DEPARTMENTAL CLINICAL

CONFERENCE
WEDNESDAY 27TH JUNE 2012
PRESENTING UNIT: GEN SURG UNIT
3 (DR AGUS UNIT)
TOPIC: MANAGEMENT OF ANAL
CANCERS
CASE SUMMARY
by
Dr Obiefuna A.G.
 BIODATA
NAME: A C
AGE: 27yrs
SEX : MALE
ADDRESS: AWKUNANAW ENUGU
TRIBE: IGBO
OCCUPATION: TRADING
RELIGION: CHRISTIANITY
 PC
ANAL SORE-----------------
8 months
ANAL PROTRUSION----------
2months
BLEEDING PER RECTUM-----------------2
months
 HPC

PX PRESENTED VIA A&E AND WAS

APPARENTLY WELL UNTIL 8MONTHS
PRIOR TO PRESENTATION WHEN HE
1ST NOTICED
RECURRENT ANAL PROTRUSION
FOLLOWING DEFAECATION WHICH
WAS PAINLESS &ASSOCIATED WITH
PASSAGE OF BLOOD PER ANUM
 HE HAD GONE TO A PERIPHERAL HOSPITAL
WHERE A DIAGNOSIS OF HAEMORRHOID
WAS MADE &PATIENT BOOKED FOR
HAEMORRHOIDECTOMY
INTRA OPERATIVELY AN ANAL TUMOUR WAS
HOWEVER DISCOVERED AND BIOPSY SENT
FOR HISTOLOGY. RESULT REVEALED
INVASIVE SIGNET RING ADENOCARCINOMA
OF THE ANUS
PX WAS REFERRED TO LUTH FOR
CHEMOTHERAPY BUT COULD NOT AFFORD IT.
 THE ANAL TUMOUR BIOPSY SITE FAILED
TO HEAL & FOR 8 MONTHS PX
EXPERIENCED WORSENING ANAL PAIN &
DIFFICULTY IN PASSING STOOL.
THERE WAS ASSOCIATED FAECAL
INCONTINENCE, WEIGHT LOSS,
GENERALIZED BODY WEAKNESS, EASY
FATIGUABILITY
NO FEVER, VOMITING, ABDOMINAL PAIN,
WEAKNESS OF LIMBS, COUGH, CHEST
PAIN, NIL URINARY SYMPTOMS
 HPC
(CONTD)

HE SUBSEQUENTLY PRESENTED TO
UNTH VIA THE CASUALTY FOR
FURTHER EXPERT MANAGEMENT
 PM/SH

NIL PREVIOUS TRANSFUSION

NOT A KNOWN ASTHMATIC, DIABETIC
&
HTNSIVE
 DRUG HX / FSH
NIL OF NOTE
PX IS THE 3RD CHILD IN A
MONOGAMOUS SETTING
PARENTS ARE PETTY TRADERS
DOES NOT DRINK ALCOHOL OR USE
TOBACCO IN ANY FORM
NIL FAMILY HX OF ANAL CANCER
 ON EXAMINATION
A YOUNG MAN, NOT IN OBVIOUS
DISTRESS, MARKEDLY PALE , ANICTERIC,
AFEBRILE, NO PEDAL OEDEMA
ABDOMEN --- WAS FULL & MWR, SOFT,
NIL AREA OF TENDERNESS
PALPABLE INGUINAL LYMPHNODE
DRE-----PATULOUS ANUS WITH POOR
ANAL HYGIENE, ULCERATED MASS
EXTENDING FROM THE ANUS
ENCROACHING UNTO THE PERIANAL SKIN
BETWEEN 6 & 11 O` CLOCK POSITION
COVERED WITH SOME SLOUGH & FAECES.
MARKED TENDERNESS, RECTUM IS EMPTY
 CHEST----- CLINICALLY CLEAR
DIAGNOSIS-----ANAL
CA(ADENOCARCINOMA, SIGNET CELL
TYPE)
INVESTIGATIONS------URGENT
HB(6.5g/dl), FBC(THROMBOCYTOSIS),
SEUCR(LOW CREATININE),
 TREATMENT
PX WAS TRANSFUSED WITH 4 UNITS OF
BLOOD
ANTIBIOTICS, ANALGESICS,
HEMATINICS, MULTIVITAMINS, LAXATIVE,
ANTIHISTAMINES
PALLIATIVE & RADIOTHERAPY TEAMS
WERE INVITED
CHEMORADIATION---FOLFOX 6 AND
CONCURRENT RADIATION
 WHILE ON TREATMENT, HE
DEVELOPED INTESTINAL
OBSTRUCTION FROM THE TUMOUR
AND HAD EMERGENCY
DEFUNCTIONING COLOSTOMY
 RADIOTHERAPY--- 18 COURSES
CHEMOTHERAPY--- 5 COURSES
TUMOUR SIZE MARKEDLY
DECREASED , PX BECAME AMBULANT
AND WAS DISCHARGED HOME TO
RETURN IN 3/52 TO RECEIVE 6TH
COURSE OF CHEMOTHERAPY
 PLAN
REASSESS HIM AFTER THE LAST
COURSE TO DETERMINE IF HE WILL
STILL NEED AP RESECTION
CASE SUMMARY 2
 BIODATA
NAME-----C . E
AGE-----54 YEARS
SEX-----FEMALE
ADDRESS-----IVA VALLEY ENUGU
TRIBE-----IGBO
RELIGION-----CHRISTIANITY
OCCUPATION------TRADER
 P.C
BLEEDING PER RECTUM-----2 YEARS
RIGHT GLUTEAL CLEFT MASS----4
MONTHS
 HPC
PATIENT WAS ADMITTED VIA A&E 3MONTHS
AGO.
SHE WAS WELL UNTIL 2 YEARS PRIOR TO
ADMISSION WHEN SHE STARTED BLEEDING
PER RECTUM
BLEEDING WAS SUDDEN IN ONSET,
PAINLESS, FRANK RED, NO HX OF TRAUMA
THERE WAS ASSOCIATED PASSAGE OF
MUCOID PELLET-LIKE STOOL &
GENERALISED WEAKNESS
 THERE WAS ALSO A 4 MONTHS HX
OF ABDOMINAL PAIN WHICH WAS
INSIDIOUS IN ONSET, GENERALISED,
SEVERE ENOUGH TO AFFECT HER
SLEEP
PX COMPLAINED OF LOSS OF
APPETITE & MILD WEIGHT LOSS
 PM / SH
TRANSFUSED FOLLOWING THE BIRTH
OF HER 2ND CHILD DUE TO POST
PARTUM HEMORRHAGE
NOT A KNOWN ASTHMATIC,
DIABETIC OR HTNSIVE
NO HX OF SURGERY
 DRUG HX / FSH
A WIDOW OF 5 YEARS WITH 7
CHILDREN
NIL FAMILY HX OF CANCER
 ON EXAMINATION
MIDDLE AGED WOMAN IN PAINFUL
DISTRESS, MODERATELY PALE, ANICTERIC,
AFEBRILE, INGUINAL LYMPHADENOPATHY
ABDOMEN-----FULL & MWR,
MILD EPIGASTRIC TENDERNESS, NO
ORGANOMEGALY, BOWEL SOUNDS
PRESENT AND NORMOTENSIVE
DRE--- ULCER OF 5X4 CM WITH
INDURATED BASE & EVERTED EDGE,
TENDERNESS
 RECTUM CONTAINED WATERY STOOL
WITH ALTERED FOUL SMELLING
BLOOD
OTHER SYSTEMS -----NAD
DIAGNOSIS----- ANAL CANCER
 INVESTIGATIONS
USS----RECTAL MASS 4.1 X 4.0 IN
DIAMETER
INCISIONAL BIOPSY/ HISTOLOGY----
INVASIVE WELL DIFFERENTIATED
SQUAMOUS CELL CA
BLOOD TESTS----FBC, HB, SEUCR
(HYPOKALAEMIA)
CHEST X-RAY ----SHOWED NO EVIDENCE
OF INFILTRATES
 TREATMENT
ANTIBIOTICS, ANALGESICS, HEMATINICS,
PROTON PUMP INHIBITOR(OMEPRAZOLE),
LAXATIVES, MULTIVITAMINS
TABS SLOW K
CHEMORADIATION----5-FU & MITOMYCIN C
(1ST COURSE HAS BEEN COMPLETED) AND
17 DOSES OF RADIATION SO FAR
DAILY DRESSING WITH SULFRATULLE
AFTER PUS EXPRESSION
 WHILE ON ADMISSION, PX COMPLAINED
OF DIARRHOEA, SORE THROAT, PERI ANAL
PAIN, NAUSEA & URINARY URGENCY
PX ALSO DEVELOPED POST RADIATION
DERMATITIS ON THE ANAL CLEFT
PX IS CURRENTLY ON ADMISSION,
AWAITING THE 2ND DOSE OF
CHEMOTHERAPY
GENERAL CONDITION IS STABLE.
 Anatomy
of the
Anal canal
by
Dr Ngwangwa C. L.
 Anatomy
Last 4cm of the
alimentary tract

Muscular tube
containing mostly
circular fibers of
internal and
external sphincters
 Anatomy
Extends from the
anorectal ring to
the anal verge,
passing downwards
and backwards
 Anatomy
Relations
Anteriorly perineal
body and vagina in
females

Posteriorly coccyx

Laterally -
ischiorectal fossa
bilaterally
 Anatomy
Relations
Anteriorly in males,
urethra
 Anatomy
Walls
External sphincter

Internal sphincter

Mucosa and
submucosa
 Anatomy
Deep
Superficial
Subcutaneous
Blend with one
another
Blends with
puborectalis superiorly
Contributes to the
anococcygeal
ligament posteriorly
 Anatomy
Lower end curves
inwards below the
lower end of the
internal spthincter
Forms an
intersphinceric
groove with the
internal sphincter
at the lower end of
the anal canal
 Anatomy
Internal sphincter
Thickened downwards
continuation of the
inner circular muscle of
the rectum
extends of the
length of the anal canal
Mucus memebrane
Upper part shows 6- 10
longitudinal ridges- anal
columns
Anal valves are small
horizontal mucosal folds
joining lower ends of
the anal columns
 Anatomy
Pectinate or
dentate line marks
the level of the anal
valves and its the
transitional zone
Above the anal
valves are the anal
sinuses into which
the anal glands
open
 Anatomy
Histologically
Anal columns- columnar epithelium
Pecten non keratinized squamous cell
Below the intersphinteric groove-
keratinizes squamous epithelium
Anal cushions
3, 7 and 11 oclock position at the upper
anal canal
 Anatomy
Anal cushions
Smaller ones may exist in between
Small submucosal masses comprising of
fibroelastic connective tissues, smooth
muscle, dialated venous spaces and
arteriovenous anastomosis
Assist the anal sphincters to maintain
water tight closure of the canal
Excessive straining can cause its dilatation
 Anatomy
Blood supply
Branch of the
superior rectal
artery upper part

Inferior rectal artery

lower end

Median sacral
artery some parts
of the muscle wall
 Anatomy
Venous drainage
Upper part drains via
the superior rectal to
the inferior mesenteric
and to the portal veins
Lower end drains into
internal iliac vein via
the middle and inferior
rectal veins
Site of portal-systemic
anastomosis and it lies
within the anal columns
 Anatomy
Lymphatic drainage
Upper canal drains upwards into the
lymphatics of the rectum to the
pararectal and inferior mesenteric
lymph nodes

Lower end into the superficial inguinal

lymph nodes
 Anatomy
Nerve supply
Somatic Inferior rectal branches of the
pudendal nerve supply the external
spincter and provide sensory supply
from 1-2cm above the pectinate line
downwards
Motor supply is from the S2 segment
Internal sphincter and upper canal is
supplied by autonomic nerves
 Anatomy
Sympathetic fibers from hypogastric
plexus from L1-L2 cause contraction
Pelvic splanchnic nerves relax it
 Anatomy
THANK YOU
PATHOLOGY OF ANAL
CANCERS
BY
DR JUDE .K. EDE
 OUTLINE
INTRODUCTION
EPIDERMIOLOGY
CLASSIFICATION
AETIOLOGY/RISK FACTORS
SPREAD
STAGING
COMPLICATIONS
DIFFERENTIAL DIAGNOSIS
CONCLUSION
 INTRODUCTION
Anal cancers comprise all malignancies arising
from the anal canal or anal margin (Peri- anal
skin)
Relatively uncommon, incidence has been
increasing in the last decades
About 80% are squamous cell Cas , of which
HPV infection is implicated in about 90%
Involvement of the anal sphincter mechanism
by the disease or its treatment affects
continence and so, quality of life
Early stages can easily be mistaken for benign
conditions, hence a high index of suspicion is
necessarry
 EPIDEMIOLOGY
2012-------6 ,230 new cases per year in the USA,
780 deaths
2007--------4, 650 new cases and 690 deaths
2002------30, 400 new cases world wide, with near
equal distribution between developed and developing
world(14,500 and 15 900)
Prevalence of 0.2---1.4/100 000 in general population
but 35/100 000 among MSMs
2-4% of GIT cancers
Mandong and Sule in JUTH, found anal Ca make up
3% of GIT cancers *
 CLASSIFICATION
ANAL CANAL TUMOURS ANAL MARGIN
Anal Intraepithelial TUMOURS
neoplasm Bowens Disease
Squamous Cell Pagets Disease
Ca(Epidermoid Ca)
Squamous Cell Ca
Cloacogenic Ca(Basaloid
Ca, Transitional Ca) Basal Cell Ca
Muco-Epidermoid Ca Verrucous
Adenocarcinoma Carcinoma( Giant
Melanoma Condylomata
Accuminatum,
Other rare tms eg--- Buschke-Loweisteins
Lymphomas, Carcinoid Tm)
tms, connactive tissue
tms etc
 AETIOLOGY/RISK
FACTORS(SQUAM CELL CA)
Age > 50 yrs
Sex M:F, 1 : 1.5
Race---Higher In African Americans
HPV infection
Receptive anal sex
Early onset of sexual activity
Multiple sexual patners
HIV infection
Cigarrete Smoking
Decreased Cell Mediated immunity eg
immunosupression after transplants
Male circumcision is protective
 SPREAD
Direct spread to contiguous
structures eg vagina etc
Lymphatic spread to pelvic and
inguinal nodes etc
Heamatogenous to distant organs eg
liver , lung etc
 staging
ANAL CARCINOMA STAGING SYSTEM OF
AMERICAN JOINT COMMITTEE ON CANCER
Primary tumour T
Tx primary tumour cannot be assessed
To no evidence of primary tumour
Tis CIN
T1 primary tumour is < or = 2cm
T2 tumour >2cm but <5cm
T3 tumour >5cm
T4 tumour of any size invades adjacent
organs vagina, urethra,bladder.
 N is nodal status.
Nx regional lymphnode cannot be assessed
N0 no regional lymphnode metastasis
N1 metastasis in perirectal L/Ns
N2 metastasis in unilat int iliac and/or inguinal
L/Ns.
N3 metastasis in perirectal and inguinal L/Ns and/or
bilat internal iliac and/or inguinal nodes

M distant metastasis
Mx presence of distant metastasis cannot be assessed
M0 no distant metastasis
M1 distant metastasis
 STAGE 0 Tis N0 M0
STAGE I T1 N0 M0
STAGE II T2 N0 M0
T3 N0 M0
STAGE IIIA T1 N1 M0
T2 N1 M0
T3 N1 M0
T4 N0 M0
STAGE IIIB Any T N2 M0
Any T N3 M0
STAGE IV AnyT Any N M0
 COMPLICATIONS
Acute on chronic Intestinal
Obstruction
Fistulae formation
Incontinence
Haemorhage
 Differential Diagnosis
Benign anal tms---lymphoid polyps,
Inflammatory polyps,hypertrophied
anal papillae, skin tags, condylomas
Dermatological Conditions eg
Psoriasis, Leucoplakia, Eczema etc
Haemorhoids
 Rectal Syphilis

STD caused by Treponema pallidum. Can cause proctitis and painful

ulcers above the dentate line in primary. Wart like Condyloma lata in
second stage. Ulcerated mass may be confused with anal cancer. Bx
shows spirochetes. Rx 2.4 million units of benzathine penicillin G.
 Condyloma Accuminata

Human papilloma virus (HPV) most common STD, 6.2 million new
cases/yr. Types 6,11, and 42 cause raised lesions. Types 16,18, &
31 associated with anal squamous cancer. Transmitted via skin
contact, risk reduced but not prevented by condoms. Vaccine for
6,11,16, 18 females age 11-12.
 CONCLUSION
A relatively uncommon condition that
may mimic benign conditions in its
early stages
May also present late because of
natural shame in complaining of
problems around the anus
High index of suspicion, and thorough
evaluation may make a lot of difference
in survival and sphincter preservation
 CLINICAL FEATURES
AND
INVESTIGATIONS
OF A PATIENT WITH
ANAL CANCER

PRESENTER:
DR. EKWEDIGWE, H. C.
 OUTLINE
Introduction
History
Examination
Investigations
Differential diagnosis
Conclusion
 Introduction
Early symptoms and signs vary and
mimic benign anal conditions leading
to late presentation.

A high index of suspicion and early

diagnosis makes a lot of difference
both in survival and preservation of
anal sphincter integrity.
 History
Age 5-6th decade
Sex more in females, male
incidence is on increase.
May be asymptomatic
Histology result for hemorrhoid
specimens
During screening for high risk patients
Anal mass
Bleeding
Discharging
 History
Groin swellings
Perianal skin changes frequent, recurrent
Pruritus
Burning
Soreness
Tenesmus
Pain, incontinence
Anal obstruction with associated constipation
Change in bowel habit
Respiratory distress
Yellowness of the eyes.
Weight loss
 History
Benign anal lesions
Hemorrhoids
Chronic fistula
Condylomas
leucoplakia
Multiple sexual partners/ Receptive
anal intercourse
Previous irradiation
Immunosuppression
Other CAs vulva, vaginal, cervix
Smoking
 Examination
General Examination.
Chronically ill looking
Pallor
Emaciated
Groin lymphadenopathy
Patient can be in painful distress: severe anal pain,
constipation.
Abdomen Distension, Organomegally,
ascitis
Perianal
Indurated perianal skin lesions
Erythematous changes
fissure
 Examination
- Nodules
- Wartlike lesions
- Ulcers -Rolled or everted edges
- Hemorrhoids
- Fistula
 Examination
DRE
Tumor location
Size
Mobility or fixity
Anal sphincteric tone
Pararectal nodes.
Anoscopy, proctoscopy.
Examination under Anaesthesia.
OTHER SYSTEMIC EXAMINATION
 Investigation
To confirm diagnosis
Biopsy
Sigmoidoscopy
Colonoscopy
To assess the extent of the disease.
Endoanal ultrasound scan.
Abdominal uss
CT scan
MRI
Electromyography
CXR
 Investigation
To rule out co-morbidities
- FBS
- ECG
- CXR
To work-up for treatment
FBC
SEUCr
Urinalysis
 Differential Diagnosis
AIN
Psoriasis
Eczema
Leukoplakia
Monilial Infections
Anal Ca
Papilloma
Anal condyloma
Hemorrhoids
 Conclusion
High index of suspicion, good
knowledge of clinical features and
investigative findings will help in
early diagnosis enabling treatment
aimed at cure.
THANKS
TREATMENT OF ANAL
CANCERS
BY
JUDE .K. EDE
 OUTLINE
INTRODUCTION
HISTORICAL PERSPECTIVES
CURRENT TREATMENT OPTIONS
FOLLOW UP
PREVENTION
PROGNOSIS
conclusion
 INTRODUCTION
ANAL MALIGNANCIES:
Treatment of anal cancers has undergone a
revolution in the last 3-4 decades since the work of
Nigro and colleagues
Histological type, tumor size, location ,stage and
patient condition at presentation determine choice
of treatment modality
Combined modality treatment has evolved over
time leading to the Organ Preservation
Treatment Concept minimizing need for radical
surgeries, yet with comparable long term survival
advantage
Emergency presentations eg intestinal obstruction
must be addressed first
 TREATMENT: Squam cell ca
HISTORICAL PERSPECTIVE
1920s-----Radiosensitive nature was already
recognized but the low energy nature of machine
led to much toxicity and low tm response
Surgery was mainstay with APR.
1950s ---- Advent of Cobalt machine. Role of
radiotherapy increases
1974------ NIGRO PROTOCOL. Combined
modality. Era of Organ Preservation
Continued evolution of both radiotherapy
regimen, and chemotherapy regimen
Role of surgery diminishing, and is more of
adjuvant role
 NIGRO PROTOCOL
EBRT-----Pelvic tm, pelvic nodes,
inguinal nodes
Total of 3000cGy over 15 fractions
5 FU 1000mg/m2/day x 4 days by
continous infusion. Then repeated
after 28 days
Mitomycin C 15mg/m2 Bolus
 Chemoradiation therapy is still
evolving. Currently tendency is to use
higher dose of radiotherapy .
Optimum dose of chemotherapy
regime, radiotherapy doze and
fractionation still subject of various
trials
Interstitial therapy with Iridium 192,
Radiotherapy alone have been tried
 Surgery alone--------5070% 5 yr survival
.This drops to 20% if pelvic lymphnodes are
involved
UKCCCR ACT I and II-----Showed clear
advantage of chemoradiation over
Radiotherapy alone. Complete Response
was 70%. 5 yr survival 75%
EORTC
RTOG 98-11 Replaces Mitomycin C with
Cisplatin
 ROLE OF SURGERY
EUA
BIOPSY
SALVAGE ----residual and recurrent
diseases
COMPLICATIONS eg Intestinal
obstruction, fistulae formations
EARLY LESIONS------Stages 0, and I
 FOLLOW UP
Starts 6 wks after treatment
seen every 3-6 months
About 87% of recurrence occur in the 1st 2
years after treatment
Response continues up till 9 months from
end of treatment
LOOK OUT FOR
HX
PE---DRE, Palpate inguinal LNs, proctoscopy,
Endoanal Ultrasonography
CT Scan of abdomen and chest
 PROGNOSIS
Chemo radiation----64-86% complete
response
5 yr survival ---------75%
PROGNOSTIC FACTORS---Inguinal LN
status, TM size > 5cm, Adjacent
organ involvement, co-morbidities
 PREVENTION
Education---aimed at preventing HPV
infection and smoking
?Anal PaP smear
Vaccination----Gardasil
 OTHERS
ADENOCARCINOMAS----- APR if Operable then adjuvant
chemotherapy and radiotherapy. Outcome is generally
poor. WLE in well differentiated TM < 2cm
PAGETS DIZ------- Accurate mapping, rule out underlying
malignancy with full colonoscopy. Rule out local invasion.
WIDE excision with 1cm margin done. Reconstruction
with V-Y advancement flap may be necessary. If diz is
extensive with local invasion or underlying Colorectal TM,
then Abdominoperineal resection is done
BOWENS DIZ----- wide excision
MELANOMA-----
LYMPHOMA--------Chemotherapy
ANAL MARGIN CANCERS------ Treated like skin cancers.
However when they are bulky and encroach into anal
canal, they are managed like anal canal tms
 CONCLUSION
Their uncommon nature should make
the clinician wary to ensure early
detection and better outcome in
terms of survival and quality of life
 THANKS FOR YOUR TIME

WE WILL BE GLAD TO HEAR YOUR

CONTRIBUTIONS