ANAL CA.

Patient History

43 year old Caucasian male

MR#: 900******
Treated on SBRT

Past Medical History

Hep B (2002)
Syphilis (2003)
HIV (2004)
Epididymitis (R) 2010,
Lymphadenopathy 2010
Dyslipidemia 2010
GERD 2011
Obese 2012
Hypertension 2012

Past Surgical History

Appendectomy
Tonsillectomy

Social and Family History

Strong family history of cancer

Hypertension (father)
Coronary artery disease (maternal uncle)
MI (maternal aunt)
Testicular CA (paternal uncle)

Tobacco use up until 2012

Half pack a day for 15 yrs

Male partners

Common Presenting Signs

Typically presents with:

Rectal bleeding
Anal discomfort
Pruritus
Rectal urgency

Presenting Signs

He denied fever, chills, night sweats, weight loss, issues with

bowels, nausea, vomiting, constipation, dysuria, or hematuria.
3-4 weeks prior...
L UQ abdominal pain
CT--- 2.3x2.4cm mass blending with the R rectal wall anterolaterally which
looked continuous with a 1.3cm perirectal rounded portion or node; Also a
1.4cm likely right perirectal node and another 1.1cm left perirectal node

Colonoscopy showed a fungating mass at the distal end of the

rectum and a small sessile polyp noted in the cecum
Anal mass= squamous cell CA
Polyp=tubular adenoma

EUS showed a lesion 5cm from the anal verge suggesting invasion
into the submucosa with extension to the muscularis propria
Also a hypoechoic mass in the perirectal fat with the 8cm position

(2.5x2cm)
A few malignant appearing nodes in the perirectal region

PET

PET

PET

PET summary

Epidemiology

Rare; 3% of the tumors of the

rectum/anal area
More common in women
Median age of diagnosis is 60 y.o.

Etiology

Associated with a history of:

Hemorrhoids, fistula, fissures, leukoplakia,

HPV, and immunosuppressive disorders

genital warts, anal intercourse, genital
infections, and other causes of chronic
irritation
smoking

Anatomy

Anal canal is 3-4cm in length

http://www.webmd.com/digestive-disorders/picture-of-the-anus

Lymphatics

Lymph includes
perirectal
nodes
Superior

lesions
internal iliac
and sacral
nodes
Inferior
lesions
inguinal nodes

Histopathology

Squamous cell CA most common

80%

Then basaloid

Adenocarcinoma, mucoepidermoid, and

melanoma

Staging- AJCC

IIIB
T2
Tumor >2cm but 5cm in greatest dimension
N3
Mets in perirectal and inguinal nodes and/or
bilateral internal iliac and/or inguinal nodes
M0
No distant mets.

Treatment Options

Small superficial lesion <2 cm - local

excision

Stage I III use concurrent

Chemotherapy with Radiation
Therapy
Use 5 FU & Mitomycin C or 5 FU &

Cisplatin

Surgery is used for salvage treatment

Treatment Plan

Curative
Pelvis IMRT
6MV
9 fields
5400 cGy
180 cGy/fx; 30 fx

Treatment Borders

AP/PA
Superior L5 S1
Inferior 3 cm below the extent of the

tumor, flashing the perineum

Lateral AP will include the inguinal nodes
- PA is 2 cm beyond the pelvic rim

Laterals
Posterior minimum 3 cm around tumor

including sacrum and coccyx

Anterior 3 cm anterior to tumor

Field Design

Critical Structures

DVH

DRR

AXIAL

CORONAL

SAGITTAL

Positioning

Supine
F head rest
Arms on chest
Vacloc
Legs frogged

Critical Structures TD 5/5

Small bowel
1/3= 5000
Whole=4000

Femoral heads
Whole=5200

Bladder
2/3= 8000
Whole= 6500

Testis
100-sterilization

Potential Side Effects

Body aches, soreness on feet from

chemo
Back pain, insomnia, rectal burning
and some itch
Frequent small stools
Burning at end of urination
Tachycardia and was hypertensive
Shortness of breath, nausea, dizzy; PICC

Bronchitis, cough
Anal pain with bowel
movements
Alternating
constipation/diarrhea
Faint erythmea

Prognosis and Survival

Radiation & chemo

65-80% at 5 years

Routes of Spread & Mets Sites

Spread by
Direct extension
Sphincter m., rectal wall, perianal skin,
vaginal septum, prostate, sacrum, and
coccyx
Lymphatics
Inf inguinal
canal-external & internal iliacs
Sup-inferior mesenteric
Bloodstream
Mets to liver and lungs

References

Hackworth, R. Colorectal/Anal Presentation.

[PowerPoint]. Columbus, OH: OSU RT(T)
Program; 2013.
Washington CM, Leaver DT. Digestive System
Tumors. In: Principles and Practice of
Radiation Therapy. 3rd ed. St. Louis, MO:
Mosby Elsevier; 2010: 779-781.
What Is Anal Cancer? WebMD. http://
www.webmd.com/cancer/what-is-anal-cancer
Reviewed: May 7, 2012. Accessed: March 27,
2014