How To Stop Diarrhea In A 3 Year Old Child Anal Cancer and Kerry’s Story: Beware of HPV

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Anal Cancer and Kerry’s Story: Beware of HPV

THE STORY OF KERRY
Kerry was a 42-year-old female executive who was in excellent health. She was married but had no children and had never been pregnant. She was a non-smoker with no past medical history and no family history of cancer. Notably, Kerry had no history of sexually transmitted diseases and was HIV negative. When he noticed blood on the toilet paper after his bowel movements, he first thought the problem was due to hemorrhoids. However, after two weeks, the bleeding increased and was accompanied by pain and itching around the anus. He went to his primary care physician whose examination revealed a 2 x 2 inch mass at the anal sphincter. Her doctor did not feel any abnormal lymph nodes in her groin. He referred her to a colorectal surgeon who performed a colonoscopy. That exam confirmed the mass seen by his primary doctor but no other lesions. The biopsy revealed squamous cell carcinoma, anal cancer.

After his diagnosis, Kerry’s surgeon sent him for a PET/CT scan which revealed abnormalities only in the anal mass. There was no distant activity to suggest metastatic (distant, incurable) spread of his cancer. Her surgeon referred her to a radiation oncologist and medical oncologist. They recommended radiotherapy (RT) and chemotherapy together (simultaneous chemoRT) which he underwent for a period of 6 weeks. Kerry was treated with intensity modulated radiation therapy (IMRT) to minimize the RT dose to critical organs including the small bowel and bladder, while treating potentially microscopic cancer cells in the lymph nodes in the pelvis and pelvis. groin and anal tumor. He received concurrent mitomycin and fluorouracil chemotherapy by IV infusion in the outpatient setting. Kerry had expected side effects of the treatment including severe irritation and redness of the skin in the groin and anus, but she did not need a break during IMRT. She had significant fatigue that kept her off work during most of her chemoRT. He had some loose bowels which was well controlled after adjusting his diet. At the end of his treatment, there was no evidence of a tumor remaining. She recovered from the side effects of the treatment in about six weeks. Kerry has seen one of her cancer doctors every three to six months for the past five years and remains cancer free!

BASICS
Although it is one of the less common cancers of the GI tract, there are still about 5,000 cases of anal cancer diagnosed in the United States each year. There are more women than men diagnosed. The average age at diagnosis is about 60 years, but it can occur in patients in their 30s and 40s. If the disease is localized, which is the case for 50% of patients, then the cure rate is about 80%.

RISKS AND CAUSES
Most patients who are diagnosed with anal cancer do not have a clearly defined risk factor. However, the factors that increase the risk of developing anal cancer are associated with the risk of infection by the human papillomavirus (HPV). This virus is the same type that causes genital warts. Certain strains of the HPV virus are associated with a high risk of developing anal cancer as well as cervical cancer and some types of throat cancer. Activities that put people at risk for HPV, such as anal receptivity, can also put them at risk of later developing anal cancer.

SIGNS & SYMPTOMS
Patients often present to their doctors with complaints of anal pain or bleeding. Many patients ignore or minimize the symptoms, often initially attributing them to hemorrhoids. While most people who have these symptoms do not have anal cancer, persistent pain or bleeding should always prompt medical attention. Less commonly, patients complain of itching or a painless mass in the groin. A lump can develop in the groin as a result of anal cancer spreading to the lymph nodes and causing them to enlarge.

DIAGNOSIS
The diagnosis of anal cancer is usually made by a biopsy of the anal mass or area of ​​ulceration. Generally, this procedure is performed by a GI specialist doctor or surgeon. These doctors are able to look directly into the anal canal and the rectum by proctoscopy (or whole colon by colonoscopy) with special instruments after which they provide medications to minimize discomfort. The biopsies are performed during these procedures, after sedation and/or injection of numbing medicine. Most anal cancers (80%) are squamous cell carcinomas. A thorough evaluation of someone suspected of having anal cancer should also include examination of the pelvis, especially both groins. If the lymph nodes are enlarged, they can also be biopsied. Many enlarged lymph nodes are simply inflamed, with no evidence of cancer. Blood tests that may be ordered include a complete blood count, kidney function tests, and possibly HIV tests, depending on the patient’s risk factors for the virus.

MISE EN SCENE
The TNM staging system of the American Committee on Cancer (AJCC) is used to determine whether anal cancer is localized (early stage) or has spread to other sites (advanced or late stage). Early stage disease is limited to the anus, while advanced disease refers to cancers that have invaded nearby organs or lymph nodes in the pelvis or groin. Imaging studies should include CT scan of the abdomen and pelvis and a chest x-ray at a minimum. Staging may also include a PET/CT scan. This imaging test allows the radiologist and cancer treatment specialists to see if the anal cancer has spread to involve the lymph nodes in the groin or pelvis, or metastasized to other sites in the body, such as the liver or lungs.

TREATMENT
The standard treatment for anal cancer does not involve surgery, which comes as a surprise and a relief to many patients. Since most anal cancers invade the sphincter that controls defecation, surgery to remove such a cancer required the removal of the sphincter and the creation of a colostomy. Therefore, surgery is generally avoided in favor of treatment that keeps the anal sphincter intact. An exception would be the very early gates of the anal margin, on the skin outside the anus.

Concurrent ChemoRT is the standard treatment for most patients with anal cancer, to obtain the best chance of cure with sphincter preservation. RT delivered over approximately 6 weeks with IV fluorouracil (5FU) and concurrent mitomycin-C chemotherapy (MMC) provides patients with the best chance for cure. RT is delivered in daily fractions using either 3D conformal RT or IMRT. The latter technique can be used to minimize the amount of normal bowel and/or genitals receiving full-dose RT (and therefore minimize side effects).

The main side effects that are possible during RT to the anus and pelvis include skin reaction that can be severe around the anus and skin folds in the groin, as well as irritation of bowel movements and diarrhea. Most patients should resolve these acute symptoms within 1-2 months after the end of treatment. Extremely rare (<1%), but serious side effects include intestinal obstruction or fistula (a hole between the anus and the bladder or urethra). 5FU can also cause bowel irritation, diarrhea, irritation in the mouth or lips, poor appetite and fatigue. Rarely, discoloration of the skin or nails or severe peeling of the hands and feet (hand-foot syndrome) or other major side effects may occur. In rare cases, heart problems including heart attack can occur. MMC can cause low blood pressure, mouth sores, poor appetite and fatigue. They can also cause nausea, vomiting and urinary irritation. Rarely, lung or kidney damage that can be life-threatening.

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