title: Salvage abdominoperineal resection after failed Nigro protocol: modest success, major morbidity.
abstract: OBJECTIVE
  Chemotherapy and radiation (C-XRT) is the first-line therapy for epidermoid carcinomas of the anal canal (ECAC). Treatment failure occurs in up to 33% of patients. Salvage-abdominoperineal resection (APR) is the treatment of choice for locoregional failure but pre-operative radiation may increase wound complications. The purpose of this study was to evaluate patient survival and wound complications after salvage-APR for C-XRT failure.
  
  
  METHODS
  We reviewed the clinical records of all patients who failed initial C-XRT for ECAC diagnosed between 1992 and 2002. We evaluated patient demographics, treatment, tumour characteristics, survival and postoperative complications.
  
  
  RESULTS
  Nineteen patients were identified. The mean age at diagnosis was 55 years. Eight (42%) patients had persistent disease; 11 (58%) had tumour recurrence. APR was performed in 15 patients. Perineal wound complications occurred in 12 (80%) patients; half were major complications. Primary flap reconstruction at time of APR was performed in 5 (33%) patients; 2 experienced major wound complications. Overall-survival after salvage APR was 40% (6/15) and disease-free survival was 47% (7/15) at a median follow-up of 14 months (range 2-95 months). Recurrence after salvage-APR occurred in 7 (47%) patients at a median follow-up of 5 months (range 3-19 months). Kaplan-Meier survival analysis showed an advantage for recurrent over persistent disease with 2-year and 5-year survival rates of 75%vs 34% and 28%vs 0%, respectively.
  
  
  CONCLUSIONS
  Failure of C-XRT for ECAC is associated with a poor prognosis. Although salvage APR may be curative in some patients, perineal wound complications are frequent and primary flap reconstruction is not reliable.
authors.affiliation: Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
authors.forename: H T
authors.initials: HT
authors.lastname: Papaconstantinou
authors.forename: K M
authors.initials: KM
authors.lastname: Bullard
authors.forename: D A
authors.initials: DA
authors.lastname: Rothenberger
authors.forename: R D
authors.initials: RD
authors.lastname: Madoff
mesh_terms: D000328:Adult; D000368:Aged; D001005:Anus Neoplasms / Q000188:drug therapy / Q000532:radiotherapy / Q000601:surgery*; D002294:Carcinoma, Squamous Cell / Q000188:drug therapy / Q000532:radiotherapy / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D016879:Salvage Therapy; D013524:Surgical Flaps; D016019:Survival Analysis; D017211:Treatment Failure