Transcript Anal Squamous Cell Carcinoma: Single Centre Observational

Anal Squamous Cell Carcinoma:
Single Centre Observational Study
Over 6 Years
Steve Emmett
Edmund Leung
Natalie Acors
James Francombe
Introduction I
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Anal carcinoma (SCC) has an incidence of
~2/100,000
Peak incidence in 70th decade, but highly variable
Known associations include:
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Human papilloma virus (HPV-16, 18 & 31)
Female gender (many series of data)
HIV positive
Sexual promiscuity- particularly receptive anal intercourse
Cigarette smoking
In HIV-positive patients rates ~37/100,000
Introduction II
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Anal Cancers only represent 1-2% of GI
malignacies:
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Presents primarily with
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Squamous cell carcinoma commonest
Adenocarcinoma of anal glands rarer
Melanoma rarer still
Proctalgia and/or
PR bleed
Spread is primarily lymphatic
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Distal anal canal drains to inguinal nodes,
femoral and hence ext iliac
Proximal tumours drain to mesorectal, then
inf mesenteric, to paraaortic.
Methods I
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Single centre study- pilot study
Retrospective analysis over last 6 years
Inclusion criteria
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Histologically diagnosed ASCC
Both anal canal and anal margin were included
Methods II
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Variables
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TNM-stage
Age
Sex
Location
Risk factors
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Cigarette Smoker
Alcohol >21 units/wk (male), >14 units/wk (female)
HPV status
Immunocomprised
Treatment modality
Recurrent rates
Methods II
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Follow up
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Recurrence and mortality was point analysed within a
median 20 month period (6-60 months)
Also recurrence and mortality was manually stratified in to
1 yr and 3 yr post diagnosis follow up.
Analysis
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All data were analysed using product moment co-efficient
and chi2 test. Significance p<0.05
Survival data was analysed by Mantel-Cox test.
Results I: Incidence
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Our incidence was 1.5/100,000
The incidence of ASCC remained
static over the last 6 years
(r=0.43)
Period prevalence is 2.1/100,000
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2001 2002 2003 2004 2005 2006 2007
Year
Data Table-3
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proceedure
recurrence
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Age range 29-81
Median 60
13 males, 10 females
10
ex
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Number of New Cases
23 patients were identified over 6
years
numbers
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Annual incidence of new SCC
Results II: Clinical presentation
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The commonest presentations were:
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Perianal bleeding (56%)
Proctalgia (30%).
No association between period prevalence and
heavy smoking or excess alcohol consumption
(p>0.05).
Formal HPV testing performed on only 22%
Results III: Demographics
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ASCC in South Warwickshire
Key to map
New cases by year
2001 (n=1)
2002 (n=2)
2003 (n=5)
2004 (n=1 (+1 missing))
2005 (n=1)
2006 (n=3)
2007 (n=8 (+1 missing))
Highest density cluster
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Cases not associated with population density
Highest prevalence; 4 cases within 1 mile radius over 5 years
Results IV: Staging & Treatment
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Staging breakdown
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Tx
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T4
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5
T3
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10
T2
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13% were Tx
9% were T1
43% were T2
22% were T3
9% were T4
T1
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Numbers
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Stage
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35% underwent surgical treatment
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61% underwent chemoradiotherapy
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17% (total n=4) had primary excision with no further intervention
The remaining 18% had surgery ± chemotherapy or radiotherapy
17% required salvage surgery
4% had not yet undergone treatment at time of analysis
Results V: Recurrence
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Median follow up was 20 months (range 6-60 mo) post
diagnosis
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Overall recurrence and mortality rates were associated with
advanced (T3 or T4) tumours at diagnosis (p<0.05).
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Overall recurrence was 22%
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2 pts has local recurrence
3 pts had a distal site of recurrence (mainly original high grade tumours)
Surgical recurrence rate of 13%
Chemoradiotherapy recurrence rate of 9%
Results VI: Mortality
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Overall period mortality was 17%
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Of pts after 1 complete year follow up
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4% had recurrence
With no mortality
Of pts followed up after >3 years
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17% had recurrence
Mortality was 13% (n=3)
Survival of patient undergoing surgical
or chemorad intervention
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There was no significant
difference between surgical and
chemorad treatments
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Median survival in chemorad group
was 84 months
Percent survival
150
Surgical
Chemo+/-radio
100
50
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0
50
100
Time (months)
150
Discussion I:
Incidence/Prevalence/Mortality
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Our period prevalence of ASCC appears slightly lower
than many centers previously reported.
Despite our belief that prevalence was locally on the
increase it remained static.
Previous reports show 5 yr survival at 58-90%
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Our overall 3 yr survival was 87%, similar to other 3yr follow up
studies (Arnott et al., 1996; Sischy et al,. 1989)
Our median survival was 84months
Due to our small number of patients there was no differences in
mortality from surgical or chemo radiotherapy.
Numerous studies (ACTI, EORTC, RTOG) have established
chemo-radiotherapy is the treatment of choice
Discussion II: Recurrence
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Recurrence rates have reportedly been 7-30%
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Our current data showed similar recurrence rates (22%)
Our surgical recurrence rate of 13% was mainly made up of low
grade tumours
While the chemo-radiation group recurrence rate was 9%; made up
of generally higher grades
In our study most low grade tumours were managed with local
excision
Although a small n our surgical outcomes appear worse:
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Even small, discrete tumours may benefit from chemoradiotherapy
Reflects the importance of follow up
Discussion III
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In 2007 the British Association of Coloproctology published clear guidelines
on anal cancer management:
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Given the clear associations of HPV with ASCC our data showed poor
clinical screening for the virus within our centre
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All pts in our centre now undergo HIV and HPV screening on diagnosis
On diagnosis pts also undergo HPV vaccination
The UKDoH/NHS has now introduced non-compulsory HPV vaccinations for
girls aged 12-13 (plus catch-up group)
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Ensure Hx asks smoking habits
At presentation consider HIV, HPV testing
Accurate assessment of size of tumour
All pts should be discussed at MDT
A potential new & different cohort
Further study should be considered on populations to establish the impact
on prevalence of anal SCC.
Conclusion
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Our incidence, recurrence and survival are
consistent with current literature
Study has resulted in changes to local
screening and follow-up procedures
Even low grade tumours may benefit from
chemoradiotherapy
Acknowledgments
• University Hospital Coventry and Warwickshire
• Mr J. Francombe and Mr Murphy, Warwick hospital
• Mr V. Menon, Upper GI Surgeon, UHCW