant CRT ( Focal RT to tumor bed )


Tx



Sent from my iPhone using SDN mobile
Click to expand...

Considering nothing changes with staging, I would say chemoRT to the primary, pelvis and inguinal lymph nodes.
 
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Without having all the specifics, this sounds like a T1 anal margin tumor removed incidentally, with no residual found on re-excision.

In this situation, unless there is some other information that has not been disclosed, close observation is very acceptable, and I would argue, highly preferred in this very young patient. Failure can be easily salvaged with chemoRT. Baseline PET recommended as well if not already done.
 
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radmonckey said:
Without having all the specifics, this sounds like a T1 anal margin tumor removed incidentally, with no residual found on re-excision.

In this situation, unless there is some other information that has not been disclosed, close observation is very acceptable, and I would argue, highly preferred in this very young patient. Failure can be easily salvaged with chemoRT. Baseline CT contrast and PET recommended as well if not already done.
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I agree.
If it's an anal margin tumor, observe.
 
Neuronix said:
Size and margins on initial pathology?

A question is going to be whether this is an anal margin cancer or did it arise from the canal/verge. Maybe the surgeon can help with this.

Prefer PET/CT in this setting to help rule out additional disease. Anal SCC tends to be very avid.
Click to expand...

This is less than 1 cm lesion rising above the dentate line with no residual dz on re-excision.


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Kroll2013 said:
This is less than 1 cm lesion rising above the dentate line with no residual dz on re-excision.


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Click to expand...

This woman did not have an oncologic surgery. In patients who had an APR in the past, 5 yr OS was only 40%-70%.
 
I think, I'd observe
Chance of recurrence is there and it's certainly not low, but I think waiting is a good trade-off considering the age of the patient too. Since no high-risk features are present (G2, small tumor), I suspect that chance of recurrence is something like 40%.
If you irradiate now, she will not be able to bear children. Not only will the ovaries get enough to dose, to cause her to turn menopausal, but she will probably receive around 30 Gy to her uterus, meaning that even with IVF she may not be able to carry a child.
What you gain from irradiating now, is that you can avoid chemotherapy in her case. There is no convincing data that you need chemo for a T1N0, especially since she has no residual disease. In case of recurrence she will need chemo together with RT, if you don't treat her now.
Down the road though, I presume that with an early salvage radiochemotherapy her chance of sphincter preservation and recurrence freedom is over 80%, if she's treated for example for a rcT1-2 recurrence, picked up timely during follow up.
If you treat her now, her chance for both is probably over 95%. So there's something like a 10-15% benefit in treating her now, if she was to develop a recurrence. Is that worth it? Hard to tell, since her chance of recurrence with active surveillance is something like 40%.
 
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Palex80 said:
I think, I'd observe
Chance of recurrence is there and it's certainly not low, but I think waiting is a good trade-off considering the age of the patient too. Since no high-risk features are present (G2, small tumor), I suspect that chance of recurrence is something like 40%.
If you irradiate now, she will not be able to bear children. Not only will the ovaries get enough to dose, to cause her to turn menopausal, but she will probably receive around 30 Gy to her uterus, meaning that even with IVF she may not be able to carry a child.
What you gain from irradiating now, is that you can avoid chemotherapy in her case. There is no convincing data that you need chemo for a T1N0, especially since she has no residual disease. In case of recurrence she will need chemo together with RT, if you don't treat her now.
Down the road though, I presume that with an early salvage radiochemotherapy her chance of sphincter preservation and recurrence freedom is over 80%, if she's treated for example for a rcT1-2 recurrence, picked up timely during follow up.
If you treat her now, her chance for both is probably over 95%. So there's something like a 10-15% benefit in treating her now, if she was to develop a recurrence. Is that worth it? Hard to tell, since her chance of recurrence with active surveillance is something like 40%.
Click to expand...

I'm with you, there definitely needs to be a conversation involving the patient and everything you have discussed above. I'm just going with data, including NCCN and there is nothing there in regards to local excision alone.

I get the rationale and I don't like irradiating young women either but a 30% mortality rate in 5 yrs (old data) is something to consider also.
 
RadOncDoc21 said:
I'm with you, there definitely needs to be a conversation involving the patient and everything you have discussed above. I'm just going with data, including NCCN and there is nothing there in regards to local excision alone.

I get the rationale and I don't like irradiating young women either but a 30% mortality rate in 5 yrs (old data) is something to consider also.
Click to expand...
The big issue is where the cancer was.... if it's anal margin, that's overkill
 
RadOncDoc21 said:
I'm with you, there definitely needs to be a conversation involving the patient and everything you have discussed above. I'm just going with data, including NCCN and there is nothing there in regards to local excision alone.

I get the rationale and I don't like irradiating young women either but a 30% mortality rate in 5 yrs (old data) is something to consider also.
Click to expand...

NCCN clearly states observation is appropriate in small anal margin tumors with negative margins.

Chemoradiation will have significant effects on this person for the rest of their life.

The only thing that has been said so far that concerns me, which was stated after my initial recommendation, is that this was "above the dentate line", which sounds like a true anal cancer if correct.

That seems more concerning, but without examining the patient, talking to the surgeon, and reviewing the path, it's hard to know.
 
radmonckey said:
NCCN clearly states observation is appropriate in small anal margin tumors with negative margins.

Chemoradiation will have significant effects on this person for the rest of their life.

The only thing that has been said so far that concerns me, which was stated after my initial recommendation, is that this was "above the dentate line", which sounds like a true anal cancer if correct.

That seems more concerning, but without examining the patient, talking to the surgeon, and reviewing the path, it's hard to know.
Click to expand...

Above the dendate line is not anal margin, hence why we are having this discussion. I saw that it clearly stated observation for anal margin as well. That's also where it mentions the 40-70% survival after an APR.
 
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The 40-70% survival is probably not based on data for T1N0 disease of less than 1cm and G2, I presume though. Probably bigger cancers got resected in the past, which also have worse survival.
 
30 gy involved field chemoradiation? I have used this regimen in elderly patients in this type of situation.

Involved-Field, Low-Dose Chemoradiotherapy for Early-Stage Anal Carcinoma

Paul Hatfield, M.D., Ph.D., F.R.C.R., Rachel Cooper, M.D., M.Sc., F.R.C.R., David Sebag-Montefiore, M.D., F.R.C.P., F.R.C.R



Purpose

To report the results of patients with early-stage anal cancer treated using a low-dose, reduced-volume, involved-field chemoradiotherapy protocol.

Methods and Materials

Between June 2000 and June 2006, 21 patients were treated with external beam radiotherapy (30 Gy in 15 fractions within 3 weeks) and concurrent chemotherapy (bolus mitomycin-C 12 mg/m2 on Day 1 to a maximum of 20 mg followed by infusion 5-fluorouracil 1,000 mg/m2/24 h on Days 1–4). Of the 21 patients, 18 underwent small-volume, involved-field radiotherapy and 3 were treated with anteroposterior–posteroanterior parallel-opposed pelvic fields. Of the 21 patients, 17 had had lesions that were excised with close (<1 mm) or involved margins, 1 had had microinvasive disease on biopsy, and 3 had had macroscopic tumor <2 cm in diameter (T1). All were considered to have Stage N0 disease radiologically.

Results

After a median follow-up of 42 months, only 1 patient (4.7%) had experienced local recurrence and has remained disease free after local excision. No distant recurrences or deaths occurred. Only 1 patient could not complete treatment (because of Grade 3 gastrointestinal toxicity). Grade 3-4 hematologic toxicity occurred in only 2 patients (9.5%). No significant late toxicity was identified.

Conclusion

The results of our study have shown that for patients with anal carcinoma who have residual microscopic or very-small-volume disease, a policy of low-dose, reduced-volume, involved-field chemoradiotherapy produces excellent local control and disease-free survival, with low rates of acute and late toxicity.
 
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Just visiting from the Path board. Over the past few decades (now retired)
I've seen a number of these found incidentally in hemorrhoids/anal tags.
The vast majority of such encounters show really pretty "trivial" tumors.
Look at it with the pathologist. Best way to understand exactly what you
are dealing with. Many written path reports can be unclear/incomplete, etc.
and lots of paths have lousy verbal communication skills. If I was a 28 y.o. lady with one of these tiny T1's with clear margins, I would certainly not want immediate aggressive TX
 
I'm down with observation once I see some good data. Until then, it looks like chemoRT is still SOC.

I'm not saying I wouldn't offer her observation, but in a field where we use data to support our decisions, each treatment option should strongly be considered. I rather see her alive in 5 yrs but after a discussion with the patient and if she doesn't want treatment, I would observe.
 
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It's anal canal cancer based off the location. Get a PET at minimum. If anything lights up, full protocol. If not, I'm probably still recommending RT, but having a discussion about observation and regular follow-up.

I wouldn't recommend a small course of RT, as it will make re-treating the area problematic with definitive dosing if the patient recurs. Multiple paths to go, however, and it all comes down to discussion with patient.
 
The problem is, there is no "protocol" for T1N0. Some people use 30 Gy + 1 cycle of MMC/5FU chemo, some 45 Gy XRT alone.

For the case above, I would observe a compliant, non-deprived patient, but I would treat someone who would not be able to follow up in clinic for 5 years.

evilbooyaa said:
It's anal canal cancer based off the location. Get a PET at minimum. If anything lights up, full protocol. If not, I'm probably still recommending RT, but having a discussion about observation and regular follow-up.

I wouldn't recommend a small course of RT, as it will make re-treating the area problematic with definitive dosing if the patient recurs. Multiple paths to go, however, and it all comes down to discussion with patient.
Click to expand...
 
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medgator said:
My understanding is these vaccines only work when they are given prior to exposure to the virus. This pt already is infected, presumably, not sure how the vaccine will help in that situation.
Click to expand...

Reminds me of a patient I saw today with metastatic lung cancer who asked me about lung cancer screening.
 
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seper said:
The problem is, there is no "protocol" for T1N0. Some people use 30 Gy + 1 cycle of MMC/5FU chemo, some 45 Gy XRT alone.

For the case above, I would observe a compliant, non-deprived patient, but I would treat someone who would not be able to follow up in clinic for 5 years.
Click to expand...

I'm saying if something does light up on pet, then treat it as it is (likely more than T1N0 anal canal carcinoma), even if the LNs aren't enlarged on pelvic CT w/ contrast.

Can't say I'm overtly familiar with T1N0 anal canal carcinoma research, but I would hestitate to drop dose that far, despite what the original nigro protocol did.
 
medgator said:
My understanding is these vaccines only work when they are given prior to exposure to the virus. This pt already is infected, presumably, not sure how the vaccine will help in that situation.
Click to expand...
I'm not a virologist, but I play one on TV... but seriously, actually, and perhaps counter-intuitively, the vaccine does seem to help even if you have already been infected. Keep in mind there is a shingles vaccine for people who have had shingles and the chickenpox virus.
Prevention of anal condyloma with quadrivalent human papillomavirus vaccination of older men who have sex with men. - PubMed - NCBI
 
Got a similar case as the above: 45 yo man underwent external hemorroidectomy with the following path: Squamous cell carcinoma, well-differentiated, focal, arising in the background of high-grade squamous intraepithelial lesion (AIN-III). Tumor depth of invasion is <0.1 cm. Gross description describes the lesion as 1.3 x 1 cm and surgeons desciption notes that it is NOT involving the sphincter. Awaiting colonoscopy.

The case is a little different from OP's case which was arising above the dentate line. Assuming colonoscopy is negative, is it reasonable to treat this as an anal margin tumor and observe? Was planning to get a PET
 
Haybrant said:
Got a similar case as the above: 45 yo man underwent external hemorroidectomy with the following path: Squamous cell carcinoma, well-differentiated, focal, arising in the background of high-grade squamous intraepithelial lesion (AIN-III). Tumor depth of invasion is <0.1 cm. Gross description describes the lesion as 1.3 x 1 cm and surgeons desciption notes that it is NOT involving the sphincter. Awaiting colonoscopy.

The case is a little different from OP's case which was arising above the dentate line. Assuming colonoscopy is negative, is it reasonable to treat this as an anal margin tumor and observe? Was planning to get a PET
Click to expand...


Observation is certainly a good option, provided the tumor was completely resected. Does pathology say anything about margins? I assume it was cut out as one piece?
 
Also HIV status is good to know. I'd not observe HIV+, but consider in healthy HIV-

Palex80 said:
Observation is certainly a good option, provided the tumor was completely resected. Does pathology say anything about margins? I assume it was cut out as one piece?
Click to expand...
 
Palex80 said:
Observation is certainly a good option, provided the tumor was completely resected. Does pathology say anything about margins? I assume it was cut out as one piece?
Click to expand...

Yes appears the full hemorrhoid was removed. No status of margins but I will clarify with path. You would get a PET yes?

Seper, HIV status is pending- Is it standard to use HIV status to decide to treat here or not? If positive you would treat with RT alone i pressume given T1N0? Thanks
 
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Depending on HemOnc's and surgeon's opinions, I've treated a situation like this 2 different ways: 45 Gy to a local field only vs. 36 G with 1 cycle of MMC-5FU.

Haybrant said:
Yes appears the full hemorrhoid was removed. No status of margins but I will clarify with path. You would get a PET yes?

Seper, HIV status is pending- Is it standard to use HIV status to decide to treat here or not? If positive you would treat with RT alone i pressume given T1N0? Thanks
Click to expand...
 
I needed some help with clarifying the situation a bit. Im slightly confused about anal margin vs anal canal. So if a hemorrhoid is external then it would be considered anal margin if it was growing from the skin surrounding the anus? But it would be anal canal if the stalk was growing out of the anal canal itself? The surgeon in the case I referenced above says she thinks it is an anal canal tumor. Would everything we discussed when it comes to observation apply for the anal canal case as well? Thank you

>>>>>>>
45 yo man underwent external hemorroidectomy with the following path: Squamous cell carcinoma, well-differentiated, focal, arising in the background of high-grade squamous intraepithelial lesion (AIN-III). Tumor depth of invasion is <0.1 cm. Gross description describes the lesion as 1.3 x 1 cm and surgeons desciption notes that it is NOT involving the sphincter. Awaiting colonoscopy.
>>>>>>>
 
My personal impression is that natural history of anal cancer and anal margin cancer arising within CIS is not different. I've seen young healthy patients observed. I've treated ones who were older or HIV +.

Haybrant said:
I needed some help with clarifying the situation a bit. Im slightly confused about anal margin vs anal canal. So if a hemorrhoid is external then it would be considered anal margin if it was growing from the skin surrounding the anus? But it would be anal canal if the stalk was growing out of the anal canal itself? The surgeon in the case I referenced above says she thinks it is an anal canal tumor. Would everything we discussed when it comes to observation apply for the anal canal case as well? Thank you

>>>>>>>
45 yo man underwent external hemorroidectomy with the following path: Squamous cell carcinoma, well-differentiated, focal, arising in the background of high-grade squamous intraepithelial lesion (AIN-III). Tumor depth of invasion is <0.1 cm. Gross description describes the lesion as 1.3 x 1 cm and surgeons desciption notes that it is NOT involving the sphincter. Awaiting colonoscopy.
>>>>>>>
Click to expand...
 
I think observation with q3 month anoscopy for 2 years is reasonable for haybrant's case, assuming 1) PET/CT is negative and 2) Margins were negative.

I don't personally know if HIV status (without development of AIDS) would influence my treatment decision.
 
evilbooyaa said:
I think observation with q3 month anoscopy for 2 years is reasonable for haybrant's case, assuming 1) PET/CT is negative and 2) Margins were negative.

I don't personally know if HIV status (without development of AIDS) would influence my treatment decision.
Click to expand...

Thanks evilB
 
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