Surgical Oncology 1994; 3: 135-146

Current management of squamous cell carcinoma of the

anal canal

W. M. MENDENHALL*, M. D. SOMBECK*, T. W. SPEER*, Ft. D. MARSH?, R. R. CARROLL? AND E. M. COPELAND Ill+

Departments of *Radiation Oncology and *Surgery, and the tDivision of Medical Oncology, University of Florida College of
Medicine, Gainesville, Florida

The management of squamous cell carcinoma of the anal canal is controversial. Treat-
ment currently varies from abdominoperineal resection to combined radiotherapy and
chemotherapy. Our aim is to review the management of this disease and present our
current treatment policies. Twenty-six patients treated at the University of Florida with
surgery and adjuvant radiotherapy are compared with 12 patients treated with radio-
therapy alone. The pertinent literature is reviewed to determine the role of primary
surgery, the efficacy of adjuvant chemotherapy, and the optimal chemotherapy
schedule. The preferred management of anal canal cancer is radiotherapy; abdomino-
perineal resection should be reserved for salvage after local recurrence and for patients
with faecal incontinence caused by the destruction of the sphincter muscle. Adjuvant
chemotherapy is probably indicated for patients with lesions that are stage T2 or larger.
The optimal chemotherapy regimen consists of 5-fluorouracil and mitomycin. Prelimin-
ary data suggest that cisplatin may be substituted for mitomycin with equivalent
efficacy and less toxicity. Surgical Oncology 1994; 3: 135-146.

Keywords: anus neoplasms, chemotherapy, radiotherapy, squamous cell carcinoma,

surgery.

INTRODUCTION and radiotherapy (chemoradiation) superior to

irradiation alone? (c) If so, what is the best chemo-
The management of squamous cell carcinoma of the therapy regimen? (d) What are the optimal radio-
anal canal has undergone dramatic changes in this therapy techniques? These questions are all the more
country over the last 15 to 20 years. The mainstay of pressing because of the relative rarity of the dis-
treatment has been the Miles abdominoperineal ease, the fact that it is curable in the majority of
resection (APR) with a permanent colostomy [I, 21. cases, and because maintenance of a functional anal
Although some authors, primarily in Europe, canal, in addition to cure, is a major goal of treat-
reported comparable results after radiotherapy ment. Our aim is to review the literature relating to
alone [3-51, a landmark paper by Nigro et a/. - the above questions, to present some previously
reporting favourable results in three patients after unpublished data from our institution, and to discuss
low-dose radiotherapy combined with 5-fluorouracil our current approach to this subject.
(5-FU) and mitomycin - stimulated considerable
interest in the conservative management of this
disease [61. There remain a number of unanswered NATURAL HISTORY AND STAGING
questions, such as: (a) Is there a role for primary
radical surgery? (b) Is concomitant chemotherapy Squamous ceil carcinoma of the anal canal repre-
sents 3% to 5% of all large bowel cancer; it occurs

Correspondence: William M. Mendenhall, MD, Department of

predominantly in women (3:2 to 5: 1 female pre-
Radiation Oncology, University of Florida Heal?h Science ponderance), and at a mean age of 60 years [7]. The
Center, PO Box 100385, Gainesville, FL 32610-0385, USA. location of lesions relative to the dentate line is as

135
136 W, M. Mendenhall et al.

follows: above (40%), below (25%), and both (35%) as well. The overall incidence of pelvic lymph node
[7]. Squamous cell carcinomas arising in the rectum metastases is in the region of 25% to 35% [7].
are similar in their natural history to those arising in Haematogenous metastases are usually in the
the anal canal, and their management is essentially liver and lung and are present in less than 10% of
the same. In contrast, squamous cell carcinomas of patients at diagnosis [7].
the anal margin (perianal skin) have a more favour- The pre-treatment evaluation of patients should
able prognosis and will not be addressed in this take into account the spread patterns of the disease
paper. The terms ‘cloacogenic carcinoma’ and and include a chest roentgenogram and computed
‘basaloid carcinoma’ are variously used by some tomography (CT) of the abdomen and pelvis. The
pathologists to describe poorly differentiated latter is obtained to determine the presence and
squamous cell carcinomas [7]. extent of regional lymph node metastases, to
The primary tumour grows in an annular fashion evaluate the liver, and to complement the physical
and extends through the wall of the anal canal to examination of the primary lesion. Additional
involve the underlying sphincter muscle. Invasion of studies, such as bone scans and CT of the brain, are
the perianal skin may occur but is rarely extensive. not warranted unless symptoms indicate the unlikely
In women, the tumour may extend anteriorly to possibility of distant metastases in these sites. The
invade the rectovaginal septum and inferiorly to site, size, annularity, mobility and configuration
involve the perineal body [7]. (ulcerative vs. exophytic) of the primary lesion and
Invasion of the regional lymph nodes occurs the presence of inguinal, pararectal, and supra-
frequently, and the attending physician must take clavicular lymph node metastases should be noted
these into account when planning the treatment on physical examination.
approach. Both the inguinal and the pelvic lymph There are two major staging systems that are
nodes may be involved, regardless of the size of the used to describe the pre-treatment extent of
primary tumour and its location relative to the disease, those of: the American Joint Committee on
dentate line. In general, the risk of lymph node Cancer (AJCC), and the International Union Against
metastases increases with tumour size and is Cancer (UICC) [9, IO]. Both are based on the size of
greater for poorly differentiated cancers. lnguinal the primary tumour and its invasion of adjacent
lymph node metastases are always unilateral or structures, the presence and extent of regional
bilateral (never contralateral), occur in 15% to 30% lymph node metastases, and the presence of
of patients, and are associated with larger and more haematogenous metastases. Another major staging
distally located tumours [7]. They reflect a poor system, the Centre Leon Berard system, was
prognosis, particularly if they are present at diagno- described by Papillon & Montbarbon and is similar
sis, compared with those that develop meta- to the UICC system [II]. To adequately evaluate
chronously [7]. treatment results, the reader must be familiar with
There are two main lymphatic pathways through the staging systems that are in use. The 1988 AJCC
which the tumour gains access to the pelvic lymph system is outlined in Table 1.
nodes: the visceral route and the parietal route [7,
81. The visceral lymphatics follow the vascular
supply from the perianal and perirectal tissues to IS THERE A ROLE FOR PRIMARY
the superior haemorrhoidal vessels and then to the SURGERY?
lymphatics adjacent to the inferior mesenteric
vessels. Pararectal lymph node metastases may be Until 1983, the preferred treatment at the University
seen beginning several centimetres above the of Florida was preoperative radiotherapy to approxi-
dentate line, are usually lateral or posterior to the mately 45 Gy followed by APR. Before this, a few
rectal wall, and are frequently adjacent to the patients who were poor surgical risks and who had
primary tumour. The parietal lymphatics follow the early-stage lesions were treated with radiotherapy
middle haemorrhoidal vessels and drain into the alone. After 1983, the treatment was usually radio-
internal iliac nodes and then into the common iliac therapy alone using external-beam irradiation to
and para-aortic lymphatics. There are some efferent 45 Gy followed by an interstitial iridium implant or
lymphatics that may drain into the presacral nodes, an external-beam boost. The change in treatment
 Management of anal canal cancer 137

philosophy was largely due to the influence of were definitely fixed to the sacrum, side wall,
Professor Jean Papillon. Chemotherapy was not bladder, and/or prostate. All of the patients treated
used routinely at our institution until 1990, when with radiotherapy alone had clinically resectable
data published by Cummings et a/., from the disease, compared with 19 of 26 (73%) of those
Princess Margaret Hospital, Toronto, indicated that treated surgically, indicating that those selected for
chemoradiation using 5-FU and mitomycin was combined therapy tended to have more advanced
probably superior to irradiation alone [12]. tumours. Twenty-six patients were treated with
Patients included in our series had previously combined surgery and radiotherapy, and 12 were
untreated squamous cell carcinoma of the anal treated with radiotherapy alone. Only one patient
canal and were treated with curative intent between received adjuvant chemotherapy, which consisted of
1964 and 1990; all had a 2 year minimum follow-up concomitant 5-FU and mitomycin.
and none were lost to follow-up. Patients were Preoperative radiotherapy doses ranged from 45
staged according to the 1988 AJCC staging system to 60 Gy and postoperative doses, from 50 to 64 Gy.
(Table 1). Total irradiation doses for patients treated with
The relationship between T stage and treatment radiotherapy alone ranged from 60 to 70 Gy. In
group is depicted in Table 2. Distribution by N stage general, external beam irradiation was administered
for the entire series was NO, 24; Nl, 2; N2, 8; and in a planned continuous course at 1.8 to 2.0 Gy per
N3, 4. The primary tumour was defined as clinically fraction, with once-daily fractionation.
resectable or clinically unresectable by the referring Surgery consisted of APR in 20 patients and wide
surgeon [13, 141. The latter subset had lesions that excision in two patients. Four patients did not
undergo resection of the primary lesion. One with a
clinically resectable lesion died before having
Table 1. 1988 AJCC staging system [9] surgery of chemotherapy-induced (5-FU and mito-
mycin) leukopenia. One with a clinically resectable
1 stage
lesion refused surgery, and two had clinically
Tl Primary tumour 52 cm in greatest diameter
unresectable cancers that remained unresectable
T2 > 2 but 6 5 cm in greatest diameter
T3 > 5 cm in greatest diameter after preoperative irradiation. All four patients had
T4 Any size invading adjacent organs tumour at the primary site at the time of death.
N stage The likelihood of local control and cause-specific
NO No regional lymph node metastasis survival was calculated using the product-limit
Nl Metastasis to pararectal nodes
method [15-171. Significance levels were calculated
N2 Metastasis to unilateral internal iliac and/or
inguinal nodes
using the log-rank test [16, 171.
N3 Metastasis to pararectal and inguinal nodes Local control (defined as continuous disease
and/or bilateral internal iliac and/or inguinal control at the primary site and in the pelvis) is
nodes shown in Fig. 1. It is apparent that there is no
M stage
obvious advantage to combined surgery and radio-
MO No distant metastases
therapy compared with irradiation alone. When eval-
Ml Metastases to distant sites
uated in a univariate analysis, the only parameter

Table 2. Treatment according to T stage

T stage Surgery + radiotherapy (n = 26) Radiotherapy alone (n = 12)

Preoperative Postoperative External-beam External-beam radiotherapy

radiotherapy radiotherapy radiotherapy + interstitial implant
(n = 22) (n=4) (n=4) (n=8)

Tl 1 0 1 1
T2 7 1 2 6
T3 7* 2 1 1
T4 7 1 0 0

*One patient received concomitant chemotherapy.

138 W M. Mendenhall et al.

Resectable 75% (n=l9)

Resectable 50% (n=l9)

Unresectable 29% (n = 7)

Unresectoble 28% (n=7)

20

P=O.O00 P=O.O9
I
0 ’ T
0 2 4 6 8 0 i 4 6 8 IO 12
Time (years) Time (years)

(b) (b)
loo
91%(n=l2)
92% (n=l2)

$ 60
tC
8

20

2 4 6 8 0 2 4 6 8
Time (years) Time (years)

Figure 1. (a) Local control after combined surgery and Figure 2. (a) Cause-specific survival after combined
adjuvant irradiation. (b) Local control after irradiation surgery and adjuvant radiotherapy. (b) Cause-specific
alone. survival after radiotherapy alone.

that significantly predicted local control was T stage duct-limit method, was 83% for the 12 patients
(P=O.O12); the other variables examined (gender, N treated with irradiation alone, compared with 6% for
stage, annular involvement, age, and well to moder- the 19 patients with clinically resectable lesions
ately differentiated squamous cell carcinoma vs. treated with combined radiotherapy and surgery.
cloacogenic carcinoma histology) did not signifi- None of the seven patients with clinically unresect-
cantly influence this end-point at the PSO.05 level. able lesions had local control with anal function at 5
Cause-specific survival is shown in Fig. 2; there is no years.
apparent advantage to combined treatment com- Papillon [7] reviewed the 5 year survival rates
pared with radiotherapy alone. Severe complica- following APR and noted that they varied from 32%
tions, defined as those necessitating hospitalization to 61% [18-321. The results of primary APR from six
or a second operation, occurred in one of 12 major institutions are summarized in Table 3 [21,
patients (8%) treated with radiotherapy alone and in 33-371. Because APR was not the only treatment
six of 26 patients (23%) treated with surgery and employed in most of these institutions, some
adjuvant irradiation. The probability of local control selection bias exists, which varies depending on the
with anal function at 5 years, calculated by the pro- series.
 Management of anal canal cancer 139

Table 3. Results after abdominoperineal resection

Institution n Local Postoperative Five-year survival

control mortality
Absolute Cause-specific

Mayo Clinic [33] 118 72% * 2.5% 71% -

M. D. Anderson Cancer Center 1341 109 73% - 62% -
Roswell Park Memorial Institute [35] 41 68% 2.4% 32%1 -
St. Mark’s Hospital 1361 118 - 4.2% 62%; 65$
University of Chicago [37] 22 - 4.5% 50%§
Memorial Sloan-Kettering Cancer Center [21] 59 - 58% -

*Reported first site of relapse; included inguinal node recurrences as ‘local recurrences’.
tThirteen of 41 patients alive and disease-free; nine of 13 for more than 5 years.
SNinety-four patients eligible for analysis of 5year survival.
§Fifty per cent alive and disease-free at various follow-up intervals.

Table 4. Results of irradiation alone

Institution n Local Severe Five-year survival

control complications
Absolute Cause-specific

lnstitut Gustave-Roussey [38] 64 81% 14% 46% -

Fondation Bergonie [39] 32 75% 13% 49% 61%
University Hospital, Geneva [40] 57 74% 5% 66% 79%
Hopital Tenon [41] 193 66% 10% - 73% for N
- 36% for N+
British Columbia Cancer Agency [42] 72 76% 4% 66% 78%
Princess Margaret Hospital [12] 57 56% 19% 61% 68%

N- =clinically negative regional nodes.

N + = clinically positive nodes.

The results after irradiation alone are depicted in sibility. Otherwise, APR should be reserved for
Tables 4 [12, 38-421 and 5 [12, 38-411. None of the locally recurrent or persistent tumour after radio-
patients in these series received adjuvant chemo- therapy or chemoradiation [43].
therapy. Despite the potential pitfalls of comparing
non-randomized, retrospective data, these results
IS ADJUVANT CHEMOTHERAPY
are comparable with those obtained with primary
INDICATED?
APR, both in terms of local control and survival.
Although a prospective, randomized trial comparing Two prospective, randomized trials comparing
primary radiotherapy and surgery would be desir- radiotherapy alone with chemoradiation have
able, such a trial has not been carried out (and is recently been completed by the United Kingdom Co-
unlikely to be undertaken); thus, comparison of ordinating Committee for Cancer Research and by
these treatment strategies must be based on non- the European Organization for Research and Treat-
randomized data. Therefore, in answer to the ment of Cancer 1441. Patient accrual for both studies
question posed at the beginning of this section, reportedly ended in 1993. Both used chemotherapy
there is no role for the routine use of primary APR in regimens that included 5-FU and mitomycin. The
the management of squamous ceil carcinoma of the results of these studies are not yet available, how-
anal canal. An exception would be the occasional ever, so we must address the question posed in this
patient with faecal incontinence due to tumour section using non-randomized data as a basis.
destruction of the sphincter muscle, in whom Intrigued by the initial data published by Nigro et
preservation of anal function is not a realistic pos- al., Papillon and his colleagues, at the Centre Leon
140 kI! M. Mendenhall et al.

Table 5. Local control after

Institution Tl T2 T3 T4 radiotherapy alone*

lnstitut Gustave-Roussey [38] 91% (Tl -T2) 76% 67%

Fondation Bergonie [39] 81% (Tl -T2) 64% -
University Hospital, Geneva [40] 100% 76% 69% 0%
Hopital Tenon [41] 71% (Tl -T2) 66% 57%
Princess Margaret Hospital [I 21 100% 56% 40% 43%

*UICC staging system was used in all of the above series.

Table 6. Local control for T3 cancers at the Centre Leon sion of 5-FU and mitomycin in the treatment
BBrard* regimen was the strongest predictor of local control.
When treatment variables were excluded, only T
Treatment n Local control
stage significantly predicted local control. The 5 year
Radiotherapy 78 70% cause-specific survival rates were as follows: RT,
(P’O.02) 68%; FUR, 64%; and FUMIR, 76%. The differences in
Radiotherapy and chemotherapy 89 90% the survival rates between FUMIR and FUR were
significant at the P=O.O2 level, but not between
Radiotherapy consisted of external beam plus iridium
FUMIR and RT (P=O.14).
implant. Chemotherapy consisted of mitomycin, 12 mg
mm2 i.v. over 24 h on day 1, and 5-FU, 600 mg m-2 In contrast, Allal and colleagues, from the
continuous i.v. infusion over days 1-4 or 1-5. University Hospital in Geneva, reported that the
*From ref. 45, Table 1, p. 1218. addition of 5-FU and mitomycin to irradiation did not
improve the likelihood of local control or survival in
a series of 125 patients (Table 7) [40]. Fifty-seven
Berard, Lyon, were among the first to employ patients were treated with irradiation alone and 68
chemoradiation in large numbers of patients with patients with chemoradiation; the authors noted that
anal canal cancer [7, 11, 451. Using adjuvant 5-FU patients in the former group tended to be older and
and mitomycin, they noted a significant improve- have less advanced disease. The incidence of
ment in local control for T3 tumours treated with severe complications was similar: radiotherapy, 5%,
chemoradiation compared with radiotherapy alone and chemoradiation, 4%.
(Table 6). Cummings et a/., subsequently published a In answer to the question posed at the beginning
series of 192 patients treated with radiotherapy of this section, the data regarding the role of chemo-
alone (RT) or combined with 5-FU (FUR) or 5-FU and therapy are inconclusive [46-481. The balance of the
mitomycin (FUMIR) [12]. The patients were treated data indicates that it is beneficial for lesions that are
using seven different prospectively designed, stage T2 or higher [I 1, 12, 491. Perhaps the results
sequential, non-randomized protocols and were of the two randomized trials will permit a definitive
grouped into three major treatment groups as stated recommendation to be made.
above. The local control rates were as follows: RT,
56%; FUR, 60%; and FUMIR, 86%. The differences in
local control between FUMIR and the other two WHAT IS THE OPTIMAL CHEMOTHERAPY
groups were significant at P10.05. No improvement REGIMEN?
was noted for Tl lesions, whereas a significant
improvement in local control was noted for T2-T4 There are two major questions regarding the
lesions treated with FUMIR. The likelihood of local optimal chemotherapy regimen: (a) is 5-FU and
control was analysed using recursive partitioning to mitomycin more effective than 5-FU alone? and, if
evaluate the following variables: age, gender, T so, (b) can cisplatin be substituted for mitomycin
stage, N stage, histopathology, total irradiation dose, without sacrificing efficacy?
dose per fraction, planned split-course vs. con- In answer to the first question, the data published
tinuous-course radiotherapy, and the use and type by Cummings et a/. indicate that 5-FU and mito-
of chemotherapy. This analysis revealed that inclu- mycin are superior to 5-FU alone [12]. Their data
 Management of anal canal cancer 141

Table 7. Local control and survival

T stage? Local control at 5 years 5-year cause-specific survival
after radiotherapy or radiotherapy
plus chemotherapy at the University
Hospital, Geneva*
RT RT-CT Pvalue RT RT-CT P value

Tl 100% 100% 0.99 100% 100% 0.90

T2 76% 65% 0.22 83% 68% 0.25
T3 69% 70% 0.90 77% 84% 0.73
T4 0% 0% - 0% 0% -
Overall 74% 66% 0.30 79% 76% 0.90

*Chemotherapy consisted of mitomycin, 0.4 mg kg-’ (20 mg maximum), i.v.

bolus on day 1, and 5-day continuous infusion 5-fluorouracil, 600-800 mg m -2
per day.
?UlCC staging system.
RT = radiotherapy alone; RT-CT = chemoradiation.
Modified from ref. 40, Tables 3 and 4, p. 62.

also indicate that radiotherapy plus 5-FU is equiva- for 5 days a week. With relatively short follow-up,
lent to radiotherapy alone [12]. An ongoing Radia- the authors noted improved local control with the
tion Therapy Oncology Group (RTOG) randomized two drug combination, 89% vs. 67%, and no signifi-
trial (87-04) is comparing adjuvant 5-FU and mito- cantly severe morbidity in either treatment group.
mycin with adjuvant 5-FU alone [50]. A preliminary The survival rates were similar, with median follow-
analysis of the data indicates that the two-drug up periods of 54 months for the 5-FU group and 20
combination probably results in a higher rate of months for the 5-FU and cisplatin group.
local control compared with 5-FU alone. Therefore, there are limited data indicating that
A significant disadvantage associated with mito- cisplatin and 5-FU may yield results that are equiva-
mycin is that it may result in profound thrombocyto- lent to 5-FU and mitomycin. Because of the signifi-
penia and leukopenia; there is also a low risk of cant potential toxicity associated with mitomycin,
thrombotic thrombocytopenic purpura. Occasionally, this is an issue worthy of further investigation.
these complications may be fatal [51]. We have
observed two fatal complications in patients under-
going chemoradiation with 5-FU and mitomycin for CURRENT TREATMENT TECHNIQUES AT
anal canal cancer; one patient died of sepsis and THE UNIVERSITY OF FLORIDA
another patient died secondary to an upper
gastrointestinal haemorrhage. In both instances, Controversial issues pertaining to the radiothera-
mitomycin-induced leukopenia and thrombocyto- peutic treatment of anal canal cancer include: the
penia were thought to be related to the occurrence arrangement and size of the irradiation portals, the
of the complication. Accordingly, there is consider- total dose and dose per fraction, continuous vs.
able interest in developing a less toxic chemothera- split-course irradiation, and boost technique. An in-
peutic regimen with an efficacy that is equivalent to depth discussion of each of these points is beyond
5-FU and mitomycin. Recently, Rich et a/., from the the scope of this paper. Rather, we will make
M.D. Anderson Hospital, published a series of 58 several general observations followed by a discus-
patients treated with radiotherapy, and either con- sion of our current treatment techniques. First,
comitant continuous-infusion 5-FU (39 patients) or because of the significant risk of regional lymph
concomitant continuous-infusion 5-FU and cisplatin node metastases (even for early-stage lesions), the
(19 patients) [52]. For patients receiving adjuvant regional nodes should be included in the initial irra-
5-FU alone, 250-300 mg m-* per day was adminis- diation portals in all cases. Second, a total dose of
tered for 5 or 7 days per week throughout the 30 Gy given in 15 fractions combined with chemo-
course of radiotherapy. For those receiving two therapy, as initially described by Nigro et a/., is prob-
drugs, the doses were, 5-FU, 250 mg mm2 per day ably too low [53, 541. Most authors report total
for 5 days a week, and cisplatin, 4.0 mg mm2 per day doses in the range 50-60 Gy. Third, the total dose
142 W M. Mendenhall et al.

should not exceed 60-65 Gy for two reasons: (a)

The likelihood of cure at these dose levels is rela-
tively high (much better than is observed for similar-
sized squamous cell carcinomas arising in other
locations), and (b) doses in excess of 65 Gy are
likely to result in an unacceptably high incidence of
necrosis, Fourth, the daily fraction size should be in
the range of 1.8-2.0 Gy; fraction sizes greater than
2.0 Gy will be associated with an increased risk of
late complications. Finally, if a perineal field is used
to boost the dose to the primary lesion, use of
an electron beam should be avoided unless all of the
perianal skin in the field is involved by the tumour.
Otherwise, an unnecessarily high irradiation dose
will be given to the uninvolved perianal skin, result-
ing in a high risk of subcutaneous fibrosis (Papillon,
personal communication, September 1983).
The initial course of irradiation is delivered with
the patient supine, using a four-field box technique
to a dose of 45 Gy in 25 fractions, as a continuous
course over 5 weeks (Fig. 3). The initial fields treat
the primary lesion with at least a 3 cm distal margin
as well as the pelvic and inguinal lymph nodes. The
superior margin of the field is usually at the L5-Sl
interspace if the pelvic nodes are clinically normal. If
the pelvic nodes are involved, the fields include the
next clinically negative echelon of nodes, if feasible.
For example, if the internal iliac nodes are involved,
the common iliac nodes would also be treated. How-
ever, the para-aortic nodes are virtually never
irradiated electively because of the excessive mor-
bidity associated with very wide-field radiotherapy
in combination with chemotherapy. The lateral por-
tals include the external iliac nodes and spare the
anterior aspect of the bladder. The dose to the ingui-
nal nodes is usually 50% to 60% of the dose to the
primary tumour. Therefore, IO to 12 MeV electron
beam fields, with a 4 cm split between the portals,
are used to bring the dose to these nodes up to
45 Gy if they are clinically uninvolved [55]. If the
nodes are involved, either their radiation dose is
boosted to 60-65 Gy, or the radiotherapy is followed
by a limited inguinal lymph node dissection.
Adjuvant chemotherapy is administered to
patients who are medically fit and who have primary
lesions that are 3 cm or larger, cloacogenic carcino-
mas of any size, or involved lymph nodes. We Figure 3. (a) Initial anterior and posterior fields. The
currently give two 4-day cycles of continuous intra- electron fields are treated from the anterior only and are
denoted by the dashed lines. (b) Initial lateral fields. From
venous 5-FU infusion (1 g day-‘) and bolus i.v. cis-
ref. 55, Fig. 1, p. 2060.
platin (100 mg m-* on day 1 of each cycle) during
the first and fifth weeks of radiotherapy.
 Management of anal canal cancer 143

The irradiation dose to the primary lesion is and involve less than two thirds of the circum-
boosted to a total dose of 60 Gy; the boost tech- ference of the anal canal are treated with an inter-
nique used depends on the extent and location of stitial iridium implant using the technique described
the tumour. Lesions that are 6 cm or less in length by Papillon et al. 17, 561. Hollow stainless steel

Figure 4. (a) Interstitial iridium implant using the Papillon technique. The steel needles are placed through the lucite
template into the anal canal and after-loaded with plastic ribbons containing iridium seeds. (b) Anteroposterior
roentgenogram of the implant. (c) Axial irradiation dose distribution. The triangles denote the location of the needles
containing the iridium sources. The isodose lines shown are 1.2 Gy h-‘, 1.0 Gy h-‘, 0.8 Gy h-’ and 0.6 Gy h-l. A 2 cm
long scale is depicted adjacent to the dosimetry.
144 I4! M. Mendenhall et al.

needles are inserted into the tumour through a rigid 4. Papillon J. Radiation therapy in the management of
lucite template and are after-loaded with iridium. epidermoid carcinoma of the anal region. Dis Colon
The template maintains an accurate 1 cm spacing Rectum 1974; 17: 181-7.

between the sources and thus minimizes inhomo- 5. Pilleron JP. La chirurgie dans le traitement du cancer
du canal anal. J Radio1 Electroll973; 54: 620-I.
geneities in the dose distribution (Fig. 4). The irradia-
6. Nigro ND, Vaitkevicius VK, Considine B Jr. Combined
tion dose is prescribed at 0.5 cm from the plane of
therapy for cancer of the anal canal: a preliminary
the needles at a dose rate of 1.0 Gy h-l. The
report. Dis Colon Rectum 1974; 17: 354-6.
advantages of the interstitial implant compared with
7. Papillon J. Rectal and Anal Cancers: Conservative
an external-beam boost include the ability to give a Treatment by Irradiation - an Alternative to Radical
high dose over a very short period of time (15 Gy Surgery. Berlin: Springer-Verlag, 1982.
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limited volume of tissue. Lesions that involve more abdominopelvic lymphadenectomy: historic perspec-
than two thirds of the circumference of the canal tive and current role in the surgical management of
and are located within 3-4 cm of the anal verge are rectal cancer. Dis Colon Rectum 1994; 37: 73-87.
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6oCo, with the patient supine, the beam angled 10 canal. In: Beahrs OH, Henson DE, Hutter RVP, Myers
MH, eds. Manual for Staging of Cancer, 3rd edn. New
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York: JB Lippincott Co., 1988: 81-3.
proximal margin of the tumour. Lesions that are
10. International Union Against Cancer UICC. TNM Classifi-
unsuitable for either of these techniques receive the
cation of Malignant Tumours. Berlin, New York:
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