treatment of perianal tumors, what to do with perianal tumors, medications for perianal tumors
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Perianal tumor diagnosis and treatment knowledge
Treatment department: Oncology Department of Anorectal Surgery Treatment cost: about (30,000-50,000 yuan) in the city's top three hospitals Cure rate: Treatment cycle: Treatment methods: surgery, radiotherapy and chemotherapy General treatment of perianal tumors
Western medicine treatment of perianal tumors
The treatment of perianal tumors is different from other tumors. The choice of treatment plan should be based on the scope of tumor invasion. The purpose of treatment is to improve the cure rate and avoid destructive surgery as much as possible. Squamous cell carcinoma at the edge of the anus is considered skin cancer if it does not invade the anal canal. The treatment of perianal cancer involving the anal canal is described below.
1. Treatment of marginal anal area cancer:
1) Treatment strategy:
For smaller tumors, it can be removed without destructive surgery; for larger tumors, radiotherapy is mainly used, but radiotherapy and chemotherapy can also be used.
2) Treatment of carcinoma in situ:
The standard treatment for carcinoma in situ is local resection, and laser treatment can also be considered for individual patients.
3) Treatment of advanced cancer:
The standard treatment for small tumors (T1N0) is local radical resection, and the range of radical resection should be an area 1cm outside the edge of the tumor, including normal tissue.
T2N0 stage tumors may have inguinal lymph node metastasis. In addition to covering the tumor itself, the radiotherapy area should also be irradiated on both sides of the inguinal area.
Chemotherapy and radiotherapy can be used at the same time for some T1~2N0 tumors. Studies have shown that combined chemotherapy can reduce tumors by 55% when local radiotherapy fails. For advanced cancer (T3~4 or N1~3), the standard treatment is radiotherapy. If the patient is suitable for chemotherapy, a combination of radiotherapy and chemotherapy should be used.
4) Treatment of recurrent cancer:
The choice of treatment options for recurrent cancer must be based on previous treatment decisions, and reoperation can be selected. For those who have recurred after partial resection, abdominal combined perineal resection is required, and standard chemotherapy and radiotherapy are also performed at the same time.
2. Anal cancer treatment:
1) Treatment strategy:
The purpose of treatment is to try to achieve a certain cure rate without destructive surgery. Remedial surgery can be used for residual lesions after radiotherapy or radiotherapy and chemotherapy, and remedial surgery can also be used for local recurrences.
2) Treatment of anal cancer in situ:
In situ anal cancer treatment is mainly local surgical resection, and some patients can also be treated with local laser.
3) Treatment of localized (T1～2N0) anal cancer:
For localized anal cancer with a diameter of less than 2cm, the treatment goal is to achieve a cure without using destructive surgery. The treatment is surgical resection or combined with radiotherapy. The local effects and survival rates of these two treatments are similar. For radiotherapy, external beam radiation or brachytherapy can be used. The local treatment effect is good, and the sphincter intact rate can reach 70%-100%, and the 3-year survival rate can reach 70%-90%. The main complications of long-term treatment are anal ulcers, hemorrhagic necrosis, stenosis and anal fistulas, with an incidence of 10%-30%, and colostomy is required in 6%-12% of patients. These complications are mainly related to the larger radiation dose. Therefore, the form of radiotherapy should not be too simplistic, and there should be a certain interval between treatments.
Recently, the United Kingdom Coordinating Committee on Cancer Research (UKCCCR) anal cancer research team believes that chemotherapy combined with radiotherapy should be used for T1 to 2N0 stage anal cancer. Their treatment results showed that 29% of patients had no local recurrence in the fourth year after the combined treatment; the recurrence rates of single treatment and combined treatment were 50% and 26%, respectively.
For tumors of 3 to 4 cm, the standard regimen is chemotherapy and radiotherapy at the same time. Combination therapy is better than single radiotherapy, and it can also reduce the chances of destructive surgery.
Yes (13% to 32% of patients can avoid colostomy); and there is no significant increase in later complications.
4) Treatment of advanced anal cancer:
The standard treatment for advanced anal cancer (T1～2N1～3 or T3～4 any N) is chemotherapy combined with radiotherapy. Remedial abdominal peritonectomy (abdominoperineal resection, APR) should be taken for partial treatment failures; radiotherapy and chemotherapy can be performed after colostomy for obstruction; radiotherapy should be stopped for patients with bleeding.
For the local remission rate, combination therapy is better than single radiotherapy (effective rate is 68% vs. 50%), and it also reduces the chance of destructive surgery (72% vs. 40% for patients who avoid colostomy); Late complications also did not increase significantly (10%). The long-term effect of combination therapy is also ideal. First, the anal sphincter function of most patients can be preserved intact; second, combined therapy also has a high tumor remission rate (80% to 90%), so most patients can avoid APR surgery. However, there is no difference in the 3-year survival rate (60% to 70%). There is no clear conclusion about whether adjuvant chemotherapy is needed after combined radiotherapy and chemotherapy.
For patients with local lymph node invasion or poor prognosis, it is recommended that individual larger lymph nodes (such as inguinal lymph nodes) be removed first, and then radiotherapy and chemotherapy. The treatment effect is similar to that of patients without lymph node invasion, and there is no significant difference.
5) Treatment of HlV-positive anal cancer:
There are currently few data on the treatment of HIV-positive anal cancer. The choice of treatment plan can be based on the patient's HIV infection, whether the patient can tolerate the treatment, and the clinical stage.
6) Treatment of anal canal cancer in the elderly:
For elderly people older than 75 years old, 80% of patients can tolerate full-dose radiotherapy [and/or combined chemotherapy]. Acute and chronic complications are similar to those of young patients, but the chemotherapy dose of mitomycin (MMC) and 5-FU should be reduced by 20%, and the radiotherapy interval should be adjusted at any time. Compared with young patients, the incidence of grade 3 acute reactions in the elderly combined with radiotherapy and chemotherapy is twice that of single radiotherapy (60% vs. 30%); and the incidence of acute fatigue failure is also significantly higher than that of young patients. Radiotherapy or chemoradiation should also be implemented according to the stage of the tumor and the general state of the patient. If necessary, the radiation dose (maximum 55 Gy) and chemotherapy dose should be appropriately reduced.
3. Treatment of residual anal cancer:
After radiotherapy and chemotherapy, residual lesions can be seen in 6% to 18% of gross or pathological sections. For these patients, the standard treatment plan is APR surgery (Miles surgery) plus permanent colostomy. There are only a few observations on the long-term efficacy of this treatment, and there are still disagreements. According to reports, the local effective rate of this treatment is 0-80%, and the long-term survival rate is 0-64%. There is no large sample observation data for when to perform pathological biopsy and when to perform this operation. However, the rate of pelvic and perineal infections complicated by this treatment can reach 30%. Therefore, the treatment of residual lesions after radiotherapy and chemotherapy still needs to be further explored and evaluated.
4. Treatment of local recurrence of anal cancer:
1) Local recurrence of lesions: In the first 2 years after radiotherapy and chemotherapy, the local recurrence rate of anal canal cancer is 10% to 32% (median recurrence time is 6 to 8 months). The staging and treatment of tumors are related to tumor recurrence. For these patients, the standard treatment is APR surgery (Miles surgery) plus permanent colostomy. About 60% of relapsed patients can be cured after surgery again, and the overall 5-year survival rate before local recurrence is 30%; 50% of patients after APR can achieve long-term remission (although the incidence of infection is higher). For patients who are already in the advanced stage after recurrence, the treatment effect and prognosis are poor. Therefore, early detection of local recurrence is very important for treatment and prognosis.
2) Local lymph node recurrence:
For patients with inguinal lymph node metastasis soon after treatment (this phenomenon is called metachronous or asynchronous metastasis), the swollen lymph nodes can be removed first, and then radiotherapy is performed again according to the previous radiation dose and scope.
5. Treatment of distant metastasis:
Approximately 20% of anal canal cancers can metastasize to distant sites. Such patients have a poor prognosis, but such tumors are generally relatively sensitive to chemotherapy. For these patients, single-agent chemotherapy is mostly used, but the current data are few, so there is no recognized program that can be recommended.
Most scholars believe that cisplatin should be used for active treatment. Cisplatin combined with bleomycin, vinblastine or vindesine also has a certain effect. Single-agent chemotherapy with doxorubicin and carboplatin can also be used.
Radiotherapy can relieve certain metastatic symptoms, such as bone pain and headache. For the turn
There is still a lack of reliable data on the surgical resection of metastatic cancer (such as liver and lung metastases).
1) Indications for radiotherapy:
The indications of radical radiotherapy are T1 and T2 stage tumors with a diameter of less than 5 cm. There are also T3 stage tumors with a diameter greater than 5 cm and T4 stage tumors with infiltration of adjacent organs as the target of radical radiotherapy.
Radical irradiation is also suitable for patients with inguinal lymph node metastasis, but lymph node metastasis is not good for local control.
2) Irradiation method and segmented irradiation:
Standard radiotherapy should cover the periphery of the rectum and the perineum. If there is metastasis to the inguinal and iliac lymph nodes, these areas should also be covered. The upper edge of the irradiation field is at the lower end of the sacroiliac joint, the left and right are the inguinal lymph nodes on both sides, and the lower edge is mostly the small pelvis including the perineum.
The commonly used radiotherapy methods include two-field, three-field, and four-field radiation, and sometimes direct radiation to the perineum area. The small intestine should be avoided as much as possible during radiation. After the front and rear facing two fields are irradiated with 30～45Gy/1.8～2Gy, the tumor will be irradiated with four fields, rotating irradiation and other 9～20Gy/1.8～2Gy supplementary irradiation. When the additional irradiation is more than 45Gy, the small pelvis is irradiated, and the end is 4～ The curative effect will be judged after 6 weeks. There may also be additional irradiation afterwards, but it is best to irradiate the entire course of treatment as quickly as possible during the first radical radiotherapy. Regarding the exposure dose and scope, the methods used in different studies are also different. The minimum dose of radiotherapy (exteRNAl beam radiotherapy, EBRT) outside the rectum and perineum is generally 45-50Gy; a retrospective analysis showed that when EBRT is greater than 55Gy, the radiation dose is dose-dependent with the local control rate. For those stage III patients who have not undergone combined chemotherapy or only undergo partial resection, the EBRT radiation dose can be increased by 19-25Gy, bringing the total dose to 55-67Gy. The radiation dose compensation method can take many forms, such as photon quadruple field irradiation, direct perineal irradiation of photons or electrons, interstitial brachytherapy and so on. 192Ir (iridium) implantable brachytherapy is only suitable for phase III clinical individualized treatment. The main complications of long-term radiation therapy are anal ulcers, hemorrhagic necrosis, stenosis and anal fistulas, with an incidence rate of 10% to 30%. A colostomy is required for 6% to 12% of patients. These complications are mainly related to the larger radiation dose. Preventive irradiation of the groin area is not recommended.
1) Common solutions:
The standard treatment plan for combined chemotherapy and radiotherapy should be based on fluorouracil (5-FU) and mitomycin (MMC), plus 2 courses of radiotherapy at the same time. Chemotherapy and radiotherapy should be performed at the same time on the first day. There are many options for this combination therapy, but there is no evidence to show which one is more advantageous. The 5-FU MMC combination is the standard regimen: 5-FU 1000 mg/m2 per day, continuous intravenous drip for 4 days. MMC 10mg/m2 was injected intravenously as a course of treatment, and the radiotherapy was repeated twice every 4 weeks. 5-FU CDDP (cisplatin) regimen: 5-FU 750mg/m2 daily for continuous intravenous infusion for 4 days, CDDP100 mg/m2 1 intravenous point for 1 course of treatment; or 5-FU 1000 mg/m2 daily for continuous intravenous infusion 4 days, 4 days of continuous use with CDDP25mg/m2 is a course of treatment, and the irradiation is repeated twice. Mitomycin combined with fluorouracil plus radiotherapy can improve the effect of local treatment.
2) Side effects:
Common side effects of chemotherapy are decreased white blood cell count, bone marrow suppression, etc. Radiotherapy is more common in acute reactions such as perineal radiation dermatitis, or diarrhea. Radiotherapy and chemotherapy have more side effects than radiotherapy alone. The incidence of acute reactions is about 30% when the radiation dose is 30Gy, and it increases to about 50% when the radiation dose is 50Gy. In the acute reaction, bone marrow suppression can cause severe infections such as sepsis, so special attention should be paid when increasing the dose of chemotherapy for obese patients.
The main complications of long-term radiation therapy are anal ulcers, hemorrhagic necrosis, stenosis and anal fistulas, with an incidence of 10% to 30%; these complications are mainly related to the larger radiation dose.
1. Perianal tumors can easily invade the anal sphincter and cause symptoms, but the symptoms are often non-specific in the early stage, which can easily be ignored by patients and doctors and cause delay in diagnosis. Therefore, most patients (60% to 70%) are already in the advanced stage at the time of the clear diagnosis; 15% to 20% of the patients found that the vagina, urethra, prostate, bladder, sacrum or ilium had been violated. Anal cancer, local lymph nodes are easily affected, and the tumor can spread along the perianal lymphatics. Distal anal canal cancer is prone to metastasize to inguinal lymph nodes, and proximal anal canal cancer is prone to metastasize to pelvic lymph nodes (such as pararectal and internal iliac lymph nodes), and finally to abdominal lymph nodes
Among them, about 25% of the lymph nodes on both sides are involved. Blood dissemination is rare (less than 10%), and the main distant metastases are the liver, lungs and skin.
2. A variety of factors can affect the prognosis, such as the histological type of the tumor, the patient's age, gender, tumor stage, metastasis, whether the tumor is sensitive to chemotherapy or radiotherapy, etc. These may all be independent factors affecting the prognosis. When evaluating the prognosis, there is no obvious correlation between squamous cell carcinoma and tumor stage. The histopathological grading is related to the prognosis. 75% of poorly differentiated patients have a 5-year survival period, while only 24% of highly differentiated patients. The exact reason for this situation is currently unclear. The prognosis of adenocarcinoma with radiotherapy is poor, and may even be lower than that of rectal cancer, but if radiotherapy and chemotherapy are taken, the prognosis can be improved. For adenocarcinoma of the anal margin, the main factor that affects the prognosis is the presence or absence of lymph node invasion.
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