1. 1 Maidstone and Tunbridge Wells NHS Trust (Kent Oncology Centre)
Surveillance CT in patients with complete remission following curative chemoradiotherapy for Anal Cancer (Single Centre experience)
Christos Mikropoulos1, Jennifer Turner1, Heather Lee1 , Gemma Hegarty1, Sasha Houghton1, Charles Bailey1,Jeff Summers1
1 Maidstone and Tunbridge Wells NHS Trust (Kent Oncology Centre)
INTRODUCTION
Imaging
Surveillance protocols following radical chemoradiotherapy (CRT) treatment for Anal Cancer vary between oncology centres. There is an increasing incidence of Anal Cancer with more women being affected. In there were 1247 new cases in the UK (65% women and 35% men) and 307 deaths from anal cancer. In view of the lack of consensus the NCCN guidelines in January 2016 advised annual imaging for 3 years for patients with locally advanced disease (T3/T4) or positive nodes
We are presenting our surveillance data for 148 patients who were treated for Anal Cancer in our centre over a period of 6 years.
AIM
The aim of this retrospective study was to review the failure pattern following CRT for Anal Cancer. We assessed the pick up rate with our current imaging surveillance protocol and identified areas for improvement.
Figure 1: Relapse with inoperable multiple liver metastases identified on year 1 surveillance CT scan
Figure 2: Local relapse with presacral mass identified on year 1 surveillance CT scan
PATIENTS AND METHODS
A total of 148 patients who completed CRT between 2006 and 2013 were included in this study. We adopted the rectal cancer surveillance protocol which involves CT scans of thorax, abdomen and pelvis on Years 1,2 and 5 post-treatment.
We used EUA and MRI post CRT to confirm complete response. We collected data on pattern of relapse and failure rates and overall survival and assessed the impact of imaging on outcomes.
RESULTS
Figure 3: Lung metastases identified on year 1 surveillance CT scan
Figure 4: Progression Free Survival with a median follow up of over 3 years reaches a plateau at 70%*
148 patients treated with CRT (73% women).
T0 (5%), T1(11%), T2(42%), T3(20%), T4(20%)
N0 (57%), N1(20%), N2(15%), N3(7.4%)
M1(2%)
MRI not done in 50% of cases (not introduced into protocol until 2009)
128 patients (86%) achieved a complete response (CR) on EUA.
The per protocol analysis of complete responders with a median follow up of 43 months identified 22 relapses (Relapse Rate=17%)*.
26 deaths (all cause mortality)
Year 1 CT (13 relapses)/122 scans performed
Year 2 CT (2 relapses)/ 104 scans performed
Year 5 CT (1 relapse)/ 53 scans performed
6 relapses on clinician initiated imaging.
45% (10/22) developed distant metastases
40% (9/22) local relapse
13% (3/22) lymph node relapse
4 patients with lung + liver metastases
3 patients with lung metastases only
3 patients with liver metastases only
Salvage interventions included 3 patients who received salvage pelvic surgery and 1 patient who underwent lung metastasectomy.
*30% of reported relapses were seen in patients with T2N0M0 disease, who wouldn’t normally be offered surveillance as per the NCCN guidelines
CONCLUSIONS
CRT offers high cure rates, even for advanced cases
The majority of relapses identified on the Year 1 follow up scan
Imaging triggered by symptoms and clinical findings identified 25% of relapses.
The majority of relapses were metastatic
Salvage treatment was offered to several patients
A structured follow up protocol for patients receiving radical CRT for Anal SCC can identify relapses and allow salvage treatment approaches in some cases.
AFFILIATIONS
ACKNOWLEDGEMENTS
CONTACT
Kent Oncology Centre
Maidstone Hospital
Kent
Patients and their families
The Radiology Department at Maidstone Hospital
Dr J Summers
Kent Oncology Unit
Maidstone
ME16 9QQ