G a s t r o i n t e s t i n a l I m a g i n g • C l i n i c a l Pe r s p e c t i ve

Kochhar et al.
Imaging of Anal Carcinoma

Gastrointestinal Imaging
Clinical Perspective
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Imaging of Anal Carcinoma

Rohit Kochhar 1 OBJECTIVE. The purpose of this article is to review the role of imaging in the manage-
Andrew A. Plumb1 ment of patients with anal cancer. The relevant anatomy, imaging techniques, and interpreta-
Bernadette M. Carrington1 tion of images of patients before and after therapy will be discussed.
Mark Saunders 2 CONCLUSION. Anal carcinomas are uncommon but increasing in frequency. Radiolo-
gists must recognize typical patterns of disease at initial evaluation, posttherapy appearanc-
Kochhar R, Plumb AA, Carrington BM, Saunders M es, and when to suspect residual or recurrent disease to guide clinicians and achieve optimal
patient outcome.

Keywords: anal carcinoma, MRI, PET/CT
DOI:10.2214/AJR.11.8027
Received September 4, 2011; accepted after revision
February 9, 2012.
1
Department of Radiology, The Christie NHS Foundation
Trust, Wilmslow Rd, Manchester, M20 4BX, United
Kingdom. Address correspondence to R. Kochhar
(rohit.kochhar@christie.nhs.uk).
2
Department of Clinical Oncology, The Christie NHS
Foundation Trust, Manchester, United Kingdom.
WEB
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AJR 2012; 199:W335–W344
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© American Roentgen Ray Society
A
nal carcinoma is an uncommon
malignancy and accounts for only
0.3% of all cancers and 1.5% of
all gastrointestinal tract cancers
[1]. Anal sphincter preservation with chemo-
radiotherapy is the standard treatment of most
patients with anal cancer and is curative in the
majority; however, anal cancer remains chal-
lenging to treat. Treatment and follow-up have
traditionally been based on clinical assess-
ment, although clinical examination alone can
result in understaging.
Imaging now has a recognized impact on pa-
tient management and it has a key role in both
primary staging and posttreatment follow-up.
The high contrast and anatomic resolution of
pelvic MRI make it an ideal modality for lo-
coregional staging and response assessment [2–
4], and 18F-FDG PET/CT has been shown to
be valuable in assessing regional nodes and
distant metastases [5]. In this review, we high-
light the role of imaging in the initial staging
and follow-up of anal carcinoma.
Normal Anatomy
The anal canal begins at the narrowing
of the rectal ampulla at the anorectal junc-
tion where the rectum enters the puborectalis
sling at the apex of the anal sphincter com-
plex. It extends distally for approximately 4
cm and ends at the anal verge (Fig. 1) where
the squamous mucosa blends with the peri-
anal skin. The anal margin is the circular rim
of pigmented skin with folds surrounding the
anus, extending over an approximately 5-cm
radius away from the anal verge. The most
significant landmark of the anal canal is the
dentate line, which lies 2.5–3 cm proximal
to the anal verge and is visible macroscopi-
cally but not on MRI. Its position can be esti-
mated either by measuring 2.5 cm above the
anal verge or by dividing the anal canal into
thirds so that the dentate line lies at the junc-
tion of the middle and upper thirds. The anal
canal is divided by the dentate line into an
upper part, lined with transitional or rectal
glandular mucosa, and a lower part, lined by
nonkeratinizing squamous epithelium, that
merges with the perianal skin. The anal tran-
sition zone is defined as the histologic zone
interposed between uniform rectal glandular
mucosa above and uninterrupted squamous
epithelium below, and it often has a hetero-
geneous histologic appearance.
An appreciation of the normal morphologic
and histologic anatomy is vital because of treat-
ment implications. Anal margin tumors can be
treated by surgical excision alone as opposed to
anal canal tumors, which have a worse progno-
sis and are treated with chemoradiotherapy. For
tumors near the anorectal junction, the Ameri-
can Joint Committee on Cancer (AJCC) [6] rec-
ommends that tumors with an epicenter more
than 2 cm superior to the dentate line should be
staged as low rectal carcinomas, whereas those
with an epicenter less than or equal to 2 cm
above the dentate line should be staged as anal
cancers; often this distinction is very difficult
on imaging. The treatments of these two neo-
plasms are entirely different and depends on
the histologic subtype. Virtually all anal can-
cers have a squamous histology, but rarely

AJR:199, September 2012 W335


tumors arise in the anal glands and produce
genuine anal adenocarcinomas.
Epidemiology
Anal carcinoma is uncommon, with an inci-
dence of 1.5:100,000 persons per year [7], but
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the incidence has approximately doubled since
1975. Mortality has also increased by over a
third to reach 0.2:100,000 in 2008 [8]. The
U.S. National Cancer Institute reported 5290
new cases in 2009 and 710 deaths. Although
the overall incidence of anal carcinoma re-
mains higher among women, it is much higher
in men who practice anoreceptive intercourse
[1, 9]. Anal carcinoma is strongly associat-
ed with human papilloma virus (HPV), HIV,
and immune suppression in transplant recipi-
ents [10, 11]. As many as 90% of anal cancers
contain HPV DNA, most commonly HPV-16
[9]. In one large study, 15% of patients with
anal carcinoma were HIV-positive [12]. HIV
probably confers its risk via increased suscep-
tibility to HPV. Other risk factors include cer-
vical dysplasia and cigarette smoking [1, 13].
Historically anal cancer was believed to be
caused by chronic irritation and inflammation
of the perianal skin, although this belief is now
thought to be erroneous [14].
Staging
The clinical rationale of accurate pretreat-
ment staging is based on several important con-
siderations. Staging, which is based on gross
tumor volume and nodal involvement, influ-
ences therapy [15]. Standard therapy consists
of radiotherapy to the anal canal; the perianal
region; the distal rectum; and the perirectal,
internal iliac, inguinal, and presacral lymph
nodes. It is combined with simultaneous che-
motherapy using 5-fluorouracil and mitomycin
C [16]. However, deviation from this treatment
approach may be appropriate for elderly, frail
patients; patients with small tumors (T1 and
early T2); those with positive margins after
incomplete resection; and those with positive
inguinal nodes [17–20]. Details of therapy
are beyond the scope of this article.
The detection of metastatic disease out-
side the pelvis on staging CT deems the dis-
ease incurable and the patient is treated with
palliative chemotherapy and radiotherapy for
control of local symptoms.
Staging helps define anal margin tumors,
which can be treated by local excision if small
(< 2 cm), well differentiated, and without evi-
dence of nodal spread or sphincter involve-
ment [21]. Staging also has prognostic signifi-
cance and identifies high-risk factors including
W336 AJR:199, September 2012
Kochhar et al.
T4 tumors and tumors with fistulation. Defunc-
tioning colostomy is considered for patients
with transmural vaginal involvement (at risk
of development of an anorectal-vaginal fistula),
those with fecal incontinence, and those with
severe anal pain and obstructive symptoms.
During staging, assessment of the cervix and
vulva is important because of the common viral
cause of vulval, cervical, and anal neoplasms.
Radiologic Staging
The TNM staging of anal cancer did not
change in the latest edition of the AJCC Can-
cer Staging Manual [6] and is shown in Ta-
ble 1. In general, two examinations are per-
formed: one for locoregional staging using
MRI with or without transanal endoscopic
ultrasound and another to search for distant
metastases with CT or, more recently, with
FDG PET/CT.
Radiologic staging is supplemented by
clinical assessment of the anal margin, verge,
and canal. This assessment often involves an
examination with the patient under anesthe-
sia and biopsy. Biopsy or fine-needle aspira-
tion cytology of any enlarged or suspicious-
appearing inguinal nodes is also essential.
Transanal Endoscopic Ultrasound
Transanal endoscopic ultrasound has re-
sults comparable to MRI for the detection
of local tumor spread in patients with anal
carcinoma and may be superior to MRI for
the detection of small superficial tumors.
However, regional lymph nodes higher in
the pelvis or groins are outside the FOV of
endosonography and supplementary MRI is
needed for N staging [15]. A meta-analysis
of staging rectal cancer using endorectal ul-
trasound revealed other limitations including
operator dependency and inability to assess
stenotic tumors [22]; these limitations likely
apply equally to anal cancer.
MRI
MRI has become the imaging modality
of choice for locoregional staging and as-
sessment of tumor response after chemora-
diotherapy [21, 23, 24]. MRI provides high-
resolution multiplanar information about the
location, size, circumferential and craniocau-
dal extent of the primary tumor and informa-
tion regarding the involvement of adjacent
structures [3].
There is no significant difference in di-
agnostic value between pelvic surface coils
and endoluminal coils [25]. Moreover, endo-
luminal coil imaging is limited by a narrow
FOV and near-field artifact and may not be
tolerated by patients with anal cancer. MRI
with a pelvic surface coil is easy, is more ac-
ceptable to the patient, and shows both local
spread of the disease as well as lymph node
involvement [26].
We routinely perform MRI of anal cancers
with a standard technique using a body coil; we
obtain transaxial T1-weighted images with a
5-mm slice thickness to cover the abdomen and
pelvis. High-resolution thin-section T2-weight-
ed images are obtained with a 3-mm slice thick-
ness in three orthogonal planes through the anal
canal using a pelvic surface coil. In our ex-
perience, contrast-enhanced MRI offers lim-
ited advantages over standard T2-weighted
sequences in routine primary staging but can
be helpful to assess fistulation to other organs.
Fat-suppressed imaging can help improve the
conspicuity of the primary tumor, and STIR
sequences are also useful to show fistula tracks.
Diffusion-weighted imaging has an emerging
role, particularly for detection of recurrent tu-
mor after therapy, and can aid in differentiation
of suspected residual or recurrent tumor from
treatment-related change.
18 F-FDG PET/CT
FDG PET/CT has an increasing role in
staging and treatment planning of anal carci-
noma, particularly because up to 98% of anal
tumors are FDG-avid [5, 27–29]. At diagno-
sis, FDG PET/CT is used to evaluate primary
tumor size, lymph node status, and whether
distant metastases are present. FDG PET/CT
can also be useful for planning radiation ther-
apy by clearly defining sites of metabolically
active tumor. Several studies have shown that
FDG PET/CT (in comparison with standard
imaging) alters staging of anal carcinoma in
approximately 20% of cases and treatment
intent in approximately 3–5% of cases [27,
28]. Although PET/CT has a lower sensitiv-
ity in detecting perirectal nodes than MRI,
this shortcoming does not affect manage-
ment because perirectal nodes are routinely
irradiated. The main impact of PET/CT on
therapy stems from its superiority in detect-
ing involved pelvic or inguinal lymph nodes,
provoking the radiation oncologist to include
them in the radiotherapy field.
Features of the Primary Tumor
Anal cancers are usually of intermediate to
high signal intensity on T2-weighted imag-
ing or STIR imaging and intermediate to low
signal intensity on T1-weighted imaging. Tu-
mors tend to spread circumferentially around
 Imaging of Anal Carcinoma

the anal wall and may form a lobulated in-
traluminal or extramural mass. Primary anal
cancers are staged purely on the basis of the
size of the tumor rather than its depth of inva-
sion. At initial staging, most tumors are T1 or
T2, lie within 1.5 cm of the anal verge, have
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ods that might improve the selection of pa-
tients for inguinal radiotherapy. FDG PET/
CT is becoming routine and is proven to al-
ter therapy planning [27, 28] (Fig. 5). Senti-
nel lymph node biopsy in patients with anal
cancer is technically feasible and has the po-
of a posttreatment anal cancer is shown in
Figure 6. Recognition of serial changes af-
ter treatment is key to the interpretation of
follow-up MRI. There is a decrease in the
size of the primary tumor and its signal on
T2-weighted imaging reduces. The adjacent

a circumferential extent of less than 50%, and
are located predominantly along the anterior
aspect of the anal canal (Fig. 2). The sphinc-
ter complex is the most commonly infiltrat-
ed structure, followed by the rectum [2]. It
should be emphasized that direct invasion of
the rectal wall, perianal skin, subcutaneous
tissues, or sphincter muscles does not signify
a T4 tumor (Fig. 3). Invasion of organs such
as the vagina, urethra, prostate, or bladder is
required to diagnose T4 disease (Fig. 4). MRI
is especially useful in staging large tumors,
particularly when the craniocaudal dimen-
sion is the largest dimension or when tumors
protrude beyond the anal verge, because en-
doscopy is inadequate in these cases [15].
Lymph Node Staging
Lymph node status is based on node loca-
tion rather than number of involved nodes, as
shown in Table 1. Nodal drainage depends
on which side of the dentate line the anal
cancer has its epicenter. Anal margin and
anal canal tumors inferior to the dentate line
spread to the inguinal and femoral lymph
nodes, whereas anal canal tumors superior
to the dentate line drain into the perirectal,
internal iliac, and retroperitoneal nodes [1,
26]. However, often tumors straddle the den-
tate line and then overlap between the two
nodal regions can occur.
Inguinal lymph node metastases in pa-
tients with anal cancer are an independent
prognostic factor for local failure and over-
all mortality; therefore, investigation of en-
larged lymph nodes is essential in the di-
agnostic and staging process. Selection of
patients with anal cancer for groin irradia-
tion needs pathologic confirmation of the en-
larged or suspicious inguinal nodes on biopsy
or ultrasound-guided fine-needle aspiration
cytology. Sonographic features suggestive
of involvement include a rounded rather than
oval shape; extracapsular spread; loss of the
normal hilar blood flow; and abnormal, lobu-
lated thickening of the node cortex [30]. Pa-
tients with large necrotic nodes may be treat-
ed even with negative histology, usually after
a repeat fine-needle aspiration cytology.
Because of the limitations of conventional
imaging tests for lymph node characteriza-
tion, there is a need to explore other meth-
tential to identify patients in whom inguinal mucosa often shows high signal and at times
radiotherapy can safely be withheld, particu- shows focal thickening, giving a pseudotu-
larly for T1 or T2 tumors [31–35]. The prin- mor appearance. However, this appearance
ciple is the same as for sentinel lymph node is a posttreatment effect due to mucosal ede-
biopsy in other malignancies such as breast ma and should not be mistaken for residual
cancer. Radiolabeled nanocolloid or methy- tumor. On T2-weighted imaging, very low
lene blue dye is injected peritumorally, and signal at the tumor site indicates the devel-
the dyed or radioactive nodes are removed at opment of posttreatment fibrosis, and on the
the time of surgery. However, because ingui- axial images, there is often a tram-track ap-
nal lymph node metastases can occur after a pearance, which we hypothesize is caused
negative sentinel lymph node biopsy, partic- by fibrosis around the reconstituted internal
ularly for T3 or T4 primaries, introduction of sphincter. Occasionally there will be a radio-
this procedure as the standard of care in all logic complete response, in which there is no
patients with anal carcinoma should be done residual tumor discernible and only a small
with caution [32]. volume of low-signal fibrosis remains (Fig.
7). It may take 3–6 months for complete res-
Posttreatment Imaging olution of tumor to occur [36].
Response assessment after treatment of MRI assessment at this time can influence
primary anal cancer with chemoradiothera- the radiation oncologist’s decision about the
py is particularly challenging. Residual dis- need to offer additional therapy. Failure of
ease is defined by the presence of a positive initial therapy is suspected on MRI by the
biopsy less than 6 months after completion of presence of a residual focus of intermedi-
chemoradiotherapy. MRI is the imaging mo- ate signal intensity at the site of the primary
dality of choice and the typical appearance tumor (Fig. 8) or if there has been obvious
TABLE 1: TNM Staging of Anal Cancer [6]
TNM Stage Explanation of Stage
Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of a primary tumor
Tis Carcinoma in situ
T1 Tumor 2 cm or less in greatest dimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest dimension
T3 Tumor more than 5 cm in greatest dimension
T4 Tumor of any size that invades adjacent organs
Regional lymph nodes (N)
NX Regional nodes cannot be assessed
N0 No regional node metastases
N1 Metastasis in perirectal lymph node(s)
N2 Metastasis in unilateral internal iliac and/or inguinal lymph nodes
N3 Metastasis in perirectal and inguinal lymph nodes and/or in bilateral
internal iliac and/or inguinal lymph nodes
Distant metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis present

AJR:199, September 2012 W337


disease progression. These findings should be
followed by biopsy confirmation at the time of
examination with the patient under anesthesia
and eligibility assessment for salvage abdomi-
noperineal resection.
At our institution clinical assessment is
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routinely performed 6 weeks after comple-
tion of chemoradiotherapy. The first fol-
low-up MRI study is performed 12 weeks
(3 months) after chemoradiotherapy. If the
MRI findings suggest that there is residual
disease, then an examination with the patient
under anesthesia and biopsy are performed
to confirm the MRI findings and salvage ab-
dominoperineal excision is considered. If the
12-week MRI scan shows a good response,
then another MR examination is performed
24 weeks (6 months) after chemoradiothera-
py to ensure complete response. In the stan-
dard-risk group, subsequent clinical assess-
ments alone are performed every 3 months
for the first 3 years (6–36 months) followed
by clinical assessments every 6 months for up
to 5 years (36–60 months). In patients with
high-risk tumors (i.e., T4 tumors, presence of
a fistula, adenocarcinoma, or perineal adeno-
carcinoma; chemotherapy intolerance, HIV-
positive patients, and immunocompromised
patients), further surveillance with MR as-
sessment is performed every 6 months for the
first 3 years in addition to the routine clinical
surveillance protocol.
Outcome
Few objective data support the ability of
imaging to predict eventual clinical outcome.
Traditionally, response to chemoradiother-
apy has been assessed clinically. A clinical
response at 6 weeks appears to be more im-
portant than initial T stage and N stage [37].
In the United Kingdom Coordinating Com-
mittee on Cancer Research study, 70% of pa-
tients who had not achieved a complete re-
sponse at the 6-week assessment showed
further tumor regression with longer follow-
up [38]. Initial tumor response or regression
at 6 weeks is shown to be predictive for colos-
tomy-free survival [39] and disease-free sur-
vival [37]. Because of these correlations be-
tween clinical response and outcome, there
has been interest in determining whether MR
features have a similar predictive value. A
small MRI study suggested that tumor shrink-
age and stabilization of signal intensity abnor-
mality 1 year after chemoradiation (12 of 15
patients imaged) may reflect treatment suc-
cess [3]. However, Goh et al. [4], in a study of
35 patients with histologically confirmed anal
W338 AJR:199, September 2012
Kochhar et al.
squamous cell carcinoma who underwent
MRI before and 6–8 weeks after definitive
chemoradiotherapy, concluded that no indi-
vidual MRI feature was predictive of even-
tual outcome (including changes in size and
signal intensity) and that early assessment of
response shown by MRI at 6–8 weeks was
unhelpful in predicting future clinical out-
come [4]. Application of advanced MR tech-
niques, such as perfusion MRI and diffusion-
weighted imaging, remains the subject of
research. Nevertheless, MRI can be useful as
a screening test after initial chemoradiother-
apy to show a high suspicion of residual dis-
ease and therefore can provoke examination
under anesthesia and biopsy.
The prognostic information provided by
an FDG PET metabolic response after initial
therapy may be stronger than that provided
by MRI and is likely to be used more fre-
quently in the future. Metabolic response in
the anal tumor as determined by posttherapy
FDG PET (a mean of 2 months after comple-
tion of chemoradiotherapy) was predictive
of significantly decreased progression-free
and cause-specific survival after chemora-
diotherapy for anal cancer [40]. A cohort of
74 patients imaged with FDG PET 2 months
after completion of chemoradiotherapy also
showed better survival with partial or com-
plete metabolic response compared with
nonresponders [41].
Imaging Recurrent Disease
Recurrent disease is defined as initial
complete response to therapy with subse-
quent positive biopsies more than 6 months
after completion of treatment. Locoregional
or metastatic relapse occurs in up to 35% of
anal cancer patients despite combined mo-
dality treatment [4]. Patients with disease re-
lapse may benefit from more aggressive sal-
vage surgery; therefore, early detection and
accurate staging are essential to ensure opti-
mal surgical outcome [39, 42, 43]. Previous-
ly published multivariate analyses have indi-
cated tumors likely to relapse include tumors
larger than 4 cm, those with nodal involve-
ment, and basaloid subtypes [18, 44, 45].
Recurrence is generally seen on MRI as a
new nodule or mass isointense to the original
tumor (Fig. 9). Dynamic contrast-enhanced
MRI and diffusion-weighted imaging also
have promise in detecting foci of recurrence,
although these techniques are not routinely
used in clinical practice. Comparison with
prior imaging, performed both before and
after treatment, is of paramount importance.
Recurrent anal cancer shows a different dis-
ease distribution with more advanced local
disease extending into adjacent organs and
the pelvic skeleton as well as more frequent
lymph node metastases in the perirectal, pre-
sacral, and internal iliac chains. Distant me-
tastases are also more common in patients
with recurrence after surgery [2]. FDG PET/
CT is an excellent modality for detecting re-
current locoregional disease and establishing
the presence of distant metastases.
Overall Imaging Strategy
Because of the complexity of management
of anal carcinoma and the relative rarity of
the tumor, ideally all cases should be man-
aged in a center with experience in treating
these cancers. A flow diagram for patient
management is shown in Figure 10.
Summary and Conclusions
Despite being a relatively uncommon ma-
lignancy, anal cancer requires rigorous im-
aging evaluation because accurate staging is
difficult by clinical methods alone. Appro-
priate treatment is underpinned by correct
staging; hence, initial high-quality MRI with
or without inguinal ultrasound for locore-
gional staging and CT or PET/CT for distant
staging are vital. Imaging also has a role in
detecting residual or recurrent disease after
therapy, with an emerging place for new mo-
lecular imaging techniques not only to detect
early recurrence but also to predict response
to further therapy and thereby guide escala-
tion of treatment when appropriate.
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 Kochhar et al.

Fig. 1—Illustrative anatomy of anal canal.

A, Line diagram shows anal anatomy.
B, Healthy 67-year-old man (with treated prostate cancer).Coronal T2-weighted
image that corresponds to A shows ischioanal fossa (IAF), external sphincter (ES),
and internal sphincter (IS).
C, Healthy 53-year-old woman (with treated carcinoma cervix). Axial T2-weighted
image through upper anal canal shows urethra (Ur) and vagina (Va).
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D, 67-year-old woman (post TAH and BSO for endometrial sarcoma). Sagittal T2-
weighted image shows pubococcygeal line (long straight line), which is generally
at level of anorectal junction. Angled line shows reference plane that one should
use when reporting distance of epicenter of abnormality from anal verge.

B C D

Fig. 2—Early anal tumors.

A, 43-year-old woman with T1 tumor. MR image
shows that normal low signal of anal canal muscle
has been replaced by intermediate-signal tumor
(arrow) that is less than 2 cm.
B, 59-year-old man with anterior T2 anal canal
carcinoma. MR image shows that lesion measures
more than 2 cm and hence achieves T2 status. There
is invasion of external sphincter (arrow).
A B

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 Imaging of Anal Carcinoma
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A B
Fig. 4—35-year-old woman with T4 anal cancer. MR
Fig. 3—46-year-old man with T3 anal carcinoma. image shows lobulated tumor with central necrosis
A, Coronal T2-weighted image shows that neoplasm (bracket) extends from anal margin into lower rectum and and invasion into posterior vagina (arrow).
is more than 5 cm in maximum dimension and therefore is T3. There is invasion of external sphincter and of left
levator ani muscle (arrow).
B, MR image shows no evidence of adjacent organ invasion, as evidenced by complete low-signal rim
(arrowheads) separating tumor from prostate anteriorly.

A B

Fig. 5—Axial fused FDG PET/CT images of 45-year-old man with upper anal
cancer.
A, Bulky anal cancer shows increased FDG uptake (arrow) and metabolically
active right inguinal node (arrowhead).
B, Increased uptake in pelvic sidewall lymph node (arrowhead) is consistent with
disease involvement.
C, Increased uptake in unsuspected liver lesion (arrowhead) was subsequently
shown to be metastasis on liver MRI (not shown). Ability of FDG PET/CT to stage
regional and metastatic disease accurately in single examination is its great
strength.
C

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 Kochhar et al.

Fig. 6—50-year-old man with anal cancer.

A, Coronal T2-weighted MR image shows bulky
T3 tumor in upper anal canal (arrow) that was
subsequently treated with chemoradiotherapy.
B, Coronal T2-weighted image obtained 8 weeks after
therapy shows that tumor has diminished in size and
there is tram-track appearance of low-signal fibrotic
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tissue encasing anal canal wall (arrowhead). Note

that masslike pseudotumor of high signal in rectal
mucosa (arrow) is edema from radiotherapy.

A B

Fig. 7—37-year-old man with bulky T3 anal cancer.

A, Axial T2-weighted MR image obtained before
treatment.
B, Axial T2-weighted image obtained 3 months after
therapy depicts low-signal fibrosis in place of tumor
(arrow). Patient had complete response clinically and
radiologically.
A B

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 Imaging of Anal Carcinoma
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A B C
Fig. 8—42-year-old woman with anal cancer.
A, T2-weighted MR image obtained at time of initial staging shows abnormal tumor tissue in lower anal canal, which was treated with chemoradiotherapy.
B, T2-weighted MR image obtained 8 weeks after therapy shows significant size reduction and fibrotic reaction, but residual nodule (arrow) suspicious for remnant tumor
is seen.
C, Repeat T2-weighted MR image obtained immediately before resection shows nodule (arrow) has enlarged compared to initial post treatment (B). This nodule was
confirmed to be tumor at histology after salvage abdominoperineal resection.

Fig. 9—69-year-old woman with low anal canal

cancer.
A, Coronal T2-weighted MR image shows small tumor
involving lower anal canal and anal margin (arrow)
that was treated with chemoradiotherapy with good
initial response.
B, Coronal MR image obtained for surveillance 1
year after chemoradiotherapy shows intermediate-
to high-signal abnormality (arrow) suspicious for
recurrent tumor at site of original primary.
(Fig. 9 continues on next page)
A B

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 Kochhar et al.

Fig. 9 (continued)—69-year-old woman with low anal

canal cancer.
C, Axial T2-weighted MR image from same
examination as B shows areas of small-volume,
linear posttherapy fibrosis (arrowhead) and bulky
intermediate- to high-signal abnormality (arrow)
suspicious for recurrence.
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D, Apparent diffusion coefficient map from diffusion-

weighted imaging series shows rim of restricted
diffusion (arrow) in intermediate T2 signal areas
indicative of high cellular content. Lesion was
removed and carcinoma found histologically.
Patient developed nodal metastases despite
abdominoperineal excision of recurrence disease
(not shown).

C D

Histological confirmation of squamous cell carcinoma

Referral to anal cancer multidisciplinary team meeting

Clinical exam Staging investigations

Contrast-enhanced CT
MRI FDG PET/CT
chest/abdomen/pelvis

Anal margin Anal canal Suspected nodal

Distant metastases
cancer cancer involvement

US/FNA

Surgery−
Palliative
local excision CRT ± local boost to groin nodes
treatment
if < 2 cm

Posttreatment follow-up imaging:

MRI & FDG PET/CT 12 weeks
after chemo-radiotherapy completion

Complete Residual/
Equivocal
response progression

EUA and biopsy

24-week MRI Salvage surgery

Negative Positive

Low risk: no further imaging follow-up Relapse

High risk:* 6 monthly MRI for 3 years

* Who is high risk?

All: Annual CT for 3 years • T4 tumors
• Presence of fistula Fig. 10—Flowchart
• Chemotherapy intolerance shows overview of
• HIV positive
All: Clinical FU for 5 years • Immunocompromised patient investigations
and management of anal
cancer.

W344 AJR:199, September 2012