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Benign and Malignant Anal Lesions

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Presentation on theme: "Benign and Malignant Anal Lesions"— Presentation transcript:

1 Benign and Malignant Anal Lesions
David E. Stein, M.D. Division of Colorectal Surgery Department of Surgery Drexel University College of Medicine

2 Benign Conditions Rectal Prolapse/Incontinence Anal Fissures
Anal Abscess Anal Fistula Hemorrhoids Hidradenitis Pilonidal Disease

3 Rectal Prolapse Another time Another Place Another Lecture
Recognize it Surgical Repairs

4 Anal Fissure A linear tear or ulcer in the anal mucosa distal to the dentate line Primary (majority) Secondary (Crohn’s, trauma, infection) Constipation is the most common predisposing factor Diarrhea may also be a factor Severe pain with defecation

5 Anal Fissure Etiology unknown Acute Fissure Chronic Fissure
IAS overactivity Ischemia Acute Fissure Superficial, no induration, defined margins Chronic Fissure Sentinel tag, anal ulcer, hypertrophic anal papilla

6 Anal Fissure Medical Management Types of Medical Therapy
85% of acute fissures will heal 50% of chronic fissures Types of Medical Therapy Fiber Nitoglycerin Ointment Calcium Channel Blockers Botox Injections

7 Anal Fissure Surgical Therapy- Failed medical management
Lateral Internal Sphincterotomy Decreases anal canal tone Increases Tissue Perfusion Successful 95% of the time 1% Complication rate incontinence

8 Anorectal Abscess Common surgical emergency Recurrence rate of 48%
Males greater than females Classified as follows Perianal Ischiorectal Submucosal Intersphinteric Supralevator

9 Anorectal Abscess

10 Anorectal Abscess Originate in Anal Glands
Perianal and Ischiorectal predominate (80%) Other etiologies include IBD, septic anal fissure, cancer, post-operative Chief Complaint – Anal Pain Treatment is Surgical Drainage One third will develop chronic fistulas

11 Fistulas Communication between the anal mucosa and the perianal skin
Most are cryptoglandular in origin Rule out IBD/malignanct/etc Goodsall’s Rule Relationship between track opening and source

12 Fistulas

13 Fistulas Parks Classification Intersphinteric Transsphinteric
Suprasphinteric Extrasphinteric

14 Fistulas

15 Fistulas - Management Risks of incontinence versus benefits of therapy
Sphincter preservation if possible Fistulotomy – opening the entire fistula track Superficial and intersphinteric fistulas Low transsphinteric fistulas Seton Placement High transsphinteric fistulas +/- Suprasphinteric fistulas

16 Fistulas - Management

17 Fistulas - Management Setons Extrasphinteric Fistulas
Cutting vs Draining Draining setons are removed after 3-6 months Cutting setons are tightened every two weeks in the office Extrasphinteric Fistulas Not cryptoglandular Post-operative

18 Hemorrhoids Everyone has hemorrhoids!
Submucosal cushions comprised of connective tissue, arterioles and venules External vs Internal (Dentate Line) Three positions Left Lateral Right Posterior Right Anterior

19 Hemorrhoids Prolapse and Induration secondary to straining, constipation and pregnancy Family History - 50% Most common presentations are rectal bleeding and prolapse Severe pain is due to thrombosis or strangulation/necrosis

20 Hemorrhoids

21 Hemorrhoids Internal First Degree: Bleeding
Second Degree : Prolapse with spontaneous reduction Third Degree: Prolapse requiring manual reduction Fourth Degree: Irreducible Prolapse

22 Hemorrhoids Internal – Management
Small with minimal bleeding – fiber/fluids Second and Third Degree: Banding/coagulation/sclerotherapy Fourth Degree or strangulated/thrombosed Surgical hemorrhoidectomy

23 Hemorrhoids External Presents as painful mass – thrombosed
Natural history is resolution over days Clot evacuation relieves symptoms

24 Hidradenitis Suppurativa

25 Pilonidal Disease Acquired abscess formation in the natal cleft
Chronic Course Acute Rx – drain Chronic WLE Flaps

26 Premalignant and Malignant Anal Disease

27 Anatomy World Health Organization and the American Joint Committee on Cancer developed universal terminology Anal Canal – extends from the upper to the lower border of the internal anal sphincter (pelvic floor to anal verge) Mucosal lining is divided into upper (rectal), middle (transitional), and lower (squamous)

28 Anatomy

29 Anatomy Lymphatic drainage follows the mucosal lining
The upper lining drains via the superior rectal lymphatics to the inferior mesenteric nodes

30 Anatomy The transitional zone (extends cephalad from the dentate line for 1cm) drains primarily cephalad via the superior rectal lymphatics with some drainage via middle and inferior rectal vessels to the internal iliac nodes The lower lining drains to the inguinal nodes, some secondary drainage to the internal iliacs

31 Anal Tumors Perianal, or anal margin cancers are those tumors arising below the anal canal and extending onto the adjacent skin for 5-6cm Perianal tumors are treated and staged as skin cancer

32 Incidence Malignant anal neoplasms account for 1-6% of all colorectal cancers 85% of these arise in the anal canal Mean age of patients range from 58–67 years Anal canal cancers have a marked female predominance (5:1 ratio) Perianal cancers have a marked male predominance (4:1 ratio)

33 Incidence Increasing incidence over the past thirty years
The AIDS epidemic has accounted for the large increase in anal cancer in males Squamous cell carcinoma of the anal canal accounts for more than 80% of anal cancers

34 Etiology and Pathogenesis
Cigarette smoking, chronic inflammatory conditions (Crohns disease), and human papilloma virus infection have been shown to increase the risk of anal cancer Mechanism of HPV induced cancer parallels the genesis of cervical cancer 60 different HPV genotypes 20 types infect anogenital region

35 Etiology and Pathogenesis
HPV types 6 and 11 are associated with benign lesions such as warts and low grade anal intraepithelial neoplasia HPV types 16, 18, 31, 33, 34 and 35 are associated with high grade AIN, carcinoma in situ, and anal and cervical cancer

36 Staging TNM classification for both perianal and anal canal lesions
T stage is based on tumor diameter, not depth of invasion Best staging includes careful physical examination (EUA as needed), multiple biopsies, TRUS, and CT or MRI

37 Screening Lessons learned from cervical cancer and the success of screening Papanicolaou smears may be applied to high risk groups High Risk Groups include HIV negative men with a history of anal receptive intercourse HIV postive men and women with CD4 counts < 500/mm3 Women with high grade CIN

38 Screening The problem: The optimal treatment for premalignant lesions is unknown

39 Neoplasms of the Anal Margin
Premalignant lesions: AIN Bowen’s Disease Paget’s Disease Malignant Lesions Squamous cell carcinoma Basal Cell Carcinoma Verrucous Carcinoma

40 Premalignant lesions

41 Bowen’s Disease Rare, slow growing, intraepidermal squamous cell carcinoma (carcinoma in situ) 5-10% may become invasive SCC Most commonly presents in the sixth decade of life Originally thought to be a marker for other malignancies Only 102 cases reported in the literature from

42 Bowen’s Disease

43 Paget’s Disease First case of perianal Paget’s disease was reported in 1893 Cells are probably of apocrine gland origin Starts as a benign lesion May progress to adenocarcinoma

44 Paget’s Disease

45 Malignant Lesions of the Anal Margin

46 SCC of the Anal Margin 5 times LESS common than SCC of the anal canal
Rolled everted edges with central ulceration Similar to other SCC of the skin May be found in chronic, non-healing ulcers Mean age is 66 years at presentation

47 SCC of the Anal Margin

48 SCC of the Anal Margin

49 SCC of the Anal Margin Usually diagnosed more than two years after the onset of symptoms Common symptoms include a lump, bleeding, pain, discharge and itching 28% of patients are misdiagnosed with hemorrhoids, fissures, eczema, fistula or a benign lesion

50 SCC of the Anal Margin No clear consensus on therapy
Local excision and APR have high failure rates for advanced cancers For T1 well differentiated lesions, WLE vs chemoradiation For T2 and more advanced lesions chemoradiation with radiation to the groin is recommended 5 yr survival is % for T1 lesions, and drops to 60% for T2 lesions

51 Basal Cell Carcinoma Rare – MSKCC reported 5 cases over a 25 year period Presents in the sixth decade, and is more common in men Grossly similar to cutaneous basal cell cancers, with central ulceration and irregular, raised edges Low invasive potential, but must be distinguished from cloacogenic tumors

52 Basal Cell Carcinoma Local excision with 1 cm margins is recommended
Local recurrence is common (29%) Recurrence is treated with re-excision APR and radiotherapy are reserved for large, extensive lesions

53 Verrucous Carcinoma aka: giant condyloma acuminatum
aka: Buschke-Lowenstein Tumor Presents as a large, slow growing, painful wart like growth that is soft, with a cauliflower like appearance Histologically benign, but clinically malignant

54 Verrucous Carcinoma

55 Verrucous Carcinoma Continuous progression and expansion with erosion and pressure necrosis of the underlying tissue No metastases have been reported Wide local excision is the treatment of choice If the tumor involves the anal sphincters, APR is indicated Chemoradiation has not been used to date

56 Neoplasms of the Anal Canal
Squamous cell carcinoma Adenocarcinoma Small cell / Neuroendocrine carcinoma Malignant Melanoma Sarcomas Lymphomas

57 SCC of the Anal Canal Squamous cell or epidermoid cancers comprise 80% of anal cancers Morphologic types include keratinizing SCC, nonkeratinizing SCC, basaloid (cloacogenic) tumors, and SCC with mucus microcysts Morphology does not alter prognosis or therapy These tumors are more aggressive and have a worse prognosis than their anal margin counterparts

58 SCC of the Anal Canal Most patients present with bleeding, pain, or tenesmus Lesions are usually felt on digital examination and are tender, indurated, and ulcerated EUA, biopsies, TRUS and CT/MRI are used for diagnosis and staging 76% of patients are initially misdiagnosed with a benign condition

59 SCC of the Anal Canal Poor results with WLE/APR
Nigro showed no residual tumor in 22 of 24 APR specimens after “neoadjuvant” chemoradiation followed by resection Nigro protocol is the standard of care for SCC of the anal canal

60 SCC of the Anal Canal Nigro Protocol – 32 days
External Beam Radiation: 3000 cGy to primary carcinoma and pelvic/inguinal lymph nodes starting day 1 (200cGy/day) Systemic Chemotherapy: 5-FU 1000mg/m2/day continuous infusion days 1-4 and 28-32 Mitomycin-C 15mg/m2 IV bolus day 1 Nigro ND DC&R 1984

61 SCC of the Anal Canal 80-93% complete regression rates
70-90% five year survival rates have been reported APR resulted in 24-62% 5yr survival with a 27-50% recurrence rate

62 SCC of the Anal Canal APR is indicated for nonresponders, anorectal complications of therapy and recurrent disease The management of residual scars is somewhat controversial, although most authors suggest local excision

63 Adenocarcinoma Most commonly a very distal rectal adenocarcinoma with caudal spread True anal canal adenocarcinomas are rare There is an association with HPV Tumors arising from chronic fistulas or longstanding Crohn’s disease have been reported

64 Adenocarcinoma In general these tumors have a poor prognosis, with aggressive spread to inguinal and pelvic nodes APR with preoperative chemoradiation therapy is the treatment of choice

65 Neuroendocrine Tumors
Anal canal carcinoids may arise from neuroectodermal cells of the anal transition zone Tumors are rare and do not secrete active peptides or neurotransmittors Lesions less than 2cm may be treated by excision, and larger lesions by APR Chemoradiation is investigational

66 Melanoma Rare, accounting for 1-3% of all melanomas
Anal canal is 3rd most common site following skin and eyes Female to male ratio is 2:1, with an average age of 63 years at presentation The tumor may arise from above or below the dentate line

67 Melanoma

68 Melanoma Rectal bleeding, a mass in the anal canal and pain are the most common signs and symptoms Average size of tumor at presentation is 4cm Pigmented polypoid lesions which may be confused with thrombosed hemorrhoids 40-70% are amelanotic, with sheets of anaplastic cells

69 Melanoma Most studies have shown no benefit to APR over wide local excision Standard of care is WLE with 1 cm margins MSKCC series spanning 64 years found a survival advantage with APR in young, node negative patients with smaller tumors Brady, Kavolius Quan DCR, 1995 Overall prognosis is poor regardless of therapy

70 Sarcomas Rare, usually leiomyosarcomas
Bleeding, pain and perianal mass are common signs and symptoms, the sphincters are usually involved High grade lesions, size greater than 6cm and previous incomplete excision worsen the prognosis Standard therapy is APR

71 Summary Anal Margin Tumors are treated with WLE
SCC of the Anal Canal is treated with the Nigro Protocol Adenocarcinoma of the anal canal is treated with APR Consult a colorectal surgeon for all of those benign problems….

72 The End

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