Anal Cancer

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The anus consists of
a mucosa-lined anal
canal and an
epidermis-lined anal
margin. The
proximal end of the
anal canal begins
anatomically at the
junction of the
puborectalis portion
of the levator ani
muscle and the
external anal
sphincter, and
extends distally to
the anal verge, a
distance of
approximately 4 cm.
The anal canal is
divided by the
dentate line, which
overlies the
transition from
glandular (columnar)
to squamous
mucosa that is often
referred to as the
transitional zone.
The anal margin
begins
approximately at the
anal verge, which
corresponds to the
introitus of the anal
orifice. It represents
the transition from
the squamous
mucosa to the
epidermis-lined
perianal skin, and
extends to the
perianal skin.

At initial
presentation, most
patients have a T1
or T2 lesion and
fewer than 20
percent are node-
positive. In a series
of 270 patients with
anal canal SCC, the
distribution of stage
at diagnosis was as
follows

T1 9
percent
T2 51
percent
T3 30
percent
T4 10
percent
Node-
positive
13 percent

In the above series

of 270 patients, the
five-year survival by
stage was

T1 86
 percent
T2 86
percent
T3 60
percent
T4 45
percent
N0 76
percent
Node-
positive
54 percent
patients with squamous cell carcinoma of the anal canal are generally treated with wide
local excision for in-situ cases (if margins are negative) or with radiation. The more
advanced cases get radiation usually combined with chemotherapy (see NCCN
guidelines for anal canal). Patients with cancer of the anal margin may be treated with
local surgery (see guidelines for anal margin). Following this, patients are checked
every few months (without biopsy unless there is a suspicious area, see NCCN follow-
up guidelines.) Go here for NCCN anal site
Radiation for Cancer of the Anal Canal

anatomy contouring here or here

Based on the studies below, it appears that

radiation combined with chemoRx (5FU +
Mitomycin see data, or perhaps new regimens
that contain Platinol, see data produce the best
results. Other recent data is here. (Cisplatin may
be less toxic than Mitomycin, see MD Anderson
study.) The proper dose of radiation is unknown.
The original trials (Nigro) used low doses (30Gy)
but the standard has become 45-50Gy plus or
minus a boost dose (9Gy if + bx or in some
protocols a routine dose of 15-20Gy is added.)
See recent MDA paper on technique here.

The RTOG tried to use higher doses (5940 with 2

w break) but had worse results than in studies
with previous lower doses (50Gy continuous.)
The anal region tolerates radiochemoRx poorly
and we generally are lucky to get in 5040cGy at
180cGy/fx. The necessity of a boost is unclear
but if the response is poor, pushing to total dose
to 54-59Gy is standard (see the current NCCN
guidelines.)

The approach at the U of Florida seems quite

reasonable. (The current NCI page notes: "The
optimal dose of radiation with concurrent
chemotherapy to optimize local control and
minimize sphincter toxic effects is under
evaluation but appears to be in the 45 Gy to 60
Gy range.") See details of RTOG anal trial 9811
and RTOG 0529 and the results here.

Typical results using modern chemoradiation with

IMRT are here and here. Some of the older
studies are here
 Anal Cancer Treatment Results
Treatment Local Control Survival
Radiation 49 - 92% 60-93%
Radiation plus
60-92% 51-90%
Chemotherapy
What is anal cancer?
The anus
The anus is the body's opening at the lower end of the intestines. The anal canal is the tube that
connects the lower part of the large intestine (rectum) to the anus and the outside of the body. As
food is digested, it passes from the stomach to the small intestine. It then travels from the small
intestine into the large intestine (colon). The colon absorbs water and liquid from the digested
food. The waste matter that is left after going through the colon is known as feces or stool. Feces
are stored in the rectum, the final 6 inches of the digestive system. From there, they pass out of
the body through the anus as a bowel movement.
The anal canal is about an inch and a half long. Its inner lining (called the mucosa) is made up of
several different kinds of cells. Learning a little about these cells is helpful in understanding the
kinds of cancer that develop in various parts of the anal canal. Glands and ducts (tubes leading
from the glands) are found under the mucosa. These glands make mucus, which acts as a
lubricating fluid.

The anal canal goes from the rectum to the anal verge (where the canal meets the outside skin at
the anus). About midway down the anal canal is the dentate line, which is where most of these
anal glands empty into the anus.

Cells above the anal canal (in the rectum) and in the part of the anal canal close to the rectum are
shaped like tiny columns. Most cells near the middle of the anal canal and around the dentate line
are shaped like cubes and are called transitional cells. This area is called the transitional zone.
Below the dentate line are flat (squamous) cells. At the anal verge, the squamous cells of the
lower anal canal merge with the skin just outside the anus. This skin around the anal verge
(called the perianal skin or the anal margin) is also made up of squamous cells, but it also
contains sweat glands and hair follicles; the lining of the lower anal canal does not. Cancers of
the anal canal (above the anal verge) and cancers of the anal margin (below the anal verge) are
treated very differently.
The anal canal is surrounded by a sphincter, which is a circular muscle that keeps feces from
coming out until it is relaxed during a bowel movement.

Anal tumors
Many types of tumors can develop in the anus. Not all of these tumors are cancers -- some are
benign (non-cancerous). There are also some growths that start off as benign but over time can
develop into cancer. These are called pre-cancerous conditions. This section discusses all of
these types of abnormal growths.

Benign (non-cancerous) anal tumors

Polyps: Polyps are small, bumpy, or mushroom-like growths that develop in the mucosa or just
under it. There are several kinds, depending on their cause and location.

Inflammatory polyps arise because of inflammation from injury or infection.

Lymphoid polyps are caused by an overgrowth of lymph tissue (which is part of the
immune system). Small nodules of lymph tissue are normally present under the anal inner
lining.
Hypertrophied anal papillae are benign growths of connective tissue that are covered by
squamous cells. They are simply an enlargement of the normal papillae, which are small
folds of mucosa found at the dentate line. Hypertrophied anal papillae are also called
fibroepithelial polyps.

Skin tags: Skin tags are benign growths of connective tissue that are covered by squamous cells.
Skin tags are often mistaken for hemorrhoids but they are not truly hemorrhoids.

Condylomas: Condylomas (also called warts) are growths that occur just outside the anus and in
the lower anal canal below the dentate line. Occasionally condylomas can be found just above
the dentate line. They are caused by infection with the human papilloma virus (HPV). People
who have had condylomas are more likely to develop anal cancer (see "Potentially pre-cancerous
anal conditions" below and the section What are the risk factors for anal cancer?).

Other benign tumors: In rare cases, benign tumors can grow in other tissues of the anus. These
include:

Adnexal tumors -- usually benign growths that start in hair follicles or sweat glands of the
skin just outside of the anus. These tumors stay in the perianal skin area and do not grow
into the anal region.
Leiomyomas -- develop from smooth muscle cells
Granular cell tumors -- develop from nerve cells and are composed of cells that contain
lots of tiny spots (granules)
Hemangiomas -- start in the lining cells of blood vessels
Lipomas -- start from fat cells
Schwannomas -- develop from cells that cover nerves
Potentially pre-cancerous anal conditions

Some changes in the anal mucosa are harmless in their early stages but might later develop into a
cancer. A common term for these potentially pre-cancerous conditions is dysplasia. Some warts,
for example, contain areas of dysplasia that can develop into cancer.

Dysplasia occurring in the anus is also known as anal intraepithelial neoplasia (AIN) and as
anal squamous intraepithelial lesions (SILs). Depending on how the cells look under the
microscope, AIN (or anal SIL) can be divided into 2 groups: low-grade and high-grade. The cells
in low-grade AIN resemble normal cells while the cells in high-grade AIN look much more
abnormal. Low-grade AIN often goes away without treatment. It has a low chance of turning into
cancer. High-grade AIN is less likely to go away without treatment. Left untreated, high-grade
AIN could eventually become cancer, and so it needs to be watched closely. Some cases of high-
grade AIN need to be treated.

Carcinoma in situ

Sometimes abnormal cells on the surface layer of the anus look like cancer cells but have not
grown into any of the deeper layers. This condition is known as carcinoma in situ, (pronounced
"in SY-too"), or CIS. Another name for this condition is Bowen's disease. Some doctors view
this as the earliest form of anal cancer and others consider it the most advanced type of AIN,
which is considered a pre-cancer but not a true cancer.

Invasive anal cancers

Squamous cell carcinomas: Most anal cancers in the United States are squamous cell
carcinomas. These tumors come from the squamous cells that line the anal margin and most of
the anal canal.

Cells of invasive squamous cell carcinomas have already spread beyond the surface to the deeper
layers of the lining. Squamous cell carcinomas of the anal canal are discussed in detail in this
document. Squamous cell carcinomas of the anal margin (perianal skin) are treated similarly to
squamous cell carcinomas of the skin elsewhere in the body. For more information, see our
document, Skin Cancer: Basal and Squamous Cell.

Cloacogenic carcinomas (also called basaloid or transitional cell carcinomas) are sometimes
listed as a subclass of squamous cell cancers. They develop in the transitional zone, also called
the cloaca. These cancers look slightly different under the microscope but they behave and are
treated like other squamous cell carcinomas of the anal canal.

Adenocarcinomas: A small number of anal cancers are known as adenocarcinomas. These can
develop in cells that line the upper part of the anus near the rectum, or in glands located under
the anal mucosa that release their secretions into the anal canal. These anal adenocarcinomas, are
treated the same way as rectal carcinomas. For more information, see our document, Colorectal
Cancer.
Adenocarcinomas can also start in apocrine glands (a type of sweat gland of the perianal skin).
Paget's disease is a type of apocrine gland carcinoma that spreads through the surface layer of
the skin. Paget's disease can affect skin anywhere in the body but most often affects skin of the
perianal area, vulva, or breast. This condition should not be confused with Paget's disease of the
bone, which is a different disease.

Basal cell carcinomas: Basal cell carcinomas are a type of skin cancer that can develop in the
perianal skin. These tumors are much more common in areas of skin that are exposed to sun,
such as the face and hands, and account for only a small number of anal cancers. They are often
treated with surgery to remove the cancer. For more information, see our document, Skin
Cancer: Basal and Squamous Cell.

Malignant melanoma: This cancer develops from cells in the skin or anal lining that make the
brown pigment called melanin. Only about 1% to 2% of anal cancers are melanomas.
Melanomas are far more common on parts of the body that are exposed to sun. If melanomas are
found at an early stage (before they have grown deeply into the skin or spread to lymph nodes)
they can be removed with surgery and the outlook (prognosis) for long-term survival is very
good. But because they are hard to see, most anal melanomas are found at a later stage. If
possible, the entire tumor is removed with surgery. If all of the tumor can be removed, a cure is
possible. If the melanoma has spread too far to be removed completely, other treatments may be
given. For more information, see our document, Melanoma Skin Cancer.

Gastrointestinal stromal tumors: These are rare anal cancers that are much more commonly
found in the stomach or small intestine. When these are found at an early stage, they are removed
with surgery. If they have spread beyond the anus, they can be treated with drug therapy. For
more information, see our document, Gastrointestinal Stromal Tumor (GIST).

After anal cancer has been diagnosed, tests are done to find out if cancer cells have spread within
the anus or to other parts of the body.

The process used to find out if cancer has spread within the anus or to other parts of the body is
called staging. The information gathered from the staging process determines the stage of the
disease. It is important to know the stage in order to plan treatment. The following tests may be
used in the staging process:

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside
the body, such as the abdomen or chest, taken from different angles. The pictures are
made by a computer linked to an x-ray machine. A dye may be injected into a vein or
swallowed to help the organs or tissues show up more clearly. This procedure is also
called computed tomography, computerized tomography, or computerized axial
tomography. For anal cancer, a CT scan of the pelvis and abdomen may be done.
Chest x-ray : An x-ray of the organs and bones inside the chest. An x-ray is a type of
energy beam that can go through the body and onto film, making a picture of areas inside
the body.
 MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and
a computer to make a series of detailed pictures of areas inside the body. This procedure
is also called nuclear magnetic resonance imaging (NMRI).
PET scan (positron emission tomography scan): A procedure to find malignant tumor
cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein.
The PET scanner rotates around the body and makes a picture of where glucose is being
used in the body. Malignant tumor cells show up brighter in the picture because they are
more active and take up more glucose than normal cells do.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

Through tissue. Cancer invades the surrounding normal tissue.

Through the lymph system. Cancer invades the lymph system and travels through the
lymph vessels to other places in the body.
Through the blood. Cancer invades the veins and capillaries and travels through the blood
to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or
blood to other places in the body, another (secondary) tumor may form. This process is called
metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor.
For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually
breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

The following stages are used for anal cancer:

Stage 0 (Carcinoma in Situ)

In stage 0, abnormal cells are found in the innermost lining of the anus. These abnormal cells
may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in
situ.

Enlarge

Pea, peanut, walnut, and lime show tumor sizes.

Stage I
In stage I, cancer has formed and the tumor is 2 centimeters or smaller.

Stage II

In stage II, the tumor is larger than 2 centimeters.

Stage IIIA

In stage IIIA, the tumor may be any size and has spread to either:

lymph nodes near the rectum; or

nearby organs, such as the vagina, urethra, and bladder.

Stage IIIB

In stage IIIB, the tumor may be any size and has spread:

to nearby organs and to lymph nodes near the rectum; or

to lymph nodes on one side of the pelvis and/or groin, and may have spread to nearby
organs; or
to lymph nodes near the rectum and in the groin, and/or to lymph nodes on both sides of
the pelvis and/or groin, and may have spread to nearby organs.

Stage IV

In stage IV, the tumor may be any size and cancer may have spread to lymph nodes or nearby
organs and has spread to distant parts of the body.

Recurrent Anal Cancer

Recurrent anal cancer is cancer that has recurred (come back) after it has been treated. The
cancer may come back in the anus or in other parts of the body.

Treatment Option Overview

Key Points for This Section

There are different types of treatment for patients with anal cancer.
Three types of standard treatment are used:
o Radiation therapy
o Chemotherapy
o Surgery
Having the human immunodeficiency virus can affect treatment of anal cancer.
New types of treatment are being tested in clinical trials.
o Radiosensitizers
 Patients may want to think about taking part in a clinical trial.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Follow-up tests may be needed.

There are different types of treatment for patients with anal cancer.

Different types of treatments are available for patients with anal cancer. Some treatments are
standard (the currently used treatment), and some are being tested in clinical trials. A treatment
clinical trial is a research study meant to help improve current treatments or obtain information
on new treatments for patients with cancer. When clinical trials show that a new treatment is
better than the standard treatment, the new treatment may become the standard treatment.
Patients may want to think about taking part in a clinical trial. Some clinical trials are open only
to patients who have not started treatment.

Three types of standard treatment are used:

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to
kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a
machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a
radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or
near the cancer. The way the radiation therapy is given depends on the type and stage of the
cancer being treated.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by
killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or
injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells
throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the
cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect
cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends
on the type and stage of the cancer being treated.

Surgery

Local resection: A surgical procedure in which the tumor is cut from the anus along with
some of the healthy tissue around it. Local resection may be used if the cancer is small
and has not spread. This procedure may save the sphincter muscles so the patient can still
control bowel movements. Tumors that form in the lower part of the anus can often be
removed with local resection.
 Abdominoperineal resection: A surgical procedure in which the anus, the rectum, and
part of the sigmoid colon are removed through an incision made in the abdomen. The
doctor sews the end of the intestine to an opening, called a stoma, made in the surface of
the abdomen so body waste can be collected in a disposable bag outside of the body. This
is called a colostomy. Lymph nodes that contain cancer may also be removed during this
operation.

Enlarge

Resection of the colon with colostomy. Part of the colon containing the cancer and
nearby healthy tissue are removed, a stoma is created, and a colostomy bag is attached to
the stoma.

Having the human immunodeficiency virus can affect treatment of anal cancer.

Cancer therapy can further damage the already weakened immune systems of patients who have
the human immunodeficiency virus (HIV). For this reason, patients who have anal cancer and
HIV are usually treated with lower doses of anticancer drugs and radiation than patients who do
not have HIV.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not
mention every new treatment being studied. Information about clinical trials is available from the
NCI Web site.

Radiosensitizers

Radiosensitizers are drugs that make tumor cells more sensitive to radiation therapy. Combining
radiation therapy with radiosensitizers may kill more tumor cells.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials
are part of the cancer research process. Clinical trials are done to find out if new cancer
treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who
take part in a clinical trial may receive the standard treatment or be among the first to receive a
new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the
future. Even when clinical trials do not lead to effective new treatments, they often answer
important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test
treatments for patients whose cancer has not gotten better. There are also clinical trials that test
new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer
treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section
that follows for links to current treatment clinical trials. These have been retrieved from NCI's
listing of clinical trials.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may
be repeated. Some tests will be repeated in order to see how well the treatment is working.
Decisions about whether to continue, change, or stop treatment may be based on the results of
these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The
results of these tests can show if your condition has changed or if the cancer has recurred (come
back). These tests are sometimes called follow-up tests or check-ups.

Treatment Options by Stage

Stage 0 (Carcinoma in Situ)
Stage I Anal Cancer
Stage II Anal Cancer
Stage IIIA Anal Cancer
Stage IIIB Anal Cancer
Stage IV Anal Cancer

A link to a list of current clinical trials is included for each treatment section. For some types or
stages of cancer, there may not be any trials listed. Check with your doctor for clinical trials that
are not listed here but may be right for you.
Stage 0 (Carcinoma in Situ)

Treatment of stage 0 is usually local resection.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting
patients with stage 0 anal cancer. For more specific results, refine the search by using other
search features, such as the location of the trial, the type of treatment, or the name of the drug.
General information about clinical trials is available from the NCI Web site.

Stage I Anal Cancer

Treatment of stage I anal cancer may include the following:

Local resection.
External-beam radiation therapy with or without chemotherapy. If cancer remains after
treatment, more chemotherapy and radiation therapy may be given to avoid the need for a
permanent colostomy.
Internal radiation therapy.
Abdominoperineal resection, if cancer remains or comes back after treatment with
radiation therapy and chemotherapy.
Internal radiation therapy for cancer that remains after treatment with external-beam
radiation therapy.

Patients who have had treatment that saves the sphincter muscles may receive follow-up exams
every 3 months for the first 2 years, including rectal exams with endoscopy and biopsy, as
needed.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting
patients with stage I anal cancer. For more specific results, refine the search by using other
search features, such as the location of the trial, the type of treatment, or the name of the drug.
General information about clinical trials is available from the NCI Web site.

Stage II Anal Cancer

Treatment of stage II anal cancer may include the following:

Local resection.
External-beam radiation therapy with chemotherapy. If cancer remains after treatment,
more chemotherapy and radiation therapy may be given to avoid the need for a
permanent colostomy.
Internal radiation therapy.
Abdominoperineal resection, if cancer remains or comes back after treatment with
radiation therapy and chemotherapy.
A clinical trial of new treatment options.
Patients who have had treatment that saves the sphincter muscles may receive follow-up exams
every 3 months for the first 2 years, including rectal exams with endoscopy and biopsy, as
needed.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting
patients with stage II anal cancer. For more specific results, refine the search by using other
search features, such as the location of the trial, the type of treatment, or the name of the drug.
General information about clinical trials is available from the NCI Web site.

Stage IIIA Anal Cancer

Treatment of stage IIIA anal cancer may include the following:

External-beam radiation therapy with chemotherapy. If cancer remains after treatment,

more chemotherapy and radiation therapy may be given to avoid the need for a
permanent colostomy.
Internal radiation therapy.
Abdominoperineal resection, if cancer remains or comes back after treatment with
chemotherapy and radiation therapy.
A clinical trial of new treatment options.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting
patients with stage IIIA anal cancer. For more specific results, refine the search by using other
search features, such as the location of the trial, the type of treatment, or the name of the drug.
General information about clinical trials is available from the NCI Web site.

Stage IIIB Anal Cancer

Treatment of stage IIIB anal cancer may include the following:

External-beam radiation therapy with chemotherapy.

Local resection or abdominoperineal resection, if cancer remains or comes back after
treatment with chemotherapy and radiation therapy. Lymph nodes may also be removed.
A clinical trial of new treatment options.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting
patients with stage IIIB anal cancer. For more specific results, refine the search by using other
search features, such as the location of the trial, the type of treatment, or the name of the drug.
General information about clinical trials is available from the NCI Web site.

Stage IV Anal Cancer

Treatment of stage IV anal cancer may include the following:

Surgery as palliative therapy to relieve symptoms and improve the quality of life.
Radiation therapy as palliative therapy.
 Chemotherapy with radiation therapy as palliative therapy.
A clinical trial of new treatment options.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting
patients with stage IV anal cancer. For more specific results, refine the search by using other
search features, such as the location of the trial, the type of treatment, or the name of the drug.
General information about clinical trials is available from the NCI Web site.

Treatment Options for Recurrent Anal Cancer

Treatment of recurrent anal cancer may include the following:

Radiation therapy and chemotherapy, for recurrence after surgery.

Surgery, for recurrence after radiation therapy and/or chemotherapy.
A clinical trial of radiation therapy with chemotherapy and/or radiosensitizers.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting
patients with recurrent anal cancer. For more specific results, refine the search by using other
search features, such as the location of the trial, the type of treatment, or the name of the drug.
General information about clinical trials is available from the NCI Web site.

http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page2

http://www.cancer.org/cancer/analcancer/detailedguide/anal-cancer-what-is-anal-cancer

http://www.nlm.nih.gov/medlineplus/analcancer.htm
anus terdiri dari kanal mukosa berlapis anal dan margin epidermis berlapis anal. Ujung proksimal
dari lubang anus dimulai anatomis di persimpangan bagian puborectalis dari otot levator ani dan
sfingter anal eksternal, dan meluas distal ke ambang anal, jarak sekitar 4 cm. Lubang anus dibagi
oleh garis dentate, yang menutupi transisi dari kelenjar (kolumnar) pada mukosa skuamosa yang
sering disebut sebagai zona transisi. Margin dubur dimulai kira-kira pada ambang anal, yang
sesuai dengan introitus dari lubang anus. Ini merupakan transisi dari mukosa skuamosa pada
kulit epidermis-berbaris perianal, dan meluas pada kulit perianal.