Journal of the Royal Society of Medicine Volume 84 July 1991
Anal
cancer:
the
A T Edwards FRCS
case
395
for earlier diagnosis
L C Morus FRcs
M E Foster MChir FRCS
G H Griffith FRCS
Department of Surgery, Royal Gwent Hospital, Newport, Gwent NP2 2UB Keywords: anal carcinoma; incorrect diagnosis; delay; surgery; results
Summary The results of treatment in 22 patients with anal carcinoma are reviewed. The overall results are disappointing with only five (28%) surviving more than 5 years. The commonest form of treatment during the study period was an abdomino-perineal excision of rectum (APER). For patients with tumours less than 2 cm in diameter local excision is an acceptable alternative. The majority (76%) of tumours were diagnosed as common benign conditions by the referring practitioners leading to a delay in initiating definitive treatment. Most tumours (81%) were greater than 2 cm in diameter and therefore unsuitable for local excision. There was a high recurrence rate (76%) amongst the group treated by APER. This along with the poor overall survival is probably due to late presentation. Introduction Anal carcinoma is an uncommon tumour accounting for 2-3% of large bowel tumours"2. Tumours are subdivided on the basis of whether they arise within the anal canal or from the anal margin. The latter behave like other skin cancers and consequently carry a better prognosis. The two main types of anal carcinoma are squamous cell and basaloid tumours. Rarer varieties are adenocarcinomas arising within the anal glands and the even rarer malignant melanoma. The traditional form of treatment in this country, for all but the smallest tumours, has been a radical operation in the form of an -abdomino-perineal excision of rectum (APER) with the formation of a permanent stoma3. However, this method of treatment has recently been challenged with good results being claimed for radiotherapy4 and chemotherapy5. We have reviewed the results of surgical treatment in 22 patients over a 10-year period, and have attempted to determine any factors which might have affected their outcome. Patients and methods A review of patients with a diagnosis of carcinoma of the anus was performed for the period 1976 to 1986. Twenty-two patients were identified from pathology department records at the Royal Gwent Hospital, Newport. There was an equal incidence in men (11) and women (11). The average age was 63 years, ranging from 45 to 81 years. The following information was recorded: mode of presentation, general practitioner diagnosis (obtained from referral letter), histological type, stage, lymph node involvement, method of treatment, timing and nature of any recurrence and final outcome.
Table 1. Presenting features amongst patients with anal carcinoma (n=22)
Presenting feature
No
%
Rectal bleeding Discharge Lump Pain
14 7 3 3 1 1 1 1
64 32 14 14 5 5 5 5
Dysuria/frequency Vaginal discharge Weight loss Incidental Table 2. Diagnosis at referral (n=21)
Referral diagnosis
No
Piles Abscess Warts Diverticulitis No diagnosis Cancer
9 2 1 1 3 5
Results Presentations The commonest presenting features were rectal bleeding and discharge. Patients complained less commonly of a lump or of pain. Other presentations are shown in Table 1.
General practitioner diagnosis The diagnosis at referral was noted by reviewing the general practitioner referral letters. In one patient the finding of an anal carcinoma was an incidental one during an examination for epigastric pain. In 17 patients a benign condition was diagnosed (Table 2). In five patients a diagnosis of a malignant process was made, but none suggested the possibility of anal carcinoma. All were assumed to be rectal cancers. The diagnosis of anal carcinoma was correctly made on rectal examination and proctoscopic appearance when seen at their first hospital visit.
Histological type and tunour stage There were 17 (77%) patients with squamous cell 0141-0768/91/ carcinoma, four (18%) had basaloid tumours and one 070395.031$02.00/0 had an adenocarcinoma arising within an anal gland. 0 1991 The tumours were staged using the system devised The Royal by Papillon6. We were only able to accurately stage Society of 18 tumours (Table 3). Medicine
396
Journal of the Royal Society of Medicine Volume 84 July 1991
Table 3. Distribution of anal carcinomas by stage (n=18) Tumour stage
No
%
T1
Anal
cancer:
the
A T Edwards FRCS
case
395
for earlier diagnosis
L C Morus FRcs
M E Foster MChir FRCS
G H Griffith FRCS
Department of Surgery, Royal Gwent Hospital, Newport, Gwent NP2 2UB Keywords: anal carcinoma; incorrect diagnosis; delay; surgery; results
Summary The results of treatment in 22 patients with anal carcinoma are reviewed. The overall results are disappointing with only five (28%) surviving more than 5 years. The commonest form of treatment during the study period was an abdomino-perineal excision of rectum (APER). For patients with tumours less than 2 cm in diameter local excision is an acceptable alternative. The majority (76%) of tumours were diagnosed as common benign conditions by the referring practitioners leading to a delay in initiating definitive treatment. Most tumours (81%) were greater than 2 cm in diameter and therefore unsuitable for local excision. There was a high recurrence rate (76%) amongst the group treated by APER. This along with the poor overall survival is probably due to late presentation. Introduction Anal carcinoma is an uncommon tumour accounting for 2-3% of large bowel tumours"2. Tumours are subdivided on the basis of whether they arise within the anal canal or from the anal margin. The latter behave like other skin cancers and consequently carry a better prognosis. The two main types of anal carcinoma are squamous cell and basaloid tumours. Rarer varieties are adenocarcinomas arising within the anal glands and the even rarer malignant melanoma. The traditional form of treatment in this country, for all but the smallest tumours, has been a radical operation in the form of an -abdomino-perineal excision of rectum (APER) with the formation of a permanent stoma3. However, this method of treatment has recently been challenged with good results being claimed for radiotherapy4 and chemotherapy5. We have reviewed the results of surgical treatment in 22 patients over a 10-year period, and have attempted to determine any factors which might have affected their outcome. Patients and methods A review of patients with a diagnosis of carcinoma of the anus was performed for the period 1976 to 1986. Twenty-two patients were identified from pathology department records at the Royal Gwent Hospital, Newport. There was an equal incidence in men (11) and women (11). The average age was 63 years, ranging from 45 to 81 years. The following information was recorded: mode of presentation, general practitioner diagnosis (obtained from referral letter), histological type, stage, lymph node involvement, method of treatment, timing and nature of any recurrence and final outcome.
Table 1. Presenting features amongst patients with anal carcinoma (n=22)
Presenting feature
No
%
Rectal bleeding Discharge Lump Pain
14 7 3 3 1 1 1 1
64 32 14 14 5 5 5 5
Dysuria/frequency Vaginal discharge Weight loss Incidental Table 2. Diagnosis at referral (n=21)
Referral diagnosis
No
Piles Abscess Warts Diverticulitis No diagnosis Cancer
9 2 1 1 3 5
Results Presentations The commonest presenting features were rectal bleeding and discharge. Patients complained less commonly of a lump or of pain. Other presentations are shown in Table 1.
General practitioner diagnosis The diagnosis at referral was noted by reviewing the general practitioner referral letters. In one patient the finding of an anal carcinoma was an incidental one during an examination for epigastric pain. In 17 patients a benign condition was diagnosed (Table 2). In five patients a diagnosis of a malignant process was made, but none suggested the possibility of anal carcinoma. All were assumed to be rectal cancers. The diagnosis of anal carcinoma was correctly made on rectal examination and proctoscopic appearance when seen at their first hospital visit.
Histological type and tunour stage There were 17 (77%) patients with squamous cell 0141-0768/91/ carcinoma, four (18%) had basaloid tumours and one 070395.031$02.00/0 had an adenocarcinoma arising within an anal gland. 0 1991 The tumours were staged using the system devised The Royal by Papillon6. We were only able to accurately stage Society of 18 tumours (Table 3). Medicine
396
Journal of the Royal Society of Medicine Volume 84 July 1991
Table 3. Distribution of anal carcinomas by stage (n=18) Tumour stage
No
%
T1
