Clinical Outcomes From Multimodality Treatment of Anal Cancer

Abstract

Background: Trial data suggests chemoradiotherapy achieves effective disease control in anal squamous cell carcinoma (SCC) but treatment can be associated with significant long-term side-effects. Methods: We retrospectively examined records for all patients treated at Ipswich Hospital for anal carcinoma to record disease, treatment and toxicity outcomes. Results: We identified 36 patients diagnosed between February 2005 and February 2012, seven male (19%) & 29 female (81%). Median age at diagnosis was 62 (range 39-93). Histopathology was SCC in 31 (86%), adenocarcinoma in 4 (11%), and one patient had metastatic poorly-differentiated neuroendocrine tumour. Two adenocarcinoma patients presenting with T3N2 disease had neoadjuvant pelvic chemoradiotherapy with a complete response on subsequent AP resection and controlled groin node disease. Two patients with metastatic adenocarcinoma survived less than one year from diagnosis. Two patients with anal SCC presented with liver metastases. Chemoradiotherapy was effective at controlling pelvic disease and symptoms. After liver and lung radiofrequency ablation plus further liver resection one patient has been disease free for 18 months. The other received induction cisplatin/ 5FU before pelvic chemoradiotherapy but died from progressive liver disease. Median follow-up for 29 patients with stage 1-3B SCC was 38 months. Four (all T1N0M0) were treated with surgery only and remain disease-free at one year of follow-up. Twenty-five patients had radical chemoradiotherapy as per the Act 2 study (phase I 30.6Gy in 17# to pelvis, phase II 19.8Gy in 11# to tumour PTV) with concomitant Mitomycin-C and 5-fluorouracil. Chemoradiotherapy patient staging: T1/2 39%, T3/4 61%; N0 55%, N1-3 45%. Acute toxicity included neutropaenia in 7/24 patients (29%) and three episodes of neutropaenic sepsis. Six patients have CTCAE grade 2 or worse late toxicity (24%) such as diarrhoea or faecal incontinence. One patient suffered a pelvic fracture as a result of avascular necrosis. Four patients have been left with a permanent stoma (16%). 21/24 (87.5%) had a Complete Response to radical chemoradiotherapy at 3 months. The three patients with persistent disease all died of disease progression within two years. One patient with complete response to chemoradiotherapy developed local disease recurrence and underwent salvage AP resection with positive margins and has progressive pelvic disease. For 28 radically-treated SCC patients, Recurrence-Free Survival was 93% at one, 82% at two and 79% at three years. For 24 chemoradiotherapy patients Recurrence-Free Survival at three years was 100% for T1/2 tumours and 67% for T3/4. Conclusion: Multimodality treatment has led to excellent results that compare favourably with clinical trial data. Surgery alone appears effective for very early T1 disease. Radical chemoradiotherapy for locoregional anal SCC resulted in acceptable rates of acute toxicity and achieved a complete response rate of 88% and overall survival of 83% at three years. Prevalence of late toxicity in survivors is low, while implementation of Intensity Modulated Radiotherapy may reduce acute and late toxicity. For patients with metastatic disease chemoradiotherapy offers effective palliation and together with RFA and/or surgery may offer long term disease control for some. (Figure Presented).