Surgery As An Alternative To Combined Chemotherapy And Radiation

Surgery for anal SCCa is an alternative for patients who are unable to complete CRT due to significant side effects, or for patients who are not candidates for CRT (such as those with previous history of pelvic RT). Special consideration has been given to patients with HIV/AIDS, especially if they have a history of fecal incontinence, chronic diarrhea, or poor performance status. Early reports suggested that these patients might suffer increased toxicity if treated with CRT for anal SCCa (25,26). However, in today's era of highly active anti-retroviral therapy (HAART), recent reports suggest low toxicity, better tolerance, and a trend toward better survival for HIV patients treated with CRT for anal SCCa, if they are receiving concomitant HAART (27,28).

The literature on surgery for anal SCCa in HIV patients is extremely limited. Tarantino and Bernstein reported briefly on their experience with such cases in a study evaluating endoanal ultrasound in the staging of patients with anal SCCa (29). Of 12 patients with anal SCCa staged by endoanal ultrasound (EAUS), 5 selected APR and the remaining 7 underwent CRT. Four of the patients who chose surgery were HIV positive, with a history of fecal incontinence, chronic diarrhea, or poor performance status. The fifth patient had received pelvic RT for another primary malignancy, and was not a candidate for additional RT treatment.

FIGURE 1 This endorectal ultrasound image demonstrates an extraluminal perirectal recurrence of a squamous-cell carcinoma of the anus, initially treated with the Nigro protocol.

In all five patients, surgical staging correlated with ultrasound staging. There were no cases of residual disease in the seven patients treated with CRT. However, this study did not include long-term follow-up and survival outcome.

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