Background 1. Incidence Anal canal cancer is a relatively rare papilloma virus tumore anale, representing approximately 1. It is approximately 20 to 30 times rarer than colon cancer, but its annual incidence is increasing, reaching up to cases, with a female predominance 2. There is an important geographic variation regarding its incidence, as well as histopathological type.
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The mainstay of the treatment is represented by chemo-radiotherapy, radical surgery being reserved to residual tumor or recurrences. Table 1; AJCC papilloma virus tumore anale for anal cancer 2. Histopathology Depending on the lining epithelium, anal canal is divided into three regions: colorectal zone: located proximally and containg columnar epithelium; transitional zone: spread over a distance that papilloma virus tumore anale between 0 and 12 mm that contains a pseudostratified type of epithelium resembling the papilloma virus tumore anale one.
A transformation zone is unanimously accepted in uterine cancer. This region of metaplasia is extremely papilloma virus tumore anale to HPV action 4 ; squamous zone: contains a non-keratinized epithelium, without hair follicles. Leiomyosarcomas, lymphomas and small cell carcinomas similar in terms of evolution and prognosis to lung small cell carcinomasundifferentiated carcinoma or anal GIST - only 17 cases described in literature up to 7 - have also been reported.
Concerning anal margin neoplasia, these are represented by: Bowen disease in situ squamous-cell carcinoma ; invasive squamous-cell carcinoma; Paget disease; basal cell carcinoma: an extremely rare tumor, approximately 20 cases having been reported in 20 years 28that is of good prognostic. The papilloma virus tumore anale consists in ample local resection or rectal amputation in case of sphincter invasion.
TNM staging Anal cancer staging is based on tumor dimension, lymph node status and presence or absence of distance metastases.
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The risk of lymph node metastases is correlated with tumor size, invasion and grading. Risk factors Benign perianal pathology - perianal fissures and fistulas determine a chronic local inflammation that can lead to genetic alterations and have been incriminated as being etiologic factors.
However, recent studies did not show a significant correlation between this pathology and the development of anal carcinoma 8.
Sexual papilloma virus tumore anale - according to a papilloma virus tumore anale lead by Daling, patients with anal cancer had genital papillomatosis, type II HSV and Chlamydia trachomatis infections in their medical history. In the case of male patients, homosexuality, bisexuality, history of genital papilomatosis or gonorrhea have been associated to papilloma virus tumore anale higher risk of anal cancer 9. Another study, published inadds to the risk factors, for females: history of gonorrhea, uterine cervix dysplasia, more than 10 sexual partners, anal sexual intercourse; for male patients: syphilis is another risk factor HPV infection - it is the widest spread sexually transmitted infection in Europe Anal HPV infection can be clinically inapparent or it may manifest as condyloma.
Of all HPV subtypes, subtype 16 is the most frequently incriminated as carcinogen. Viral transmission is not influenced by the use of condoms as it is localized at the papilloma virus tumore anale of the penis and scrotum. Cigarette smoking - a study conducted in the early s highlighted a relative risk of 1. Carcinogenesis associated to cigarette smoking can be linked to an anti-androgenic effect of tobacco.
HIV infection - some studies showed an increase in anal canal cancer in seropositive patients. The severity and length of HPV infection are inversely proportional correlated to CD4 lymphocyte number. Immunocompromised patients, either due to HIV infection or to post-transplantation status or chemotherapy, have an increased risk of HPV infection and progression to squamous cell carcinoma Anatomy Surgical anal canal spreads from ano-rectal ring 2 cm above the dentate line to the external anal orifice.
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Anal cancer must be distinguished from anal margin neoplasia that originates from papilloma virus tumore anale skin that presents perianal hair. Some authors consider a 5 cm distance from the external anal orifice as the lateral limit The correct classification of perianal neoplasia into the two mentioned categories papilloma virus tumore anale extremely important as those of anal margin are of better prognosis. Altogether, an erroneous classification could overestimate the role of radio-chemotherapy Pectinate line represents an extremely important landmark for the vascularization and lymph node drainage.
Thus, above this line, venous drainage is to the portal circulation, by way of inferior mesenteric vein and below venous blood drains into systemic circulation through pudendal and hypogastric veins.
Above the pectinate line lymphatics drain into the inferior papilloma virus tumore anale, but also to hypogastric and obturatory lymph nodes, while below pectinate line-especially to inguinal lymph nodes, but also to femoral ones Due to the resemblance to papilloma virus tumore anale perianal pathology, the diagnosis is too often delayed.
Clinical examination consists in the inspection of perianal skin, anal margin, rectal examination and anoscopy and should indicate tumor localization above or below the pectinate line or its pertaining to anal margin. Bilateral papilloma virus tumore anale region palpation is mandatory due to the lymphatic drainage to those lymphatic groups.
Echo-endoscopy points our eventual loco-regional lymphadenopathies and gynecologic examination can indicate the coexistence of a uterine cervix lesion.
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The diagnostic of certainty is based on histopathologic examination. Bioptic samples can be easily obtained with the patient in gynecological position; however, colonoscopy with exploration up to the cecum is obligatory to exclude eventual synchronous lesions.
As with other paraclinical investigations, a CT examination of the thorax, abdomen and pelvis or an MRI is recommended to point out possible secondary tumors.
Untill the papilloma virus tumore anale, standard treatment consisted in abdominoperineal rectal amputation. For patients having small lesions, a large local excision has been proposed, accompanied however by disappointing results, excepting patients with a smaller than 2 cm anal margin cancer Abdominoperineal rectal amputation is the standard salvage therapy for patients who develop local recurrences.
Tumor invasion into neighboring organs is not a contraindication of resection, provided a R0 resection is achieved.
This fact has lead to the use of rotated or advanced musculocutaneous flaps to ameliorate the healing process. Provided the pelvic disease is controlled, isolated liver or lung metastases have indications papilloma virus tumore anale surgical resection.
Due to significant morbidity and the relatively low impact on survival, prophylactic inguinal lymphadenectomy is not recommended Inguinal lymphadenectomy is indicated for patients with voluminous lymphatic blocks or to those with an obvious lymphadenopathy after chemo-radiotherapy Some authors recommend for synchronous lymphadenopathies inguinal lymphadenectomy with chemo- and radiotherapy following the healing of the wound.
For metachronous lymphadenopathies, the treatment consists of lymphadenectomy followed by radiotherapy. The complications of the intervention consist in: wound dehiscence, hematomas, seromas, lymphoceles and lymphedema. Cancer statistics, CA Papilloma virus tumore anale J Clin ; 2.
CA Cancer J Clin ; International Agency for Research on Cancer. Cancer incidence in five continents. Springer Philadelphia: Lippincott Raven; Malignant tumors of the anal canal: the spectrum of disease, treatment, and outcomes.
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Cancer ; 85 8 — 7. Gastrointestinal stromal tumor of the anus. Tech Coloproctol ; Anal cancer incidence: genital warts, anal fissure or fistula, hemorrhoids, and smoking. J Natl Cancer Inst ; Sexual practices, sexually transmitted diseases, and the incidence of anal cancer. N Engl J Med Sexually transmitted infection as a cause of anal cancer.
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Declety G - Cancer de canal anal in Les cancers digestifs. Springer, Detection of human papillomavirus DNA in anal intraepithelial neoplasia and anal cancer. Cancer Res Am J Epidemiol. Tobacco smoking as a risk factor in anal carcinoma: an antiestrogenic mechanism? Mullerat J, Northover J.
Human papilloma virus and anal neoplastic lesions in the immunocompromised Transplant patient. Semin Colon Rectal Surg ; Results of definitive irradiation in a series of epidermoid carcinomas of the anal canal. Management of inguinal lymph node metastases in patients with carcinoma of the anal canal: experience in a series of patients treated in Lyon and review of papilloma virus tumore anale literature.
Cancer ; Epidermoid anal cancer: results from the UKCCCR randomised trial of radiotherapy alone versus radiotherapy, papilloma virus tumore anale, and mitomycin.
Papilloma virus tumore anale ; Anal carcinoma: histology, staging, epidemiology, treatment. Curr Opin Oncol ; Surgical management of epidermoid carcinoma of the anus. Am J Surg. Salvage abdomino-perineal resection after failed Nigro protocol: modest succes, major morbidity. Papilloma virus tumore anale Dis. Salvage abdominoperineal resection following combined chemotherapy and radiotherapy for epidermoid carcinoma of the anus.
Ann Surg Oncol ; 1: Results of surgical salvage after failed chemoradiation therapy for epidermoid carcinoma of the anal canal.
Ann Surg Oncol. Malignant tumors of the anal canal: the spectrum of disease, treatment and outcomes. Appraisal of the treatment of carcinoma of the anus and anal canal. Surg Gynecol Obstet ; Surgical management of metastatic inguinal lymphadeopathy. Recurrent epidermoid cancer cancer cap chemo the anus.
Cancer ; Basal cell carcinoma of the perianal region. Dis Colon Rectum ; Cummings BJ.
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Oncology ; Does an erroneous diagnosis of squamous-cell carcinoma of the anal canal and anal margin at first physician visit influence prognosis? Metastases to the lymph nodes in epidermoid carcinoma of the anal canal studied by a clearing technique.