Anal Cancer - Case 1  62 years old woman with 6 months history of anal pain  Clinically T 3 squamous cell carcinoma growing anteriorly  Which staging process ?

Anal Cancer - Case 1  62 years old woman with 6 months history of anal pain  Clinically T 3 squamous cell carcinoma growing anteriorly  Which staging process ?  MRI; T 3, N 1 (left groin), M 0

Anal Cancer - Case 1  MRI; T 3, N 1, M 0  What treatment option ?

Anal Cancer - Case 1  MRI; T 3, N 1, M 0  What treatment option ?  Induction therapy (3 months) with chemo followed by chemo - rad  Which radiation dose ?

Anal Cancer - Case 1   50 Gy chemo - rad  How about the groin metastasis ?

Anal Cancer - Case 1   50 Gy chemo - rad  How about the groin metastasis ?  Wait and see ?  When and how to evaluate the effect of the treatment ?

Anal Cancer - Case 1  When and how to evaluate the effect of the treatment ?  Continuously during the radiation period

Anal Cancer - Case 1  Evaluate outcome continuously during the radiation period  If poor effect, when is the best timing for surgery ?  What type of surgery and how about the groin ?  How handle the perineal wound ?

Anal Cancer - Case 1  Surgery was planned weeks after the end of chemo-radiation.  The patient had a laparoscopic APR with resection of the posterior vaginal wall. No dissection of the groin.  If surgery was performed later due to a recurrence ? Any difference ?

Anal Cancer - Case 1  Any difference with delayed surgery ?  Perineal wound healing ?  Consider TRAM - graft ?

Case 2

Anal Cancer - Case 2  78 years old gentleman had a stalked polyp in the anal canal. Biopsy showed cancer. Clearly resectable.  Which staging process ?

Anal Cancer - Case 2  78 years old gentleman had a stalked polyp in the anal canal. Biopsy showed cancer. Clearly resectable.  Which staging process ?  Ultrasound T 1, N 0  MRI T 1, N 0, M 0

Anal Cancer - Case 2  Ultrasound T 1, N 0  MRI T 1, N 0, M 0  How to treat ?

Anal Cancer - Case 2  Ultrasound T 1, N 0  MRI T 1, N 0, M 0  How to treat ?  Pathology; Malignant melanoma !  What to do now ?

Anal Cancer - Case 2  Malignant melanoma  Treatment options ?  T 3 - 4, N 0, M 0  APR ? Local excision ?  Curable at all ?

Case 3

Anal Cancer - Case 3  Treatment options ?

Case 4

Anal Cancer - Case 4  26 years old woman with a rather small (< 2 cm) squamous cell cancer growing anteriorly in the anal canal.  Staging ; T 1, N 0, M 0  Treatment options ?

Anal Cancer - Case 4  Local excision ?  Radiotherapy ? Pros and cons !

ANAL CARCINOMA Timing of surgery The decision of whether or not surgery has to be done is often based on the pre-radiotherapy status

ANAL CARCINOMA Timing of surgery The main discussion comes after Gy

ANAL CARCINOMA Timing of surgery If surgery has been decided wait weeks but not more 8 weeks

ANAL CARCINOMA Timing of surgery Avoid surgery after 60 Gy Main reason is impaired healing

ANAL CARCINOMA Local excision Never after radiotherapy !

ANAL CARCINOMA Local excision If the tumour recur after local excision do not operate again use radiotherapy