CSS.47.AnalCarcinoma

Question 1

what procedure/evaluation is indicated in a patient with anal bleeding that does not respond to medical management?

Answer 1

anoscopy and/or colonoscopy

Question 2

is the first-line treatment for nonmetastatic anal canal carcinoma surgical or nonsurgical?

Answer 2

nonsurgical

Question 3

how long should you wait after chemoradiation for anal carcinoma prior to proceeding to surgery and why?

Answer 3

allow up to 12 weeks for regression of lesion after chemoradiation prior to proceeding to surgery

Question 4

what surgery is indicated if combined chemoradiation fails to treat anal carcinoma?

Answer 4

abdominoperineal resection

Question 5

what is the primary presentation of anal fissure?

Answer 5

sharp pain with defecation, associated with bright red blood when wiping

Question 6

what is the primary presentation of internal hemorrhoids?

Answer 6

painless rectal bleeding

Question 7

what is the primary presentation of thrombosed external hemorrhoids?

Answer 7

constant pain that persists for days

Question 8

what are three common causes of pruritus ani

Answer 8

rectal mucosal prolapse, irritation of hemorrhoidal skin tags, dietary irritants (citrus, caffeine, spicy food, tomatoes, dairy)

Question 9

what are 5 risk factors for anal carcinoma (what makes a patient “high risk”) and what evaluation should you perform for any anal complaints?

Answer 9

age > 50, HIV, HPV (anal/gyn), colorectal adenomas, and relevant family history - endoscopy

Question 10

when evaluating for suspected anal carcinoma, which lymph node basin should you evaluate? how should you evaluate associated lymphadenopathy and why?

Answer 10

pay attention to inguinal nodes, evaluate LA with FNA to r/o regional LN involvement

Question 11

when evaluating suspected anal carcinoma, what three imaging modalities can be used to assess for distant mets?

Answer 11

abdominal/pelvic CT; abdominal pelvic MRI; PET-CT

Question 12

why should you perform a gynecologic evaluation in female patients with suspected anal carcinoma?

Answer 12

evaluate for gynecologic dysplasia b/c HPV is implicated in both neoplastic processes

Question 13

Define T1 anal canal carcinoma

Answer 13

size < 2 cm

Question 14

Define T2 anal canal carcinoma

Answer 14

size 2-4.9cm

Question 15

Define T3 anal canal carcinoma

Answer 15

size >5 cm

Question 16

Define T4 anal canal carcinoma

Answer 16

invades adjacent organs

Question 17

Define N1 anal canal carcinoma

Answer 17

perirectal node involvement

Question 18

Define N2 anal canal carcinoma

Answer 18

Unilateral internal iliac or inguinal LN involvement

Question 19

Define N3 anal canal carcinoma

Answer 19

perirectal AND inguinal LN involvement or bilateral internal iliac / inguinal nodes

Question 20

Define M0 anal canal carcinoma

Answer 20

no distant mets

Question 21

Define M1 anal canal carcinoma

Answer 21

distant mets

Question 22

What are the TNM stages (1) a/w Stage I anal canal carcinoma?

Answer 22

T1N0M0

Question 23

What are the TNM stages (2) a/w Stage II anal canal carcinoma?

Answer 23

T2-3, N0, M0

Question 24

What are the TNM stages (3) a/w Stage IIIA anal canal carcinoma?

Answer 24

T1-3, N1, M0

Question 25

What are the TNM stages (2) a/w Stage IIIB anal canal carcinoma?

Answer 25

T4, N1, M0 OR T-any, N2, M0

Question 26

What are the TNM stages (1) a/w Stage I anal canal carcinoma?

Answer 26

T any, N any, M1

Question 27

why is nonsurgical therapy the standard of care for initial treatment of anal canal carcinoma?

Answer 27

high response rate and high rate of sphincter preservation

Question 28

what is the standard chemoradiation protocol to treat anal canal carcinoma

Answer 28

45 Gy in 25 fractions over 5 weeks to the primary cancer + 5-FU infused on days 1-4 & 29-32 + mitomycin C bolus days 1 & 29

Question 29

what is the systemic therapy for metastatic anal canal carcinoma?

Answer 29

5-FU & cisplatin

Question 30

how long does it take residual anal canal carcinoma to regress after chemoradiation?

Answer 30

up to 12 weeks

Question 31

when should you perform repeat assessment of residual masses after chemoradiation for anal canal carcinoma and how should you evaluate?

Answer 31

biopsy mass at 12 weeks after completion of chemoradiation. If positive, proceed to surgery.

Question 32

Name three preoperative considerations prior to APR for anal canal carcinoma

Answer 32

1) stoma site marking; 2) preop abx; 3) VTE ppx

Question 33

what step should be considered to facilitate wound healing in patients undergoing APR after radiation therapy?

Answer 33

consider a myocutaneous flap

Question 34

what are the basic steps of APR?

Answer 34

1) pt in lithotomy; 2) lap or open mobilization of distal colon and rectum; 3) divide mesentery at proximal SMA pedicle; 4) once dissected to pelvic floor, start dissection from perineal approach cephalad to meet intraabdominal portion while maintaining a wide dissection thru levator muscles; 5) resect specimen and send grossly close margins to frozen for eval; 5) place muscle flap in pelvis and close perineal defect in several layers with absorbable suture

Question 35

how is an APR performed in the supine and prone positions?

Answer 35

perform abdominal portion of procedure in supine position, create colostomy, close abdominal incision, place patient prone to complete perineal portion of procedure

Question 36

what is the postoperative follow up for anal canal carcinoma s/p APR?

Answer 36

follow up q3-6mo for 5 years with inguinal LN examination and anoscopy + topical acetic acid to survey for recurrent HPV dysplasia. If pt with T3 or greater disease or node posiitve disease, annual C/A/P imaging x 3 years

Question 37

what should you do if you encounter metastatic disease at the time of APR?

Answer 37

continue to proceed with APR b/c this may be appropriate for palliation of symptoms from local dz