Intersphincteric resection (ISR) is the ultimate sphincter-preserving surgical technique for low rectal cancer. To promote the standardized implementation of ISR, this review discusses the important issues regarding the clinical application of ISR with reference to the latest Chinese expert consensus on ISR. In terms of ISR-related pelvic anatomy of the rectum/anal canal, hiatal ligament is not identical with the anococcygeal ligament. At the level where the rectourethralis muscle continuously extends to the posteroinferior area of the membranous urethra from the rectum, the neurovascular bundle is identified between the posterior edge of rectourethralis muscle and the anterior edge of the longitudinal muscle of the rectum. This knowledge is crucial to detect the anterior dissection plane during ISR at the levator hiatus level. The indication criteria for ISR included: (1) stage I early low rectal cancer; (2) stage II-III low rectal cancer undergoing neoadjuvant treatment, and supra-anal tumors and juxta-anal tumors of stage ycT3NxM0, or intra-anal tumors of stage ycT2NxM0. However, signet ring cell carcinoma, mucinous adenocarcinoma and undifferentiated carcinoma should be contraindicated to ISR. For locally advanced low rectal cancer (especially anteriorly located tumor), neoadjuvant treatment should be carried out in a standardized manner. However, it should be recognized that neoadjuvant chemoradiotherapy was a risk factor for poor anal function after ISR. For surgical approaches for ISR, including transanal, transabdominal, and transanal transabdominal approaches, the choice should be based on oncological safety and functional consequences. While ensuring the negative margin, maximal preservation of rectal walls and anal canal contributs to better postoperative anorectal function. Careful attention must be paid to complications regarding ISR, with special focus on the anastomotic complications. The incidence of low anterior resection syndrome (LARS) was higher than 40%. However, this issue is often neglected by clinicians. Thus, management and rehabilitation strategies for LARS with longer follow-ups were required.
Humans ; Rectal Neoplasms/pathology* ; Postoperative Complications ; Laparoscopy/methods* ; Anal Canal/pathology* ; Anus Neoplasms/pathology* ; Anus Diseases/surgery* ; Low Anterior Resection Syndrome ; Carcinoma, Signet Ring Cell/pathology* ; Treatment Outcome

Objective: To investigate the effects of radical radiotherapy combined with different chemotherapy regimens (fluorouracil-based versus docetaxel plus cisplatin) on the incidence of radiation intestinal injury and the prognosis in patients with non-metastatic anal squamous cell carcinoma. Methods: A retrospective cohort study was conducted to recruit non-metastatic anal squamous cell carcinoma patients who underwent chemoradiotherapy in the Sixth Affiliated Hospital of Sun Yat-sen University and Nanfang Hospital from July 2013 to January 2021. Inclusion criteria: (1) newly diagnosed anal and perianal squamous cell carcinoma; (2) completed radical radiotherapy combined with concurrent chemotherapy; (3) tumor could be evaluated before radiotherapy. Exclusion criteria: (1) no imaging evaluation before treatment, or the tumor stage could not be determined; (2) patients undergoing local or radical resection before radiotherapy; (3) distant metastasis occurred before or during treatment; (4) recurrent anal squamous cell carcinoma. A total of 55 patients (48 from the Sixth Affiliated Hospital of Sun Yat-sen University and 7 from Nanfang Hospital) were given fluorouracil (the 5-FU group, n=34) or docetaxel combined with the cisplatin (the TP group, n=21). The evaluation of radiation intestinal injury, hematological toxicity and 3-year disease-free survival (DFS) rate were compared between the two groups. The effects of chemotherapy regimen and other clinicopathological factors on the incidence and severity of acute and chronic radiation intestinal injury were analyzed. The assessment of radiation intestinal injury was based on the American Cancer Radiotherapy Cooperation Group (RTOG) criteria. Results: During radiotherapy and within 3 months after radiotherapy, a total of 45 patients developed acute radiation intestinal injury, including 18 cases of grade 1 (32.7%), 22 cases of grade 2 (40.0%) and 5 cases of grade 3 (9.1%). No patient developed chronic radiation intestinal injury. Among the 34 patients in the 5-FU group, 21 had grade 2-3 radiation intestinal injury (21/34, 61.8%), which was significantly higher than that in the TP group (6/21, 28.6%) (χ(2)=5.723, P=0.017). Multivariate analysis showed that 5-FU chemotherapy regimen was an independent risk factor for radiation intestinal injury (HR=4.038, 95% CI: 1.250-13.045, P=0.020). With a median follow-up period of 26 (5-94) months, the 3-year DFS rate of patients in TP group and 5-FU group was 66.8% and 77.9%, respectively, whose difference was not significant (P=0.478). Univariate analysis showed that the DFS rate was associated with sex, age, tumor location, T stage, N stage, and induction chemotherapy (all P<0.05), while the DFS rate was not associated with chemotherapy regimen or radiation intestinal injury (both P>0.05). Multivariate analysis revealed that age ≥ 50 years old was an independent risk factor affecting the prognosis of patients (HR=8.301, 95% CI: 1.130-60.996, P=0.038). Conclusions: For patients with non-metastatic anal squamous cell carcinoma, radical radiotherapy combined with TP chemotherapy regimen can significantly reduce the incidence of radiation intestinal injury as compared to 5-FU regimen. However, due to the short follow-up time, the effect of different chemotherapy regimens on the prognosis is not yet clear.
Antineoplastic Combined Chemotherapy Protocols/therapeutic use* ; Anus Neoplasms/radiotherapy* ; Carcinoma, Squamous Cell/radiotherapy* ; Chemoradiotherapy ; Cisplatin/therapeutic use* ; Fluorouracil/therapeutic use* ; Humans ; Middle Aged ; Neoplasm Recurrence, Local ; Retrospective Studies

Although a rare disease, anal cancer is increasingly being diagnosed in patients with risk factors, mainly anal infection with the human papilloma virus. Magnetic resonance imaging (MRI) with external phased-array coils is recommended as the imaging modality of choice to grade anal cancers and to evaluate the response assessment after chemoradiotherapy, with a high contrast and good anatomic resolution of the anal canal. MRI provides a performant evaluation of size, extent and signal characteristics of the anal tumor before and after treatment, as well as lymph node involvement and extension to the adjacent organs. MRI is also particularly helpful in the assessment of complications after treatment, and in the diagnosis for relapse of the diseases.
Anal Canal* ; Anus Neoplasms ; Chemoradiotherapy ; Diagnosis* ; Follow-Up Studies* ; Humans ; Lymph Nodes ; Magnetic Resonance Imaging* ; Papillomaviridae ; Rare Diseases ; Recurrence ; Risk Factors

PURPOSE: The purpose of this study was to explore the dosimetric difference between simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) and three-dimensional conformal radiotherapy (3DCRT), and the clinical outcomes of anal squamous cell carcinoma (ASCC) chemoradiotherapy featuring SIB-IMRT. MATERIALS AND METHODS: This study included ten patients with ASCC who underwent chemoradiotherapy using SIB-IMRT with 5-fluorouracil and mitomycin C. SIB-IMRT delivered 54 Gy to each primary tumor plus metastatic lymph nodes and 45 Gy to regional lymph nodes, in 30 fractions. Four patients received additional boosts to the primary tumors and metastatic lymph nodes; the median total dose was 54 Gy (range, 54 to 60 Gy). We additionally created 3DCRT plans following the Radiation Therapy Oncology Group 9811 protocol to allow dosimetric comparisons with SIB-IMRT. Locoregional control, overall survival, and toxicity were calculated for the clinical outcome evaluation. RESULTS: Compared to 3DCRT, SIB-IMRT significantly reduced doses to the external genitalia, bladder, and intestine, delivering the doses to target and elective nodal region. At a median follow-up time of 46 months, 3-year locoregional control and overall survival rates were 88.9% and 100%, respectively. Acute toxicities were treated conservatively. All patients completed radiotherapy with brief interruptions (range, 0 to 2 days). No patient experienced ≥grade 3 late toxicity during the follow-up period. CONCLUSION: The dosimetric advantages of SIB-IMRT appeared to reduce the toxicity of chemoradiotherapy for ASCC achieving high locoregional control in the extended period.
Anus Neoplasms ; Carcinoma, Squamous Cell* ; Chemoradiotherapy ; Epithelial Cells* ; Fluorouracil ; Follow-Up Studies ; Genitalia ; Humans ; Intestines ; Lymph Nodes ; Mitomycin ; Radiotherapy ; Radiotherapy Planning, Computer-Assisted ; Radiotherapy, Conformal ; Radiotherapy, Intensity-Modulated* ; Survival Rate ; Treatment Outcome ; Urinary Bladder

OBJECTIVETo explore the surgical treatment patterns and clinicopathological prognostic factors of anorectal malignant melanoma (ARMM).

METHODSThe medical records and follow-up data of 64 patients with anorectal malignant melanoma undergoing surgical treatment from August 1972 to December 2015 were collected and analyzed retrospectively. Distant metastasis was discovered in 4 patients when diagnosis, of whom 3 underwent abdominoperineal resection(APR), the other underwent wide local excision (WLE). In the other 60 cases, 46 underwent ARP(1 case received additional right inguinal lymph node dissection), the other 14 underwent WLE(1 case received additional right inguinal lymph node dissection).

RESULTSThe median follow-up time of 64 cases was 24(4 to 139) months. The 1-year, 3-year and 5-year overall survival rate was 70.3%, 35.3% and 18.4%, respectively. The 5-year survival rate of 60 patients without distant metastasis undergoing APR and WLE was 19.7% and 23.1%, and the median survival was 19.6 and 24.3 months, respectively(P =0.634), which was not significantly different. According to the Kaplan-Meier method for univariate analysis, involved margins (P=0.024), lymph metastasis (P=0.018) and clinical staging(P=0.003) had significant effects on overall survival. Multivariate analysis indicated that only the lymph node metastasis was significant predictive factor (RR=16.614, 95%CI:1.165 to 236.847, P=0.038).

CONCLUSIONSThe prognosis of ARMM is poor. The lymph node metastasis is the main predictive factors. Operation procedure (APR or WLE) has no obvious effect on prognosis.

Adult ; Aged ; Anus Neoplasms ; pathology ; therapy ; Female ; Humans ; Lymph Node Excision ; Lymphatic Metastasis ; Male ; Melanoma ; pathology ; therapy ; Middle Aged ; Multivariate Analysis ; Prognosis ; Rectal Neoplasms ; pathology ; therapy ; Retrospective Studies ; Skin Neoplasms ; pathology ; therapy ; Survival Rate ; Treatment Outcome

PURPOSE: The aim of this study is to analyze the oncological outcomes of squamous cell carcinoma (SCC) of the anal canal after chemoradiation therapy (CRT) in a single institution.METHODS: Fifty-one patients with anal SCC who had been treated with CRT between January 2000 and December 2010 were analyze data single center in Korea.RESULTS: Forty-eight patients exhibited clinical complete response. After a median follow-up of 42.1 months, 13 patients (25.5%) showed recurrence. The disease-free survival (DFS) rate was 63.4% at 5 and 10 years. The overall survival (OS) rates were 83.6% (5 years) and 75.2% (10 years). Stage I: DFS, 100%; OS, 100%; stage II: DFS, 85.7%; OS, 100%; stage IIIA: DFS, 68.6%; OS, 87.5%; stage IIIB: DFS, 34.7%; OS, 48.4%; and stage IV: DFS and OS, 0%. The local recurrence patterns were as follows: pelvic node (n=4, 7.8%), inguinal node (n=1, 2.0%), and inguinal and pelvic node (n=1, 2.0%). The systemic recurrence patterns were as follows: lung (n=2, 3.9%), para-aortic node (n=1, 2.0%), and extrapelvic site (n=2, 3.9%). N-stage represented a single independent prognostic factor for recurrence (P<0.05).CONCLUSION: CRT for SCC of the anal canal is effective for oncological outcomes and sphincter preservation. The initial nodal status may affect the oncological outcome.
Anal Canal ; Anus Neoplasms ; Carcinoma, Squamous Cell ; Chemoradiotherapy ; Disease-Free Survival ; Epithelial Cells ; Follow-Up Studies ; Humans ; Korea ; Lung ; Recurrence

PURPOSE: To evaluate the appropriateness of prophylactic inguinal nodal irradiation (PINI), we analyzed patterns of failure in anal cancer patients who were inguinal node-negative at presentation and did not receive PINI. MATERIALS AND METHODS: We retrospectively reviewed the records of 33 anal cancer patients treated by definitive concurrent chemoradiation therapy (CCRT) between 1994 and 2013. Radiotherapy consisted of a total dose of 44-45 Gy (22-25 fractions in 5 weeks) on the whole pelvis, anus, and perineum. Except inguinal lymphadenopathy was present at initial diagnosis, the entire inguinal chain was not included in the radiation field. In other words, there was no PINI. RESULTS: The median follow-up duration was 50 months (range, 4 to 218 months). Median survival and progression-free survival (PFS) were 57 months (range, 10 to 218 months) and 50 months (range, 4 to 218 months), respectively. Among the survival, the median follow-up duration was 51 months (range, 12 to 218 months). The 5-year overall survival and PFS rates were 93.4% and 88.8%, respectively. Although none of the patients received inguinal node irradiation for prophylactic purposes, there was no inguinal recurrence. CONCLUSION: Treatment of anal cancer by omitting PINI might be considered in selected patients with clinically uninvolved inguinal nodes.
Anal Canal ; Anus Neoplasms* ; Diagnosis ; Disease-Free Survival ; Follow-Up Studies ; Humans ; Lymph Nodes ; Lymphatic Diseases ; Pelvis ; Perineum ; Radiotherapy ; Recurrence ; Retrospective Studies

PURPOSE: To evaluate the appropriateness of prophylactic inguinal nodal irradiation (PINI), we analyzed patterns of failure in anal cancer patients who were inguinal node-negative at presentation and did not receive PINI. MATERIALS AND METHODS: We retrospectively reviewed the records of 33 anal cancer patients treated by definitive concurrent chemoradiation therapy (CCRT) between 1994 and 2013. Radiotherapy consisted of a total dose of 44-45 Gy (22-25 fractions in 5 weeks) on the whole pelvis, anus, and perineum. Except inguinal lymphadenopathy was present at initial diagnosis, the entire inguinal chain was not included in the radiation field. In other words, there was no PINI. RESULTS: The median follow-up duration was 50 months (range, 4 to 218 months). Median survival and progression-free survival (PFS) were 57 months (range, 10 to 218 months) and 50 months (range, 4 to 218 months), respectively. Among the survival, the median follow-up duration was 51 months (range, 12 to 218 months). The 5-year overall survival and PFS rates were 93.4% and 88.8%, respectively. Although none of the patients received inguinal node irradiation for prophylactic purposes, there was no inguinal recurrence. CONCLUSION: Treatment of anal cancer by omitting PINI might be considered in selected patients with clinically uninvolved inguinal nodes.
Anal Canal ; Anus Neoplasms* ; Diagnosis ; Disease-Free Survival ; Follow-Up Studies ; Humans ; Lymph Nodes ; Lymphatic Diseases ; Pelvis ; Perineum ; Radiotherapy ; Recurrence ; Retrospective Studies

We report a case of anal squamous cell carcinoma extended to the rectal mucosa that was clinically mistaken for rectal adenocarcinoma and literature reviwed. Sigmoidoscopic finding showed spherical shaped elevated lesion with central ulceration, interpreted as rectal adenocarcinoma in the distal portion of rectum. Anal squamous cell carcinoma is very rare among gastrointestinal cancer. Pathological study of the biopsy specimen demonstrated squamous cell carcinoma and normal rectal glands. Sigmoidoscopic finding of the presented case showed the ulcerarive lesion contineuosly extended from anal verge upward to the rectum. We postulate that the presented case is primarilly originated from the anal squamous cell carcinoma extended proximally to the rectum. Immunohistochemical stain(p-63) of the biopsy specimens showed squamous cell carcinoma. This patient has been completely recovered after treartment of chemoradiation and trans-anal excision. We present a case of anal squamous cell carcinoma invading rectal mucosa clinically mistaken for rectal adenocarcinoma and literature reviewed.
Adenocarcinoma* ; Anus Neoplasms ; Biopsy ; Carcinoma, Squamous Cell* ; Gastrointestinal Neoplasms ; Humans ; Mucous Membrane ; Rectum ; Salt Gland ; Ulcer

Insufficiency fracture occurs when normal or physiological stress applied to weakened bone with demineralization and decreased elastic resistance. Recently, many studies reported the development of IF after radiation therapy (RT) in gynecological cancer, prostate cancer, anal cancer and rectal cancer. The RT-induced insufficiency fracture is a common complication during the follow-up using modern imaging studies. The clinical suspicion and knowledge the characteristic imaging patterns of insufficiency fracture is essential to differentiate it from metastatic bone lesions, because it sometimes cause severe pain, and it may be confused with bone metastasis.
Anus Neoplasms ; Follow-Up Studies ; Fractures, Stress* ; Neoplasm Metastasis ; Prostatic Neoplasms ; Rectal Neoplasms ; Stress, Physiological