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Radiotherapy with or without chemotherapy in the treatment of anal cancer: 20-year experience from a single institute

Strahlentherapie mit oder ohne Chemotherapie bei der Behandlung des Analkarzinoms: 20-jährige Erfahrungen einer Klinik

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Abstract

Purpose

To report the efficacy and toxicity of radio(chemo)therapy (RCT) in the management of squamous cell anal carcinoma (SQ-AC) and to evaluate the prognostic factors influencing the outcomes.

Patients and methods

A consecutive cohort of 138 patients with cT1-4, cN0-3, cM0 SQ-AC were treated with RCT between 1988 and 2011 at our department. Median follow-up time for surviving patients from the start of RCT was 98 months (range, 1–236 months). Patients were treated with a median radiation dose of 56 Gy (range, 4–61 Gy). Concurrent chemotherapy was administered to 119 patients (86%).

Results

The survival rates at 2, 5, and 10 years were 88 ± 3, 82 ± 4, and 59 ± 6%, respectively, with a median overall survival (OS) of 167 months. The cumulative incidence for local recurrence at 2 and 5 years was 8 ± 2 and 11 ± 3%, respectively. The median disease-free survival (DFS) and colostomy-free survival (CFS) times were 132 and 135 months, respectively. In 19 patients (14%), a distant metastasis was diagnosed after a median time of 19 months. In the multivariate analysis, UICC (International Union Against Cancer) stage I-II, female gender, Eastern Cooperative Oncology Group (ECOG) performance status of 0–1, and good/moderate histologic differentiation (G1–2) were significantly associated with a better OS, DFS, and CFS. Conformal radiotherapy planning techniques were significantly associated with a lower cumulative incidence of local recurrence (11 ± 3% vs. 38 ± 19% at 5 years, p = 0.006). A higher radiation dose beyond 54 Gy was not associated with an improvement in outcome, neither for smaller—(T1/T2) nor for larger tumors (T3/T4).

Conclusion

RCT leads to excellent outcomes—especially in patients with stage I/II and G1/G2 tumors—with acceptable toxicity. The probable advantages of high-dose radiotherapy should be considered carefully against the risk of a higher rate of toxicity. Future studies are needed to investigate the role of a more intensified (systemic) treatment for patients with unfavorable prognostic factors such as T3/T4, N+, and/or poor cell differentiation.

Zusammenfassung

Zielsetzung

Es wird über die Wirksamkeit und die Toxizität einer Radio(chemo)therapie [R(C)T] bei der Behandlung von Analkarzinomen berichtet und der Einfluss prognostischer Faktoren auf das klinische Ergebnis ausgewertet.

Patienten und Methode

Eine konsekutive Kohorte von 138 Patienten mit cT1–4, cN0–3, cM0, Plattenepithelkarzinom des Anus, wurde im Zeitraum zwischen 1988 und 2011 mit einer R(C)T in unserer Klinik behandelt. Das mediane Follow-up lag bei 98 Monaten (Spanne: 1–236 Monate). Die Patienten wurden mit einer medianen Gesamtdosis von 56 Gy (Spanne: 4–61 Gy) bestrahlt. Eine simultane Chemotherapie wurde bei 119 Patienten (86%) verabreicht.

Ergebnisse

Die Überlebensraten für 2, 5 und 10 Jahre lagen bei 88 ± 3, 82 ± 4 bzw. 59 ± 6% mit einem medianen Gesamtüberleben von 167 Monaten. Die kumulative Inzidenzrate für Lokalrezidiv nach 2 und 5 Jahren lag bei 8 ± 2 bzw. 11 ± 3%. Das mediane krankheitsfreie Überleben und das mediane kolostomiefreie Überleben betrugen 132 bzw. 135 Monate. Bei 19 Patienten (14%) wurden nach einem medianen Intervall von 19 Monaten Fernmetastasen diagnostiziert. In der multivariaten Analyse waren das Stadium I–II nach UICC (Union Internationale Contre le Cancer), ein weibliches Geschlecht, ein Eastern-Cooperative-Oncology-Group(ECOG)-Performance-Status von 0–1 und eine gute- bzw. mäßige histologische Differenzierung (G1–2) signifikant mit einem besseren Gesamt-, krankheitsfreien und kolostomiefreien Überleben assoziiert. Konformale Radiotherapietechniken waren signifikant mit einer niedrigeren kumulativen Inzidenzrate für ein Lokalrezidiv verbunden (11 ± 3 vs. 38 ± 19% nach 5 Jahren, p = 0,006). Eine höhere Bestrahlungsdosis über 54 Gy brachte weder für kleine (T1/T2) noch für große Tumoren (T3/T4) eine Verbesserung des Ergebnisses.

Schlussfolgerung

R(C)T führt zu einem ausgezeichneten Ergebnis, vor allem bei Tumoren im Stadium I/II und G1/2, bei vertretbarer Toxizität. Mögliche Vorteile einer Hochdosisradiotherapie sollten sorgfältig mit dem Risiko einer höheren Toxizität abgewogen werden. Weitere Studien sind nötig, um die Rolle einer intensivierten (systemischen) Therapie für Patienten mit ungünstigen prognostischen Faktoren, wie positivem Lymphknotenstatus, T3/T4 und/oder schlechte Zelldifferenzierung, zu untersuchen.

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On behalf of all authors, the corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Klinikum rechts der Isar, Technische Universität München, Munich, Germany

    K. Fakhrian MD, T. Sauer MD, S. Klemm MD, C. Bayer PhD, B. Haller, M. Molls MD & H. Geinitz MD

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  1. K. Fakhrian MD
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  2. T. Sauer MD
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  3. S. Klemm MD
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Correspondence to K. Fakhrian MD.

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Fakhrian, K., Sauer, T., Klemm, S. et al. Radiotherapy with or without chemotherapy in the treatment of anal cancer: 20-year experience from a single institute. Strahlenther Onkol 189, 18–25 (2013). https://doi.org/10.1007/s00066-012-0236-7

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