Salvage Surgery for Anal Cancer

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Few surgeons in the UK provide this service. There is a growing argument that this type of surgery should be concentrated in the hands of even fewer surgeons to improve results. I am one of the surgeons who provide this service in Kent.

Anal cancers are treated initially by combined modality therapy (CMT), which means radiotherapy and chemotherapy. This is successful in many patients and has essentially replaced surgery as the primary modality since Nigro's pioneering work in the 1970s.

However, surgery is far from being obsolete in this cancer. Up to 30 - 40% of patients with anal squamous cancer will fail CMT or have local recurrence after such treatment. Furthermore surgeons play an important role in other aspects of management as summarized below:

Role of surgery in anal cancer

1. Follow Up, especially the role of EUAs (Examination Under Anaesthesia) & biopsies, to detect residual or recurrent cancer earlier.

2. Salvage surgery (Salvage abdominoperineal resection)

3. Salvage inguinal Lymphadenectomy (Salvage removal of groin lymph glands, affected by tumour spread)

4. Management of CMT complications. These can include post radiation faecal incontinence, development of anterior rectovaginal or rectourethral fistulae (abnormal communications or holes between rectum and vagina or urinary passage allowing escape of faeces through these abnormal communications), radionecrosis, ulceration & persistent pain.

Salvage Abdominoperineal resection for anal cancer

Is it reasonable to offer patients who failed radiochemotherapy salvage surgery?

Yes. Failures of CMT are often locoregional (local or in the lymph glands) & not associated with disseminated disease recurrence, at least initially. The published studies (see table below) suggest that one can expect 30-60% of patients treated with salvage surgery (for persistent or recurrent anal cancer following CMT) to survive 5 years.

Publication	No. of patients	Median FU (Months)	Survival
Tanum, 1993	9	36	67%
Ellenhorn et al, 1994	38	47	44% 5Y
Longo et al, 1994	14	18	53%
Pocard et al, 1998	21	40	58% 3Y
Van der Wal et al, 2001	17	53	47% 5Y
Allal et al, 1999	23	21.5	44.5% 5Y
Akbari et al, 2004	57 47	24 (overall) 59 (potentially curative)	33% 5Y 40% 5Y
Nilsson et al, 2004	35	33	52% 5Y
Ghouti et al, 2005	36	67	69.4% 5Y
Renehan et al, 2005	73		40% 5Y

How difficult are these operations?

Can be difficult

The operation itself can be technically demanding, because of the need for wider perineal clearance, the need to be familiar with inguinal and pelvic lymphadenectomy as well as either familiarity with (or access to) reconstructive techniques such as gracilis & rectus abdominis myocutaneous flaps. Because of the inevitable previous radiotherapy and the large perineal wounds, perineal wounds breakdown in a large proportion of patients, hence the not infrequent need for myocutaneous flaps

The decision making regarding any potential further CMT also need to be made during the surgery. This will influence the use of Vicryl mesh to exclude small bowel from pelvis, marking areas with potential incomplete excision with metal clips. It will also influence the decision of whether to reconstruct the perineal wound primarily or whether to let it granulate and wait until any further CMT is finished.

Salvage lymphadenectomy (especially inguinal)

Again this is a very worthwhile procedure and the literature suggest that 50-60% of patients in this situation will have extended long term survival after lymphadenectomy