Comparison between pelvic MRI, CT, and PET/CT in baseline staging and radiation planning of anal squamous cell carcinoma.

PURPOSE: To investigate the differences in baseline staging of anal squamous cell carcinoma based on CT, MRI, and PET/CT, and the resultant impact on the radiation plan. METHODS: This retrospective study included consecutive patients with anal squamous cell carcinoma who underwent baseline pelvic MRI, CT, and PET/CT (all examinations within 3 weeks of each other) from January 2010 to April 2020. CTs, MRIs, and PET/CTs were re-interpreted by three separate radiologists. Several imaging features were assessed; tumor stage was determined based on the eight edition of the American Joint Committee on Cancer (AJCC) staging manual; and T (tumor), N (node), and M (metastasis) categories were determined based on National Comprehensive Cancer Network (NCCN) guidelines. Radiologist assessments were then randomly presented to a radiation oncologist who formulated the radiation plan in a blinded fashion. RESULTS: Across 28 patients (median age, 62 years [range, 31-78], T-category classification was significantly different on PET/CT compared to MRI and CT (p = 0.037 and 0.031, respectively). PET/CT staged a higher proportion of patients with T1/T2 disease (16/28, 57%) compared to MRI (11/28, 39%) and CT (10/28, 36%). MRI staged a higher proportion of patients with T3/T4 disease (14/28, 50%) compared to CT (12/28, 43%) and PET/CT (11/28, 39%). However, there was no significant difference between the three imaging modalities in terms of either N-category, AJCC staging, or NCCN TNM group classification, or in treatment planning. CONCLUSION: Our exploratory study showed that MRI demonstrated a higher proportion of T3/T4 tumors, while PET/CT demonstrated more T1/T2 tumors; however, MRI, CT, and PET/CT did not show any significant differences in AJCC and TNM group categories, nor was there any significant difference in treatment doses between them when assessed independently by an experienced radiation oncologist.

Imaging of Anal Squamous Cell Carcinoma: Survey Results and Expert Opinion from the Rectal and Anal Cancer Disease-Focused Panel of the Society of Abdominal Radiology.

The role and method of image-based staging of anal cancer has evolved with the rapid development of newer imaging modalities and the need to address the rising incidence of this rare cancer. In 2014, the European Society of Medical Oncology mandated pelvic magnetic resonance imaging (MRI) for anal cancer and subsequently other societies such as the National Comprehensive Cancer Network followed suit with similar recommendations. Nevertheless, great variability exists from center to center and even within individual centers. Notably, this is in stark contrast to the imaging of the anatomically nearby rectal cancer. As participating team members for this malignancy, we embarked on a comprehensive literature review of anal cancer imaging to understand the relative merits of these new technologies which developed after computed tomography (CT), e.g., MRI and positron emission tomography/computed tomography (PET/CT). The results of this literature review helped to inform our next stage: questionnaire development regarding the imaging of anal cancer. Next, we distributed the questionnaire to members of the Society of Abdominal Radiology (SAR) Rectal and Anal Disease-Focused Panel, a group of abdominal radiologists with special interest, experience, and expertise in rectal and anal cancer, to provide expert radiologist opinion on the appropriate anal cancer imaging strategy. In our expert opinion survey, experts advocated the use of MRI in general (65% overall and 91-100% for primary staging clinical scenarios) and acknowledged the superiority of PET/CT for nodal assessment (52-56% agreement for using PET/CT in primary staging clinical scenarios compared to 30% for using MRI). We therefore support the use of MRI and PET and suggest further exploration of PET/MRI as an optimal combined evaluation. Our questionnaire responses emphasized the heterogeneity in imaging practice as performed at numerous academic cancer centers across the United States and underscore the need for further reconciliation and establishment of best imaging practice guidelines for optimized patient care in anal cancer.

Molecular Imaging and Therapy of Colorectal and Anal Cancer.

Colorectal cancer is the cancer with the third highest incidence both in males and females in the USA and is also frequently occurring in other industrialized nations. Anal cancer on the other hand is much rarer, but has a rising incidence, especially in high income nations and with a connection to HIV infections, homosexual men and a younger age of the first sexual encounter. Both have high mortality rates in common and are complex to handle in terms of prevention, staging, treatment and diagnostic of recurrence. This article aims to give an overview about the established diagnostic methods of nuclear medicine, especially sole PET and (contrast enhanced) hybrid imaging with 18F-FDG as tracer for primary staging, restaging, therapy monitoring and radiotherapy planning in current guidelines, with a special focus on the American guidelines of the National Comprehensive Cancer Network for colorectal and anal cancer. There will also be an outlook on potential future adjustments in those leading to a more significant representation of nuclear medicine by giving a synopsis of the available studies and data published in international medical press. New tracers that are still in research stage, progress in the imaging techniques, for example a further establishment of PET/MR hybrid imaging, the use of artificial intelligence and parametric imaging, as well as possible future theranostic applications like c-MET binding peptides will also be shortly discussed.

[Cylindric Abdominoperineal Rectum Exstirpation with Partial Vulvar and Vaginal Resection as well as Perineal and Vaginal Defect Reconstruction by a Vertical Rectus Abdominis Myocutaneous (VRAM) Flap]. / Zylindrische abdominoperineale Rektumexstirpation mit partieller Vulva- und Vaginaresektion sowie perinealer und vaginaler Defektrekonstruktion durch einen vertikalen Rectus-abdominis-Muskel-Haut-Lappen (VRAM-Lappen).

Introduction Patients with low rectal cancer or anal cancer undergoing abdominoperineal excision (APE) benefit from extended surgery and the subsequent avoidance of surgical "waisting" at the level of the puborectalis muscle. The method of cylindrical APE was introduced by T. Holm and led to a reduction of intraoperative perforations and involvement of circumferential resection margins, and subsequently reduced the risk of local recurrence. The use of myocutaneous flaps reduces perineal wound complications, which occur in up to 60% of patients with primary closure of perineal defects, especially following neoadjuvant radiochemotherapy. Flaps obliterate pelvic dead space, recruit well-vascularised tissue into irradiated regions, facilitate wound closure and allow for vaginal and perineal reconstructions. This video shows the technique of extended cylindrical APE with partial vulvar and vaginal resection and subsequent reconstruction of the posterior vaginal wall and the pelvic floor defect by a vertical rectus abdominis myocutaneous (VRAM) flap. Indication Locally advanced anal cancer with infiltration and fistula to the posterior vaginal wall without metastatic spread following neoadjuvant radiochemotherapy. Procedure Extended cylindric APE with partial vulvar and vaginal resection, construction of a descending colostomy with parastomal intraperitoneal onlay mesh augmentation, pelvic reconstruction with a VRAM flap and inlay mesh augmentation of the anterior rectus sheath. Conclusion From the oncological point of view, extralevator APE is superior to standard surgery. The use of myocutaneous flaps improves postoperative wound healing and quality of life.

Phase II study of computed tomography-guided (125)I-seed implantation plus chemotherapy for locally recurrent rectal cancer.

BACKGROUND AND PURPOSE: This trial evaluated the efficacy and safety of CT guided (125)I-seed implantation (CTII) plus chemotherapy with fluorouracil, leucovorin, and irinotecan (FOLFIRI) compared with FOLFIRI alone as second-line treatment for locally recurrent rectal cancer (LRRC). MATERIAL AND METHODS: Patients with LRRC who received one prior chemotherapy regimen were enrolled and divided randomly assigned to FOLFORI alone (Arm A) and FOLFORI plus CTII (Arm B). The primary endpoint was local control time (LCT). Overall survival (OS) and treatment related adverse events (TRAEs) were also observed. RESULTS: Fifty-seven patients were enrolled from October 2008 and December 2014. Twenty-seven were assigned into Arm A and 30 into Arm B. The overall response rate of locally recurrent tumor was improved to 100% in Arm B versus 29.6% in Arm A (P<0.001). A significant longer LCT was observed in Arm A (P<0.001); median LCT was 12 months in Arm B versus 4 months in Arm A. A borderline significant improvement in OS was also observed in Arm B (P=0.0464); median OS was 25 months in Arm B versus 19 months in Arm A. For patients without distant metastases, median OS was 37 months in Arm B versus 21 months in Arm A (P=0.0101). For patients with (neo)adjuvant radiotherapy (ART), a longer LCT and OS were also found in Arm B (P<0.001 and P=0.0217, respectively). TRAEs were not serious generally. There was no statistically significant difference in treatment related toxicity between Arm A and B both for all patients and patients receiving ART. CONCLUSIONS: CTII plus FOLFIRI improves the LCT with tolerable toxicities as a second-line treatment in patients with local recurrent rectal cancer, and is helpful to prolong the OS, particularly in patients without distant metastases or with a history of radiotherapy.

Eight years of IMRT quality assurance with ionization chambers and film dosimetry: experience of the Montpellier Comprehensive Cancer Center.

BACKGROUND: To present the results of quality assurance (QA) in IMRT of film dosimetry and ionization chambers measurements with an eight year follow-up. METHODS: All treatment plans were validated under the linear accelerator by absolute and relative measures obtained with ionization chambers (IC) and with XomatV and EDR2 films (Kodak). RESULTS: The average difference between IC measured and computed dose at isocenter with the gantry angle of 0° was 0.07 ± 1.22% (average ± 1 SD) for 2316 prostate, 1.33 ± 3.22% for 808 head and neck (h&n), and 0.37 ± 0.62% for 108 measurements of prostate bed fields. Pelvic treatment showed differences of 0.49 ± 1.86% in 26 fields for prostate cases and 2.07 ± 2.83% in 109 fields of anal canal.Composite measurement at isocenter for each patient showed an average difference with computed dose of 0.05 ± 0.87% for 386 prostate, 1.49 ± 1.86% for 158 h&n, 0.37 ± 0.34% for 23 prostate bed, 0.80 ± 0.28% for 4 pelvis, and 2.31 ± 0.56% for 17 anal canal cases. On the first 250 h&n analyzed by film in absolute dose, the average of the points crossing a gamma index 3% and 3 mm was 93%. This value reached 99% for the prostate fields. CONCLUSION: More than 3500 beams were found to be within the limits defined as validated for treatment between 2001 and 2008.

Extramedullary plasmacytoma of anorectum: case report.

A young anxious looking male presented with a referral diagnosis of recurred bilateral ischiorectal abscesses. Clinical examination and investigations showed an advanced lesion of the anorectum. Histology revealed an extramedullary plasmacytoma of the anorectum to which the patient succumbed and died within two weeks of presentation.

Squamous cell carcinoma of the anus and rectum in homosexual men: CT findings.

OBJECTIVE: Homosexual men are at risk for a variety of infectious and neoplastic diseases of the anus and rectum, many of which have been reported in the radiologic literature. The purpose of this study was to describe the CT findings in homosexual men with squamous cell carcinoma of the anus and rectum, a topic that has received little attention. MATERIALS AND METHODS: Computed tomography examinations of the abdomen and pelvis of nine homosexual men with squamous cell carcinoma of the anus and rectum were reviewed retrospectively. Six HIV-positive men were 28-44 years old (average, 37 years). Three HIV-negative men were 47-61 years old (average, 54 years). RESULTS: In six of the nine patients, CT showed a mass involving the anal canal. In five of these six patients, the tumor extended caudad to involve perianal fat and skin (one patient), cephalad to involve the rectum and perirectal fat (two patients), or both (two patients). In three of the nine patients, the anal canal did not appear to be involved by the tumor; CT showed circumferential rectal wall thickening (one patient), an excavated eccentric rectal tumor (one patient), or a cystic extramucosal rectal mass (one patient). Computed tomography evidence of noncontiguous metastasis was limited to inguinal and iliac lymph node enlargement in two of the nine patients. CONCLUSION: Because CT findings are varied and nonspecific, squamous cell carcinoma should be included in the differential diagnosis of anorectal lesions in homosexual men.

Polypoid lesions at the anorectal junction: barium enema findings.

Although the anorectal junction is easily accessible, this area may be difficult to evaluate both radiologically and endoscopically because it is relatively collapsed. This pictorial essay illustrates the barium enema radiographic findings and reviews the radiologic and endoscopic pitfalls in the diagnosis of lesions of the anorectal junction.

[Anorectal anaplastic cancer (neuroendocrine)]. / Cancer anaplasique (neuro-endocrinien) anorectal.

An extensive case of undifferentiated neuroendocrine carcinoma with small cells of the anorectal region is reported. The carcinoma is related to pulmonary anaplasia and quite rare in the colonic and rectal region. Its aggressivity is considerable with a strong propensity for hematogenous and lymphatic metastases and with a disastrous prognosis: 0% survival over 1 year. The incidence, the characteristic features, the histogenesis, and the anatomical pathology of this rare neoplasm are mentioned. Furthermore, the case illustrates a radiological pattern typical for major lymphatic dissemination with an intra- and extraparietal component. The mechanism of dissemination is explained by the "lymphatic block" theory. The absolute necessity of obtaining an histology in radiologically unusual and/or extensive cases is mentioned.

[Cloacogenic carcinoma. Radiological appearance during double-contrast enema]. / Il carcinoma cloacogenico. Aspetto radiologico al clisma a doppio contrasto.

Radiographic appearances at double contrast enema of 8 cases of anorectal cloacogenic carcinoma are described. In all cases tumor was radiologically identified as a neoplastic lesion, but the correct histologic diagnosis was not reached in any case. Radiological features of the cloacogenic carcinoma are: the evident submucosal mass, the poor mucosal involvement and the eccentricity of the lesion. However, the characteristics of the tumor are not peculiar and radiologic diagnosis of the nature of tumor can only be suspected.

[Internal hemorrhoids--roentgen symptoms and differential diagnostic demarcation from rectal and anal cancer]. / Die inneren Haemorrhoiden--Röntgensymptomatik und differentialdiagnostische Abgrenzung zum Rectum- bzw. Analcarcinom.

The main indication for colon barium enema examination is occult bleeding or bleeding noticed by the patient himself. The radiologist has to take into account all clinical details that could lead to bleeding and to document them. The most frequent causes of rectal bleeding are hemorrhoids and diverticulosis/itis which in marked cases may have a tumor-like appearance. A good double-contrast examination of the colon must not only exclude tumors, polyps or inflammatory diseases but also demonstrate other causes of bleeding. The presented paper describes typical roentgen signs and gives criteria to differentiate hemorrhoids from deeply situated cancer of the rectum or anus.

The use of computerized tomography scan in the staging and follow-up study of carcinoma of the rectum.

We have reviewed the CT scans of 30 patients who were evaluated for either primary or recurrent carcinoma of the colon and rectum in the pelvis. The results of our experience have shown that pelvic CT scans can provide accurate information regarding the extramural extension of carcinoma of the rectosigmoid undetected by other means. CT scans can detect significant ureteral pathology as accurately as can IVP and have essentially replaced the IVP in the preoperative evaluation of carcinoma of the rectum. Inflammation of the perirectal musculature, either by the effect of the local tumor or secondary to preoperative radiation, can make it difficult to determine if these structures are invaded by tumor. Tumor involvement, however, can be proved using CT localization and percutaneous fine needle aspiration biopsy techniques. During radiation therapy and chemotherapy, CT scans may also assist in treatment planning and may be the most reliable way of observing the objective response of the recurrent tumor in the pelvis. Finally, in the patient in whom the recurrent tumor does not produce abnormally high levels of CEA, the CT scan may be the only method by which the early and treatable recurrence may be detected. It is, therefore, appropriate to recommend that pelvic CT scan be a routine test for every patient who has had abdominoperineal resection or low anterior resection for carcinoma of the rectum and rectosigmoid.

The hypertrophied anal papilla: recognition on air-contrast barium enema examinations.

Anal papillae are acquired structures that arise from the base of the rectal columns of Morgagni at the dentate line. They enlarge in response to congestion, irritation, injury, or infection. Although anal papillae are commonly seen endoscopically, they are rarely demonstrated radiographically. Three cases are reported of hypertrophied anal papillae that were demonstrated on air-contrast barium enema examinations. Radiographically an enlarged anal papilla appears as a smooth polyp located just inside the anal verge. Endoscopically it is differentiated from an adenomatous polyp by its white appearance and its origin from the lower (squamous) aspect of the dentate line in the anal canal. Hypertrophied anal papilla should be included in the differential diagnosis of a smooth mass located near the anal verge, especially in a patient with a history of chronic and irritation or infection.

Lymphoscintigraphy for malignant melanoma. Surgical considerations.

Lymphoscintigraphy using technetium-99m atimony sulfur colloid was performed in 22 patients with melanoma referred to Duke University Comprehensive Cancer Center in an attempt to identify patterns of regional lymphatic drainage. Scans from six patients revealed lower extremity lesions with three located below the knee, one in the popliteal space, and two others proximal to the knee joint. Despite the location of the primary, all scans but one showed initial drainage to the inguinal nodes bypassing the popliteal lymph node group. Of the three patients who had primary melanoma of the posterior scalp, the lymphatic drainage was directed to the posterior cervical nodes. No drainage to the parotid nodes or anterior neck nodes was visualized. The knowledge gained from lymphoscintigraphy resulted in posterior neck dissections instead of the standard anterior neck dissection and superficial parotidectomy. In areas of ambiguous lymphatic drainage from the trunk, radiocolloid scanning can identify areas at risk for developing metastatic disease. Six lesions within 5 cm of the midline demonstrated bilateral axillary or groin drainage in 83 per cent of the patients. For two lesions near Sappey's line colloidal uptake to the ipsilateral axilla and groin was the rule. After a 3-year follow-up, during which time 70 to 90 per cent of lymph node metastases are predicted to occur, no nodal metastases were ever documented in areas that did not show colloidal uptake. No correlation was found between amount of radiolabel in positive compared to negative nodes, although those nodes that were completely replaced by tumor contained no 99mTc activity and were negative on scanning.(ABSTRACT TRUNCATED AT 250 WORDS)

Work in progress. The anal canal: distinction of internal hemorrhoids from small cancers by double-contrast barium enema examination.

Sixty-six patients with normal anal canals, 66 patients with internal hemorrhoids, and 6 patients with small cancers in the anal canal were examined by double-contrast barium enema examination. Internal hemorrhoids appeared as single nodules in 3 patients, multiple nodules in 59 patients, a polypoid mass in 3 patients, and a varicoid mass in 1 patient. Small cancers appeared as slightly irregular polypoid masses in 5 patients and as a plaque-like lesion in 1 patient. The sensitivity for detecting internal hemorrhoids was 83%, the specificity was 88%, and the overall accuracy was 86%. The sensitivity for detecting small cancers in the anal canal was 83% and the specificity was 98%. Internal hemorrhoids and small cancers in the anal canal can be easily detected and distinguished from one another by double-contrast barium enema examination.

Double contrast examination in disease of the anorectal region.

Patients with symptoms from the anorectal region will not always be rectoscopically examined and sometimes lesions of the ano-rectal region are overlooked by the rectoscopist. In order to increase the overall diagnostic accuracy and make possible an early diagnosis of pathological changes in the ano-rectal region, the radiologist should take responsibility also for this part of the bowel. Minor lesions are often difficult to demonstrate by the conventional barium enema, but they are readily seen on an adequately performed double contrast examination. Of special importance is the diagnosis of small polypoid tumors which may become malignant. An early diagnosis and subsequent surgical removal of these tumors prevent spread and minimizes the surgical procedure.