Anal carcinoma C44.5

Author: Prof. Dr. med. Peter Altmeyer

All authors of this article

Last updated on: 29.10.2020

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anal carcinoma; Cloacogenic carcinoma

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Carcinomas in the area of the anal margin, anal canal or the transformation zone (Linea dentata).

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A distinction is made:
  • Anal rim carcinoma: Skin carcinoma with predominantly flat and ulcerous spread.
  • Anal channel carcinoma: Predominantly squamous cell carcinoma.
  • Transitional cell carcinoma: Carcinoma originating from the transitional epithelium.
  • Adenocarcinoma of the anal canal.
TNM stages of anal carcinoma:
Primary tumor
TX Primary tumor cannot be assessed
T0 no evidence of primary tumor
Tis carcinoma in situ
T1 Tumour 2 cm or less in the largest extension
T2 tumour more than 2 cm but not more than 5 cm in the largest dimension
T3 Tumour more than 5 cm in the largest extension
T4 Tumour of any size with infiltration of neighbouring organs such as the vagina, urethra or bladder (the affection of the sphincter muscles alone is not classified as T4)
Regional lymph nodes
NX NX Regional lymph nodes cannot be assessed
N0 no regional lymph node
N1 Metastases in perirectal lymph nodes
N2 Metastases in inguinal lymph nodes of one side and/or in lymph nodes of the internal iliac artery of one side
N3 metastases in perirect and inguinal lymph nodes and/or in internal iliac artery lymph nodes on both sides and/or in bilateral inguinal lymph nodes
Remote metastases
MX Minimum requirements for the detection of distant metastases are not fulfilled
M0 no detection of distant metastases
M1 Detection of distant metastases
Stadium Grouping
Stage 0 Tis N0 M0
Stage I T1 N0 M0
stage II T2/3 N0 M0
Stage IIIa T4 N0 M0
T1-3 N1 M0
Stage IIIb T4 N0 M0
each T N2, 3m M0
Stage IV each T each N M1
Stage classification of anal carcinoma (according to Dukes)
Stage I T1 N0 M0
stage II T2-3 N0 M0
Anal channel
Stage IIIA T4 N0 M0
T1-3 N1 M0
Stage IIIB T4 N1 M0
each T N2-3 M0
Anal rim
Stage III T4 N0 M0
Stadium each T N1 M0
Stage IV each T each N M1

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  • Rarely. Anal carcinomas account for about 1-2% of all colorectal carcinomas and about 4% of all rectal carcinomas. 60-70% of carcinomas are squamous cell carcinomas. Constant increase in the number of new cases in recent decades with a further rise in incidence.
  • Frequency peaks between 60 and 70 years of age.
  • Increasingly frequent in cases of infection with HIV, HSV, gonorrhoea, risky sexual practices, organ transplantation.

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  • Tumor growth does not usually begin de novo; it usually develops on previously damaged skin, such as lichen planus, acne inversa, inflammatory bowel diseases such as Crohn's disease or lichen sclerosus et atrophicus.
  • Long-term immunosuppression (especially HIV infection) promotes the development of tumours.
  • The connection between "high-risk" papilloma viruses (usually HPV 16 or 18), long-standing condyloma acuminata and malignant transformation into anal carcinoma is confirmed.

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Women are more frequently affected than men.

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  • Anal rim carcinoma: Perineal cutis
  • Anal canal carcinoma: Between linia dentata and anocutaneous border
  • Transitional cell carcinomas: transition zone.

Clinical features
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  • Coarse, sometimes smooth, mostly woolly skin-coloured to reddish knots. It grows in the course of months and years peripherally and in depth. Patients have increasing complaints only in case of exulceration; in the early stages (see below AIN) often asymptomatic course or perception of a palpable, firm, non-painful skin change.
  • Often a complex of symptoms consisting of peranal blood loss (50%), perianal pain, tenesmus, itching, foreign body sensation, stool irregularities, incontinence, enlarged inguinal lymph nodes. Frequently benign concomitant diseases (haemorrhoids, fissure, fistula, condylomata acuminata etc.).
  • High-set anal carcinomas metastasize to the inferior mesenteric lymph nodes. Carcinomas of the middle anal canal metastasize into the pelvic lymph nodes. Deep-seated anal carcinomas and anal rim carcinomas metastasize to the inguinal lymph nodes. Rare distant metastases, if occurring, mainly in the liver and lungs.

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  • BKS, large blood count, electrolytes, creatinine, total protein, Quick, PTT, serum iron, LDH, gamma-GT, AP, GPT
  • Tumour markers: CEA, CA 19-9. Tumour markers not for screening! At elevated values, tumour markers are an excellent way to measure the effectiveness of the therapy.

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Essential principles of early diagnosis: biopsy in case of chronic perianal eczema, anal fissure refractory to therapy, nodular changes and any anal findings which are not completely typical. Histological examination of the entire biopsy taken from the anorectal region, even if haemorrhoids, fissures or fistulae do not appear to be clinically suspect. Necessary tests: anamnesis and clinical examination (including inguinal lymph nodes), examination of the anal canal (with an anal spreading speculum), digital-rectal examination, proctoscopy, rectoscopy. In case of suspected tumour, bioptic backup (if necessary under anaesthesia):
  • Small lesions (< 1 cm and isolated mucosal involvement): total biopsy (tumour excision).
  • Larger lesions and infiltration of muscles: incision or punch biopsy.
  • Computer tomography (or PetCT) or MRI of the abdomen and pelvis
  • X-ray examination of the thorax in two planes.
In individual cases useful examinations: endosonography of the anal canal, gynaecological examination, urological examination in case of advanced tumour.


In the case of poorly differentiated squamous epithelium and the very rare small cell and undifferentiated carcinomas, the differential diagnosis must be made to distinguish them from malignant melanomas and lymphomas.

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Locoregional recurrences after radiochemotherapy of anal canal carcinomas usually occur in the first two years after therapy. Cisplatin and 5-FU are still considered the cytostatic therapy of choice. Recurrences should be diagnosed at an early stage, as there is usually a high chance of recovery through rectal extirpation. The general principles of metastasis surgery apply to isolated lung or liver metastases. Incurable local recurrences usually require a colostomy for stool drainage. Palliative chemotherapy with cisplatin and 5-FU is a therapeutic option here, as is the case with tumor mineralization.l

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  • Radiotherapy:
    • Single dose of 1.8 Gy in once-daily and five times-weekly fractionation up to a total dose of 50.4 Gy.
    • Irradiation of the groin electively up to a total dose of 45 Gy.
  • Simultaneous chemotherapy: In the first and fifth week of treatment:
    • 5-FU (1000 mg/day/m2 KO on days 1 to 5 and 29 to 33 as 120-hour infusion).
    • Mitomycin C (10 mg/day/m2 KO on days 1 and 29 as an intravenous bolus).
  • Alternatively:
    • 5-FU (1000 mg/day/m2 KO on days 1-4 or 750 mg/day/m2 KO on days 1-5).
    • Mitomycin C (10-15 mg/day/m2 KO on days 1 and 29 as an intravenous bolus).
The maximum therapeutic effect is expected at the earliest six to eight weeks after the end of therapy.

General therapy
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Therapeutic procedures with curative aim are surgical removal of the tumor with TU-diameter up to 2 cm (local excision, abdomino-perineal extirpation). For larger carcinomas, combined radio-chemotherapy is the therapy of choice.

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5-year survival rate for carcinomas of the anal rim: 50-70%, for carcinomas of the anal canal: 30-60%.

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Required in patients with anal canal cancer, after radiochemotherapy or local excision.

Examination Weeks * months *
6 3 6 9 12 18 24 36 48 60
Medical history, physical examination 4 + + + + + + + + +
Abdomen Sonography + + + + + + +
X-ray thorax in two planes + + + +
Rectoscopy, possibly endosonography + + + + + +
MRT or spiral CT pelvis + + + +
* after completion of radiochemotherapy

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In recent years, the incidence of anal carcinomas has increased among homosexual men. HPV infections and chronic inflammation in the anal region as well as immunosuppression are considered risk factors. After cervical carcinoma, anal carcinoma is the second most common carcinoma associated with high-risk HPV types (cervical carcinoma 100%, anal carcinoma > 80%). The anal carcinoma is therefore a "vaccine-preventable carcinoma".

Case report(s)
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  • A 50-year-old non-homosexual patient noticed for about 10 weeks a newly appeared, little itchy, firm lump in the perianal area. Since this time continuous growth in size. Slight burning and pulling as well as increased secretion is indicated. Previous local therapies were insufficient. The patient lives in a stable partnership and has no history of changing sexual contacts.
  • STD-diagnostics: Swabs for Neisseria gonorrhoeae, trichomonads and mycoplasmas, Candida albicans as well as HIV and syphilis serology were o.B.
  • Proctoscopically, a fixed, centrally ulcerated lump, limited to the perianal region, was visible, which was movable on the surface.
  • Histology: Part of a moderately differentiated, invasive, keratinizing squamous cell carcinoma.
  • HPV diagnostics: Detection of HPV-16/18/45 DNA (high-risk HPV DNA)
  • Sonography and Pet-CT: No lymph node or distant metastases.
  • Therapy: Combined radio-chemotherapy.

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  1. Fenger C (2002) Prognostic factors in anal carcinoma. Pathology 34: 573-378
  2. Hung A et al (2003) Cisplatin-based combined modality therapy for anal carcinoma. Cancer 97: 1195-1202
  3. Rode S et al (2011) Perianal ulcerated node. Abstract CD 46th DDG meeting AKS19/05
  4. Saldanha G et al (2003) Basal cell carcinoma: a dermatopathological and molecular biological update. Br J Dermatol 148: 195-202
  5. Guidelines for the treatment of anal carcinoma (2002) (Interdisciplinary guideline of the German Cancer Society and the German Society for Surgery/AWMF Guidelines)


Please ask your physician for a reliable diagnosis. This website is only meant as a reference.


Last updated on: 29.10.2020