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Title:

Surgery for Anal Cancer

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... junction of the hair-bearing skin and anoderm of the anal canal Perianal neoplasms Squamous cell carcinoma Basal cell carcinoma Bowen s disease Perianal ... – PowerPoint PPT presentation

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Title: Surgery for Anal Cancer


1
Surgery for Anal Cancer
  • Peter Sagar
  • The General Infirmary at Leeds

2
Where is the anal canal?
  • Perianal cancer
  • Anal canal cancer

3
Anal canal
4
Perianal neoplasms
  • Perianal skin junction of the hair-bearing skin
    and anoderm of the anal canal

5
Perianal neoplasms
  • Squamous cell carcinoma
  • Basal cell carcinoma
  • Bowens disease
  • Perianal Pagets disease

6
Squamous cell carcinoma
  • Rolled everted edges
  • Central ulceration
  • Late diagnosis
  • 30 misdiagnosed
  • Spread to lymph nodes

7
Perianal squamous cell carcinoma- treatment
  • Wide local excision well differentiated, up to
    3 cm
  • Less favourable lesions- chemoradiation (40-70 Gy)

8
Perianal basal cell carcinoma
  • Uncommon
  • 1-2 cm
  • Rarely metastasize
  • Misdiagnosed in 33
  • Delayed diagnosis
  • Rx local excision with adequate margins

9
Bowens disease
  • Intraepidermal squamous cell carcinoma
  • Associated with primary internal malignancies
    (5)
  • Discrete scaly or crusted plaques

10
Bowens disease- mapping biopsies
11
Bowens disease- excise deep to subcutaneous fat
12
Perianal Pagets disease
  • Extramammary Pagets found in axilla and
    anogenital region
  • Uncommon
  • Eczematous lesions
  • Visceral carcinomas in 50

13
Perianal Pagets disease- biopsy identify
Pagets cells
14
Perianal Pagets disease-
15
Excise deep to subcutaneous fat up to dentate
line
16
Outline of flaps
17
Arrowhead flaps
18
Flaps sutured to anal canal
19
Y shaped flaps at completion
20
Squamous cell carcinoma of the anal canal
  • Long h/o minor perianal symptoms
  • 33 misdiagnosed
  • Assess primary lesion
  • Examine groins
  • Proctoscopy
  • Endoanal ultrasound
  • MRI

21
Squamous cell carcinoma of the anal canal
  • Spread determined by dentate line
  • 20 nodal involvement at presentation
  • Extensive Ca may invade muscular/bony walls of
    the pelvis

22
Squamous cell cancer - treatment
  • Local excision
  • CHEMORADIATION
  • Abdominoperineal resection

23
Inguinal lymph node
  • No indication for prophylactic groin dissection
  • Ominous sign if present at presentation
  • Rx chemoradiation to groin nodes

24
Patient Numbers
Total Number of Patients 188
Not treated with XRT 13
Treated with XRT 175
50Gy
49.9-30.1Gy
30Gy
lt30Gy
17
110
9
39
25
Clinical Stage - primary
26
Clinical stage - nodes
27
Patterns of failure
28
TIME TO LOCAL FAILURE
29
Local control
30
Overall survival
31
Overall survival by stage
32
Local control by stage
33
Salvage Surgery
Treated to 50Gy 110
Local recurrence 23
Number had salvage surgery 13/23
Alive and well
Dead disease
Dead other
6
2
5
34
Patterns of failure
  • Anal area or regional lymph nodes
  • APER for residual or recurrent carcinoma
  • Fixed disease at time of Rx failure, median
    survival 8 mths

35
APER for local failure of treatment
  • Not easy

36
Technical tips
  • Fill the hole
  • Tackle pelvic side wall involvement
  • Sacral invasion

37
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38
Rectus abdominus flap
39
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40
Sidewall vessel involvement
41
Pelvic side wall
  • BLEEDING
  • Suture
  • Fibrillar surgicell
  • Argon beamer
  • Be prepared to pack

42
Direct invasion of the sacrum
  • Choose level of sacrectomy carefully
  • Frozen section
  • Beware bleeding from pre-sacral veins

43
APRS vs TPES
44
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45
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46
Summary
  • High index of suspicion
  • Mapping biopsies (4 or 12 quadrants)
  • Excision biopsy
  • Failure of local treatment referral to
    specialist centre

47
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48
Anorectal melanoma
  • Depressing
  • Third most common site
  • Confused with thrombosed haemorrhoid
  • Spread submucosally

49
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50
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51
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52
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53
WLE vs APER
  • 428 patients
  • WLE n90, APER n189
  • Free of disease at 5yrs
  • WLE 8
  • APE 13
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