Requiem for Nigro or is anal squamous carcinoma still a surgical problem: Abdominoperineal excision rather than a defunctioning stoma?

Abstract

Background: Combined multimodal treatment (CMT) is the preferred treatment for anal squamous carcinoma with radical surgery reserved for treatment failure. Some patients require a defunctioning stoma prior to CMT. Successful closure of such a stoma is unlikely. Abdominoperineal excision (APE) may be suitable as primary treatment in these patients. Objectives: To evaluate organ preservation in the treatment of anal squamous cancer and the closure rate of pre-treatment, temporary diverting colostomy, thereby assessing whether APE could be offered as primary treatment in those requiring a pre-treatment colostomy. Methods: A retrospective review of all patients with anal squamous carcinoma was undertaken. Patients who required defunctioning colostomies prior to CMT were analysed for potential resectability of tumour prior to CMT and rate of permanent stoma. Results: One hundred and twenty-five patients were included of which 58 were males. The mean age was 56 years. 107 were treated with curative intent. Six received primary APE and 12 salvage APE. Thirty (22 males) required pretreatment diverting colostomies. Three (10%) stomas were successfully reversed. Forty-eight (38%) of the 125 completed treatment with a permanent colostomy. Six patients who needed a stoma prior to CMT were deemed resectable. Conclusion: Organ preservation was not possible in about a third of patients. Defunctioning stomas prior to CMT were likely to be permanent. We propose that APE could be considered as an alternative in selective cases where the tumour is resectable with low morbidity and a stoma is indicated.

Pretreatment colostomy in patients with anal squamous cell carcinoma: Risk factors for a permanent stoma

“…Previous studies have documented divergent results regarding the indications for and reversal rates of pretreatment stomas. The need for a colostomy ranges from 9% to 51%, and the reversal rates range from 5% to 48% 9–13 . Case series considering distinct numbers of patients with advanced tumors, less strict indications and cultural aspects may help to explain this discrepancy.…”

“…Other authors have suggested that since these stomas are rarely reverted, primary APR might be considered in selected patients 13 . Although no previous RCT has compared both strategies directly, primary APR has been historically associated with shorter overall survival.…”

“…The need for a colostomy ranges from 9% to 51%, and the reversal rates range from 5% to 48%. [9][10][11][12][13] Case series considering distinct numbers of patients with advanced tumors, less strict indications and cultural aspects may help to explain this discrepancy. Some series do not report the clinical stage specifically for this group of patients, 9,[11][12][13] while others do not report the rationale for the stoma, 11 making direct comparisons of the data difficult.…”

“…Limited data exist regarding the reversion of pretreatment stomas. The literature suggests that they are unlikely to be reverted, although the reported reversion rates range from 5% to 48% 9–13 . Heterogeneous populations, different indications for surgery, and cultural aspects regarding the acceptance of a stoma may explain these findings.…”

“…The literature suggests that they are unlikely to be reverted, although the reported reversion rates range from 5% to 48%. [9][10][11][12][13] Heterogeneous populations, different indications for surgery, and cultural aspects regarding the acceptance of a stoma may explain these findings. From a patient's perspective, retaining a pretreatment stoma after successful oncological treatment may be very frustrating.…”