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Anal Squamous Cell Carcinoma: Single Centre Observational Study Over 6 Years

Anal Squamous Cell Carcinoma: Single Centre Observational Study Over 6 Years. Steve Emmett Edmund Leung Natalie Acors James Francombe. Introduction I. Anal carcinoma (SCC) has an incidence of ~2/100,000 Peak incidence in 70 th decade, but highly variable Known associations include:

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Anal Squamous Cell Carcinoma: Single Centre Observational Study Over 6 Years

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  1. Anal Squamous Cell Carcinoma: Single Centre Observational Study Over 6 Years Steve Emmett Edmund Leung Natalie Acors James Francombe

  2. Introduction I • Anal carcinoma (SCC) has an incidence of ~2/100,000 • Peak incidence in 70th decade, but highly variable • Known associations include: • 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

  3. Introduction II • Anal Cancers only represent 1-2% of GI malignacies: • Squamous cell carcinoma commonest • Adenocarcinoma of anal glands rarer • Melanoma rarer still • Presents primarily with • Proctalgia and/or • PR bleed • Spread is primarily lymphatic • Distal anal canal drains to inguinal nodes, femoral and hence ext iliac • Proximal tumours drain to mesorectal, then inf mesenteric, to paraaortic.

  4. Methods I • Single centre study- pilot study • Retrospective analysis over last 6 years • Inclusion criteria • Histologically diagnosed ASCC • Both anal canal and anal margin were included

  5. Methods II • Variables • TNM-stage • Age • Sex • Location • Risk factors • Cigarette Smoker • Alcohol >21 units/wk (male), >14 units/wk (female) • HPV status • Immunocomprised • Treatment modality • Recurrent rates

  6. Methods II • Follow up • 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 • All data were analysed using product moment co-efficient and chi2 test. Significance p<0.05 • Survival data was analysed by Mantel-Cox test.

  7. Results I: Incidence • 23 patients were identified over 6 years • Age range 29-81 • Median 60 • 13 males, 10 females • 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

  8. Results II: Clinical presentation • The commonest presentations were: • 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%

  9. Key to map 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)) 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)) Results III: Demographics • ASCC in South Warwickshire Highest density cluster • Cases not associated with population density • Highest prevalence; 4 cases within 1 mile radius over 5 years

  10. Results IV: Staging & Treatment • Staging breakdown • 13% were Tx • 9% were T1 • 43% were T2 • 22% were T3 • 9% were T4 • 35% underwent surgical treatment • 17% (total n=4) had primary excision with no further intervention • The remaining 18% had surgery ± chemotherapy or radiotherapy • 61% underwent chemoradiotherapy • 17% required salvage surgery • 4% had not yet undergone treatment at time of analysis

  11. Results V: Recurrence • Median follow up was 20 months (range 6-60 mo) post diagnosis • Overall recurrence and mortality rates were associated with advanced (T3 or T4) tumours at diagnosis (p<0.05). • Overall recurrence was 22% • 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%

  12. Results VI: Mortality • Overall period mortality was 17% • Of pts after 1 complete year follow up • 4% had recurrence • With no mortality • Of pts followed up after >3 years • 17% had recurrence • Mortality was 13% (n=3) • There was no significant difference between surgical and chemorad treatments • Median survival in chemorad group was 84 months

  13. Discussion I: Incidence/Prevalence/Mortality • 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% • 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

  14. Discussion II: Recurrence • Recurrence rates have reportedly been 7-30% • 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: • Even small, discrete tumours may benefit from chemoradiotherapy • Reflects the importance of follow up

  15. Discussion III • In 2007 the British Association of Coloproctology published clear guidelines on anal cancer management: • Ensure Hx asks smoking habits • At presentation consider HIV, HPV testing • Accurate assessment of size of tumour • All pts should be discussed at MDT • Given the clear associations of HPV with ASCC our data showed poor clinical screening for the virus within our centre • 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) • A potential new & different cohort • Further study should be considered on populations to establish the impact on prevalence of anal SCC.

  16. Conclusion • 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

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