Anal Cancer Guidelines

Updated: Sep 25, 2018
  • Author: Thomas R Dekoj, MD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Guidelines

Guidelines Summary

Guidelines for the management of anal cancer have been published by the following organizations:

  • American Society of Colon and Rectal Surgeons (ASCRS) [26]
  • National Comprehensive Cancer Network (NCCN) [27]

 

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ASCRS Practice Parameters

Practice parameters, issued by the ASCRS in 2012, cover pretreatment evaluation, treatment, and post-treatment surveillance of anal squamous neoplasms. Recommendations for anal margin squamous cell carcinomas (SCCs) and anal intraepithelial neoplasia (AIN) are also provided. [26]

Pretreatment evaluation

For the pretreatment evaluation, the ASCRS recommends performing the following:

  • A disease-specific history, emphasizing symptoms, risk factors, and signs of advanced disease (strong recommendation based on low-quality evidence, 1C)
  • A disease-specific physical examination, to determine size, possible lymph node involvement, or metastatic disease (strong recommendation based on mod­erate-quality evidence, 1B)
  • Endoscopic and radiologic evaluation, to help determine staging, and concomitant or metastatic disease (strong recommendation based on moderate-quality evidence, 1B)

Similarly, for anal margin squamous cell carcinoma, the ASCRS also recommends performing a disease-specific history and physical examination that emphasizes risk factors, tu­mor size, location, and signs of advanced disease (strong recommendation based on low-quality evidence, 1C).

The ASCRS determined that sentinel lymph node evaluation for detection of re­gional nodal metastases is still investigational (Weak recommendation based on low-quality evidence, 2C)

Treatment

For primary treatment, the ASCRS recommends the following:

  • For most SCCs of the anal canal, use combined chemotherapy and radiation therapy (strong recommendation based on high-quality evidence, 1A)
  • For the chemotherapy arm, mitomycin plus 5-fluorouracil (5-FU) is usually preferable to other regimens (strong recommendation based on high-quality evidence, 1A)
  • Consider intensity-modulated radiation therapy–based chemoradiotherapy (IMRT) to decrease treatment-related toxicity (weak recommendation based on moderate-quality evidence, 2B)
  • Higher doses of radiation therapy without prolonged breaks in treatment are preferable when tolerated (weak recommendation based on moderate-quality evidence, 2B)

For treatment of recurrent or persistent disease, the ASCRS recommendations include the following:

  • Abdominoperineal resection is effective salvage therapy for persistent or recurrent disease (strong recommendation based on moderate-quality evidence, 1B)
  • Consider systemic chemotherapy in pa­tients with extrapelvic metastasis or recurrence after surgical salvage (strong recommendation based on low-quality evi­dence, 1C)

Additional treatment recommendations include the following:

  • For ingui­nal lymph node disease, chemoradiation is the treatment of choice (strong recommendation based on low-quality evi­dence, 1C)
  • In HIV-positive patients, CD4 counts may be used to predict the outcome and tolerance of chemoradiation therapy (weak recommendation based on low-quality evidence, 2C)(

Post-treatment surveillance

The ASCRS recommends that patients treated for anal cancer be followed up with anorectal examinations that typically include the following (strong recommendation based on low-quality evidence, 1C):

  • Digital rectal examination
  • Anoscopy
  • Inguinal palpation

To assess for persistent or recurrent disease, imaging studies such as the following should be considered for post-treatment sur­veillance (strong recommendation based on low-quality evidence, 1C):

  • Endoanal ultrasound
  • Computed tomography (CT)
  • Magnetic resonance imaging
  • Fluorodeoxyglucose positron emission tomography (FDG-PET)/CT 

Anal intraepithelial neoplasms

ASCRS recommendations cover both low-grade and high-grade AIN.

Pretreatment Evaluation

  • A disease-specific history and physical examination should be performed, emphasiz­ing symptoms, risk factors, and location of disease (strong recommendation based on low-quality evidence, 1C)
  • Anal Papanicolaou smear cytological examination may be useful in the detection and follow-up of AIN (strong recommendation based on low-quality evidence, 1C)

Treatment

  • Observation alone with close clinical follow-up may be considered in select cases (weak recommendation based on low-quality evidence, 2C)
  • Topical 5% imiquimod cream with close long-term follow-up is an appropriate therapy for AIN of the anal margin (strong recommendation based on low-quality evidence, 1C)
  • Topical 5% 5-FU cream with close long-term follow-up is an appropriate therapy for AIN (strong recommendation based on low-quality evidence, 1C)
  • Photodynamic therapy with close long-term follow-up may be appropriate therapy for select patients with AIN (weak recommendation based on low-quality evidence, 2C)
  • Targeted destruction and close clinical long-term follow-up is appropriate therapy for AIN (strong recommendation based on low-quality evidence, 1C)
  • Patients with AIN should be offered close long-term clinical follow-up (strong recommendation based on low-quality evi­dence, 1C)
  • Vaccination against human papillomavirus (HPV) serotypes 16 and 18 may be considered in high-risk patients such as HIV-positive patients and men who have sex with men (Weak recommen­dation based on low-quality evidence, 2C)

 

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NCCN Guidelines

The NCCN guidelines cover the workup, treatment, and post-treatment surveillance of anal carcinoma. [27]

Workup

When biopsy confirms SCC of the anal canal or anal margin, the NCCN recommends the following workup:

  • Digital rectal examination (DRE)
  • Inguinal lymph node evaluation – Consider biopsy or fine needle aspiration (FNA) of suspicious nodes
  • Chest/abdominal CT plus pelvic CT or MRI – Consider PET/CT scan
  • Anoscopy
  • Consider HIV testing + CD4 level if indicated
  • Gynecologic exam for women, including screening for cervical cancer

Treatment

For primary treatment of locoregional SCC of the anal canal, recommended chemoradiation regimens include the following;

  • Mitomycin/5-fluorouracil (5-FU) plus radiation therapy (RT)
  • Mitomycin/capecitabine plus RT 
  • 5-FU/cisplatin plus RT (category 2B)

For RT, the NCCN panel consensus was that intensity-modulated radiation therapy (IMRT) is preferred over 3-D conformal RT.

For metastatic SCC of the anal canal, the NCCN recommends primary treatment with 5-FU/cisplatin, with or without RT,  or enrolling the patient in a clinical trial.

For primary treatment of SCC of the anal margin, treatment recommendations vary by clinical stage, as follows:

  • T1, N0, well differentiated – Local excision; if margins are adequate, observe; if margins are inadequate, treat with re-excision (preferred) or consider local RT with or without chemotherapy
  • T1, N0, poorly differentiated; T2-T4, N0; or any T, N+  – Chemoradiation therapy
  • Metastatic disease – 5-FU/cisplatin, with or without RT,  or clinical trial

Follow-up

The NCCN recommends evaluation in 8-12 weeks with physical examination plus DRE. For patients in complete remission, surveillance recommendations are as follows:

  • DRE and inguinal node palpation every 3-6 mo for 5 y
  • Anoscopy every 6-12 mo for 3 y
  • For patients with T3-T4 disease or positive inguinal nodes – Chest/abdomen/pelvic CT with contrast annually for 3 y

If surveillance reveals recurrent disease, treatment recommendations are as follows:

  • Local recurrence – Abdominopelvic resection (APR), plus groin resection if inguinal nodes are positive
  • Inguinal node recurrence – Groin dissection; consider RT if patient had no prior groin RT, with or without 5-FU or mitomycin/capecitabine
  • Distant metastasis – 5-FU/cisplatin or clinical trial

Surveillance after treatment for local recurrence includes the following:

  • Inguinal node palpation every 3-6 mo for 5 y
  • Chest/abdomen/pelvic CT with contrast annually for 3 y

Surveillance after treatment for inguinal node recurrence includes the following:

  • DRE and inguinal node palpation every 3-6 mo for 5 y
  • Anoscopy every 6-12 mo for 3 y
  • Chest/abdomen/pelvic CT with contrast annually for 3 y

If initial post-treatment evaluation reveals persistent disease, the NCCN recommends re-evaluation in 4 wk; if serial exams show regression or stable disease, the NCCN recommends continued observation, re-evaluation in 3 mo, and biopsy at 6 mo. In cases of progressive disease, biopsy proven, recommendations are as follows:

  • Locally recurrent – APR, plus groin resection if inguinal nodes are positive
  • Metastatic disease – 5-FU/cisplatin or clinical trial
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