Anal carcinoma C44.5

• Anal rim carcinoma: Skin carcinoma with predominantly flat and ulcerous spread.
• Anal channel carcinoma: Predominantly squamous cell carcinoma.
• Transitional cell carcinoma: Carcinoma originating from the transitional epithelium.
• Adenocarcinoma of the anal canal.

• Rarely. Anal carcinomas account for about 1-2% of all colorectal carcinomas and about 4% of all rectal carcinomas. 60-70% of carcinomas are squamous cell carcinomas. Constant increase in the number of new cases in recent decades with a further rise in incidence.
• Frequency peaks between 60 and 70 years of age.
• Increasingly frequent in cases of infection with HIV, HSV, gonorrhoea, risky sexual practices, organ transplantation.

• Tumor growth does not usually begin de novo; it usually develops on previously damaged skin, such as lichen planus, acne inversa, inflammatory bowel diseases such as Crohn's disease or lichen sclerosus et atrophicus.
• Long-term immunosuppression (especially HIV infection) promotes the development of tumours.
• The connection between "high-risk" papilloma viruses (usually HPV 16 or 18), long-standing condyloma acuminata and malignant transformation into anal carcinoma is confirmed.

• Anal rim carcinoma: Perineal cutis
• Anal canal carcinoma: Between linia dentata and anocutaneous border
• Transitional cell carcinomas: transition zone.

• Coarse, sometimes smooth, mostly woolly skin-coloured to reddish knots. It grows in the course of months and years peripherally and in depth. Patients have increasing complaints only in case of exulceration; in the early stages (see below AIN) often asymptomatic course or perception of a palpable, firm, non-painful skin change.
• Often a complex of symptoms consisting of peranal blood loss (50%), perianal pain, tenesmus, itching, foreign body sensation, stool irregularities, incontinence, enlarged inguinal lymph nodes. Frequently benign concomitant diseases (haemorrhoids, fissure, fistula, condylomata acuminata etc.).
• High-set anal carcinomas metastasize to the inferior mesenteric lymph nodes. Carcinomas of the middle anal canal metastasize into the pelvic lymph nodes. Deep-seated anal carcinomas and anal rim carcinomas metastasize to the inguinal lymph nodes. Rare distant metastases, if occurring, mainly in the liver and lungs.

• BKS, large blood count, electrolytes, creatinine, total protein, Quick, PTT, serum iron, LDH, gamma-GT, AP, GPT
• Tumour markers: CEA, CA 19-9. Tumour markers not for screening! At elevated values, tumour markers are an excellent way to measure the effectiveness of the therapy.

• Small lesions (< 1 cm and isolated mucosal involvement): total biopsy (tumour excision).
• Larger lesions and infiltration of muscles: incision or punch biopsy.
• Computer tomography (or PetCT) or MRI of the abdomen and pelvis
• X-ray examination of the thorax in two planes.

Caution!

• Radiotherapy:
  • Single dose of 1.8 Gy in once-daily and five times-weekly fractionation up to a total dose of 50.4 Gy.
  • Irradiation of the groin electively up to a total dose of 45 Gy.
• Simultaneous chemotherapy: In the first and fifth week of treatment:
  • 5-FU (1000 mg/day/m2 KO on days 1 to 5 and 29 to 33 as 120-hour infusion).
  • Mitomycin C (10 mg/day/m2 KO on days 1 and 29 as an intravenous bolus).
• Alternatively:
  • 5-FU (1000 mg/day/m2 KO on days 1-4 or 750 mg/day/m2 KO on days 1-5).
  • Mitomycin C (10-15 mg/day/m2 KO on days 1 and 29 as an intravenous bolus).

Required in patients with anal canal cancer, after radiochemotherapy or local excision.

• A 50-year-old non-homosexual patient noticed for about 10 weeks a newly appeared, little itchy, firm lump in the perianal area. Since this time continuous growth in size. Slight burning and pulling as well as increased secretion is indicated. Previous local therapies were insufficient. The patient lives in a stable partnership and has no history of changing sexual contacts.
• STD-diagnostics: Swabs for Neisseria gonorrhoeae, trichomonads and mycoplasmas, Candida albicans as well as HIV and syphilis serology were o.B.
• Proctoscopically, a fixed, centrally ulcerated lump, limited to the perianal region, was visible, which was movable on the surface.
• Histology: Part of a moderately differentiated, invasive, keratinizing squamous cell carcinoma.
• HPV diagnostics: Detection of HPV-16/18/45 DNA (high-risk HPV DNA)
• Sonography and Pet-CT: No lymph node or distant metastases.
• Therapy: Combined radio-chemotherapy.

1. Fenger C (2002) Prognostic factors in anal carcinoma. Pathology 34: 573-378
2. Hung A et al (2003) Cisplatin-based combined modality therapy for anal carcinoma. Cancer 97: 1195-1202
3. Rode S et al (2011) Perianal ulcerated node. Abstract CD 46th DDG meeting AKS19/05
4. Saldanha G et al (2003) Basal cell carcinoma: a dermatopathological and molecular biological update. Br J Dermatol 148: 195-202
5. Guidelines for the treatment of anal carcinoma (2002) (Interdisciplinary guideline of the German Cancer Society and the German Society for Surgery/AWMF Guidelines)