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Anal cancers are rare disease entities. Their treatment requires interdisciplinary multimodal therapy in experienced and specialized centers. Many studies have shown remarkable results in terms of individual aspects of diagnosis and treatment, but in the context of a review article addressing a general medical readership, it was not possible always to reflect these in detail.
For HIV patients, the 2013 German-language guidelines from the Association of the Scientific Medical Societies in Germany (AWMF) apply (1). However, as these guidelines are not widely accepted internationally, and as our article is available in an English version, it seemed more appropriate in the given context to explain the international guidelines. In the guidelines of the National Comprehensive Cancer Network (NCCN), screening in HIV positive patients and homosexual men is the subject of controversial discussion, since to date, no randomized study has evaluated the effectiveness of a screening program in terms of a reduced incidence and mortality in anal carcinoma in HIV positive patients (2). The European Society for Medical Oncology (ESMO) expresses similar sentiments in its guidelines (3).
We explicitly highlighted immunosuppression as a risk factor in our article in Box 1. The effectiveness of the quadrivalent HPV vaccine given prophylactically in order to prevent anal dysplasia in men who have sex with men is unequivocally confirmed. The results of the larger study from England were presented. In addition to England, vaccination against HPV is recommended for both sexes in Canada, Austria, and Australia (4).
According to current guidelines, only the well differentiated T1 lesions of the anal margin should be treated by primary excision. In T2 carcinomas on the anal margin (measuring 2–5 cm at their largest diameter), neoadjuvant radiochemotherapy is the preferred option because of deleterious effects of surgery on sphincter function and continence. The American Society of Colon and Rectal Surgeons (ASCRS) in its guideline recommends excision unequivocally for T1 (≤2 cm), N0, G1 anal margin carcinomas with a safety resection margin of 1 cm. The European guidelines recommend a 5 mm safety margin for adequate resection. In larger cancers of the anal margin and in tumors of the anal canal in any stage, primary local excision is contraindicated (2, 3).
In suspected recurrence, incision biopsies should—in our experience—be avoided, if possible, since only more extensive excisions would find possible diffuse or scattered/dispersed tumor islands in the case of incomplete remission or relapse. Excisions in the anal canal should also be avoided at initial diagnosis as the risk of incontinence and vastly delayed wound healing in the radiation field are is very high.
In addition to disrupted wound healing, sexual dysfunction can occur after irradiation of the female pelvic region, owing to hormonal ovarian endocrine insufficiency and trophic changes to the vagina, some of which require treatment. These aspects of treatment are covered in the regular information given to patients; the standardized information for patients unambiguously mentions ovarian endocrine insufficiency as well as changes to the vaginal epithelium as adverse effects.
Dr. Dimitrios Raptis,
Prof. Dr. med. Ignaz Schneider,
Prof. Dr. med. Klaus E. Matzel,
Prof. Dr. med. Dr. h.c. Werner Hohenberger,
Chirurgische Klinik, Universitätsklinikum Erlangen
PD Dr. med. Oliver Ott,
Prof. Dr. med. Rainer Fietkau
Strahlenklinik, Universitätsklinikum Erlangen
Conflict of interest statement
The authors declare that no conflict of interest exists.
|1.||AWMF: Anale Dysplasien und Analkarzinome bei HIV-Infizierten: Prävention, Diagnostik und Therapie. www.awmf.org/leitlinien/detail/ll/055–007.html (last accessed on 20 May 2015).|
|2.||NCCN: NCCN Guidelines Anal Carcinoma Version 2.2015. www.nccn.org/professionals/physician_gls/f_guidelines.asp#anal (last accessed on 20 May 2015).|
|3.||Glynne-Jones R, Nilsson PJ, et al.: Anal cancer: ESMO-ESSO-ESTRO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 25 Suppl 3:iii10-iii20 MEDLINE|
|4.||Stanley M: HPV vaccination in boys and men. Hum Vaccin Immunother 2014; 10: 2109–11.|
|5.||Raptis D, Schneider I, Matzel KE, Ott O, Fietkau R, Hohenberger W: The differential diagnosis and interdisciplinary treatment of anal carcinoma. Dtsch Arztebl Int 2015; 112: 243–9 MEDLINE|