BACKGROUND Locally persistent or recurrent anal carcinoma represents a clinically significant problem, the management of which remains the subject of some controversy. Although the few current data suggest that radical surgery remains the sole salvage treatment able to provide some chance of cure, some authors have reported disappointingly low success rates. The current study presents the outcome of patients who failed locally after receiving radiotherapy or chemoradiotherapy for anal carcinoma. METHODS Of 185 consecutive patients treated between January 1976 and December 1996 with sphincter conservation, 42 subsequently presented with local failure, either alone (27 patients) or with regional or distant metastases (15 patients). Nine patients (21%) received supportive care only, 7 patients (17%) received palliative therapy, and 26 patients (62%) underwent potentially curative surgical salvage treatment, including 23 abdominoperineal resections (APR) and 3 local excisions. The median follow‐up after local failure for all patients was 21.5 months (range, 1–231 months). RESULTS With the exception of 2 patients who committed suicide, all patients who did not undergo surgical salvage therapy died of progressive disease. Among 26 patients who received curative treatment, 11 ultimately achieved disease control. The 5‐year overall survival rate after the diagnosis of local failure was 28% for all patients and 44.5% for those receiving curative salvage treatment. For the latter group the 5‐year actuarial secondary local and locoregional control rates were 53% and 43%, respectively. CONCLUSIONS Although APR no longer is the first‐line treatment of patients with anal carcinoma, it continues to play an essential role in salvage therapy, resulting in ultimate disease control in approximately 50% of patients with isolated local failure. The curative potential of secondary surgical treatment suggests the possible importance of early detection of persistent or recurrent local disease after nonsurgical, sphincter‐conserving therapy. Cancer 1999;86:405–9. © 1999 American Cancer Society.

Local application of 4% formaldehyde for the treatment of haemorrhagic radiation-induced proctitis gives good results, is well tolerated and easy to perform. Formaldehyde applied selectively causes thromboses of the bleeding vessels, without deep lesions or extended necrosis.

Radiation-induced proctitis with hemorrhage is not a common complication of radiotherapy to the pelvis for carcinoma. In the most severe forms, massive hemorrhage may necessitate repeated transfusions and inpatient treatment. In severe cases medical treatment has not been proved effective. Surgery may lead to serious complications and is technically difficult. Six patients who showed a hemorrhagic radiation-induced proctitis have been treated as outpatients with application of formaldehyde 4%. In four cases the bleeding ceased after the first formaldehyde application; two patients continued to bleed, but another application of formaldehyde 3 weeks later definitively controlled the hemorrhage. Follow-up evaluation at 12 months showed in each case that the hemorrhage was controlled and treated. There were no complications, such as burns or late stenoses of the deep layers of the rectum. This inexpensive technique is well tolerated by the patient, gives good long-term results, and is available at every hospital. Local application of formaldehyde 4% to the rectum may be the treatment of choice for hemorrhagic radiation-induced proctitis.

BACKGROUND This study was conducted to investigate the influence of therapeutic parameters on local control (LC) in the sphincter‐conserving treatment of T2‐T3 anal carcinoma. METHODS From 1976 to 1993, 137 patients with anal carcinoma classified as T2 (85 patients) or T3 (52 patients) were treated curatively by radiotherapy (RT) alone (54 patients) or by concomitant chemotherapy and RT (83 patients). RT was delivered in two sequences, with a median gap of 46 days between the sequences. The first sequence was delivered at a median dose of 39.6 gray (Gy) using megavoltage photon beams. Boost treatment consisted of either 192Ir implantation or external beam RT (median dose, 20 Gy). Chemotherapy started on Day 1 and generally consisted of 1 cycle of mitomycin C (10 mg/m2) and a 5‐day infusion of 5‐fluorouracil (600‐800 mg/m2/day). For surviving patients, median follow‐up was 83 months. Univariate and multivariate analyses were performed to determine therapeutic parameters affecting LC after adjustment for clinical factors. RESULTS The 5‐year actuarial LC was 76%. Factors associated with poorer LC (univariate) were as follows: age < 66 years (LC was 67% with the factor vs. 85% without), male gender (65% vs. 81%), tumor extent > 1/3 canal circumference (67% vs. 90%), lymph node involvement (64% vs. 81%), use of external beam boost (62% vs. 79%), and overall treatment time (OTT) ≥ 75 days (69% vs. 85%). In multivariate analysis, no therapeutic parameters remained significant when adjusted for significant clinical factors, although OTT was of borderline significance (P = 0.09). CONCLUSIONS The results of this multivariate analysis suggest that therapeutic factors have a less marked effect on LC compared with clinical parameters; the only factor that appeared to have some effect was OTT. Efforts to improve LC in patients with poor prognoses should concentrate on optimizing OTT and the chemotherapeutic aspects of treatment (in other words, attempts should be made to provide more effective agents and optimize scheduling). Cancer 1997; 79:2329‐35. © 1997 American Cancer Society.

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