Anal cancer When to operate, when to irradiate?

Since the 1980s the treatment of anal cancer has fundamentally changed. Whereas up until then abdominoperineal rectal extirpation with definitive colostomy was the established therapy, it was replaced by simultaneous continence-preserving chemoradiotherapy as primary treatment, beginning with the studies by Nigro. Indications for primary surgical treatment are nowadays limited to local excision of the tumor in well-differentiated tumors up to 1cm in size (T1N0G1-2) and well-differentiated T1-2N0G1-2 tumors of the anal rim. In both cases primary chemoradiotherapy is also feasible. Several studies were conducted to find the optimal regimen for chemoradiotherapy. It consists of radiation of the primary tumor and inguinal as well as pelvic lymph nodes with a total dosage of 50.4-59.4Gy and simultaneous chemotherapy with 5-fluorouracil (days 1-4 and 29-32) and mitomycin C (days 1 and 29) as i.v. bolus. No other combination treatment could achieve a better outcome for the patients. An abdominoperineal rectal extirpation with a definitive colostomy (salvage therapy) as surgical treatment mainly figures in the treatment of residual or recurrent disease after primary chemoradiotherapy, if necessary, combined with plastic surgery. In some cases, a temporary or permanent sigmoid end colostomy alone is indicated. Non-metastatic anal cancer responds well to treatment and shows a good prognosis.