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Anal Cancer

By Elliot M. Livstone, MD, Emeritus Staff, Sarasota Memorial Hospital, Sarasota, FL

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Anal cancer accounts for an estimated 8080 cases and about 1080 deaths in the US annually (1). The main symptom is bleeding with defecation. Diagnosis is by colonoscopy. Treatment options include excision and chemotherapy and radiation therapy.

Squamous cell carcinoma (nonkeratinizing squamous cell or basaloid carcinoma) of the anorectum accounts for 3 to 5% of distal large-bowel cancers. Basal cell carcinoma, Bowen disease (intraepidermal squamous cell carcinoma), extramammary Paget disease, cloacogenic carcinoma, and malignant melanoma are less common. Other tumors include lymphoma and various sarcomas. Metastasis occurs along the lymphatics of the rectum and into the inguinal lymph nodes.

Risk factors for anal cancer include the following:

People having receptive anal intercourse are at increased risk. Patients with HPV infection may manifest dysplasia in slightly abnormal or normal-appearing anal epithelium (anal intraepithelial neoplasia—histologically graded I, II, or III). These changes are more common among HIV-infected patients (see Squamous cell cancer of the anus and vulva). Higher grades may progress to invasive carcinoma. It is unclear whether early recognition and eradication improve long-term outcome; hence, screening recommendations are unclear.

General reference

Symptoms and Signs

Bleeding with defecation is the most common initial symptom of anal cancer. Some patients have pain, tenesmus, or a sensation of incomplete evacuation. A mass may be palpable on digital rectal examination.

Diagnosis

  • Colonoscopy

  • Sometimes biopsy

Whenever rectal bleeding occurs, even in patients with obvious hemorrhoids or known diverticular disease, coexisting cancer must be ruled out. Typically, colonoscopy is done, but skin biopsy by a dermatologist or surgeon might be needed for lesions near the squamocolumnar junction (Z line).

Staging by CT, MRI, or PET is advisable.

Treatment

  • Excision

  • Combination chemotherapy and radiation therapy

  • Sometimes surgical resection

Wide local excision is often satisfactory treatment of perianal carcinomas.

Combination chemotherapy and radiation therapy result in a high rate of cure when used for anal squamous and cloacogenic tumors.

Abdominoperineal resection is indicated when radiation and chemotherapy do not result in complete regression of tumor and there are no metastases outside of the radiation field.

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