Salvage surgery

After treatment with Chemoradiotherapy, recurring or persistent disease is treated with salvage surgery. This is usually Radical Abdominoperineal Resection but can also be Total pelvic Exenteration depending on presentation. Recurring disease occurs in up to 15% of patients diagnosed with Anal SCC. Salvage surgery is associated with a  high morbidity and mortality. Many patients with relapsing disease are unfortunately not suitable for high risk surgery.  

If suitable for salvage surgery it has been reported that 40-60% survive 5 years compared to a 5% 3 year survival rate if salvage surgery is not attempted.  

An abdominoperineal resection for recurrent and persistent disease is associated with  low post-operative mortality risk (3%) however, there is a risk of up to 70% of delayed wound healing, perineal hernias (15%) and up to 20% risk of significant cardiovascular or respiratory complications. 

The single most important factor in disease control and survival is achieving a complete (R0) resection. Unfortunately this is only being achieved in 9-16% of available case series in the literature.  

Most of the data reporting success rates of salvage surgery for persistent or recurrent disease is from small single centre case series that are limited by historical data, small sample sizes and patients being largely female and HIV negative. 

Ko et al (2019) has written a great systematic review this year which extensively summarised the findings of 28 retrospective salvage surgery case series. On meta-analysis they demonstrated that there was no significant difference in overall survival between patients receiving salvage surgery for persistent compared to recurrent disease. The median 5 years disease free survival was 44% and 23.5% of patients had a locoregional recurrence after salvage surgery. 14 studies reported HIV status and one study included only HIV positive patients. The authors reported that the included studies did not analyse HIV positive and HIV negative survival outcomes separately. Of 14 studies reporting HIV status, 12 reported less than 20% HIV prevalence in their patients undergoing salvage surgery.  

It is unclear whether the low numbers of HIV positive patients undergoing salvage surgery in the literature are appropriate for the population studied or whether HIV patients are less likely to undergo salvage surgery as either they are not fit for salvage surgery or that they are less likely to have recurrent/persistent disease in the first place.  

We hope that mASCARA, by including HIV outcomes and recurrence outcomes may add further information into this topic.  

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