1. 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 ?

2. 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

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

4. 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 ?

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

6. 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 ?

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

8. 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 ?

9. Anal Cancer - Case 1  Surgery was planned 6 - 8 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 ?

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

11. Case 2

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

13. 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

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

15. 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 ?

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

17. Case 3

19. Anal Cancer - Case 3  Treatment options ?

20. Case 4

21. 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 ?

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

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

24. ANAL CARCINOMA Timing of surgery The main discussion comes after 45 - 50 Gy

25. ANAL CARCINOMA Timing of surgery If surgery has been decided wait 4 - 6 weeks but not more 8 weeks

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

27. ANAL CARCINOMA Local excision Never after radiotherapy !

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