Anal cancer is a disease in which malignant (cancer) cells form in the tissues of the anus.
The anus is the end of the large intestine, below the rectum, through which stool (solid waste) leaves the body. The anus is formed partly from the outer, skin layers of the body and partly from the intestine. Two ring-like muscles, called sphincter muscles, open and close the anal opening to let stool pass out of the body. The anal canal, the part of the anus between the rectum and the anal opening, is about 1½ inches long.
Anatomy of the lower digestive system, showing the colon and other organs.
The skin around the outside of the anus is called the perianal area. Tumors in this area are skin tumors, not anal cancer.
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, ifbreast 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.
Risk factors include the following:
- Being older than 50 years.
- Being infected with human papillomavirus (HPV).
- Having many sexual partners.
- Having receptive anal intercourse (anal sex).
- Frequent anal redness, swelling, and soreness.
- Having anal fistulas (abnormal openings).
- Smoking cigarettes.
Possible signs of anal cancer include bleeding from the anus or rectum or a lump near the anus. Check with your doctor if you have any of the following problems:
- Bleeding from the anus or rectum.
- Pain or pressure in the area around the anus.
- Itching or discharge from the anus.
- A lump near the anus.
- Weakness or feeling very tired
- A change in bowel habits.
Diagnosis & Staging
The following tests and procedures may be used:
Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Digital rectal examination (DRE) : An exam of the anus and rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual.
Digital rectal exam (DRE). The doctor inserts a gloved, lubricated finger into the rectum and feels the prostate to check for anything abnormal.
Certain factors affect the prognosis (chance of recovery) and treatment options.
- Anoscopy : An exam of the anus and lower rectum using a short, lighted tube called an anoscope.
- Proctoscopy : An exam of the rectum using a short, lighted tube called a proctoscope.
- Endo-anal or endorectal ultrasound : A procedure in which an ultrasound transducer (probe) is inserted into the anus or rectum and used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called asonogram.
- Biopsy : The removal of cells or tissues so they can be viewed under a microscope by apathologist to check for signs of cancer. If an abnormal area is seen during the anoscopy, a biopsy may be done at that time.
The prognosis (chance of recovery) depends on the following:
- The size of the tumor.
- Where the tumor is in the anus.
- Whether the cancer has spread to the lymph nodes.
The treatment options depend on the following:
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 stage of the cancer.
- Where the tumor is in the anus.
- Whether the patient has human immunodeficiency virus (HIV).
- Whether cancer remains after initial treatment or has recurred.
The process used to find out if cancer has spread within the anus or to other parts of the body is calledstaging. 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:
Three types of standard treatment are used:
- 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 theorgans 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 thepelvis 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 scannerrotates 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.
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 radioactivesubstance 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 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 avein 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.
- 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 thesigmoid 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 nodesthat contain cancer may also be removed during this operation.
Over-view of Cancer Surgery
Goal of Cancer Surgery
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.
Depending on your cancer type and stage, our goals for treatment are:
Role of Surgery for Cancer treatment
- Cure : This is the most important goal of cancer surgery. In fact as a cancer patient you are also strongly willing to have cure of cancer for forever. For most of the Liver & Gastro-intestinal cancers perhaps surgery is the first step for cure. Radiation &/or Chemotheray may be advised as an additional tool to achieve this goal.
- Control : If your cancer is at a later stage or if previous treatments have been unsuccessful, we aim to control your cancer by removing as much as safely possible. Once you recover from surgery, radiation or chemotherapy is advised as important tool to control your cancer.
- Comfort : If you have an advanced stage of cancer or one that hasn't responded to treatments and having symptoms because of tumor i.e pain, jaundice, vomiting, bleeding either in vomitus or in stool, then our multi-specialist team work together to sure you are free of pain and other symptoms.
Surgery can be done for many reasons for treatment of cancer.
Diagnostic & Staging Surgery
- Curative surgery is done when cancer is found in only one area, and it’s likely that all of the cancer can be removed. In this case, curative surgery can be the main treatment. It may be used alone or along with chemotherapy or radiation therapy, which can be given before or after the operation.
- This type of surgery is used to take out a piece of tissue (biopsy) to find out if cancer is present or what type of cancer it is. The diagnosis of cancer is made by looking at the cells under a microscope. Staging surgery is done to find out how much cancer there is and how far it has spread. The physical exam and the results of lab and imaging tests are used to figure out the clinical stage of the cancer. But the surgical stage (also called the pathologic stage) is usually a more exact measure of how far the cancer has spread. Examples of surgical procedures commonly used to stage cancers, like laparoscopy or laparotomy.
Approach for Surgery:
- This type of surgery is used to treat problems caused by advanced cancer. It is not done to cure the cancer. For example, cancers of intestine may grow large enough to block off (obstruct) the intestine, or tumor is bleeding and unable to control bleed by medical/endoscopic technique. If this happens, surgery can be used to remove the blockage/control bleeding.
How surgery is performed? (Special surgery techniques): Open Or Laparoscopic
- It is the Gold Standard approach for Liver & Gastro-Intestinal cancer. An incision is given on the belly depending upton the underlying location of tumor so that surgeon can directly approach the cancer on cutting the belly. Open Surgery help to remove tumor safely if its adherent to near by blood vessels or organ, that is otherwise difficult in laparoscopic surgery.
Biopsy of Cancer before Surgery
- A laparoscope is a long, thin, flexible tube that can be put through a small cut (incision) to look inside the body. In recent years, doctors have found that by creating small holes and using special instruments, the laparoscope can be used to perform surgery without making a large cut. This can help reduce blood loss during surgery and pain afterward. It can also shorten hospital stays and allow people to heal faster.
- The role of laparoscopic surgery in cancer treatment is not yet clear. Doctors are now studying whether it is safe and effective to use laparoscopic surgeries for cancers of the stomach, colon, rectum & liver. It may prove to be as safe and work as well as standard surgery while cutting less and causing less damage to healthy tissues (being less invasive).
Biopsy is procedure to confirm the presence of cancer. It’s not essential before surgery. Usually biopsy is performed when 1. Suspicion is cause other than cancer, 2. When surgery cannot be done for cancer due to advanced stage of cancer or 3. Patient is unfit to undergo surgery. In these situation, biopsy guides for further therapy.
If all investigations suggest that cancer can be removed in totality from body, then biopsy can be avoided in to minimize the risk of spillage of cancer cell during biopsy procedure.
There is variety of way to perform biopsies:
Fine Needle Aspiration (FAN) biopsy
Core Needle biopsy
- Fine needle aspiration (FNA) uses a very thin needle attached to a syringe to pull out small bits of tissue. The needle is guided into the tumor by looking at it using an imaging test, like an ultrasound or CT scan.
- The main advantage of FNA is that there is no need to cut through the skin, so there is no surgical incision.
- A drawback is that in some cases the needle can’t take out enough tissue for an exact diagnosis. A more invasive type of biopsy (one that involves larger needles or a cut in the skin) may then be needed.
Excisional or Incisional biopsy
- This type of biopsy uses a larger needle to take out a core of tissue and done under guidance of imaging test like an ultrasound or CT scan. The advantage of core biopsy is that it usually collects enough tissue to find out whether the tumor is cancer.
Know about Anal Surgery
Preparation for Surgery
- For these biopsies, the surgeon remove the entire tumor (excisional biopsy) or a small part of the tumor (incisional biopsy).
Our expert team members shall help you to prepare you for surgery. You are strongly advised to stop smoking, stop drinking alcohol, try to improve your diet, lose weight, or actively exercise before surgery.
In most cases, you will need some tests before your surgery. The tests routinely used include:
Anaesthetic Assessment before Surgery:
- Blood tests to measure your blood counts, your risk of bleeding or infection, and how well your liver and kidneys are working. Your blood group type is also be checked in case you need blood transfusions during the operation.
- Chest x-ray and ECG (electrocardiogram) to check your lungs and your heart’s electrical system.
- USG/CT scans/ MRI to look at the size and location of the tumors and see if the cancer looks like it has spread to nearby tissues.
Our expert team of Anaesthetist will ask you questions pertaining to your health and to assess your fitness for surgery. You are requested to tell them in detail about your current and past medical ailments, allergic reactions you’ve had in the past and current medicines that you are taking like blood thinning medicine. This medicine should be stopped 1 week prior to surgery.
Informed consent is one of the most important parts of “getting ready for surgery”. It is a process during which you are told about all aspects of the treatment before you give your doctor written permission to do the surgery.
Getting ready for Surgery
Depending on the type of operation you have, there may be things you need to do to be ready for surgery:
- Emptying your stomach and bowels (digestive tract) is important. Vomiting while under anaesthesia can be very dangerous because the vomit could get into your lungs and cause an infection. Because of this, you will be asked to not eat or drink anything starting the night before the surgery.
- Laxative: You may also be asked to use a laxative or an enema to make sure your bowels are empty.
- Shaving of Operative part: You need to have an area of your body shaved to keep hair from getting into the surgical cut (incision). The area will be cleaned before the operation to reduce the risk of infection.
Anaesthesia is the use of drugs to make the body unable to feel pain for a period of time. General anaesthesia puts you into a deep sleep for the surgery. It is often started by having you breathe into a face mask or by putting a drug into a vein in your arm. Once you are asleep, an endotracheal or ET tube is put in your throat to make it easy for you to breathe. Your heart rate, breathing rate, and blood pressure (vital signs) will be closely watched during the surgery. A doctor watches you throughout the procedure and until you wake up. They also take out the ET tube when the operation is over. You will be taken to the recovery room to be watched closely while the effects of the drugs wear off. This may take hours. People waking up from general anaesthesia often feel “out of it” for some time. Things may seem hazy or dream-like for a while. Your throat may be sore for a while from the endotracheal (ET) tube.
Recovery from Surgery
Your recovery right after surgery depends on many factors, including your state of health before the operation and how extensive the operation was performed.
You may feel pain at the site of surgery. We aim to keep you pain free after surgery with the help of latest and most effective technique or analgesic (pain relieving medicine).
Leg Stocking / Compression boot
- You may also have Ryle’s Tube (tube going through nose to stomach) that drain out intestinal fluid. This tube helps to relieve nausea and vomiting after surgery and usually removed 1-2 day after surgery.
- You may also have “Tube” (called a Foley catheter) draining urine from your bladder into a bag. This will be taken out soon after surgery, once you are comfortable enough to go to bathroom.
- You may have a tube or tubes (called Drains) coming out of the surgical opening in your skin (incision site). Drains allow the excess fluid that collects at the surgery site to leave the body. Drain tube will also be removed once they stop collecting fluid, usually a few days after the operation.
As you are remains in bed on day of surgery, circulation of blood in leg become sluggish that may increase possibility of thrombo-embolism. To minimise it, you will be wearing leg stocking/ pneumatic compression boot to improve your leg circulation thus minimising the risk of thrombolism.
Eating and Drinking
You may not feel much like eating or drinking, but this is an important part of the recovery process. Our health care team may start you out with ice chips or clear liquids. The stomach and intestines (digestive tract) is one of the last parts of the body to recover from the drugs used during surgery. You will need to have signs of stomach and bowel activity before you will be allowed to eat. You will likely be on a clear liquid diet until this happens. Once it does, you may get to try solid foods.
- Our health care team will try to have you move around as soon as possible after surgery. They may even have you out of bed and walking the same day. While this may be hard at first, it helps speed your recovery by getting your digestive tract moving. It also helps your circulation and helps prevent blood clots from forming in your legs.
- Our team shall also encourage you to do deep breathing exercises. This helps fully inflate your lungs and reduces the risk of pneumonia. You are advised to take deep breaths and cough every hour to help prevent lung infections. You will use an incentive spirometer (a small device used in breathing exercises to prevent complications after major surgery) 10-15 times every hour.
Once you are eating and walking, all tube/drains placed during surgery are removed, and then you may be ready to go home. Before leaving for home our health care team shall give you detailed guidance regarding diet, activities, medications & further plan of treatment.
Risks and Side effects of Surgery
There are risks that go with any type of medical procedure and surgery is no longer an exception. Success of surgery depends upon 3 factors: type of disease/surgery, experience of surgeon and overall health of patients. What’s important is whether the expected benefits outweigh the possible risks.
Doctors have been performing surgeries for a very long time. Advances in surgical techniques and our understanding of how to prevent infections have made modern surgery safer and less likely to damage healthy tissues than it has ever been. Still, there’s always a degree of risk involved, no matter how small. Different procedures have different kinds of risks and side effects. Be sure to discuss the details of your case with our health care team, who can give you a better idea about what your actual risks are. During surgery, possible complications during surgery may be caused by the surgery itself, the drugs used (anesthesia), or an underlying disease. Generally speaking, the more complex the surgery is the greater the risk. Complications in major surgical procedures include:
Life after Surgery
- Complications related to Anaesthesia : Reactions to drugs used (anesthesia) or other medicines. Although rare, these can be serious because they can cause dangerously low blood pressures. Your doctors will watch your heart rate, breathing rate, blood pressure, and other signs throughout the procedure to look for this.
- Complications related to underlying medical illness like heart disease, diabetes, kidney disease, obesity, malnutrition.
- Lung : Pneumonia, Atelectasis (collapse of lung), effusion (fluid in chest) can occur, especially in patients with reduced lung function, such as smokers. Doing deep breathing exercises as soon as possible after surgery helps lessen this risk.
- Thrombosis (blood clot) in leg & embolism (blood clot) in lung : Blood clots can form in the deep veins of the legs after surgery, especially if a person stays in bed for a long time. Such a clot can become a serious problem if it breaks loose and travels to another part of the body, such as a lung. This is a big reason why you will be encouraged to get out of bed to sit, stand, and walk as soon as possible.
- Cardiovascular : Myocardial infarction (heart attach), Arrhythmia (irregular heart beat), Stroke (cerebro-vascular accidents).
- Kidney & urinary tract infection, acute kidney failure if patient has uncontrolled/non-responding infection.
- Complications related to Specific Operations
- There are specific complications related to type of surgery. You are encouraged with discuss in detail with our health care team before you give your consent for surgery.
- Bile leak
- Complications related to Major Surgery
- Infection : Infection at the site of the wound, lung and urinary infection. Infection risk is more if intestine is perforated before surgery, operated for colon and rectum, stent in placed in bile duct to relieve jaundice or intestinal joint is leaking.
- Bleeding : The risk of bleeding during or after surgery is more if patient taking blood thinning medicine till day of surgery or having liver dysfunction. Bleeding during surgery that may cause you to need blood transfusions. There is a risk of certain problems with transfusions, some of them serious. Still, some operations involve a certain amount of controlled blood loss. Bleeding can happen either inside the body (internally) or outside the body (externally). It can occur if a blood vessel sealed during surgery opens up or if a wound opens up. Serious bleeding may cause the person to need another operation to find the source of the bleeding and stop it.
- Leakage from anastomosis (joint of anastomosis) & fluid collection in tummy.
- Blockage of intestine (Intestinal obstruction)
- Following treatment, you may feel change in your taste. This improves over a time and we encourage having health food habit like fresh vegetables, fruits and high protein diet.
Follow up care
- Along with healthy food habits, we also encourage for exercise. Exercise improves your health in different ways: It improves your heart and circulation, makes your muscles stronger & makes you feel happier. You should do your regular activities like walking, and rather increase day by day. Weight lifting and strenuous exercise are avoided for initial 2-3 months.
- You'll need regular check-ups after treatment for anal canal cancer. This help to find out any change in your recovery. Sometimes liver cancer comes back after treatment. Our health care team will check for return of cancer. Checkups may include a physical exam, blood tests, ultrasound / CT scan.
- If you have any health problems between checkups, you should contact our health care team. Report to our health care team, if you have any redness/ swelling or discharge of any type of fluid from your operative incision site, pain abdomen, vomiting or fever, breathing difficulty etc.