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The first 25 slides, exactly as they appear. The full deck has 175 content slides.
General Surgery
Cancer of the Anus
Built from Maingot's Abdominal Operations
What’s inside
16 sections · 175 slides
Overview
- Scope of this topic
- >80%
- Why the surgeon still matters
Anatomy and classification
Where the anal canal begins and ends, what lines it, and how tumours there are named
- Boundaries of the anal canal
- Lining of the anal canal
- Anal canal, margin and the modern zones of anal cancer
- Landmarks of the anal canal
- The anal transition zone
- Keratinizing and nonkeratinizing tumours
- World Health Organization classification
- Modern clinical classification by site
- Advantages of the three-zone scheme
- Coronal view of the three zones
- Perianal view of lesion zones
- Lymphatic drainage above the dentate line
- Lymphatic drainage below the dentate line
How common, and in whom
A rare cancer whose numbers are rising, and the groups where the rise is concentrated
- Rising incidence of anal cancer
- Viral basis of anal squamous cell carcinoma
- Age and sex pattern
- Risk with anoreceptive intercourse
- Cancer risk in the AIDS-Cancer registry
- Relative risk in people under 30
Causes and risk factors
Human papillomavirus, HIV, smoking, and the risks that turned out not to be risks
- Human papillomavirus
- Warts versus precancerous lesions
- Oncogenic HPV types
- Transmission and mechanism of HPV
- Sequence from infection to invasive cancer
- HIV infection and anal squamous cell carcinoma
- HPV prevalence and early epidemiological signals
- Anal cancer in the HAART era
- Anal cancer beyond men who have sex with men
- Cigarette smoking
- Benign anorectal conditions and cancer risk
- Inflammatory bowel disease and anal cancer
- Risk factors for anal squamous cell carcinoma
Precursor lesions and prevention
Anal intraepithelial neoplasia, screening, high-resolution anoscopy, and HPV vaccines
- Anal intraepithelial neoplasia
- Grading systems for anal dysplasia
- The dysplasia spectrum
- Case for screening high-risk groups
- Wide local excision for high-grade lesions
- Results of wide local excision for HSIL
- Shift away from radical excision
- Anal cytology screening
- Barriers to anal cytology uptake
- High-resolution anoscopy
- How high-resolution anoscopy is performed
- Interpreting the stains and vessel patterns
- Ten-year outcomes of anoscopy with targeted ablation
- Progression rates without anoscopic surveillance
- Prophylactic and therapeutic HPV vaccines
- Quadrivalent HPV vaccine
- Reported adverse effects and vaccine use in males
- Bivalent vaccine and therapeutic vaccination
- Results with the therapeutic vaccine HspE7
Pathology, presentation and staging
What the tumour looks like down the microscope, how patients present, and how the disease is staged
- Histology of anal canal tumours
- Effect of cell type on treatment and outcome
- Treatment before 1974
- Failure patterns of radical surgery
- Nigro's observation in 1974
- Presenting symptoms
- Large fungating anal squamous cell carcinoma
- Initial physical examination
- Procedures to avoid before treatment
- Staging investigations
- Endoanal ultrasound before and after chemoradiation
- Principles of the AJCC staging system
- Tumour, node and metastasis definitions for anal canal carcinoma
- Stage groupings for anal canal carcinoma
- Tumour size and survival
- The 5 cm threshold
- Regional nodal metastases and prognosis
- Treatment algorithm for the common anal neoplasms
- Squamous pathways in the treatment algorithm
Surgery for anal canal cancer
Why radical resection became the exception, and the narrow place local excision still holds
- Decline of radical surgery
- Local excision for anal canal carcinoma
- Depth of invasion and local excision failure
Chemoradiation
From Nigro's protocol to the randomised trials that made chemoradiation the standard
- Evolution of treatment
- The Nigro protocol
- Outcome of Nigro's first three patients
- Early confirmatory series
- Phase II experience with chemoradiation
- Further phase II results
- Toxicity of early chemoradiation
- Radiation alone: the comparison arm
- The UKCCCR randomised trial
- UKCCCR outcomes and morbidity
- The EORTC randomised trial
- Randomised phase III trials of radiation and chemotherapy for anal canal cancer
- Role of mitomycin-C
- Salvage chemoradiation within the trial
- Rationale for cisplatin
- Design of the RTOG 98-11 trial
- Results of the RTOG 98-11 trial
- Treatment of anal cancer in HIV-positive patients
- Standard of care for anal canal carcinoma
Newer radiotherapy techniques
The toxicity price of standard chemoradiation, and what conformal planning changes
- Effectiveness and toxicity of standard chemoradiation
- Intensity-modulated radiation therapy
- Multicentre experience with IMRT
- Cancer control with IMRT
- Recent trials of chemoradiation for anal canal cancer
Inguinal nodal disease
What groin nodes mean for prognosis, and how they are treated now
- Assessment of palpable inguinal nodes
- Synchronous versus metachronous nodal disease
- Radiation to the inguinal nodes
- Current management of inguinal metastases
Recurrent disease and salvage
Following patients up, judging response, and operating when chemoradiation fails
- Follow-up after chemoradiation
- Timing of post-treatment biopsy
- Rate and pattern of recurrence
- Outcomes of salvage abdominoperineal resection
- Abdominoperineal resection after failure of radiation for anal cancer
- How recurrent disease causes death
- Contraindications to salvage surgery
- Preoperative assessment before salvage
- Technical problems in the irradiated pelvis
- Wound complications after salvage surgery
- Chemoradiation after inadvertent local excision
- Results of chemoradiation after excision
- Very early tumours: excision or radiation
- Who should have chemoradiation after excision
- Distant metastatic disease
Perianal (anal margin) cancer
A skin cancer in an awkward place: excision first, radiation when the sphincter is at stake
- Nature of perianal squamous cell carcinoma
- Symptoms and diagnostic delay
- Biopsy of a perianal lesion
- Deeply ulcerating anal margin tumour
- Inguinal node metastasis by tumour size
- Surgical treatment of perianal tumours
- Published surgical series
- Further surgical outcomes
- When the sphincter is at risk
- Radiotherapy results for perianal tumours
- Evidence gaps in perianal cancer
Anal melanoma
Rare, usually mistaken for piles, and grim whatever operation is done
- Rarity of anorectal melanoma
- Epidemiology of anorectal melanoma
- Presentation of anal melanoma
- Site of origin
- Staging and pattern of spread
- ~6%
- Surgical approach to anal melanoma
- Local recurrence after limited surgery
- Lymph node surgery in anal melanoma
- Adjuvant therapy for anorectal melanoma
- Newer agents and palliative radiation
- Melanoma pathway in the treatment algorithm
Other anal neoplasms
Adenocarcinoma, Paget's disease, giant condyloma, stromal tumours and Kaposi's sarcoma
- Anal adenocarcinoma
- Treatment of anal adenocarcinoma
- Perianal Paget's disease
- Appearance and histology of Paget's disease
- Proposed origins of Paget's disease
- Associated visceral malignancy
- Surgical treatment of Paget's disease
- Recurrence and surveillance in Paget's disease
- Buschke-Lowenstein tumour
- Behaviour of giant condyloma
- Pelvic invasion by a giant condyloma
- Treatment of Buschke-Lowenstein tumour
- Gastrointestinal stromal tumours of the anus
- Prognosis and treatment of anal GIST
- Anal Kaposi's sarcoma
Summary
The points to carry away from anal cancer
- Diagnosis: points to remember
- Treatment: points to remember
- Rare tumours: points to remember
References
The 107 sources cited in the original text
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- Maingot's Abdominal Operations, 12th Edition