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Tassapong Raiyawa, MD.

Non-metastatic Anal canal cancer. Tassapong Raiyawa, MD. 2 cm 2 cm. Anal canal - SCCA 86 % - AdenoCA 7 % Rx ~ Rectum. 5 cm radius. Anal margin Rx ~ Skin. Uncommon. Staging. T1 : ≤ 2 cm T2 : 2 - 5 cm T3 : > 5 cm T4 : Invade organ N1 : perirectal

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Tassapong Raiyawa, MD.

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  1. Non-metastatic Anal canal cancer Tassapong Raiyawa, MD.

  2. 2 cm 2 cm Anal canal - SCCA 86 % - AdenoCA 7 % Rx~ Rectum 5 cm radius Anal margin Rx ~ Skin

  3. Uncommon

  4. Staging T1 : ≤ 2 cm T2 : 2 - 5 cm T3 : > 5 cm T4 : Invade organ N1 : perirectal N2 : unilat int. iliac / inguinal N3 : bilat int. iliac / inguinal, perirectal + inguinal M1 : distant met N+ 25 % M+ 5-10 %

  5. Treatment

  6. APR • Permanent colostomy • APR ~ RT ? : LC, OS

  7. Initial studies of Nigro • Chemo-RT  Sx • Chemo - 5FU 1000 mg/m2/d x 4 d - MMC 15 mg/m2 • RT- 30 Gy in 15 F • - Tumor + Pelvic + Inguinal • Sx- APR in first 6 cases  pCR 5/6 • - Biopsy  APR if positive

  8. Nigro ND. Dis Colon Rectum 1974; 17: 354-6. Nigro ND. Cancer 1983; 51: 1826-9. Leichman L. Am J Med 1985; 78: 211-5.

  9. RT vs Ch-RT

  10. Northover J. Br J Cancer 2010; 102: 1123-8. Bartelink H. J Clin Oncol 1997; 15: 2040-9.

  11. ACT I

  12. Chemotherapy Regimen

  13. Mitomycin C • Common side effects • Leukopenia, Thrombocytopenia • Fever • Anorexia, NV • Stomatitis, Diarrhea • Alopecia • Extravasation  Cellulitis, Necrosis

  14. Rare side effects • Hemolytic uremic syndrome • - Hct < 25% • - Platelet < 100,000 /mm3 • - Cr > 1.6 mg/dL • Nephropathy • Pneumonitis • Congestive heart failure

  15. 5FU vs 5FU+MMC

  16. Flam M. J Clin Oncol 1996; 14: 2527-39.

  17. Cisplatin • Poor results in T3-4 by 5FU+MMC • Standard Chemo-RT in SCCA • - H+N • - Esophagus • - Cervix

  18. 5FU+CDDP vs 5FU+MMC

  19. Ajani JA. JAMA 2008; 199: 1914-21. James R. J Clin Oncol (Proc ASCO) 2009; 27: 797s [abstract LBA-4009].

  20. Comment RTOG 9811 • Neoadjuvant = Confounding factor ? - Delayed RT • - Tumor shrinkage  Reproliferate • Cisplatin = Inferior ? New agents • - Oxaliplatin • - Cetuximab  Ongoing • Glynne-Jones R. J Clin Oncol 2008; 26: 3669-71.

  21. No benefit of • Neoadjuvant 5FU+CDDP, High-dose RT • Conroy T. J Clin Oncol 2009; 27: 176s [abstract 4033]. • Adjuvant 5FU+CDDP • ACT II.

  22. 5FU+MMC vs CDDP+MMC

  23. Matzinger O. Eur J Cancer 2009; 45: 2782-91.

  24. 5FU + MMC ( Randomized phase III )

  25. 5FU + CDDP ( Randomized phase III )

  26. Others ( Phase I-II ) Matzinger O. Eur J Cancer 2009; 45: 2782-91. Bosset JF. Eur J Cancer 2003; 39: 45-51.

  27. Others ( Phase I-II ) Glynne-Jones R. Int J Radiat Oncol Biol Phys 2008; 72: 119-26. Eng C. J Clin Oncol 2009; 27: 15s [abstract 4116]. Olivatto LO. J Clin Oncol 2008; 26: 240 [abstract 4609].

  28. HIV-positive patients

  29. Gervaz P. World J Gastroenterol 2011; 17: 2987-91.

  30. HAART era • Young male • Tolerate 5FU+MMC • ( but more side effects ) • OS ~ HIV-negative patients • ( due to high LRR ) • Oehler-Janne C. J Clin Oncol 2008; 26: 2550-7. • Fraunholz I. Radiother Oncol 2011; 98: 99-104. • Chiao EY. J Clin Oncol 2008; 26: 474-9.

  31. Salvage Treatment

  32. Salvage Chemo-RT(RTOG 8704) • 45-50.4 Gy + 5FU + MMC • 25 pt • 9 Gy + 5FU + CDDP • 13 pt • ( 9 persistent, 4 recurrent) • APR

  33. Salvage Sx(MDACC) • Chemo-RT • 31 pt • APR 29 pt, LAR 2 pt Mullen JT. Ann Surg Oncol 2007; 14: 478-83.

  34. Salvage treatment(VA) Longo WE. Ann Surg Oncol 1994; 220: 40-9.

  35. Radiotherapy

  36. RT dose ( Randomized phase III )

  37. Dose escalation + Gap John M. Cancer J Sci Am 1996; 2: 205-11. Konski A. Int J Radiat Oncol Biol Phys 2008; 72: 114-8.

  38. Overall treatment time Glynne-Jones R. Int J Radiat Oncol Biol Phys 2010; [Article in press]. Ben-Josef E. J Clin Oncol 2010; 28: 5061-6.

  39. Prognostic factors ( RTOG 9811 ) N+, T ≥ 5 cm  Higher dose ? Ajani JA. Cancer 2010; 116: 4007-13.

  40. Target volume • Anus + Perineum • Pelvic LN • Inguinal LN  LRR 5 – 25 % (untreated) × LN dissection ? Sentinel LN biopsy • Elective RT Femor fracture 15 % at 10 yr (AP-PA) Grigsby PW. Int J Radiat Oncol Biol Phys 1995; 32: 63-7.

  41. RTOG 9811

  42. Inguinal RT Gilroy JS. Med Dosim 2004; 29: 258-64. Dittmer PH. Radiother Oncol 2001; 59: 61-4. Moran M. Int J Radiat Oncol Biol Phys 2004; 59: 1523-30. Menkarios C. Radiat Oncol 2007; 2: 41.

  43. Photon through-and-through • Wide AP + Wide PA • Simple • High femor dose • Homogeneous (no matchline)

  44. Electron tag • Narrow AP + Narrow PA • Skin match of ant. electron • Low femor dose • High matchline dose

  45. Electron thunderbird(RTOG 9811) • Wide AP + Narrow PA • Skin match of ant. electron + PA exit • Moderate femor dose • Moderate matchline dose

  46. Photon thunderbird(Segmental boost) • Wide AP + Narrow PA • Skin/deep match of ant. photon + PA exit • Moderate femor dose • Moderate matchline dose

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