Techniques in Coloproctology

, Volume 17, Issue 2, pp 171–179 | Cite as

The treatment of squamous anal carcinoma: guidelines of the Italian society of colo-rectal surgery

  • I. Giani
  • M. Mistrangelo
  • C. Fucini
Practice Parameters


The Italian society of colo-rectal surgery (SICCR) is dedicated to improving the study, prevention and management of the diseases of the colon, rectum and anus. One of the aims of the society is to establish guidelines to the treatment of these diseases. These guidelines are based on the international literature and on the best available evidence. Clinical practice guidelines are one of the most important instruments to provide therapeutic decision-making support, based on the best scientific evidence available at the time. Guidelines are advisory and not prescriptive, susceptible to continual variations secondary to innovations and new scientific evidence. These guidelines are a guide for all colo-rectal surgeons and physicians who approach anal cancer.


Anal cancer Guidelines Squamous cancer Anal intraepithelial neoplasia Radiochemotherapy 


Conflict of interest



  1. 1.
    Cook DJ, Guyatt GH, Laupacis A, Sackett DL (1992) Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest 102:S305–S311Google Scholar
  2. 2.
    Clark MA, Hartley A, Geh JI (2004) Cancer of the anal canal. Lancet Oncol 5:149–157PubMedCrossRefGoogle Scholar
  3. 3.
    Klas J, Rothenberger D, Wong WD, Madoff R (1999) Malignant tumors of the anal canal. The spectrum of disease, treatment and outcome. Cancer 85:1686–1693PubMedCrossRefGoogle Scholar
  4. 4.
    Minsky BD, Hoffman JP, Kelsen DP (2001) Cancer of the anal region. In: DeVita VT Jr, Hellman S, Rosenberg SA (eds) Cancer: principles & practice of oncology, 6th edn. Lippincott-Williams & Wilkins, Philadelphia, pp 1319–1342Google Scholar
  5. 5.
    Tanum G (1991) Diagnosis of anal carcinoma-doctor’s finger still the best? Oncology 48:383–386PubMedCrossRefGoogle Scholar
  6. 6.
    Deans GT, McAleer JJA, Spence RAJ (1994) Malignant anal tumours. Br J Surg 81:500–508PubMedCrossRefGoogle Scholar
  7. 7.
    Ryan D, Compton C, Mayer R (2000) Carcinoma of the anal canal. N Engl J Med 342:792–800PubMedCrossRefGoogle Scholar
  8. 8.
    Frisch M, Fenger C, van den Brule AJ et al (1999) Variants of squamous cell carcinoma of the anal canal and perianal skin and their relation to human papilloma viruses. Cancer Res 59:753–757PubMedGoogle Scholar
  9. 9.
    Holmes F, Borek D, Owen-Kummer M et al (1988) Anal cancer in women. Gastroenterology 95:107–111PubMedGoogle Scholar
  10. 10.
    Ryan DP, Mayer RJ (2000) Anal carcinoma: histology, staging, epidemiology, treatment. Curr Opin Oncol 12:345–352PubMedCrossRefGoogle Scholar
  11. 11.
    Beckmann AM, Daling JR, Sherman KJ et al (1989) Human papillomavirus infection and anal cancer. Int J Cancer 43:1042–1049PubMedCrossRefGoogle Scholar
  12. 12.
    Williams GR, Talbot IC (1994) Anal carcinoma: a histological review. Histopathology 25:507–516PubMedCrossRefGoogle Scholar
  13. 13.
    Palmer JG, Scholefield JH, Coates PJ et al (1989) Anal cancer and human papillomaviruses. Dis Colon Rectum 32:1016–1022PubMedCrossRefGoogle Scholar
  14. 14.
    Morson BC, Sobin LH (1976) Histological typing of intestinal tumours. In International histological classification of tumors, no 15. World Health Organization, GenevaGoogle Scholar
  15. 15.
    Cummings BJ, Keane TJ, OSullivan B, Wong CS, Catton CN (1991) Epidermoid anal cancer: treatment by radiation alone or by radiation and 5-fluorouracil with and without mitomycin C. Int J Rad Oncol Biol Phys 21:1115–1125CrossRefGoogle Scholar
  16. 16.
    Greene FL, Page DL, Fleming ID et al (2002) American joint committee on cancer: AJCC cancer staging manual, 6th edn. Springer, New York, pp 157–164Google Scholar
  17. 17.
    Friedlander MA, Stier E, Lin O (2004) Anorectal cytology as a screening tool for anal squamous lesions. Cancer 102:19–26PubMedCrossRefGoogle Scholar
  18. 18.
    Gerard JP, Chapet O, Samiei F et al (2001) Management of inguinal lymph node metastases in patients with carcinoma of the anal canal: experience in a series of 270 patients treated in Lyon and review of the literature. Cancer 92:77–84PubMedCrossRefGoogle Scholar
  19. 19.
    Arnott SJ, Cunningham D, Gallagher J et al (1996) Epidermoid anal cancer: results from the UKCCCR randomised trial of radiotherapy alone versus radiotherapy, 5-fluorouracil, and mitomycin. Lancet 348:1049–1054CrossRefGoogle Scholar
  20. 20.
    Bartelink H, Roelofsen F, Eschwege F et al (1997) Concomitant radiotherapy and chemotherapy is superior to radiotherapy alone in the treatment of locally advanced anal cancer: results of a phase III randomized trial of the European organization for research and treatment of cancer radiotherapy and gastrointestinal cooperative groups. J Clin Oncol 15:2040–2049PubMedGoogle Scholar
  21. 21.
    American Joint Committee on Cancer (1997) AJCC cancer staging manual, 5th edn. Lippincott-Raven Publishers, PhiladelphiaGoogle Scholar
  22. 22.
    Mistrangelo M, Morino M (2009) Sentinel lymph node biopsy in anal cancer: a review. Gastroenterol Clin Biol 33:446–450PubMedCrossRefGoogle Scholar
  23. 23.
    Tarantino D, Bernstein MA (2002) Endoanal ultrasound in the staging and management of squamous-cell carcinoma of the anal canal: potential implications of a new ultrasound staging system. Dis Colon Rectum 45:16–22PubMedCrossRefGoogle Scholar
  24. 24.
    Martellucci J, Naldini G, Colosimo C, Cionini L, Rossi M (2009) Accuracy of endoanal ultrasound in the follow-up assessment for squamous cell carcinoma of the anal canal treated with radiochemotherapy. Surg Endosc 23:1054–1057PubMedCrossRefGoogle Scholar
  25. 25.
    Cotter SE, Grigsby PW, Siegel BA et al (2006) FDG-PET/CT in the evaluation of anal carcinoma. Int J Radiat Oncol Biol Phys 65:720–725PubMedCrossRefGoogle Scholar
  26. 26.
    Anderson C, Koshy M, Staley C et al (2007) PET-CT fusion in radiation management of patients with anorectal tumors. Int J Radiat Oncology Biol Phys 69:155–162CrossRefGoogle Scholar
  27. 27.
    Nguyen BT, Joon DL, Khoo V et al (2008) Assessing the impact of FDG-PET in the management of anal cancer. Radiother Oncol 87:376–382PubMedCrossRefGoogle Scholar
  28. 28.
    de Winton E, Heriot AG, Ng M et al (2009) The impact of 18-fluorodeoxyglucose positron emission tomography on the staging, management and outcome of anal cancer. Br J Cancer 100:693–700PubMedCrossRefGoogle Scholar
  29. 29.
    Renaud S, Guillermand S, Eberlé-Pouzeratte MC et al (2009) Apport de la tomographie par émission de positrons au 18F-fluorodéoxyglucose (TEP-FDG) dans la prise en charge du cancer du canal anal. Med Nucl 33:415–424Google Scholar
  30. 30.
    Mistrangelo M, Pelosi E, Bellò M et al (2010) Comparison of positron emission tomography scanning and sentinel node biopsy in the detection of inguinal node metastases in patients with anal cancer. Int J Radiation Oncol Biol Phys 77:73–78CrossRefGoogle Scholar
  31. 31.
    Franceschi S, De Vuyst H (2009) Human papillomavirus vaccines and anal carcinoma. Curr Opin HIV AIDS 4:57–63PubMedCrossRefGoogle Scholar
  32. 32.
    Monsonego J (2010) Anal cancer and human papillomaviruses: a perspective based on the cervical cancer model. Gynecol Obstet Fertil 38:250–254PubMedCrossRefGoogle Scholar
  33. 33.
    Edge SE, Byrd DR, Compton CC et al (2009) AJCC cancer staging manual, 7th edn. Springer, New YorkGoogle Scholar
  34. 34.
    Martenson JA, Gunderson LL (1993) External radiation therapy without chemotherapy in the management of anal cancer. Cancer 71:1736–1740PubMedCrossRefGoogle Scholar
  35. 35.
    Ajani JA, Winter KA, Gunderson LL et al (2006) Intergroup RTOG 98-11: a phase III randomized study of 5-fluorouracil (5-FU), mitomycin, and radiotherapy versus 5-fluorouracil, cisplatin and radiotherapy in carcinoma of the anal canal. J Clin Oncol 24:4009Google Scholar
  36. 36.
    Faynsod M, Vargas H, Tolmos J et al (2000) Patterns of recurrence in anal canal carcinoma. Arch Surg 135:1090–1095PubMedCrossRefGoogle Scholar
  37. 37.
    International Union Against Cancer (1987) TNM classification of malignant tumors, 4th edn. In: Hermanek P, Sobin LH (eds) Springer, New YorkGoogle Scholar
  38. 38.
    American Joint Committee on Cancer (1987) Manual for staging of cancer, 3rd edn. J B Lippincott, PhiladelphiaGoogle Scholar
  39. 39.
    Nigro ND (1987) Multidisciplinary management of carcinoma of the anus. World J Surg 11:446–451PubMedCrossRefGoogle Scholar
  40. 40.
    Nigro ND, Vaitkevicius VK, Considine B (1974) Combined therapy for cancer of the anal canal. A preliminary report. Dis Colon Rectum 17:354–356PubMedCrossRefGoogle Scholar
  41. 41.
    Fuchshuber PR, Rodriguez-Bigas M, Weber T, Petrelli NJ (1997) Anal canal and perianal epidermoid cancers. J Am Coll Surg 185:494–505PubMedGoogle Scholar
  42. 42.
    Constantinou EC, Daly W, Fung CY et al (1997) Time-dose considerations in the treatment of anal cancer. Int J Radiat Oncol Biol Phys 39:651–657PubMedCrossRefGoogle Scholar
  43. 43.
    Touboul E, Schlienger M, Buffat L et al (1994) Epidermoid carcinoma of the anal canal. Results of curative-intent radiation therapy in a series of 270 patients. Cancer 73:1569–1579PubMedCrossRefGoogle Scholar
  44. 44.
    Graf R, Wust P, Hildebrandt B et al (2003) Impact of overall treatment time on local control of anal cancer treated with radiochemotherapy. Oncology 65:14–22PubMedCrossRefGoogle Scholar
  45. 45.
    Deniaud-Alexandre E, Touboul E, Tiret E et al (2003) Epidermoid carcinomas of the anal canal treated with definitive radiation therapy in a series of 305 patients. Cancer Radiotherapie 7:237–253PubMedCrossRefGoogle Scholar
  46. 46.
    Berry JM, Palefsky JM, Welton ML (2004) Anal cancer and its precursors in HIV-positive patients: perspectives and management. Surg Oncol Clin N Am 13:355–373PubMedCrossRefGoogle Scholar
  47. 47.
    Papaconstantinou HT, Bullard KM, Rothenberger DA, Madoff RD (2006) Salvage abdominoperineal resection after failed Nigro protocol: modest success, major morbidity. Colorectal Dis 8:124–129PubMedCrossRefGoogle Scholar
  48. 48.
    Renehan AG, Saunders MP, Schofield PF, ODwyer ST (2005) Patterns of local disease failure and outcome after salvage surgery in patients with anal cancer. Br J Surg 92:605–614PubMedCrossRefGoogle Scholar
  49. 49.
    Das P, Bhatia S, Eng C et al (2007) Predictors and patterns of recurrence after definitive chemoradiation for anal cancer. Int J Rad Oncol Biol Phys 68:794–800CrossRefGoogle Scholar
  50. 50.
    Nilsson PJ, Svensson C, Goldman S, Glimelius B (2002) Salvage abdominoperineal resection in anal epidermoid cancer. Br J Surg 89:1425–1429PubMedCrossRefGoogle Scholar
  51. 51.
    Akbari RP, Paty PB, Guillem JG et al (2004) Oncologic outcomes of salvage surgery for epidermoid carcinoma of the anus initially managed with combined modality therapy. Dis Colon Rectum 47:1136–1144PubMedCrossRefGoogle Scholar
  52. 52.
    Carey RW (1984) Regression of pulmonary metastases from cloacogenic carcinoma after cis-platinum/5-fluorouracil treatment. J Clin Gastroenterol 6:257–259PubMedGoogle Scholar
  53. 53.
    Ajani JA, Carrasco CH, Jackson DE, Wallace S (1989) Combination of cisplatin plus fluoropyrimidine chemotherapy effective against liver metastases from carcinoma of the anal canal. Am J Med 87:221–224PubMedCrossRefGoogle Scholar
  54. 54.
    Longo WE, Vernava AM, Wade TP et al (1994) Recurrent squamous cell carcinoma of the anal canal. Predictors of initial treatment failure and results of salvage therapy. Ann Surg 220:40–49PubMedCrossRefGoogle Scholar
  55. 55.
    Herzog U, Boss M, Spichtin H (1998) Endoanal ultrasonography in the follow-up of anal carcinoma. Surg Endosc 8:1186–1189CrossRefGoogle Scholar
  56. 56.
    Christensen AF, Nielsen MB, Svendsen LB, Engelholm SA (2006) Three-dimensional anal endosonography may improve detection of recurrent anal cancer. Dis Colon Rectum 49:1527–1532PubMedCrossRefGoogle Scholar
  57. 57.
    Palefsky J, Holly EA, Hogeboom CJ et al (1998) Virologic, immunologic, and clinical parameters in the incidence and progression of anal squamous intraepithelial lesions in HIV-positive and HIV-negative homosexual men. J Acquir Immune Defic Syndr Hum Retrovirol 17:314–319PubMedCrossRefGoogle Scholar
  58. 58.
    Ogunbiyi OA, Scholefield JH, Raftery AT et al (1994) Prevalence of anal human papillomavirus infection and intraepithelial neoplasia in renal allograft recipients. Br J Surg 81:365–367PubMedCrossRefGoogle Scholar
  59. 59.
    Holly EA, Ralston ML, Darragh TM, Greenblatt RM, Jay N, Palefsky JM (2001) Prevalence and risk factors for anal squamous intraepithelial lesions in women. J Natl Cancer Inst 93:843–849PubMedCrossRefGoogle Scholar
  60. 60.
    Chin-Hong PV, Vittinghoff E, Cranston RD et al (2005) Age related prevalence of anal cancer precursors in homosexual men: the EXPLORE study. J Natl Cancer Inst 97:896–905PubMedCrossRefGoogle Scholar
  61. 61.
    Frisch M, Glimelius B, van den Brule AJ et al (1997) Sexually transmitted infection as a cause of anal cancer. N Engl J Med 337:1350–1358PubMedCrossRefGoogle Scholar
  62. 62.
    Chang GJ, Welton ML (2003) Anal neoplasia. Sem Colon Rectal Surg 14:111–118CrossRefGoogle Scholar
  63. 63.
    Arbesman H, Ransohoff DF (1987) Is Bowens disease a predictor for the development of internal malignancy? A methodological critique of the literature. JAMA 257:516–518PubMedCrossRefGoogle Scholar
  64. 64.
    Wieland U, Brockmeyer NH, Weissenborn SJ et al (2006) Imiquimod treatment of anal intraepithelial neoplasia in HIV-positive men. Arch Dermatol 142:1438–1444PubMedCrossRefGoogle Scholar
  65. 65.
    Bargman H, Hochman J (2003) Topical treatment of Bowen’s disease with 5-fluorouracil. J Cutan Med Surg 7:101–105PubMedCrossRefGoogle Scholar
  66. 66.
    Webber J, Fromm D (2004) Photodynamic therapy for carcinoma in situ of the anus. Arch Surg 139:259–261PubMedCrossRefGoogle Scholar
  67. 67.
    Pineda CE, Berry JM, Welton ML (2006) High-resolution anoscopy and targeted treatment of high-grade squamous intraepithelial lesions. Dis Colon Rectum 49:126PubMedCrossRefGoogle Scholar
  68. 68.
    Chang GJ, Berry JM, Jay N, Palefsky JM, Welton ML (2002) Surgical treatment of high-grade anal squamous intraepithelial lesions: a prospective study. Dis Colon Rectum 45:453–458PubMedCrossRefGoogle Scholar
  69. 69.
    Goldstone SE, Kawalek AZ, Huyett JW (2005) Infrared coagulator: a useful tool for treating anal squamous intraepithelial lesions. Dis Colon Rectum 48:1042–1054PubMedCrossRefGoogle Scholar
  70. 70.
    Jay N, Berry JM, Hogeboom CJ, Holly EA, Darragh TM, Palefsky JM (1997) Colposcopic appearance of anal squamous intraepithelial lesions: relationship to histopathology. Dis Colon Rectum 40:919–928PubMedCrossRefGoogle Scholar
  71. 71.
    Bertram P, Treutner KH, Rubben A, Hauptmann S, Schumpelick V (1995) Invasive squamous-cell carcinoma in giant anorectal condyloma (Buschke-Lowenstein tumor). Langenbecks Arch Chir 380:115–118PubMedCrossRefGoogle Scholar
  72. 72.
    Garrett K, Kalady MF (2010) Anal neoplasms. Surg Clin North Am 90:147–161PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2012

Authors and Affiliations

  1. 1.Department of General SurgeryUSL 8ArezzoItaly
  2. 2.Department of Digestive and Colorectal Surgery, c/o Molinette Hospital, Centre of Minimal Invasive SurgeryUniversity of TurinTurinItaly
  3. 3.Department of General and Emergency Surgery 3Careggi Main Florence University and District HospitalFlorenceItaly

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