Anal Cancer

Diagnosis

Finding anal cancer in the early stages and diagnosing it accurately can help improve your chances for successful therapy. We have the most advanced and accurate technology, as well as specialized experts to interpret results.

Anal Cancer Diagnosis

If you have symptoms that may signal anal cancer, your doctor will examine you and ask you questions about your health, your lifestyle, including smoking and drinking habits, and your family history.

One or more of the following tests may be used to find out if you have anal cancer and if it has spread. These tests also may be used to find out if treatment is working.

Imaging tests, which may include :

  • ♦ Anoscopy : A short tube with a camera is inserted into the anus and lower rectum. The doctor examines the anus and can biopsy tissue.
  • ♦ Proctoscopy: A short tube with a camera is inserted into the anus to the rectum. The doctor examines the anus and can biopsy tissue.
  • ♦ Double contrast barium enema (DCBE): Barium is a chemical that allows the bowel lining to show up on an X-ray. You will be given an enema with a barium solution, and then X-rays will be taken.
  • ♦ Colonoscopy
  • ♦ Virtual colonoscopy or CT (computed tomography) colonoscopy
  • ♦ CT or CAT (computed tomography) scans
  • ♦ MRI (magnetic resonance imaging) scans
  • ♦ PET/CT (positron emission tomography) scans
  • ♦ Endo-anal or endorectal ultrasound: An endoscope is inserted into the anus. A probe at the end of the endoscope bounces high-energy sound waves (ultrasound) off organs to make an image (sonogram). Also called endosonography.
  • ♦ Chest X-Ray

Fine-needle aspiration (FNA) biopsy : Anal cancer may spread through the lymph system, and sometimes it is found in lymph nodes. A tiny needle is placed into a lymph node, and cells are removed and looked at with a microscope. A positive lymph node biopsy may help the doctor decide what areas to treat with radiation therapy.

Introduction

Anal Cancer Facts

According to the American Cancer Society, more than 5,000 people are diagnosed with anal cancer in the United States each year. Unfortunately, this figure is increasing. The average age of people diagnosed with anal cancer is the early 60s. It occurs slightly more often in women than men because more women have human papilloma virus (HPV), which is a risk factor for anal cancer. Anal cancer often can be treated successfully if it is found early.

The anus, which is about 1-1/2 inches long, connects the rectum (lower part of the large intestine) to the outside of the body. It allows solid waste (also called stool or feces) to pass from the body. The sphincter is two muscles that open and close the anus to let waste pass. The anus is lined with squamous cells, which also are found in the bladder, cervix, vagina, urethra and other places in the body.

Anal Cancer Types

Several types of tumors may be found in the anus. While some of them are malignant (cancer), others are benign (not cancer) or precancerous (may develop into cancer). The main types of anal cancer are :

Carcinoma in situ is early cancer or precancerous cells. They are only on the surface cells of the anal canal. This also may be called Bowen’s disease.

Squamous cell cancer (carcinoma) forms in the cells that line the anus. This is the most common type of anal cancer.

Adenocarcinomas develop in the glands around the anus.

Skin cancers, including basal cell and melanoma, often are found when they are in advanced stages.

Our Approach :

This depth of experience and expertise sets us apart, enabling us to offer you the most accurate diagnosis methods and the very latest treatments for anal cancer.

Your care plan is customized by a team of renowned anal cancer specialists. They work together to ensure the most-advanced therapies with the fewest possible side effects. During treatment and beyond, they are supported by specially trained nurses, social workers, nutritionists and others.

Our high level of experience in minimally invasive and sphincter-sparing surgeries and other innovative techniques can help many people with anal cancer. We offer the most advanced therapies for every type of anal cancer, including in people with HIV and AIDS. Because we know quality of life is important, we make every effort to preserve the sphincter, without affecting control of bowel movements.

Symptoms & Sings

Anal cancer often does not have symptoms. When it does have symptoms, they vary from person to person. If you have anal cancer symptoms, they may include :

♦ Anal or rectal bleeding

♦ Pain or pressure around the anus

♦ Change in bowel habits

♦ Narrower stool than usual

♦ A lump close to the anus

♦ Swollen lymph nodes in the anal or groin area

♦ Anal discharge

These symptoms do not always mean you have anal cancer. However, it is important to discuss any symptoms that last more than two weeks with your doctor, since they may signal other health problems.

Staging

Anal Cancer Staging

If you are diagnosed with anal caner, your doctor will determine the stage of the disease. Staging is a way of talking about how much disease is in the body and where it has spread. This information helps the doctor treat the cancer. Once the staging classification is determined, it stays the same even if treatment is successful or the cancer spreads.

Anal Cancer Stages :

  • ♦ Stage I : Cancer has formed. The tumor is 2 centimeters or smaller
  • ♦ Stage II : Tumor is larger than 2 centimeters but not greater than or equal to 5 centimeters
  • ♦ Stage IIIA : Tumor is 5 centimeters or greater and/or has spread to either :
    • Lymph nodes near the rectum
    • Nearby organs, such as the vagina, urethra or bladder
  • ♦ Stage IIIB : Tumor is 5 centimeters or greater and/or may be any size and has spread to :
    • Nearby organs and lymph nodes near the rectum
    • Lymph nodes on one side of the pelvis and/or groin and may have spread to nearby organs
    • Lymph nodes near the rectum and in the groin and/or lymph nodes on both sides of the pelvis and/or groin and may have spread to nearby organs
  • ♦ Stage IV : Tumor may be any size and may have spread to lymph nodes or nearby organs and has spread to distant parts of the body
Prevention

Anal Cancer Screening

Cancer screening exams are important medical tests done when you’re healthy and don’t have symptoms. They help find cancer at its earliest stage, when the chances for treating it are best.

The chances for successful treatment are much higher when anal cancer is found early. While anal cancer often does not have symptoms, a digital rectal exam (DRE) can diagnose some cases early.

Men over 50 years old should have annual rectal exams. Once they are sexually active, women should have annual pelvic exams that include rectal exams.

If you have risk factors for anal cancer, talk to your doctor about other tests, including an anal Pap test. In this test, much like the Pap test for cervical cancer, cells from the anus are removed and looked at under a microscope.

Anal Cancer Risk Factors

Anything that increases your chance of getting anal cancer is a risk factor. These include :

  • ♦ Age: Squamous cell carcinoma of the anus most often is found in people older than 50
  • ♦ Human papillomavirus (HPV) infection
  • ♦ Human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS)
  • ♦ Having more than 10 sexual partners
  • ♦ Anal intercourse
  • ♦ Frequent anal redness, swelling and soreness
  • ♦ Tobacco use
  • ♦ Immunosuppression, including taking immune-suppressing drugs after an organ transplant

Not everyone with risk factors gets anal cancer. However, if you have risk factors, it’s a good idea to discuss them with your doctor.

Anal Cancer Prevention :

Certain lifestyle choices can help prevent anal cancer. One of the most important is to avoid HPV infection. Some ways you can lower your chances of getting HPV include :

  • ♦ Wait until you are older to have sex and limit your number of sexual partners
  • ♦ Use condoms during sex
  • ♦ Don’t smoke or use other types of tobacco
  • ♦ Avoid sex with people with sexually transmitted diseases (STD) or who have had multiple sexual partners
  • ♦ Get an HPV vaccine. Gardasil® and Cervarix® help protect against certain types of HPV. But if you have HPV, they do not cure it.
Treatment

Our Treatment Approach

As one of the nation’s largest cancer centers, we care for more patients with anal cancer than most other hospitals. A team of experts personalizes your comprehensive care plan to be sure you receive the most effective treatment with the fewest possible side effects.

A team of anal cancer specialists, including oncologists, radiation oncologists, surgeons and others as needed, focus on your treatment. They are supported by a group of specially trained nurses, nutritionists and social workers.

Most Advanced Therapies

We make every effort to preserve the sphincter without affecting control of bowel movements, and we use all means possible to decrease the risk of a colostomy. However, if a colostomy is needed, highly qualified nurses help you make the transition and maintain your quality of life.

If you have anal cancer that has spread (metastasized) and/or have HIV or AIDS, we offer the most advanced treatments for them.

BONE CANCER

Diagnosis

Accurate diagnosis is essential to successful treatment of bone cancer. The wrong kind of biopsy may make it more difficult later for the surgeon to remove all of the cancer without having to also remove all or part of the arm or leg with the tumor. A biopsy that is not done correctly may cause the cancer to spread.

If your doctor thinks you may have bone cancer, it’s important to go to a cancer center with a specialized bone cancer program. You should look for a program that does as many diagnostic procedures as possible. Also, if possible, the surgeon who performs the biopsy should also do the surgery to remove the cancer.

Bone Cancer Diagnosis

If you have symptoms that may signal bone cancer, your doctor will examine you and ask you questions about your health and your family history. One or more of the following tests may be used to find out if you have cancer and if it has spread. These tests also may be used to find out if treatment is working.

Biopsy : A biopsy, which removes a tiny piece of bone, is used to confirm the presence of cancer cells. This is the only way to find out for certain if the tumor is cancer or another bone disease. It is very important for the biopsy procedure to be done by a surgeon with experience in diagnosing and treating bone tumors.

There are two types of bone biopsy :

  • Needle biopsy : A long, hollow needle is inserted through the skin to the area of bone to be tested. The needle removes a cylindrical sample of bone to look at under a microscope.
  • Open or surgical biopsy : An incision (cut) is made, and the surgeon removes a tiny piece of bone for examination under a microscope.

Your doctor will decide which type of biopsy is best for you based on several factors, including the type and location of the tumor. If possible, the surgeon who performs the biopsy should also do the surgery to remove the cancer.

Imaging tests, which may include :

  • ♦ X-ray
  • ♦ CT or CAT (computed axial tomography) scans
  • ♦ MRI (magnetic resonance imaging) scans
Introduction

Bone Cancer Facts

Bone cancer is a sarcoma (type of cancerous tumor) that starts in the bone. Other cancers may affect the bones, including :

  • ♦ Secondary cancers that metastasize, or spread, from other parts of the body
  • ♦ Other types of cancer including non-Hodgkin’s lymphoma and multiple myeloma

This information is about primary bone cancers.

Bones support and give structure to the body. They usually are hollow. The main parts of the bones are :

Matrix is the outer part of bones. It is made of fiber-like tissue and is covered with a layer of tissue called the periosteaum.

Bone marrow is the soft tissue in the space in hollow bones called the medullary cavity. Cells inside bone marrow include :

  • ♦ Fat cells
  • ♦ Red blood cells, white blood cells and platelets
  • ♦ Fibroblasts, a type of cell that helps build connective tissue
  • ♦ Plasma, in which blood cells are suspended
  • ♦ Cartilage is at the end of most bones. It is softer than bone, but it is firmer than soft tissue. Cartilage and other tissues, including ligaments, make up joints, which connect some bones.
  • ♦ Bone constantly changes as new bone forms and old bone dissolves. To make new bone, the body deposits calcium into the cartilage. Some of the cartilage stays at the ends of bones to make joints.

Bone Cancer Types

There are several types of bone tumors. They are named according to the area of bone or tissue where they start and the type of cells they contain. Some bone tumors are benign (not cancer), and some are malignant (cancer). Bone cancer also is called sarcoma.

The most commonly found types of primary bone cancer are :

Osteosarcoma or osteogenic sarcoma is the main type of bone cancer. It occurs most often in children and adolescents, and it accounts for about one-fourth of bone cancer in adults. More males than females get this cancer. About 1,000 people in the United States are diagnosed with osteosarcoma each year. It begins in bone cells, usually in the pelvis, arms or legs, especially the area around the knee.

Chondrosarcoma is cancer of cartilage cells. More than 40% of adult bone cancer is chondrosarcoma, making it the most prevalent bone cancer in adults. The average age of diagnosis is 51, and 70% of cases are in patients over 40. Chondrosarcoma tends to be diagnosed at an early stage and often is low grade. Many chondrosarcoma tumors are benign (not cancer). Tumors can develop anywhere in the body where there is cartilage, especially the pelvis, leg or arm.

Ewing’s sarcoma is the second most prevalent blood cancer in children and adolescents, and the third most often found in adults. It accounts for about 8% of bone cancers in adults. Ewing’s sarcoma can start in bones, tissues or organs, especially the pelvis, chest wall, legs or arms.

Less – commonly found types of bone cancer include :

  • ♦ Chordoma, which is found in 10% of adult bone cancer cases, usually in the spine and base of the skull
  • ♦ Malignant fibrous histiocytoma/fibrosarcoma, which usually starts in connective tissue
  • ♦ Fibrosarcoma, which often is benign and found in soft tissue in the leg, arm or jaw
  • ♦ Secondary (or metastatic) bone cancer is cancer that spreads to the bone from another part of the body. This type of bone cancer is more prevalent than primary bone cancer. For more information about this type of cancer, see the type of primary cancer (where the cancer started)
Symptoms & Sings

Bone cancer symptoms vary from person to person. They also depend on the size and location of the cancer.

If you have symptoms, they may include :

  • ♦ Pain
  • ♦ Swelling or tenderness in or near a joint
  • ♦ Difficulty with normal movement
  • ♦ Fatigue
  • ♦ Fever
  • ♦ Weight loss
  • ♦ Anemia (low red blood cell count)
  • ♦ Fractures

Having one or more of these symptoms does not mean you have bone cancer. However, it is important to discuss any symptoms with your doctor, since they may indicate other health problems.

Staging

Bone Cancer Staging

If you are diagnosed with bone cancer, your doctor will determine the stage (or extent) of the disease. Staging is a way of determining how much disease is in the body and where it has spread. This information is important because it helps your doctor determine the best type of treatment for you and the outlook for your recovery (prognosis). Once the staging classification is determined, it stays the same even if treatment is successful or the cancer spreads.

AJCC Staging System

One system that is used to stage all bone cancer is the American Joint Commission on Cancer (AJCC) system.

  • ♦ T stands for features of tumor (its size)
  • ♦ N stands for spread to lymph nodes
  • ♦ M is for metastasis (spread) to distant organs
  • ♦ G is for the grade of the tumor

This information about the tumor, lymph nodes, metastasis and grade is combined in a process called stage grouping. The stage is then described in Roman numerals from I to IV (1-4).

T stages of bone cancer

  • ♦ TX: Primary tumor can’t be measured
  • ♦ T0: No evidence of the tumor
  • ♦ T1: Tumor is 8 centimeters (around 3 inches) or less
  • ♦ T2: Tumor is larger than 8 centimeters
  • ♦ T3: Tumor is in more than one place on the same bone

N stages of bone cancer

  • ♦ N0: The cancer has not spread to the lymph nodes near the tumor
  • ♦ N1: The cancer has spread to nearby lymph nodes

M stages of bone cancer

  • ♦ M0: The cancer has not spread anywhere outside of the bone or nearby lymph nodes
  • ♦ M1: Distant metastasis (the cancer has spread)
    • M1a: The cancer has spread only to the lung
    • M1b: The cancer has spread to other sites (like the brain, the liver, etc)

Grades of bone cancer

  • ♦ G1-G2: Low grade
  • ♦ G3-G4: High grade

TNM stage grouping

After the T, N and M stages and the grade of the bone cancer have been determined, the information is combined and expressed as an overall stage. The process of assigning a stage number is called stage grouping. To determine the grouped stage of a cancer using the AJCC system, find the stage number below that contains the T, N and M stages, and the proper grade.

Stage I: All stage I tumors are low grade and have not yet spread outside of the bone.

  • ♦ Stage IA: T1, N0, M0, G1-G2: The tumor is 8 centimeters or less.
  • ♦ Stage IB: T2 or T3, N0, M0, G1-G2: The tumor is either larger than 8 centimeters or it is in more than one place on the same bone.

Stage II: Stage II tumors have not spread outside the bone (like stage I) but are high grade.

  • ♦ Stage IIA: T1, N0, M0, G3-G4: The tumor is 8 centimeters or less.
  • ♦ Stage IIB: T2, N0, M0, G3-G4: The tumor is larger than 8 centimeters.

Stage III: T3, N0, M0, G3-G4: Stage III tumors have not spread outside the bone but are in more than one place on the same bone. They are high grade.

Stage IV: Stage IV tumors have spread outside of the bone they started in. They can be any grade.

  • ♦ Stage IVA: Any T, N0, M1a, G1-G4: The tumor has spread to the lung.
  • ♦ Stage IVB: Any T, N1, any M, G1-G4 OR Any T, any N, M1b, G1-G4: The tumor has spread to nearby lymph nodes or to distant sites other than the lung (or both).

Even though the AJCC staging system is widely accepted and used for most cancers, bone cancer specialists tend to simplify the stages into localized and metastatic. Localized includes stages I, II and III, while metastatic is stage IV.

Prevention

Bone Cancer Screening

Screening tests are important ways to find cancer if you are at risk but do not have symptoms. Unfortunately, no standardized screening tests have been shown to improve bone cancer outcomes.

Bone Cancer Risk Factors

Anything that increases your chance of getting bone cancer is a risk factor. However, having risk factors does not mean you will get bone cancer. In fact, most people who develop bone cancer do not have any risk factors. If you have risk factors, it’s a good idea to discuss them with your health care provider.

Teenagers and young adults are at greatest risk of developing osteosarcoma, a type of bone cancer, because it often is associated with growth spurts. Some diseases that run in families can slightly increase the risk of bone cancer. These include :

  • ♦ Li-Fraumeni syndrome
  • ♦ Rothmund-Thompson syndrome
  • ♦ Retinoblastoma (an eye cancer of children)
  • ♦ Multiple osteochondromas

Other risk factors for bone cancer include :

  • ♦ Paget’s disease
  • ♦ Prior radiation therapy for cancer, especially treatment at a young age or with high doses of radiation
  • ♦ Bone marrow transplant
Treatment

Surgery

Surgery is the main treatment for most bone cancers. Both the biopsy and surgery should be done by a surgeon with extensive experience in these procedures. A biopsy in the wrong location can cause surgical problems and lower your chances of successful treatment.

If at all possible, the same surgeon should perform both the biopsy and surgery. The biopsy will help the surgeon locate the tumor more precisely.

The goal of surgery is to remove as much of the cancer as possible. If any cancer cells remain, they may grow and spread. To get as much of the cancer as possible, the surgeon performs a wide-excision surgery. This involves removing the cancer, as well as a margin of healthy tissue around it.

If the tumor is in an arm or leg, the surgeon almost always is able to perform limb-sparing surgery, which removes the cancer cells but allows you to keep full use of your leg or arm. To replace bone that is removed during surgery, a bone graft may be done or an internal device called an endoprosthesis may be implanted.

If this is not possible, an amputation, or removal of the limb, may be performed. Reconstructive surgery and/or prosthesis will be needed. Rehabilitation is necessary after either procedure.

Chemotherapy

Chemotherapy may be recommended to treat osteosarcoma or Ewing’s sarcoma. In osteosarcoma, it is often given before surgery to shrink the tumor and make it easier to remove, and after surgery to destroy remaining cancer cells. Chemotherapy is also used for bone cancer that has metastasized (spread) to the lungs or other organs.

Radiation Therapy

Bone cancer is not highly sensitive to radiation, so radiation usually is not a treatment. It sometimes may be given if the tumor cannot be operated on or if cancer cells remain after surgery. Radiation may help relieve symptoms if bone cancer returns.

New radiation therapy techniques and remarkable skill allow doctors to target tumors more precisely, delivering the maximum amount of radiation with the least damage to healthy cells.

Proton therapy delivers high radiation doses directly into the tumor, sparing nearby healthy tissue and vital organs. For many patients, this results in a higher chance for successful treatment with less impact on your body.

Targeted Therapy

These newer agents are used to help fight some types of bone cancer, including chordoma. Targeted therapies attack cancer cells by using small molecules to block pathways that cells use to survive and multiply.

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