Squamous carcinoma in situ of anal canal

[communitydoc13]

50+ year old woman, otherwise healthy with squamous cell CIS of the anal canal (at dentate line). Discovered incidentally on endoscopy. Just roughness on DRE and can visualize on anoscopy. Unfortunately, significant circumferential involvement and unlikely to be a candidate for surgery with both adequate margin and sphincter preservation.

Doing staging workup, etc. Assuming no more advanced disease will become evident.

Concurrent chemorads just seems harsh here (could treat relatively low dose with concurrent therapy).

Thoughts?

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[evilbooyaa]

Did biopsy get enough layers of mucosa/anus to confirm no penetration past basement membrane?

Tough situation. If patient agreeable to full kit and caboodle then yeah would probably do definitive therapy with multiagent concurrent chemo

Consider MRI to see if there is a gross mass that could at least make you feel like the biopsy was just scraping the top of the layer and treat like an invasive squam.

All I could find for true anal CIS was this Mednet response from 2014: theMednet

Seems not unreasonable to me in a patient who wants aggressive therapy....

 

[BobbyHeenan]

agree with @evilbooyaa

If not already done (you mentioned anoscopy, so maybe so) would send to a surg onc or GI surgeon who sees a lot of anal cancer to do an EUA and proctoscope and re-biopsy it. I had a similar case not long ago and upon re-biopsy it was invasive...but it looked angry and more aggressive than yours. GI docs in my area are good, but anal canal for them is a big blind spot. the surgeons are so much better.


If it remains as in-situ disease then I think one cycle of chemo with the radiation is likely adaquate. Would not rec'd two. there are data for single cycle I believe.

Seems like a lot though and I'd have to read more on the subject.

 

[Ray D. Ayshun]

I generally do 5040 for t1a, but nccn suggests 45 for t1n0, and if all disease has resolved at that point just stop. Could do that. What do you do about the nodes though?

Edit: wrt nodes, perhaps such low risk you could do 3060 at 180.

 

[SneakyBooger]

For me, I have decided to avoid treating in situ of anus. Over the past 20+ yrs I can think of one lunchtime conversation with a surgeon where I was asked about cis of the anus and I recommended the patient be seen and treated, if recommended, at the Ivory Tower. I don't know what transpired after. FWIW, the physicians at the Ivory Tower have sovereign immunity granted by the state. You can sue the Ivory Tower, but not the individual physicians. I sleep better at night.

I tend to favor Christopher Crane's sobering views (below) as described on themednet.org: How do you manage patients with history of multiple perianal condylomas who develop focal high grade squamous intraepithelial lesions in the anal margin?

"In the absence of invasive disease, surgical resection is always the treatment of choice for in-situ disease. If the recommendation is APR, it should be well documented. If the patient refuses the surgical option, then radiation can be offered with very careful documentation. The reason for that is that these cases are a setup for medicolegal action. The cancer related morality is extremely low. Patients live a very long time with the consequences of any late effects of radiation that might happen. For instance, sexual function could be affected, especially in females. There could be fecal incontinence that may or may not be related to radiation. There could be chronic discomfort or pain. All of these consequences are more defensible in the setting of invasive cancer. "

 

[RadOncDoc21]

Google Review: “Dr. SneakyBooger refused to treat my cancer!” 0/4 stars. Loves to see people die!”

 

[RickyScott]

Involved-field, low-dose chemoradiotherapy for early-stage anal carcinoma - PubMed

The results of our study have shown that for patients with anal carcinoma who have residual microscopic or very-small-volume disease, a policy of low-dose, reduced-volume, involved-field chemoradiotherapy produces excellent local control and disease-free survival, with low rates of acute and...

pubmed.ncbi.nlm.nih.gov

 

[Ray D. Ayshun]

Involved-field, low-dose chemoradiotherapy for early-stage anal carcinoma - PubMed

The results of our study have shown that for patients with anal carcinoma who have residual microscopic or very-small-volume disease, a policy of low-dose, reduced-volume, involved-field chemoradiotherapy produces excellent local control and disease-free survival, with low rates of acute and...

pubmed.ncbi.nlm.nih.gov

Geez. I'd love it if that were either not 15 years old or recommended by anyone I know in GI. I might actually look forward to the occasional anal patient.

 

[communitydoc13]

Involved-field, low-dose chemoradiotherapy for early-stage anal carcinoma - PubMed

The results of our study have shown that for patients with anal carcinoma who have residual microscopic or very-small-volume disease, a policy of low-dose, reduced-volume, involved-field chemoradiotherapy produces excellent local control and disease-free survival, with low rates of acute and...

pubmed.ncbi.nlm.nih.gov

Very helpful. Thanks

 

[RickyScott]

Geez. I'd love it if that were either not 15 years old or recommended by anyone I know in GI. I might actually look forward to the occasional anal patient.

I think tsome of the important anal cancer studies were from uk. Senior author well published . Here another from same group

Effective treatment of anal cancer in the elderly with low-dose chemoradiotherapy - PubMed

Chemoradiotherapy (CRT) is accepted as the standard initial treatment for squamous cell anal cancer. However, frail elderly patients cannot always tolerate full-dose CRT. This paper reports the results of a modified regimen for this group of patients. In all, 16 patients with biopsy-proven...

pubmed.ncbi.nlm.nih.gov

 

[Mandelin Rain]

For me, I have decided to avoid treating in situ of anus. Over the past 20+ yrs I can think of one lunchtime conversation with a surgeon where I was asked about cis of the anus and I recommended the patient be seen and treated, if recommended, at the Ivory Tower. I don't know what transpired after. FWIW, the physicians at the Ivory Tower have sovereign immunity granted by the state. You can sue the Ivory Tower, but not the individual physicians. I sleep better at night.

I tend to favor Christopher Crane's sobering views (below) as described on themednet.org: How do you manage patients with history of multiple perianal condylomas who develop focal high grade squamous intraepithelial lesions in the anal margin?

"In the absence of invasive disease, surgical resection is always the treatment of choice for in-situ disease. If the recommendation is APR, it should be well documented. If the patient refuses the surgical option, then radiation can be offered with very careful documentation. The reason for that is that these cases are a setup for medicolegal action. The cancer related morality is extremely low. Patients live a very long time with the consequences of any late effects of radiation that might happen. For instance, sexual function could be affected, especially in females. There could be fecal incontinence that may or may not be related to radiation. There could be chronic discomfort or pain. All of these consequences are more defensible in the setting of invasive cancer. "

Man. That's kind of a lousy rationale by Crane, imo. APRs aren't benign surgeries. To force a patient into one for non-invasive disease because you're concerned about a hypothetical medicolegal defense strategy for a generally highly effective and fairly well tolerated treatment is... disappointing.

 

[Palex80]

Treat with RT only and without lymphatics. 50.4/1.8 appear reasonable, likely 45/1.8 will be also fine.

 

[JS1987]

Man. That's kind of a lousy rationale by Crane, imo. APRs aren't benign surgeries. To force a patient into one for non-invasive disease because you're concerned about a hypothetical medicolegal defense strategy for a generally highly effective and fairly well tolerated treatment is... disappointing.

He has a lot of hot takes.

The problem with CIS is that it can be extensive and very easy to miss/under-treat underlying invasive disease. What would happen medico-legally in that situation?

 

[SneakyBooger]

fairly well tolerated treatment is...

Beauty is in the eye of the beholder.

My surgeon buddy says that some people will nearly cut off all their fingers with a skill saw and then duct tape them back together and see how it goes for a few days.

But if even the most stoic person gets the smallest of lacerations to their anus they immediately go to the ER to see her.

She declares the anus is "special".

 

[SneakyBooger]

Google Review: “Dr. SneakyBooger refused to treat my cancer!” 0/4 stars. Loves to see people die!”

What is a "Google Review"? 😝

 

[Ray D. Ayshun]

Beauty is in the eye of the beholder.

My surgeon buddy says that some people will nearly cut off all their fingers with a skill saw and then duct tape them back together and see how it goes for a few days.

But if even the most stoic person gets the smallest of lacerations to their anus they immediately go to the ER to see her.

She declares the anus is "special".

Sadly, on a day-to-day basis, my anus is the source of my greatest accomplishments, so I understand the sentiment.

 

[Mandelin Rain]

Beauty is in the eye of the beholder.

My surgeon buddy says that some people will nearly cut off all their fingers with a skill saw and then duct tape them back together and see how it goes for a few days.

But if even the most stoic person gets the smallest of lacerations to their anus they immediately go to the ER to see her.

She declares the anus is "special".

In my experience, most people would rather deal with some short term anal pain than not have an anus at all, ymmv.

Are people really seeing lots of failures and terrible long term toxicity from anal cancer treatment? Enough that you’d consider medicolegal risk as a contraindication to treatment? Maybe I’ve just had good luck?

 

[Neuronix]

When do we ever treat carcinoma in situ? DCIS maybe. Anything else? Is there another body site I'm forgetting?

I feel similarly here. In situ is not malignancy. You haven't given me a cancer diagnosis yet.

I would send for re-biopsy or follow closely.

 

[communitydoc13]

When do we ever treat carcinoma in situ? DCIS maybe. Anything else? Is there another body site I'm forgetting?

I feel similarly here. In situ is not malignancy. You haven't given me a cancer diagnosis yet.

I would send for re-biopsy or follow closely.

We treat Bowen's disease on occasion. Urology treats in-situ bladder CA fairly aggressively with intrathecal treatments.

In this case, it is not perianal or anal verge. It is at the dentate line. I think the likelihood of progression to invasive disease over time is very, very high.

I have observed perianal squamous cell in situ s/p inadequate surgery in an elderly person before. I think this is a very different scenario here. (Surveillance more difficult, even local excision more difficult, time for progression notably longer).

 

[taserlaser]

When do we ever treat carcinoma in situ? DCIS maybe. Anything else? Is there another body site I'm forgetting?

I feel similarly here. In situ is not malignancy. You haven't given me a cancer diagnosis yet.

I would send for re-biopsy or follow closely.

I mean sometimes in skin. Where BED doesn’t necessarily correlate with LC if you believe this (older) small PMH series Radiation therapy for Bowen's disease of the skin - PubMed

I get a reasonable amount of referrals from derm where it looks like SCC in situ, and then referrals where it’s obviously SCC “in situ”.

 

[taserlaser]

We treat Bowen's disease on occasion. Urology treats in-situ bladder CA fairly aggressively with intrathecal treatments.

In this case, it is not perianal or anal verge. It is at the dentate line. I think the likelihood of progression to invasive disease over time is very, very high.

I have observed perianal squamous cell in situ s/p inadequate surgery in an elderly person before. I think this is a very different scenario here. (Surveillance more difficult, even local excision more difficult, time for progression notably longer).

Haha you beat me to it!

 

[RickyScott]

When do we ever treat carcinoma in situ? DCIS maybe. Anything else? Is there another body site I'm forgetting?

I feel similarly here. In situ is not malignancy. You haven't given me a cancer diagnosis yet.

I would send for re-biopsy or follow closely.

I have treated in situ of the larynx

 

[Mandelin Rain]

Outside of breast, it's obviously rare, especially when there are limited surgical options available, but I have treated each of these a couple times to preserve organs/function/medically challenged for surgery
Larynx
Bladder
Anus
Vulva

 

[metallica81788]

Larynx all day every day - CIS w "suspicion of invasion"
You're going to make an ENT go back and take half a vocal cord just to "prove" there is cancer when their entire larynx looks like cancer

 

[RickyScott]

Larynx all day every day - CIS w "suspicion of invasion"
You're going to make an ENT go back and take half a vocal cord just to "prove" there is cancer when their entire larynx looks like cancer

This not that different from anus. If mass can be palpated, pt can decide if he wants to keep getting biopsies or just have definitive xrt