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Anal Cancer Anal Intraepithelial neoplasia and Pre- sacral lesions

Anal Cancer Anal Intraepithelial neoplasia and Pre- sacral lesions. Paul Skinner. Anal Cancer. Incidence Aetiology Staging Treatment:- primary disease recurrent disease Follow up. Anal cancer. Incidence. Anal cancer MDT. INCIDENCE: “Uncommon cancer”

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Anal Cancer Anal Intraepithelial neoplasia and Pre- sacral lesions

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  1. Anal CancerAnal Intraepithelial neoplasiaandPre- sacral lesions Paul Skinner

  2. Anal Cancer Incidence Aetiology Staging Treatment:- primary disease recurrent disease Follow up

  3. Anal cancer • Incidence

  4. Anal cancer MDT • INCIDENCE: • “Uncommon cancer” • Approx 600 cancers p.a. U.K. • 0.5 – 1 per 100,000 pop p.a. • Local population approx 5/p.a • North Trent approx 20p.a.

  5. Anal Cancer • Increasing Incidence • Frisch BMJ 1995 increasing incidence • Classification ?anal canal/ margin

  6. Anal Cancer • Aetiology

  7. Anal Cancer • Oncogenic HPV • Smoking • ?STD • ?at Risk groups

  8. Anal cancer • ?Increasing Incidence: • At risk population ?

  9. Anal Cancer • At Risk groups: • Cervical cancerVulval CancerImmunosuppressedMSM population?screening groups/AIN

  10. Anal Cancer • Diagnosis and staging

  11. Anal Cancer • Staging • No formal recommended plan: • Practise: EUA/biopsy/ ?nodal biopsy or FNA CT: chest/ abdo / pelvis MRI Renal function ?HIV status

  12. Anal Cancer • Treatment?

  13. Anal cancer • Treatment: Local excision ?? Nodes Chemo radiotherapy//APER

  14. Anal cancer • Treatment: Primary: Combination Chemoradiotherapy UKCCCR Lancet 1996;348:1049 -1054 Bartelink H, J clin oncology 1997;15:2040-2049 Radical surgery: Residual, Recurrent disease

  15. Anal Cancer • Chemotherapy • Radiotherapy

  16. Anal cancer • Chemotherapy: • 5fu and mitomycin c • ?ACT I cisplatinum • Radiotherapy types

  17. Anal Cancer • Results of treatment??

  18. Anal Cancer • Treatment: • 5 year survival • Local failure • Mets • Stoma

  19. Anal cancer MDT • Treatment: • ?failure rates high • Ryan DP, N Eng J Med 2000;342: 792 – 800 • 70 – 80% 5 year survival • O ‘Dwyer 5 year ca 60% 5 year ca survival • O’Dwyer 50% 3 year local failure (increasing age, T) • Distant mets: Lung, liver,bone, multiple, brain • O’Dwyer 5 year colostomy rate 40%

  20. Anal cancer • Treatment: • Recurrent Disease: • Local/Distant • ? Booster Radiotherapy • Salvage surgery local disease

  21. Anal cancer • Technique salvage Surgery • Considerations??

  22. Anal Cancer • Salvage Surgery: • Considerations: • Fitness • ?local disease only • Clearance • Perineal Wound Failure • Omental pedicle/Enough local skin/Flap • 40 – 50% perineal dehsicence

  23. Anal Cancer • Follow Up: • Local recurrence, residual disease • Distant Disease

  24. Anal Cancer • Local: • Clinical follow up: Recurrence majority – first 3 years 3 monthly first two years 6 monthly there after until 5 years

  25. Anal Cancer • Distant Disease: • Clinical: Lung, liver, bone, multiple • CT : chest/ abdo /pelvis • Little guidance ?annually • ?treatment metastatic recurrence

  26. Anal Cancer • The MDT: • Members: Local colorectal MDT • ?Gynae, dermtol, plastic, GUmed • ? Network Cancers: Discussion • ?Surgical input, returned to local group • Salvage surgery • Database

  27. Anal Cancer Incidence Aetiology Staging Treatment:- primary disease recurrent disease Follow up

  28. Anal Intraepithelial Neoplasia Clinical Presentation Diagnosis/Histology Natural History Management

  29. AIN • Clinical Presentation:

  30. AIN • Clinical Presentation: • Incidenntal Finding • Pigmented anal lesion • Raised/plaque • Note extent ? Into anal canal

  31. AIN • Diagnosis/Histology:

  32. AIN • Diagnosis/histology • Biopsy • Intraepithelial Neoplasia; • nuclear hyperchromasia • Immature epithelium • Abnormal mitosis

  33. AIN • Natural history

  34. AIN • Natural History: • Unknown • Potentially premalignant ?degree • Associated conditions

  35. AIN • Management

  36. AIN • Management: • Extent/Mapping • Genital intraepithelial Neoplasia • Stop Smoking • Surgery/Monitoring

  37. Pre-Sacral Lesions • Anatomy of Area • Imaging • Presentation • Cysts/Tumours

  38. Pre- sacral lesions • Presentation: • Incidental • Late • Pain • Recurrent unexplainable per anal discharge • Anal Dimple • Incontinence and sexual dysfunction • Obstructed Labour

  39. Pre – Sacral lesions • Appearance on imaging: • Cystic/solid • 2/3 are congenital of these 2/3 development • Developmental: • Epidermoid / dermoid • Tailgut / teratomas

  40. Pre-Sacral lesions • Solid: • Commonest malignancy: Chordoma • Benign solid: ganglioneurommas

  41. Pre sacral Lesions • Management. ?Diagnosis on imaging ?if Solid ? Biopsy for diagnosis Rationale for Surgery: Malignancy Infection Malignant potential S3

  42. Pre – Sacral Lesions • Surgery: • Approaches: • Intersphincteric • Posterior Approach, lateral sacrum • En bloc rectal/sacral resection with reconstruction

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