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Salvage abdominoperineal excisions in recurrent anal cancer—impact of different reconstruction techniques on outcome, morbidity, and complication rates

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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Background

Squamous cell cancer of the anus (SCCA) is a rare disease of the gastrointestinal tract. Even though chemoradiation therapy is the treatment of choice, a substantial number of patients develop recurrent cancers or present with persisting SCCA. Therefore, abdominoperineal excisions as a salvage therapy are the only chance of cure.

Patients and methods

Hospital files of all patients with recurrent squamous cell carcinoma of the anus who underwent abdominoperineal excision performed at the Department of General and Visceral Surgery of the University Hospital Frankfurt between January 2003 and December 2013 were retrospectively reviewed.

Results

Fourteen (nine males, five females) patients underwent abdominoperineal resections for recurrent SCCA. In six patients, the pelvic floor was closed by direct suture, four patients underwent reconstruction using a vertical rectus abdominis myocutaneous (VRAM) flap, and four patients received a gluteal myocutaneous flap. Patients receiving flap-mediated closure revealed a median hospital stay of 26 days (range 13–60 days) compared to 11 days (range 9–30 days) in patients with direct closure (p = 0.01). Two patients (14 %) suffered from wound infections (Dindo–Clavien II), whereas three patients (21 %) underwent up to seven reoperations for breakdown of their wounds and/or laparotomies (Dindo–Clavien IIIb). The calculated 5-year survival rate was 86 %. Patients with rpT0/T1 stage had a significantly longer survival compared to patients presenting with rpT2/T3/T4 tumors.

Conclusion

Abdominoperineal excisions in patients with recurrent SCCA can provide long-term local control and survival. The complication rate is not associated with the closure technique employed, but patients undergoing flap-mediated closure revealed a significantly longer hospital stay.

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References

  1. Jemal A, Simard EP, Dorell C et al (2013) Annual report to the nation on the status of cancer, 1975–2009, featuring the burden and trends in human papillomavirus (HPV)-associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst 105:175–201

    Article  PubMed  PubMed Central  Google Scholar 

  2. Glynne-Jones R, Nilsson PJ, Aschele C, Goh V, Peiffert D, Cervantes A, Arnold D, European Society for Medical Oncology (ESMO); European Society of Surgical Oncology (ESSO); European Society of Radiotherapy and Oncology (ESTRO) (2014) Anal cancer: ESMO-ESSO-ESTRO clinical practice guidelines for diagnosis, treatment and follow-up. Eur J Surg Oncol 40(10):1165–1176

    Article  CAS  PubMed  Google Scholar 

  3. Flam M, John M, Pajak TF et al (1996) Role of mitomycin in combination with fluorouracil and radiotherapy, and of salvage chemoradiation in the definitive nonsurgical treatment of epidermoid carcinoma of the anal canal: results of a phase III randomized intergroup study. J Clin Oncol 14:2527–2539

    CAS  PubMed  Google Scholar 

  4. Mariani P, Ghanneme A, De la Rochefordiere A et al (2008) Abdominoperineal resection for anal cancer. Dis Colon Rectum 51:1495–1501

    Article  CAS  PubMed  Google Scholar 

  5. Mullen JT, Rodriguez-Bigas MA, Chang GJ et al (2007) Results of surgical salvage after failed chemoradiation therapy for epidermoid carcinoma of the anal canal. Ann Surg Oncol 14:478–483

    Article  PubMed  Google Scholar 

  6. Chessin DB, Hartley J, Cohen AM et al (2005) Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol 12:104–110

    Article  PubMed  Google Scholar 

  7. Arnold PG, Lovich SF, Pairolero PC (1994) Muscle flaps in irradiated wounds: an account of 100 consecutive cases. Plast Reconstr Surg 93:324–327, discussion 328–329

    Article  CAS  PubMed  Google Scholar 

  8. Bell SW, Dehni N, Chaouat M et al (2005) Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection. Br J Surg 92:482–486

    Article  CAS  PubMed  Google Scholar 

  9. McCraw JB, Massey FM, Shanklin KD et al (1976) Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg 58:176–183

    Article  CAS  PubMed  Google Scholar 

  10. Taylor GI, Corlett R, Boyd JB (1983) The extended deep inferior epigastric flap: a clinical technique. Plast Reconstr Surg 72:751–765

    Article  CAS  PubMed  Google Scholar 

  11. Shaw A, Futrell JW (1978) Cure of chronic perineal sinus with gluteus maximus flap. Surg Gynecol Obstet 147:417–420

    CAS  PubMed  Google Scholar 

  12. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196

    Article  PubMed  Google Scholar 

  13. Lefevre JH, Parc Y, Kernéis S, Shields C, Touboul E, Chaouat M, Tiret E (2009) Abdomino-perineal resection for anal cancer: impact of a vertical rectus abdominis myocutaneus flap on survival, recurrence, morbidity, and wound healing. Ann Surg 250(5):707–711

    Article  PubMed  Google Scholar 

  14. Sunesen KG, Buntzen S, Tei T, Lindegaard JC, Nørgaard M, Laurberg S (2009) Perineal healing and survival after anal cancer salvage surgery: 10-year experience with primary perineal reconstruction using the vertical rectus abdominis myocutaneous (VRAM) flap. Ann Surg Oncol 16(1):68–77

    Article  CAS  PubMed  Google Scholar 

  15. Horch RE, Hohenberger W, Eweida A, Kneser U, Weber K, Arkudas A, Merkel S, Göhl J, Beier JP (2014) A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration. Int J Color Dis 29(7):813–823

    Article  CAS  Google Scholar 

  16. Holm T, Ljung A, Häggmark T, Jurell G, Lagergren J (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94(2):232–238

    Article  CAS  PubMed  Google Scholar 

  17. Anderin C, Martling A, Lagergren J, Ljung A, Holm T (2012) Short-term outcome after gluteus maximus myocutaneous flap reconstruction of the pelvic floor following extra-levator abdominoperineal excision of the rectum. Color Dis 14(9):1060–1064

    Article  CAS  Google Scholar 

  18. Harris DA, Williamson J, Davies M, Evans MD, Drew P, Beynon J, Swansea Pelvic Oncology Group (2013) Outcome of salvage surgery for anal squamous cell carcinoma. Color Dis 15(8):968–973

    Article  CAS  Google Scholar 

  19. Correa JH, Castro LS, Kesley R, Dias JA, Jesus JP, Olivatto LO, Martins IO, Lopasso FP (2013) Salvage abdominoperineal resection for anal cancer following chemoradiation: a proposed scoring system for predicting postoperative survival. J Surg Oncol 107(5):486–492

    Article  PubMed  Google Scholar 

  20. Wright JL, Gollub MJ, Weiser MR, Saltz LB, Wong WD, Paty PB, Temple LK, Guillem JG, Minsky BD, Goodman KA (2011) Surgery and high-dose-rate intraoperative radiation therapy for recurrent squamous-cell carcinoma of the anal canal. Dis Colon Rectum 54(9):1090–1097

    Article  PubMed  Google Scholar 

  21. Nilsson PJ, Svensson C, Goldman S, Glimelius B (2002) Salvage abdominoperineal resection in anal epidermoid cancer. Br J Surg 89:1425–1429

    Article  CAS  PubMed  Google Scholar 

  22. Hallemeier CL, You YN, Larson DW, Dozois EJ, Nelson H, Klein KA, Miller RC, Haddock MG (2014) Multimodality therapy including salvage surgical resection and intraoperative radiotherapy for patients with squamous-cell carcinoma of the anus with residual or recurrent disease after primary chemoradiotherapy. Dis Colon Rectum 57(4):442–448

    Article  PubMed  Google Scholar 

  23. Ong JJ, Temple-Smith M, Chen M, Walker S, Grulich A, Hoy J, Fairley CK (2015) Why are we not screening for anal cancer routinely - HIV physicians’ perspectives on anal cancer and its screening in HIV-positive men who have sex with men: a qualitative study. BMC Public Health 15:67

    Article  PubMed  PubMed Central  Google Scholar 

  24. Czoski-Murray C, Karnon J, Jones R, Smith K, Kinghorn G (2010) Cost-effectiveness of screening high-risk HIV-positive men who have sex with men (MSM) and HIV-positive women for anal cancer. Health Technol Assess 14(53):iii–iv, ix-x, 1–101

    Article  CAS  PubMed  Google Scholar 

  25. Duncan KC, Chan KJ, Chiu CG, Montaner JS, Coldman AJ, Cescon A, Au-Yeung CG, Wiseman SM, Hogg RS, Press NM (2015) HAART slows progression to anal cancer in HIV-infected MSM. AIDS 29(3):305–311

    Article  CAS  PubMed  Google Scholar 

  26. Fraunholz IB, Haberl A, Klauke S, Gute P, Rödel CM (2014) Long-term effects of chemoradiotherapy for anal cancer in patients with HIV infection: oncological outcomes, immunological status, and the clinical course of the HIV disease. Dis Colon Rectum 57(4):423–431

    Article  PubMed  Google Scholar 

  27. Cunin L, Alfa-Wali M, Turner J, Bower M, Ion L, Allen-Mersh T (2014) Salvage surgery for residual primary and locally recurrent anal squamous cell carcinoma after chemoradiotherapy in HIV-positive individuals. Ann Surg Oncol 21(2):527–532

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of General and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany

    Sabine Hannes, Alexander Reinisch, Wolf O. Bechstein & Nils Habbe

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  1. Sabine Hannes
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  2. Alexander Reinisch
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  3. Wolf O. Bechstein
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  4. Nils Habbe
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Correspondence to Nils Habbe.

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Hannes, S., Reinisch, A., Bechstein, W.O. et al. Salvage abdominoperineal excisions in recurrent anal cancer—impact of different reconstruction techniques on outcome, morbidity, and complication rates. Int J Colorectal Dis 31, 653–659 (2016). https://doi.org/10.1007/s00384-015-2474-5

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  • DOI: https://doi.org/10.1007/s00384-015-2474-5

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