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DOI: 10.1055/a-2321-9527
Endoscopic intermuscular dissection of early anal cancer
Anal cancer accounts for 0.5% of all new cancer cases, with an observed annual increase in incidence of up to 2.7% over the past decade [1]. This increase has closely mirrored the rise in human papillomavirus infections, the most important risk factor for anal cancer. According to international guidelines [2] [3] [4], marginal/perianal lesions smaller than 2 cm without lymphatic involvement or metastatic spread can be curatively treated with complete local excision, thereby sparing patients the adverse effects of surgery or chemoradiotherapy. Here, we describe a case of early anal cancer which was successfully treated by endoscopic intermuscular dissection (EID).
A 44-year-old woman presented with rectal blood loss. Colonoscopy revealed a 30-mm laterally spreading polyp with a large nodule and involvement of the dentate line. Endoscopic assessment showed an unusual pit pattern on the top of the large nodule ([Fig. 1]). Virtual chromoendoscopy showed nonstructured, amorphous pits and nearly avascular and loose microcapillary vessels ([Fig. 2]). As deep submucosal invasion was suspected, EID was performed (see step-by-step explanation in [Video 1]). We used a conventional video endoscope (GIF-TH190; Olympus, Germany) with a small-caliber-tip transparent hood (DH-28GR; Fujifilm, Japan) fitted to the tip of the endoscope. A FlushKnife BT (DK2618JB-15; Fujifilm, Japan) was used for incision and dissection. For electrical cutting and coagulation, a VIO 300D electrosurgical generator (Erbe Elektromedizin, Germany) was used. EID was carried out using the tunneling method [5]: an intermuscular tunnel was created from the anal canal to the proximal side in the distal rectum, followed by mobilization of the lateral edges. Complete en bloc resection was achieved ([Fig. 3], [Fig. 4]; total procedure time 120 min). Histological analysis showed a T1Sm2 squamous cell carcinoma with free resection margins (>2 mm) and no signs of lymphovascular invasion or high-grade tumor budding ([Fig. 5]).
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In conclusion, EID is a feasible and potentially curative treatment option for small, localized early-stage anal cancers.
Endoscopy_UCTN_Code_TTT_1AQ_2AD_3AF
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Conflict of Interest
The authors declare that they have no conflict of interest.
Acknowledgement
We would like to thank our expert gastrointestinal pathologist Stijn Crobach (Department of Pathology, Leiden University Medical Center) for examining and providing histological images of the resected specimen.
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References
- 1 Eng C, Ciombor KK, Cho M. et al. Anal cancer: emerging standards in a rare disease. J Clin Oncol 2022; 40: 2774-2788 DOI: 10.1200/JCO.21.02566. (PMID: 35649196)
- 2 Rao S, Guren MG, Khan K. et al. Anal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2021; 32: 1087-1100 DOI: 10.1016/j.annonc.2021.06.015. (PMID: 34175386)
- 3 Benson AB, Venook AP, Al-Hawary MM. et al. Anal carcinoma, version 2.2023, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2023; 21: 653-677 DOI: 10.6004/jnccn.2023.0030. (PMID: 37308125)
- 4 Valadao M, Riechelmann RP, Silva J. et al. Brazilian Society of Surgical Oncology: guidelines for the management of anal canal cancer. J Surg Oncol 2023; DOI: 10.1002/jso.27269. (PMID: 37021640)
- 5 Dang H, Hardwick JCH, Boonstra JJ. Endoscopic intermuscular dissection with intermuscular tunneling for local resection of rectal cancer with deep submucosal invasion. VideoGIE 2022; 7: 273-277 DOI: 10.1016/j.vgie.2022.02.012. (PMID: 36034064)
Correspondence
Publication History
Article published online:
05 June 2024
© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
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References
- 1 Eng C, Ciombor KK, Cho M. et al. Anal cancer: emerging standards in a rare disease. J Clin Oncol 2022; 40: 2774-2788 DOI: 10.1200/JCO.21.02566. (PMID: 35649196)
- 2 Rao S, Guren MG, Khan K. et al. Anal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2021; 32: 1087-1100 DOI: 10.1016/j.annonc.2021.06.015. (PMID: 34175386)
- 3 Benson AB, Venook AP, Al-Hawary MM. et al. Anal carcinoma, version 2.2023, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2023; 21: 653-677 DOI: 10.6004/jnccn.2023.0030. (PMID: 37308125)
- 4 Valadao M, Riechelmann RP, Silva J. et al. Brazilian Society of Surgical Oncology: guidelines for the management of anal canal cancer. J Surg Oncol 2023; DOI: 10.1002/jso.27269. (PMID: 37021640)
- 5 Dang H, Hardwick JCH, Boonstra JJ. Endoscopic intermuscular dissection with intermuscular tunneling for local resection of rectal cancer with deep submucosal invasion. VideoGIE 2022; 7: 273-277 DOI: 10.1016/j.vgie.2022.02.012. (PMID: 36034064)