Anal Carcinoma

Background:

• Risk factor: HPV (high risk) > HIV, smoking

• Mostly SCC

Work-up:

• DRE

• Anoscopy

• LN biopsy/FNA

• HIV test

• Chest/abd CT scan

Staging:

• T1: ≤ 2cm

• T2: 2-5 cm

• T3: > 5cm

• T4: Any tumor size invaded to adjacent organs

Perianal SCC

• Non-metastatic disease (M0):

  • Local excision/surgery:

    • Indications:

      • T1 N0 well/moderately differentiated

      • T2 N0 with no sphincter involvement

  • ChemoRT:

    • Indications:

      • T1 N0 poorly differentiated

      • T2-4 N0

      • Any T N+

    • ChemoRT can cure without requiring an abdominoperineal resection (APR)

      • 1st line:

        • 5-FU + Mitomycin + RT

        • Capecitabine + Mitomycin + RT

      • Category 2B:

        • 5-FU + Cisplatin + RT

    • The 5-year survival rate ~90%

    • If a patient did not achieve CR 6 months after chemoRT→ definitive surgery (APR)

• Metastatic disease:

  • First line: 

    • Carbo/taxol + Retifanlimab (preferred)

    • Carbo/taxol

    • mFOLFOX6

    • FOLFCIS

      • Leucovorin (Folinic acid), 5-FU, Cisplatin

  • Category 2B:

    • 5FU/Cisplatin

    • DCF

      • Docetaxel, Cisplatin, 5-FU

  • Subsequent line: 

    • PD-1 inhibitors (if no prior immunotherapy received)

Anal SCC

• Non-metastatic disease (M0):

  • ChemoRT (regimens mentioned above)

  • If good response to chemoRT but residual mass:

    • Reassess in a few months (up to 6 months after chemoRT)

  • If progression after chemoRT → typically receive APR

• Metastatic disease:

  • (Regimens mentioned above)