Salvage Abdominoperineal Resection for Squamous Cell Anal Cancer: A 30-Year Single-Institution Experience

Abstract

BackgroundFailure of chemoradiotherapy (CRT) for anal squamous cell carcinoma (SCC) results in persistent or recurrent anal SCC. Treatment with salvage abdominoperineal resection (APR) can potentially achieve cure. The aims of this study are to analyze oncological and surgical outcomes of our 30-year experience with salvage APR for anal SCC after failed CRT and identify prognostic factors for overall survival (OS).MethodsAll consecutive patients who underwent salvage APR between 1990 and 2016 for histologically confirmed persistent or recurrent anal SCC after failed CRT were retrospectively analyzed.ResultsForty-seven patients underwent salvage APR for either persistent (n = 24) or recurrent SCC (n = 23). Median OS was 47 months [95% confidence interval (CI) 10.0–84.0 months] and 5-year survival was 41.6%, which did not differ significantly between persistent or recurrent disease (p = 0.551). Increased pathological tumor size (p < 0.001) and lymph node involvement (p = 0.014) were associated with impaired hazard for OS on multivariable analysis, and irradical resection only (p = 0.001) on univariable analysis. Twenty-one patients developed local recurrence after salvage APR, of whom 8 underwent repeat salvage surgery and 13 received palliative treatment. Median OS was 9 months (95% CI 7.2–10.8 months) after repeat salvage surgery and 4 months (95% CI 2.8–5.1 months) following palliative treatment (p = 0.055).ConclusionsSalvage APR for anal SCC after failed CRT resulted in adequate survival, with 5-year survival of 41.6%. Negative prognostic factors for survival were increased tumor size, lymph node involvement, and irradical resection. Patients with recurrent anal SCC after salvage APR had poor prognosis, irrespective of performance of repeat salvage surgery, which never resulted in cure.

ASO Author Reflections: Salvage Surgery for Anal Cancer

“…This study confirmed that salvage APR for either persistent or recurrent anal SCC, after failed initial treatment with CRT, can achieve long-term survival and durable local control 2. An overall 5-year survival rate of 41.6% was achieved, and the 5-year local recurrence rate was 44.7%.…”

Outcomes of surgery following chemoradiotherapy for anal cancer: A 10-year retrospective study

“…In their 26-year study in 2018, Hagemans, et al [6] conducted a study which included 47 patients and reported better results compared to the other published studies. The R0 rate was higher (80.9%) and the 5-year survival rate was 41.6% (against 35.2% in our study).…”

Evolution of the Role of Radiotherapy for Anal Cancer

“…Efforts have been made to identify differences in outcome comparing persistent vs. recurrent disease [ 128 ]. Although some studies demonstrate no survival difference among patients who receive salvage APR for persistent vs. recurrent disease [ 135 , 137 , 138 ], others suggest that persistent disease or early recurrence may be associated with worse outcomes, possibly due to more aggressive tumor biology in persistent disease or early recurrence [ 132 , 133 , 139 , 140 ]. Innovations in surgical technique for APR may improve outcomes [ 131 ].…”