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  • • Account for 1.5% of GI tract cancers

    • Usually long history of perianal complaints

    • Disease may be quite extensive at presentation

    • Associated with chronic anal infection (human papillomavirus)

    • Tumors anatomically found from the upper to lower border of the internal anal sphincter, 6-12 mm above dentate line

    • Referred to as epidermoid carcinoma

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Epidemiology

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  • • Women are at increased risk

    • Homosexual males at greatly increased risk

    • 7/106 men; 9/106 women

    • Increased incidence in males and females practicing anal sex

    • Increased risk with history of anogenital warts; STD; > 10 sexual partners; cervical, vulvar, or vaginal cancer

    • Increased incidence in persons who smoke or who are immunosuppressed (HIV infection and transplantation)

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Symptoms and Signs

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  • • Perianal irritation, may be long-standing

    • Palpable mass, may be indurated

    • Bleeding

    • Itching

    • Tenesmus

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Laboratory Findings

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  • • No specific abnormalities

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Imaging Findings

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  • CT/MRI: Reveal anal mass

    Endorectal US: Reveals size and depth of invasion and perianal nodes

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  • • Tumor of anal margin

    • Hemorrhoids

    • Anal melanoma

    • Perianal/perirectal abscess/fistula

    • Low rectal cancer

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Rule Out

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  • • Extension of low rectal adenocarcinoma

    • Anal melanoma

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  • • Physical exam with digital rectal exam

    • Assessment for lymphadenopathy (groins)

    • Exam under anesthesia, anoscopy with biopsy

    • Endorectal US to assess size and depth of invasion

    • Chest film, CT to assess for metastatic disease

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When to Admit

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  • • Severe bleeding with hemodynamic compromise

    • Intractable symptoms: itching, pain

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  • • Chemoradiation is mainstay of therapy

    • Role of surgery limited

    • Overall reported recurrence rates with local excision high

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Surgery

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Indications

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  • • Local excision for small, well-differentiated, mobile lesions confined to the submucosa

    • Surgery is largely used as salvage procedure or for recurrent/persistent disease (abdominal perineal resection)

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Contraindications

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  • • Nigro protocol of chemoradiation is first-line therapy

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Medications

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  • • Radiation therapy (XRT): 30 Gray to primary tumor and pelvic and inguinal nodes

    • Mitomycin is given on day 1 of XRT

    • Two 4-day infusions of 5-fluorouracil (5-FU) given on day 1 and day 28 of chemoradiation therapy

    • Cisplatin may be used in place of mitomycin

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Treatment Monitoring

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  • • Follow-up rectal and node exam

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Complications

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  • • Recurrence of disease

    • Metastatic disease

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Prognosis

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  • • Tumor size is best predictor

    • Mobile lesions < 2 cm have cure rates of 80%

    • Tumors > 5 cm associated with 50% mortality

    • Metastatic disease more likely to be present with increasing depth of invasion, size, and histologic grade

    • Lymph node disease at presentation is poor prognostic indicator

    • 40% ...

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