Background 1. Hpv anorectal cancer Anal canal cancer is a relatively rare tumor, 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.
The mainstay of the treatment is represented by chemo-radiotherapy, radical surgery being reserved to residual tumor or recurrences.
Table 1; AJCC staging for anal cancer 2. Histopathology Depending on the lining epithelium, anal canal is divided hpv anorectal cancer three regions: colorectal zone: located proximally and containg columnar epithelium; transitional hpv anorectal cancer spread over a distance that varies between 0 and 12 mm that contains a pseudostratified type of epithelium resembling the urothelial one.
A transformation zone is unanimously accepted in uterine cancer. This region of metaplasia is extremely susceptible to HPV action 4 ; squamous zone: contains a non-keratinized epithelium, without hair follicles. Leiomyosarcomas, lymphomas and small cell hpv anorectal cancer 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 hpv anorectal cancer 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. The hpv anorectal cancer 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 activity - according to hpv anorectal cancer study 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, hpv anorectal cancer, bisexuality, history of genital papilomatosis or gonorrhea have been associated to a 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 hpv anorectal cancer the most frequently incriminated as carcinogen. Viral transmission is not influenced by the use of condoms as it is localized at the base of the penis and scrotum.
Ce este cancerul anal?
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 hpv anorectal cancer 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 hpv anorectal cancer Anatomy Surgical anal canal spreads from ano-rectal ring 2 cm above the dentate line to the external anal orifice.
Anal cancer must be distinguished hpv anorectal cancer anal margin neoplasia that originates from the 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 is 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 cancer uretra feminina 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 mesenteric, 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 benign 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 inguinal region palpation is mandatory due to the lymphatic drainage to those lymphatic groups.
Echo-endoscopy points our eventual loco-regional lymphadenopathies and hpv anorectal cancer examination can indicate the coexistence of a uterine cervix lesion. 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 hpv anorectal cancer MRI is recommended hpv anorectal cancer point out possible secondary tumors. Untill the s, 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 for surgical resection.
Cancerul de canal anal - aspecte legate de diagnostic și tratament
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 hpv anorectal cancer in: wound dehiscence, hematomas, seromas, lymphoceles and lymphedema.
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Cancerul de canal anal - aspecte legate de diagnostic și tratament
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