Management of Anal Cancer



Anal cancer is a rare malignancy, accounting for 2 % of colorectal cancer diagnoses. Over the last few decades, the number of new cases diagnosed has been increasing, driven by multifactorial etiology and associated with HPV infection, smoking, high-risk sexual activity, and immunocompromise. The primary histologic type of anal cancer is squamous cell carcinoma. While historically these tumors were treated with abdominoperineal resection, today the primary treatment is combined modality chemoradiotherapy. Success rates can be as high as 80 %, with APR primarily used as salvage therapy for persistent or recurrent disease. Despite the success of combined modality therapy, investigations are ongoing to discover methods that will improve survival and avoid the need for colostomy.


Anal cancer Anal epidermoid carcinoma Anal canal Anal margin Combined modality therapy Salvage therapy 


  1. 1.
    Howlader N, Noone AM, Krapcho M, Garshell J, Neyman N, et al., editors. SEER cancer statistics review, 1975–2010. Bethesda: National Cancer Institute., based on Nov 2012 SEER data submission, posted to the SEER web site, 2013.
  2. 2.
    Daling JR, Sherman KJ, Hislop TG, Maden C, Coates RJ, et al. Sexual practices, sexually transmitted disease, and the incidence of anal cancer. N Engl J Med. 1987;317:973–7.CrossRefPubMedGoogle Scholar
  3. 3.
    Frisch M, Glimelius B, van den Brule AJC, Wohlfahrt J, Meijer CJ, et al. Sexually transmitted infection as a cause of anal cancer. N Engl J Med. 1997;337(19):1350–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Chang GJ, Welton ML. Human papillomavirus, condylomata acuminata, and anal neoplasia. Clin Colon Rectal Surg. 2004;17:221–30.CrossRefPubMedCentralPubMedGoogle Scholar
  5. 5.
    Daling JR, Madeleine MM, Johnson LG, Schwartz SM, Shera KA, et al. Human papillomavirus, smoking, and sexual practices in the etiology of anal cancer. Cancer. 2004;101:270–80.CrossRefPubMedGoogle Scholar
  6. 6.
    Silverberg MJ, Lau B, Justice AC, Engels E, Gill MJ, et al. Risk of anal cancer in HIV-infected and HIV-uninfected individuals in North America. Clin Infect Dis. 2012;54(7):1026–34.CrossRefPubMedCentralPubMedGoogle Scholar
  7. 7.
    Salit IE, Lytwyn A, Raboud J, Sano M, Chong S, et al. The role of cytology (Pap tests) and human papillomavirus testing in anal cancer screening. AIDS. 2010;24:1307–13.PubMedGoogle Scholar
  8. 8.
    Berry JM, Palefsky JM, Jay N, Cheng SC, Darragh TM, et al. Performance characteristics of anal cytology and human papillomavirus testing in patients with high-resolution anoscopy-guided biopsy of high-grade anal intraepithelial neoplasia. Dis Colon Rectum. 2009;52:239–47.CrossRefPubMedGoogle Scholar
  9. 9.
    Ogunbiyi OA, Scholefield JH, Raftery AT, Smith JH, Duffy S, et al. Prevalence of anal human papillomavirus infection and intraepithelial neoplasia in renal allograft recipients. Br J Surg. 1994;81:365–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Engels EA, Pfeiffer RM, Fraumeni Jr JF, Kasiske BL, Israni AK, et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA. 2011;306(17):1891–901.CrossRefPubMedCentralPubMedGoogle Scholar
  11. 11.
    Nordenvall C, Nillson PJ, Ye W, Nyren O. Smoking, snus use, and risk of right- and left-sided colon, rectal, and anal cancer: a 37 year follow-up study. Int J Cancer. 2011;128(1):157–65.CrossRefPubMedGoogle Scholar
  12. 12.
    Daling JR, Sherman KJ, Hislop TJ, Maden C, Mandelson MT, et al. Cigarette smoking and the risk of anogenital cancer. Am J Epidemiol. 1992;135(2):180–9.PubMedGoogle Scholar
  13. 13.
    Buckwalter JA, Jurayj MN. Relationship of chronic anorectal disease and carcinoma. Arch Surg. 1957;75:352–61.CrossRefGoogle Scholar
  14. 14.
    Holly EA, Whittemore AS, Aston DA, Ahn DK, Nickoloff BJ, Kristiansen JJ. Anal cancer incidence: genital warts, anal fissure or fistula, hemorrhoids, and smoking. J Natl Cancer Inst. 1989;81:726–31.CrossRefGoogle Scholar
  15. 15.
    Tseng HF, Morgenstern H, Mack TM, Peters RK. Risk factors for anal cancer: results of a population-based case-control study. Cancer Causes Control. 2003;14:837–46.CrossRefPubMedGoogle Scholar
  16. 16.
    Nordenvall C, Nyren O, Ye W. Elevated anal squamous cell carcinoma risk associated with benign inflammatory anal lesions. Gut. 2006;55:703–7.CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Holmes F, Borek D, Owen-Kummer M, Hassanein R, Fishback J, et al. Anal cancer in women. Gastroenterology. 1988;95:107–11.PubMedGoogle Scholar
  18. 18.
    Frisch M, Olsen JH, Bautz A, Melbye M. Benign anal lesions and the risk of anal cancer. N Engl J Med. 1994;331:300–2.CrossRefPubMedGoogle Scholar
  19. 19.
    Frisch M, Glimelius B, van den Brule AJ, Wohlfahrt J, Mejier CJ, et al. Benign anal lesions, inflammatory bowel disease and risk for high risk human papillomavirus-positive and–negative anal carcinoma. Br J Cancer. 1998;78(11):1534–8.CrossRefPubMedCentralPubMedGoogle Scholar
  20. 20.
    Barleben A, Mills S. Anorectal anatomy and physiology. Surg Clin N Am. 2010;90:1–15.CrossRefPubMedGoogle Scholar
  21. 21.
    Garrett K, Kalady MF. Anal neoplasms. Surg Clin N Am. 2010;90:147–61.CrossRefPubMedGoogle Scholar
  22. 22.
    Martin F, Bower M. Anal intraepithelial neoplasia in HIV positive people. Sex Transm Infect. 2001;77:327–31.CrossRefPubMedCentralPubMedGoogle Scholar
  23. 23.
    Critchlow CW, Surawicz CM, Holmes KK, Kuypers J, Daling JR, et al. Prospective study of high grade anal squamous intraepithelial neoplasia in a cohort of homosexual men: influence of HIV infection, immunosuppression and human papillomavirus infection. AIDS. 1995;9:1255–62.CrossRefPubMedGoogle Scholar
  24. 24.
    Chang GJ, Berry JM, Jay N, Palefsky JM, Welton ML. Surgical treatment of high-grade anal squamous intraepithelial lesions: a prospective study. Dis Colon Rectum. 2002;45:453–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Devaraj B, Cosman BC. Expectant management of anal squamous dysplasia in patients with HIV. Dis Colon Rectum. 2006;49:36–40.CrossRefPubMedGoogle Scholar
  26. 26.
    Beck DE, Fazio VW. Perianal Paget’s disease. Dis Colon Rectum. 1987;30:263–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Tulchinsky H, Zmora O, Brazowski E, Goldman G, Rabau M. Extramammary Paget’s disease of the perianal region. Color Dis. 2004;6:206–9.CrossRefGoogle Scholar
  28. 28.
    De Toma G, Cavallaro G, Bitonti A, Polistena A, Onesti MG, Scuderi N. Surgical management of perianal giant condyloma acuminatum (Buschke-Lowenstein tumor). Report of three cases. Eur Surg Res. 2006;38:418–22.CrossRefPubMedGoogle Scholar
  29. 29.
    Lam DT, Batista O, Weiss EG, Nogueras JJ, Wexner SD. Staged excision and split-thickness skin graft for circumferential perianal Paget disease. Dis Colon Rectum. 2001;44:868–70.CrossRefPubMedGoogle Scholar
  30. 30.
    Seckel BR, Schoetz DJ, Coller JA. Skin grafts for circumferential coverage and perianal wounds. Surg Clin N Am. 1985;65:365–71.PubMedGoogle Scholar
  31. 31.
    Orkin BA. Perineal reconstruction with local flaps: technique and results. Tech Coloproctol. 2013;17:663–70.CrossRefPubMedGoogle Scholar
  32. 32.
    Burke TW, Morris M, Roh MS, Levenback C, Gershenson DM. Perineal reconstruction using single gracilis myocutaneous flaps. Gynecol Oncol. 1995;57:221–5.CrossRefPubMedGoogle Scholar
  33. 33.
    Solomon MJ, Atkinson K, Quinn MJ, Eyers AA, Glenn DC. Gracilis myocutaneous flap to reconstruct large perineal defects. Int J Color Dis. 1996;11:49–51.CrossRefGoogle Scholar
  34. 34.
    Fleshner PR, Chalasani S, Chang GJ, Levien DH, Hyman NH, et al. Practice parameters for anal squamous neoplasms. Dis Colon Rectum. 2008;51:2–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Robb BW, Mutch MG. Epidermoid carcinoma of the anal canal. Clin Colon Rectal Surg. 2006;19:54–60.CrossRefPubMedCentralPubMedGoogle Scholar
  36. 36.
    de Jong JS, Beukema JC, van Dam GM, Slart R, Lemstra C, Wiggers T. Limited value of staging squamous cell carcinoma of the anal margin and canal using the sentinel lymph node procedure: a prospective study with long-term follow-up. Ann Surg Oncol. 2010;17:2656–62.CrossRefPubMedCentralPubMedGoogle Scholar
  37. 37.
    Tarantino D, Bernstein MA. Endoanal ultrasound in the staging and management of squamous-cell carcinoma of the anal canal. Dis Colon Rectum. 2002;45:16–22.CrossRefPubMedGoogle Scholar
  38. 38.
    Roach SC, Hulse PA, Moulding FJ, Wilson R, Carrington BM. Magnetic resonance imaging of anal cancer. Clin Radiol. 2005;60:1111–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Salerno G, Daniels IR, Brown G. Magnetic resonance imaging of the low rectum: defining the radiological anatomy. Color Dis. 2006;8 Suppl 3:10–3.CrossRefGoogle Scholar
  40. 40.
    Bannas P, Weber C, Adam G, Frenzel T, Derlin T, et al. Contrast-enhanced [18F]fluorodeoxyglucose-positron emission tomography/computed tomography for staging and radiotherapy planning in patients with anal cancer. Int J Radiat Oncol Biol Phys. 2011;81:445–51.CrossRefPubMedGoogle Scholar
  41. 41.
    Mistrangelo M, Pelosi E, Bello M, Ricardi U, Milanesi E, et al. Role of positron emission tomography-computed tomography in the management of anal cancer. Int J Radiat Oncol Biol Phys. 2012;84:66–72.CrossRefPubMedGoogle Scholar
  42. 42.
    Krengli M, Milia ME, Turri L, Mones E, Bassi MC, et al. FDG-PET/CT imaging for staging and target volume delineation in conformal radiotherapy of anal carcinoma. Radiat Oncol. 2010;5:10.CrossRefPubMedCentralPubMedGoogle Scholar
  43. 43.
    Winton E, Heriot AG, Ng M, Hicks RJ, Hogg A, et al. The impact of 18-fluorodeoxyglucose positron emission tomography on the staging, management and outcome of anal cancer. Br J Cancer. 2009;100:693–700.CrossRefPubMedCentralPubMedGoogle Scholar
  44. 44.
    Trautmann TG, Zuger JH. Positron emission tomography for pretreatment staging and post-treatment evaluation in cancer of the anal canal. Mol Imaging Biol. 2005;7:309–13.CrossRefPubMedGoogle Scholar
  45. 45.
    Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2009, pp 165–173.Google Scholar
  46. 46.
    Nigro ND, Vaitkevicius VK, Considine Jr B. Combined therapy for cancer of the anal canal: a preliminary report. Dis Colon Rectum. 1974;17:354–6.CrossRefPubMedGoogle Scholar
  47. 47.
    Nigro ND. An evaluation of combined therapy for squamous cell cancer of the anal canal. Dis Colon Rectum. 1984;27:763–6.CrossRefPubMedGoogle Scholar
  48. 48.
    UKCCCR Anal Cancer Trial Working Party. Epidermoid anal cancer: results from the UKCCCR randomized trial of radiotherapy alone versus radiotherapy, 5-fluorouracil, and mitomycin. Lancet. 1996;348:1049–54.CrossRefGoogle Scholar
  49. 49.
    Bartelink H, Roelofsen F, Eschwege F, Rougier P, Bosset JF, et al. 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. 1997;15:2040–9.PubMedGoogle Scholar
  50. 50.
    John M, Pajak T, Flam M, Hoffman J, Markoe A, et al. Dose escalation in chemoradiation for anal cancer: preliminary results of RTOG 92–08. Cancer J Sci Am. 1996;2:205–11.PubMedGoogle Scholar
  51. 51.
    Martenson JA, Lipsitz SR, Wagner Jr H, Kaplan EH, Otteman LA, et al. Initial results of a phase II trial of high dose radiation therapy, 5-fluorouracil, and cisplatin for patients with anal cancer (E4292): an Eastern Cooperative Oncology Group study. Int J Radiat Oncol Biol Phys. 1996;35:745–9.CrossRefPubMedGoogle Scholar
  52. 52.
    Salama JK, Mell LK, Schomas DA, Miller RC, Devisetty K, et al. Concurrent chemotherapy and intensity-modulated radiation therapy for anal canal cancer patients: a multicenter experience. J Clin Oncol. 2007;25:4581–6.CrossRefPubMedGoogle Scholar
  53. 53.
    Kachnic LA, Winter K, Myerson RJ, Goodyear MD, Willins J, et al. RTOG 0529: a phase 2 evaluation of dose-painted intensity modulated radiation therapy in combination with 5-flurouracil and mitocycin-C for the reduction of acute morbidity in carcinoma of the anal canal. Int J Radiat Oncol Biol Phys. 2013;86:27–33.CrossRefPubMedCentralPubMedGoogle Scholar
  54. 54.
    Gerard JP, Mauro F, Thomas L, Castelain B, Mazeron JJ, et al. Treatment of squamous cell anal canal carcinoma with pulsed dose rate brachytherapy. Feasibility study of a French cooperation group. Radiother Oncol. 1999;51:129–36.CrossRefPubMedGoogle Scholar
  55. 55.
    Bruna A, Gastelblum P, Thomas L, Chapet O, Bollet MA, et al. Treatment of squamous cell anal canal carcinoma with pulsed dose rate brachytherapy: a retrospective study. Radiother Oncol. 2006;79:75–9.CrossRefPubMedGoogle Scholar
  56. 56.
    Rich TA, Ajani JA, Morrison WH, Ota D, Levin B. Chemoradiation therapy for anal cancer: radiation plus continuous infusion of 5-fluorouracil with or without cisplatin. Radiother Oncol. 1993;27:209–15.CrossRefPubMedGoogle Scholar
  57. 57.
    Doci R, Zucali R, La Monica G, Meroni E, Kenda R, et al. Primary chemoradiation therapy with fluorouracil and cisplatin for cancer of the anus: results in 35 consecutive patients. J Clin Oncol. 1996;14:3121–5.PubMedGoogle Scholar
  58. 58.
    Gerard JP, Ayzac L, Hun D, Romestaing P, Coquard R, et al. Treatment of anal canal carcinoma with high dose radiation therapy and concomitant fluorouracil-cisplatinum. Long-term results in 95 patients. Radiother Oncol. 1998;46:249–56.CrossRefPubMedGoogle Scholar
  59. 59.
    James RD, Glynne-Jones R, Meadows HM, Cunningham D, Myint AS, et al. Mitomycin or cisplatin chemoradiation with or without maintenance chemotherapy for treatment of squamous-cell carcinoma of the anus (ACT II): a randomized, phase 3 open-label, 2 × 2 factorial trial. Lancet. 2013;14:516–24.CrossRefPubMedGoogle Scholar
  60. 60.
    Peiffert D, Giovannini M, Ducreux M, Michel P, Francois E, et al. High-dose radiation therapy and neoadjuvant plus concomitant chemotherapy with 5-fluorouracil and cisplatin in patients with locally advanced squamous-cell anal carcinoma: final results of a phase II study. Ann Oncol. 2001;12:397–404.CrossRefPubMedGoogle Scholar
  61. 61.
    Ajani JA, Winter KA, Gunderson LL, Pedersen J, Benson 3rd AB, et al. Fluorouracil, mitomycin, and radiotherapy vs fluorouracil, cisplatin, and radiotherapy for carcinoma of the anal canal: a randomized controlled trial. JAMA. 2008;299:1914–21.CrossRefPubMedGoogle Scholar
  62. 62.
    Gunderson LL, Winter KA, Ajani JA, Pedersen JE, Moughan J, et al. Long-term update of US GI intergroup RTOG 98–11 phase 3 trial for anal carcinoma: survival, relapse, and colostomy failure with concurrent chemoradiation involving fluorouracil/mitomycin versus fluorouracil/cisplatin. J Clin Oncol. 2012;30:4344–51.CrossRefPubMedCentralPubMedGoogle Scholar
  63. 63.
    Tanum G, Tveit K, Karlsen KO, Hauer-Jensen M. Chemotherapy and radiation therapy for anal carcinoma: survival and late morbidity. Cancer. 1991;67:2462–6.CrossRefPubMedGoogle Scholar
  64. 64.
    Broens P, Van Limbergen E, Penninckx F, Kerremans R. Clinical and manometric effects of combined external beam radiation and brachytherapy for anal cancer. Int J Color Dis. 1998;13:68–72.CrossRefGoogle Scholar
  65. 65.
    Vordermark D, Sailer M, Flentje M, Thiede A, Kӧlbl O. Curative-intent radiation therapy in anal carcinoma: quality of life and sphincter function. Radiother Oncol. 1999;52:239–43.CrossRefPubMedGoogle Scholar
  66. 66.
    Johnston MJ, Robertson GM, Frizelle FA. Management of late complications of pelvic radiation in the rectum and anus. Dis Colon Rectum. 2003;46:247–59.CrossRefPubMedGoogle Scholar
  67. 67.
    Turina M, Mulhall AM, Mahid SS, Yashar C, Galandiuk S. Frequency and surgical management of chronic complications related to pelvic radiation. Arch Surg. 2008;143:46–52.CrossRefPubMedGoogle Scholar
  68. 68.
    Das P, Bhatia S, Eng C, Ajani JA, Skibber JM, et al. Predictors and patterns of recurrence after definitive chemoradiation for anal cancer. Int J Radiat Oncol Biol Phys. 2007;68:794–800.CrossRefPubMedGoogle Scholar
  69. 69.
    Tan KK, Pal S, Lee PJ, Rodwell L, Solomon MJ. Pelvic exenteration for recurrent squamous cell carcinoma of the pelvic organs arising from the cloaca—a single institution’s experience over 16 years. Color Dis. 2013;15:1227–31.CrossRefGoogle Scholar
  70. 70.
    Longo WE, Vernava III AM, Wade TP, Coplin MA, Virgo KS, Johnson FE. Recurrent squamous cell carcinoma of the anal canal: predictors of initial treatment failure and results of salvage therapy. Ann Surg. 1994;220:40–9.CrossRefPubMedCentralPubMedGoogle Scholar
  71. 71.
    Ellenhorn JD, Enker WE, Quan SH. Salvage abdominoperineal resection following combined chemotherapy and radiotherapy for epidermoid carcinoma of the anus. Ann Surg Oncol. 1994;1:105–10.CrossRefPubMedGoogle Scholar
  72. 72.
    Pocard M, Tiret E, Nugent K, Dehni N, Parc R. Results of salvage abdominoperineal resection for anal cancer after radiotherapy. Dis Colon Rectum. 1998;41:1488–93.CrossRefPubMedGoogle Scholar
  73. 73.
    Nilsson PJ, Svensson C, Goldman S, Glimelius B. Salvage abdominoperineal resection in anal epidermoid cancer. Br J Surg. 2002;89:1425–9.CrossRefPubMedGoogle Scholar
  74. 74.
    Akbari RP, Paty PB, Guillem JG, Weiser MR, Temple LK, et al. Oncologic outcomes of salvage surgery for epidermoid carcinoma of the anus initially managed with combined modality therapy. Dis Colon Rectum. 2004;47:1136–44.CrossRefPubMedGoogle Scholar
  75. 75.
    Ghouti L, Houvenaeghel G, Moutardier V, Giovannini M, Magnin V, et al. Salvage abdominoperineal resection after failure of conservative treatment in anal epidermoid cancer. Dis Colon Rectum. 2005;48:16–22.CrossRefPubMedGoogle Scholar
  76. 76.
    Ferenschild FT, Vermaas M, Hofer SO, Verhoef C, Eggermont AM, et al. Salvage abdominoperineal resection and perineal wound healing in local recurrent or persistent anal cancer. World J Surg. 2005;48:16–22.Google Scholar
  77. 77.
    Papaconstantinou HT, Bullard KM, Rothenberger DA, Madoff RD. Salvage abdominoperineal resection after failed Nigro protocol: modest success, major morbidity. Color Dis. 2006;8:124–9.CrossRefGoogle Scholar
  78. 78.
    Mullen JT, Rodriguez-Bigas MA, Chang GJ, Barcenas CH, Crane CH, et al. Results of surgical salvage after failed chemoradiation therapy for epidermoid carcinoma of the anal canal. Ann Surg Oncol. 2007;14:478–83.CrossRefPubMedGoogle Scholar
  79. 79.
    Schiller DE, Cummings BJ, Rai S, Le LW, Last L, et al. Outcomes of salvage surgery for squamous cell carcinoma of the anal canal. Ann Surg Oncol. 2007;14:2780–9.CrossRefPubMedGoogle Scholar
  80. 80.
    Stewart D, Yan Y, Kodner IJ, Birnbaum E, Fleshman J, et al. Salvage surgery after failed chemoradiation for anal canal cancer: should the paradigm be changed for high-risk tumors? J Gastrointest Surg. 2007;11:1744–51.CrossRefPubMedGoogle Scholar
  81. 81.
    Eeson G, Foo M, Harrow S, McGregor G, Hay J. Outcomes of salvage surgery for epidermoid carcinoma of the anus following failed combined modality treatment. Am J Surg. 2011;201:628–33.CrossRefPubMedGoogle Scholar
  82. 82.
    Harris DA, Williamson J, Davies M, Evans MD, Drew P, et al. Outcome of salvage surgery for anal squamous cell carcinoma. Color Dis. 2013;15(8):968–73.CrossRefGoogle Scholar
  83. 83.
    Tonouchi H, Ohmori Y, Kobayashi M, Konishi N, Tanaka K, et al. Operative morbidity associated with groin dissections. Surg Today. 2004;34:413–8.CrossRefPubMedGoogle Scholar
  84. 84.
    Soliman AA, Heubner M, Kimmig R, Wimberger P. Morbidity of inguinofemoral lymphadenectomy in vulval cancer. ScientificWorldJournal. 2012;2012:341253.CrossRefPubMedCentralPubMedGoogle Scholar
  85. 85.
    Paley PJ, Johnson PR, Adcock LL, Cosin JA, Chen MD, et al. The effect of Sartorius transposition on wound morbidity following inguinal-femoral lymphadenectomy. Gynecol Oncol. 1997;64:237–41.CrossRefPubMedGoogle Scholar
  86. 86.
    Pawlik TM, Gleisner AL, Bauer TW, Adams RB, Reddy SK, et al. Liver-directed surgery for metastatic squamous cell carcinoma to the liver: results of a multi-center analysis. Ann Surg Oncol. 2007;14:2807–16.CrossRefPubMedGoogle Scholar
  87. 87.
    Butler CE, Gundeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg. 2008;206:694–703.CrossRefPubMedGoogle Scholar
  88. 88.
    Sunesen KG, Buntzen S, Tei T, Lindegaard JC, Nørgaard M, Laurberg S. 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. 2009;16:68–77.CrossRefPubMedGoogle Scholar
  89. 89.
    Tei TM, Stolzenburg T, Buntzen S, Laurberg S, Kjeldsen H. Use of transpelvic rectus abdominis musculocutaneous flap for anal cancer salvage surgery. Br J Surg. 2003;90:575–80.CrossRefPubMedGoogle Scholar
  90. 90.
    Shibata D, Hyland W, Busse P, Kim HK, Sentovich SM, et al. Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum. Ann Surg Oncol. 1999;6:33–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  1. 1.Department of General SurgeryUniversity of Texas Medical School at HoustonHoustonUSA
  2. 2.Department of Surgical OncologyUniversity of Texas MD Anderson Cancer CenterHoustonUSA

Personalised recommendations