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Anorectal Cancer

by Elliot M. Livstone, MD

There are about 7000 cases per year of anorectal cancer and > 900 deaths.

The most common anorectal cancer is adenocarcinoma. Squamous cell (nonkeratinizing squamous cell or basaloid) carcinoma of the anorectum accounts for 3 to 5% of distal large-bowel cancers. Basal cell carcinoma, Bowen disease (intradermal 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 include infection with human papillomavirus (HPV), chronic fistulas, irradiated anal skin, leukoplakia, lymphogranuloma venereum, and condyloma acuminatum. 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. Higher grades may progress to invasive carcinoma. It is unclear whether early recognition and eradication improve long-term outcome; hence, screening recommendations are unclear.

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

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.

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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