A systematic review of outcomes after salvage abdominoperineal resection for persistent or recurrent anal squamous cell cancer

Abstract

Aim Up to 30% of patients with squamous cell cancer of the anus (SCCA) will require a salvage abdominoperineal resection (APR) for either persistent or recurrent disease. The objective of this study was to assess cancer‐related outcomes in patients with (i) persistent or (ii) recurrent SCCA. Method Embase and MEDLINE were searched. Publications were included if they assessed overall survival (OS), disease‐free survival (DFS) and locoregional recurrence or metastatic disease after salvage APR for persistent or recurrent SCCA. Results A total of 28 retrospective case series (study size ranged from nine to 111) met our inclusion criteria. The median time to salvage APR was 2.6 months [interquartile range (IQR) 2.6–5.0 months, six studies] for persistent disease and 27.6 months (IQR 15.0–32.7 months, five studies) for recurrent disease. The median 5‐year OS from the time of salvage APR was 45.0% (IQR 32.0%–52.3%, 10 studies) for persistent disease and 51.0% (IQR 36.0%–60.9%, 11 studies) for recurrent disease. The median 5‐year DFS following salvage APR was 44.0% (IQR 29.5%–53.0%, 10 studies) for all patients. Following salvage APR, the median locoregional recurrence rate was 23.5% (IQR 15.8%– 46.9%, 19 studies) and 9.0% (IQR 6.4%–13.3%, 16 studies) of patients developed metastatic disease after salvage APR. Conclusion Our review characterizes the best evidence for outcomes following salvage APR for patients with persistent or recurrent SCCA. The evidence is limited by the quality of included studies, as many were single centre case series.

Pelvic Exenteration for Squamous Cell Carcinoma of the Anus: Oncological, Morbidity, and Quality-of-Life Outcomes

“…These survival outcomes are comparable to the outcomes of salvage APR for anal SCC without adjacent organ involvement, for which the reported median 5-year overall survival was 45% in a recent systematic review (interquartile range, 32%-52%; 10 studies). 6 SCC arising from pelvic organs of cloacal origin (ie, the lower genitourinary tract and anal canal) tend to relapse locally after definitive chemoradiotherapy and/or surgical excision, often in an aggressive, multifocal manner. On this basis, an ultraradical surgical approach, particularly in the inferior pelvic compartment, is required for attempted salvage.…”

“…These survival outcomes are comparable to the outcomes of salvage APR for anal SCC without adjacent organ involvement, for which the reported median 5-year overall survival was 45% in a recent systematic review (interquartile range, 32%–52%; 10 studies). 6…”

“…5 Salvage abdominoperineal resection (APR) is the only potentially curative treatment option for these patients with locally persistent or recurrent disease, with reported rates of 5-year overall survival ranging from 23% to 78%. 6 The ability to achieve clear resection margins may be the most important predictor of survival for patients undergoing salvage surgery for anal SCC. 5 Where adjacent pelvic viscera, soft tissues, and bone are involved, pelvic exenteration (PE) with wide excision of the perineal skin and pelvic floor musculature can be considered to ensure clear resection margins and offer a chance of cure to highly selected patients in an otherwise palliative situation.…”

“…5 Salvage abdominoperineal resection (APR) is the only potentially curative treatment option for these patients with locally persistent or recurrent disease, with reported rates of 5-year overall survival ranging from 23% to 78%. 6…”

Anal squamous cell carcinoma: standards of care, new data and ongoing clinical trials

“…Local excision is an acceptable option for early (i.e. T1N0) tumours of the anal margin with no risk factors, whereas APR should be considered as the standard approach for patients with progressing tumours during CRT, persistent disease after 6 months from start of CRT or isolated locally recurrent disease [20,21].…”