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The anus is an organ that lies at the end of the digestive tract below the rectum. It consists of two sections: the anal canal and the anus (or anal verge). The anal canal is a 3-4 cm long structure that lies between the anal sphincter (one of the muscles controlling bowel movements) just below the rectum and the anal verge which represents the transition point between the digestive tract and the skin on the outside of the body. Muscles within the anal canal and anus control the passage of stool from the rectum to outside the body. Normally, cells in the body will grow and divide to replace old or damaged cells in the body. This growth is highly regulated, and once enough cells are produced to replace the old ones, normal cells stop dividing. Tumors occur when there is an error in this regulation and cells continue to grow in an uncontrolled way. Tumors can either be benign or malignant. Although benign tumors may grow in an uncontrolled fashion sometimes, they do not spread beyond the part of the body where they started (metastasize) and do not invade into surrounding tissues. Malignant tumors, however, will grow in such a way that they invade and damage other tissues around them. They also may spread to other parts of the body, usually through the blood stream or through the lymphatic system where the lymph nodes are located. Over time, the cells within a malignant tumor become more abnormal and appear less like normal cells. This change in the appearance of cancer cells is called the tumor grade, and cancer cells are described as being well-differentiated, moderately-differentiated, poorly-differentiated, or undifferentiated. Well-differentiated cells are quite normal appearing and resemble the normal cells from which they originated. Undifferentiated cells are cells that have become so abnormal that often we cannot tell what types of cells they started from. Anal cancer is a malignant tumor of either the anal canal or anal verge. In the United States, 80% of anal cancers are squamous cell cancers, resembling the cells found in the anal canal. This is not true in other parts of the world, however. In Japan, 80% of anal cancers are adenocarcinomas, resembling the glandular cells seen in the rectum. Cancers of the anal verge may be referred to as "perianal skin cancers," because they usually behave more like skin cancers than like anal cancers. They may respond more poorly to treatment than other forms of anal cancers. Perianal skin cancers represent about 25% of all anal cancers. Occasionally, other types of cancer, such as melanoma, Kaposi's sarcoma, and lymphoma may develop in the anus. These other types of cancer will not be addressed further in this review. Anal cancers frequently begin as anal dysplasia. Cells of the anus that have abnormal changes are called anal dysplasia, but do not show evidence of invasion into the surrounding tissue. The most severe form of anal dysplasia is called carcinoma in situ. In the case of carcinoma in situ, cells have become cancerous, but have not begun to invade normal tissue yet. Over time, anal dysplasia changes to the point where cells become invasive and gain the ability to metastasize, or break way to other parts of the body. Anal dysplasia is sometimes referred to as anal intraepithelial neoplasia (AIN), or a "pre-cancer." When anal cancer does spread, it most commonly spreads through direct invasion into the surrounding tissue or through the lymphatic system. Spread of anal cancer through the blood is less common, although it can occur. In the United States in 2015, there will be an estimated 7,720 cases diagnosed and 1,010 deaths related to anal cancer. In general, the incidence of anal cancers has been increasing over the past 30-40 years. The vast majority (85%) of cases are in Caucasians. The incidence of anal cancer increases with age: patients with anal cancer have an average (median) age of 62 years. Anal cancers are more common in women. Several factors have been associated with anal cancer. Most importantly, infection with the human papilloma virus (HPV) has been shown to be related to anal cancers and has been associated with several other cancers, including cervical cancer and cancers of the head and neck. HPV can be transmitted from person to person through sexual contact, so individuals with a history of multiple sexual partners, anal receptive intercourse, and genital warts are at an increased risk for infection. Probably due to the association between HPV and anal cancer, women with history of cervical cancer are at increased risk of developing anal cancer. Another sexually transmitted virus, the human immunodeficiency virus (HIV), has been linked to anal cancers, and individuals infected with HIV are at increased risk for infection with HPV, particularly if the CD4 count is low. The relationship between HIV and anal cancer will be discussed in more detail in the next section (entitled "How are anal cancer and HIV/AIDS related?") Several other factors have been linked to anal cancer. Anal cancer has been associated with smoking. Patients who smoke are three times more likely to develop anal cancer as those that don't smoke. The risk of anal cancer increases with the number of cigarettes smoked per day and the number of years that a person has been smoking. Although there appears to be an increased rate of anal cancer in patients who have benign anal conditions such as anal fistulae, anal fissures, perianal abscesses, or hemorrhoids, it does not appear that these benign conditions are a cause of anal cancer. Alternatively, an undiagnosed anal cancer may actually be causing these conditions, and then is subsequently diagnosed when the benign condition is being treated. HIV is the virus responsible for Acquired Immune Deficiency Syndrome (AIDS), a severe disease that results in loss of the ability of the body to fight off certain types of infections. The incidence of anal cancer is increased in patients with HIV. This is likely related to the fact that patients with HIV are at an increased risk for infection with HPV as well. This relationship between HIV and HPV is not related to the immune status or the sexual practices of the patient infected with HIV. The rate of infection of HPV is increased in patients with HIV even if they do not engage in anal receptive intercourse and do not have evidence of suppression of their immune system. A patient is considered to have progressed from being HIV positive to having AIDS if they develop certain infections or diseases that are uncommon except in AIDS patients. Currently, anal cancer is not considered an AIDS-defining illness. However, frequently, patients who have been newly diagnosed with anal cancer are tested for HIV if they have other risk factors for infection with HIV. Anal cancer is an uncommon cancer, and the risk of developing anal cancer is quite low. Avoidance of risk factors for anal cancer, however, will reduce the risk of development of anal cancer even further. By far, the most important factor in developing anal cancer is infection with HPV. Gardasil is a vaccine directed against HPV. This vaccination is currently recommended for children, ages 11-12. Vaccination against HPV would certainly be expected to reduce the incidence of anal cancer in both men and women. Avoiding smoking and unsafe sexual practices can reduce the risk of anal cancer. This is because the immune system in people who smoke is less able to clear the HPV virus than those who do not smoke. In patients who are known to have anal dysplasia, careful surveillance can result in early detection of anal cancer, and a higher rate of cure with treatment. Removal of areas of anal dysplasia is usually unsuccessful and the rate of recurrence of anal dysplasia after surgical or laser removal is very high. This is likely due to the fact that even if areas of dysplasia are removed, the patient remains infected with HPV, which can cause the development of additional areas of anal dysplasia. The most common initial symptom of anal cancer is rectal bleeding, which occurs in about half of patients with new anal cancers. Pain or sensation of an anal mass is seen in about 30% of patients with new anal cancers. Occasionally, patients may experience itching, anal discharge, change in bowel patterns, or tenderness with palpation. In certain patients, these symptoms may be associated with the presence of warts in the anal region. Rarely, in advanced cases, anal cancers can disrupt the function of the anal muscles, resulting in loss of control of bowel movements. In general, these symptoms are vague and non-specific. As a result, in one-half to two-thirds of patients with anal cancer, a delay of up to 6 months occurs between the time when symptoms start and when a diagnosis is made. When anal cancer is suspected, the physician should perform a thorough history and physical examination. The physical exam should consist of a digital rectal examination (DRE) as well as visualization of the anal canal using an anoscope (a long, thin instrument that is inserted into the anus to allow the physician to see the inside of the anus and rectum). Ultimately, anal cancer can only be diagnosed with a biopsy. To perform a biopsy, the physician uses a needle or a small pair of scissors or clamps to remove a piece of the tumor. It is common for there to be some mild bleeding after a biopsy is taken, and this bleeding can last for a few days after the procedure. The tissue is then sent to a pathologist who looks at the tissue underneath a microscope to determine whether the tumor is cancerous or not. Because a number of benign tumors and lesions can resemble anal cancer on physical examination, a biopsy should always be performed before initiating treatment for anal cancer. Once a diagnosis of anal cancer is made, additional test should be ordered to determine the extent of the disease. A CT (CAT) scan or MRI of the abdomen and pelvis should be performed to look for abnormally enlarged lymph nodes, which can result from spread of the cancer, and to examine the liver for metastatic disease. A PET/CT is useful to assess the extent of disease including the lymph nodes, and to detect distant metastases. In some cases, an ultrasound of the tumor using a probe that is inserted into the anus can be used to determine the amount of invasion of the tumor into the surrounding tissues. Women with advanced tumors should also have a pelvic exam to assess if the tumor has invaded into the vagina. Anal cancer is most commonly staged using the TNM staging system, which is determined by the American Joint Committee on Cancer. The "T stage" represents the extent of the primary tumor itself. The "N stage" represents the degree of involvement of the lymph nodes. The "M stage" represents whether or not there is spread of the cancer to distant parts of the body. These are scored as follows: The staging can be further condensed into a stage group, which takes the various combinations of TNM and places them into groups designated stage 0-IV (See below). While there is a system for stage grouping of anal cancers, these tumors are more commonly referred to by their direct TNM stage. Although this system of cancer staging is quite complicated, it is designed to help physicians describe the extent of the cancer, and therefore, helps to direct what type of treatment is given. Radiation therapy has become the mainstay of treatment of anal squamous cell cancer. The radiation comes in the form of high energy x-rays that are delivered to the patient only in the areas at highest risk for cancer. These x-rays are similar to those used for diagnostic x-rays, but they are of a much high energy. The high energy of x-rays in radiation therapy results in damage to the DNA of cells. Cancer cells divide faster than healthy cells, and so their DNA is more likely to be damaged than that of normal cells. Additionally, cancer cells are generally less able to repair damaged DNA than normal cells are, so cancer cells are killed more easily by radiation than normal cells are. Radiation therapy exploits this difference to treat cancers by killing cancer cells, while killing fewer cells in normal, healthy tissue. Typically, radiation for anal cancer is given daily, Monday through Friday, for 5 to 6 weeks. The radiation treatments themselves are short, lasting only a few minutes. Like diagnostic x-rays, radiation treatments cannot be felt and do not hurt. Radiation is delivered like a beam of light, only affecting areas where it is aimed. In treatment of anal cancer, the radiation is usually aimed at the entire pelvis for the first 2-3 weeks so that any cells in the lymph nodes surrounding the anus are treated with radiation. After this, the radiation is aimed more specifically at the anus in the lower part of the pelvis. Most commonly, radiation treatment for anal cancer can result in irritation to the skin. This reaction can be quite severe with redness, dryness, and breakdown of the skin. Often, patients will require a break during radiation treatment to allow the skin to heal prior to resuming treatment. Other side effects of radiation can include fatigue, diarrhea, and lowering of blood counts. Increasingly, a technique of radiation delivery called IMRT is being used in an attempt to decrease skin and gastrointestinal toxicities, as well as decrease the need for treatment breaks. Chemotherapy refers to medications that are usually given intravenously or in pill form. Chemotherapy travels throughout the bloodstream and throughout the body to kill cancer cells. This is one of the big advantages of chemotherapy. If cancer cells have broken off from the tumor and are somewhere else inside the body, chemotherapy has the chance killing them, while radiation does not. In the setting of anal cancer, chemotherapy is most commonly given at the same time as radiation. This will be discussed further below under the section entitled "Combined Modality (Chemoradiotherapy)." A number of different chemotherapeutic agents exist, each with their own side effects. The preferred chemotherapies used in anal cancer are flourouracil (5FU) and mitomycin C. Sometimes, mitomycin C may be replaced with cisplatin in order to reduce toxicities from chemotherapy. Exactly which chemotherapeutic agents are given for anal cancer varies according to the physician's preference. It is important to discuss the risk of each of these medications with your medical oncologist. Based on your own health status and the risks of side effects that you are willing to accept, the choice of chemotherapy can vary. Chemotherapy is used in different situations to treat anal cancer. If the cancer is localized to the anus and pelvic lymph nodes, it may be used in combination with radiation therapy to achieve the best chance of killing all of the cancer cells (see "Combined Modality (Chemoradiotherapy)." If the cancer has spread to distant parts of the body, chemotherapy drugs such as cisplatin, carboplatin, and 5FU may be used without radiation to reduce the number of tumor cells and prevent or minimize symptoms all over the body. This is the case because chemotherapy is able to travel throughout the bloodstream, while radiation is not. In this setting, radiation may be used separately to relieve certain symptoms, such as pain, from cancer in other parts of the body. Unfortunately, if cancer is present in organs distant from the anus, chemotherapy is generally not very successful at controlling it. As molecular targets are identified for specific mutations in the tumor, these targets will become the focus of treatment. One such target that is being evaluated, in combination with chemotherapy, is epithelial growth factor receptor (EGFR) inhibitors. Squamous cell cancers often over-express EGFR. Chemotherapy has been shown to be radiosensitizing when given at the same time as radiation therapy. This means that the effect of the radiation is increased when given together with chemotherapy. Several large trials have shown that local control of the tumor is significantly improved when 5FU and mitomycin chemotherapy are used with radiation, as compared to radiation alone. Using chemotherapy and radiation together has not been shown to change the rate of survival of patients when compared to radiation alone; however, using chemotherapy and radiation together has been shown to reduce the risk of cancer recurring (coming back) in the anus. For this reason, combined modality treatment is recommended for most patients with anal cancer, unless a certain patient is unable to tolerate chemotherapy and radiation together. If this is the case, the patient may have radiation, with or without chemotherapy, given at a separate time. Although surgery was the primary treatment for anal cancer 20 years ago, its role has greatly diminished since then. When performed, surgical resection usually is an abdominal perineal resection (APR), which consists of a wide excision of the anus, including the anal muscles, with placement of a permanent colostomy. A colostomy is performed by connecting the bowel to a hole in the abdominal wall (called a stoma). The stool that passes through the stoma is collected in a bag that is attached to the outside of the abdominal wall with adhesive. This bag can then be emptied by the patient as needed. Because the combination of chemotherapy and radiation for squamous cell carcinoma results in similar rates of local control and survival when compared to surgery, chemoradiation has been favored over surgery because it offers patients a good chance at preserving anal sphincter function, and avoiding the need for permanent colostomy. In contrast, for adenocarcinomas of the anus, surgery is still recommended after chemoradiation. There are several situations in which surgery should be considered up-front for anal cancer. Patients with carcinoma in situ or small, well-differentiated anal cancers that have not invaded into the anal sphincter can sometimes undergo a surgical excision without removing the anal muscles. In these early cases, the results of surgical excision can be quite good, and the patient can avoid the potential side effects of chemoradiotherapy. Alternatively, extensive anal cancers that have destroyed the anal sphincter, such that the patient cannot control bowel movements, are often treated with surgery (an APR). In these cases, patients have already lost their sphincter function, and require a colostomy to handle bowel movements. Because patients in this situation usually have very large tumors, they may require surgical removal of the tumor, which will usually be followed by radiation, with or without chemotherapy, after the operation. Surgery can also be performed in patients who cannot otherwise tolerate radiation therapy, or who do not want radiation therapy. Finally, surgery is often performed if cancer recurs in the anus following previous treatment with radiation therapy, if additional chemotherapy and radiation cannot be given. After treatment for anal cancer, patients are usually followed every 3-6 months for five years with CT scans. The most important aspect of follow-up after completion of treatment is a thorough physical examination including a digital rectal exam. Anal cancers can take some time to respond to treatment and often continue to shrink months after chemotherapy and radiation have ended. Therefore, it is not unusual to have a residual mass immediately after treatment. The presence of a residual mass does not mean that the treatment did not work. Overall, the chance of long-term cure of anal cancer depends on the extent of the disease at the time it was first diagnosed. Patients with smaller disease without lymph node involvement or distant metastases have a better chance at long-term tumor control than those with larger disease or with lymph node involvement or distant metastases. If anal cancers do recur, they usually do so within the first 2 years after treatment, although recurrences after 2 years can occur. In general, the further out from treatment a patient is without evidence of a recurrence, the better the chances that the cancer will never come back. The treatment of anal cancer should be a cooperative effort among the patient, the radiation oncologist, the medical oncologist, and the surgeon. It is important that all patients with anal cancer know about their disease so that they can make an informed decision about their treatment. This article was intended to help answer some of the common questions patients face when they have anal cancer. If you have any additional questions, please contact your doctor. The HPV and Anal Cancer Foundation Facts about HPV – McGill University Men who have engaged in anal receptive intercourse can learn more about anal pap testing through the UCSF website. Cotter SE, Grigsby PW, Siegel BA, et al. FDG-PET in the evaluation of anal carcinoma Int J Rad Oncol Biol Phys 2006; 65: 720-725. Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 165-73. Gunderson LL, Winter KA, Ajani JA, et al. Long-term update of U. S GI Intergroup RTOG 98-11 phase III trial for anal carcinoma: comparison of concurrent chemoradiation with 5FU-mitomycin vs 5FU-cisplatin for disease-free and overall survival. Abstract # 367. ASCO 2011 Gastrointestinal Cancers Symposium. San Francisco, CA. Kachnic LA, Winter KA, Myerson J, et al. Two-year outcomes of RTOG 0529: A phase II evaluation of dose-painted IMRT in combination with 5-fluorouroacil and mitomycin-C for the reduction of acute morbidity in carcinoma of the anal canal. Abstract #368. ASCO 2011 Gastrointestinal Cancers Symposium. San Francisco, CA. NCCN Clinical Practice Guidelines: Anal Carcinoma (V.2.2015). http://www.nccn.org/professionals/physician_gls/pdf/anal.pdf Siegel, R. L, Miller, K. D. & Jemal, A. (2015). Cancer Statistics, 2015. CA: A Cancer Journal for Clinicians, 65(1). Anal Cancer. In Yarbro C. H, Wujcik, D. & Gobel, B.H. (2011). Cancer Nursing (pp. 1246- 1257). Sudbury, MA: Jones and Bartlett. Zeller JL, Lymn C, Glass RM. Anal Cancer. J Am Med Assoc. http://jama.ama-assn.org/content/299/16/1980.full.pdf
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Rak anusa i rektuma – uzroci, simptomi, komplikacije i liječenje Rak anusa je rijetka vrsta raka koji se javlja u analnom kanalu. Analni kanal je kratka cijev na kraju rektuma kroz koju stolica napušta tijelo. Rak anusa može uzrokovati znakove i simptome kao što su rektalno krvarenje i analna bol. Simptomi raka anusa mogu sličiti simptomima drugih bolesti, poput hemoroida. Iz tog razloga, osobe s rakom anusa često ne odlaze odmah liječniku. U većini slučajeva rak anusa se dijagnosticira u ranoj fazi, kada su šanse za izlječenje najveće. Većina osoba liječi se kombinacijom kemoterapije i zračenja. Simptomi raka anusa i rektuma Rak anusa i rektuma obično uključuje sljedeće simptome: - Krvarenje iz anusa ili rektuma - Bol u području anusa - Izrasline u analnom kanalu - Svrbež u području anusa ili rektuma Kada posjetiti liječnika? Znakovi i simptomi raka anusa i rektuma nisu specifični te ih neke osobe često pogrešno pripisuju drugim bolestima, poput hemoroida. Posjetite vašeg liječnika u slučaju bilo kakvih simptoma koji vam smetaju, osobito u slučaju čimbenika koji povećavaju rizik od raka anusa. Liječenje ove bolesti je vrlo učinkovito ako se rak otkrije u ranoj fazi. Faktori rizika kod raka anusa i rektuma Za nekoliko čimbenika je utvrđeno da povećavaju rizik od raka anusa, uključujući: - Starija dob – većina slučajeva raka anusa se pojavljuje kod osoba starijih od 50 godina - Veliki broj seksualnih partnera – kod muškaraca i žena koji imaju mnogo seksualnih partnera postoji povećan rizik od raka anusa. - Analni seks – muškarci i žene koji prakticiraju analni seks imaju povećan rizik od raka anusa. - Pušenje – pušenje cigareta može povećati rizik od raka anusa. Bivši pušači imaju samo blago povišen rizik od raka anusa. - Humani papiloma virus (HPV) – HPV infekcija povećava rizik od nekoliko vrsta raka, uključujući rak anusa i rak vrata maternice. HPV infekcija je spolno prenosiva bolest koja također može uzrokovati i genitalne bradavice. HPV infekcija može uzrokovati javljanje abnormalnih stanica u analnom kanalu. Te abnormalne stanice nisu rak, ali se mogu razviti u rak anusa. - Lijekovi ili stanja koja potiskuju imunološki sustav – osobe koje uzimaju lijekove za suzbijanje imunološkog sustava (imunosupresivni lijekovi), uključujući i osobe koje su primile transplantirani organ, imaju povećan rizik od raka anusa. Dugotrajna primjena kortikosteroida, kao što su oni propisani za kontrolu autoimunih poremećaja, također može povećati rizik od raka anusa. HIV virus, koji uzrokuje AIDS, potiskuje imunološki sustav i povećava rizik od raka anusa. Uzroci raka anusa i rektuma Rak anusa formira se kada genetska mutacija pretvara normalne, zdrave stanice u abnormalne stanice. Zdrave stanice rastu i množe se te na kraju umiru, dok abnormalne stanice rastu i množe se izvan kontrole i ne umiru. Akumulacija abnormalnih stanica oblikuje tumor. Stanice raka zahvaćaju okolno tkivo i mogu se odvojiti od početnog tumora i proširiti tijelom (metastazirati). Rak anusa je usko vezan uz spolno prenosive infekcije humanog papiloma virusa (HPV). Prisutnost HPV-a je otkrivena u velikom broju slučajeva raka anusa. Smatra se da je HPV najčešći uzrok raka anusa. Komplikacije kod raka anusa i rektuma Rak anusa i rektuma se rijetko širi (metastazira) na udaljene dijelove tijela. Samo mali postotak tumora će se proširiti, a njih je posebno teško liječiti. Rak anusa koji metastazira najčešće se širi na jetra i pluća. Testovi i dijagnoza raka anusa i rektuma Pretrage i postupci koji se koriste za dijagnosticiranje raka anusa i rektuma su: - Pregled analnog kanala i rektuma zbog utvrđivanja abnormalnosti – tijekom ovog ispitivanja, liječnik će prstom pregledati rektum i analni kanal kako bi utvrdio postojanje abnormalnosti, poput izraslina. Ova metoda se ne koristi za dijagnosticiranje raka, no može vašem liječniku dati naznaku bolesti, koja se dijagnosticira dodatnim testiranjima. - Vizualni uvid u analni kanal i rektum – vaš liječnik može koristiti osvijetljenu cijev kako bi pregledao analni kanal i rektum te utvrdio abnormalnosti. - Ultrazvuk analnog kanala – emitiranjem visoko energetskih zvučnih valova, koji se odbijaju od tkivo i organe, te tako stvaraju sliku unutrašnjosti tijela, mogu se utvrditi abnormalnosti. - Uzimanje uzorka tkiva za laboratorijska ispitivanja – ako vaš liječnik otkrije bilo kakve abnormalnosti, može mali uzorak zahvaćenog tkiva poslati u laboratorij na analizu. Pregledom stanica pod mikroskopom liječnici mogu utvrditi postojanje stanica raka. Određivanje stadija raka anusa i rektuma Nakon što je potvrđeno da imate rak anusa, vaš liječnik će poduzeti postupke za određivanje veličine raka i je li se proširio, što pomaže liječniku da odredi najbolji pristup liječenju vaše bolesti. Ispitivanja i postupci koji se koriste kod određivanja stadija raka mogu uključivati: - Slike zdjelice i trbuha – vaš liječnik može koristiti kompjuteriziranu tomografiju (CT), magnetsku rezonanciju (MR) i pozitronsku emisijsku tomografiju (PET) kako bi skenirao vašu zdjelicu i trbuh te procijenio razmjere raka. - Rendgen prsa – može otkriti je li se rak proširio na pluća i kosti u prsima. Liječnik koristi ove pretrage kako bi odredio stadij raka anusa. Faze raka anusa su: - Stadij I – rak je veličine od 2 cm ili manji (tj. otprilike veličine kikirikija ili manji) - Stadij II – rak je veći od 2 cm, ali se nije proširio izvan analnog kanala. - Stadij III A – rak je bilo koje veličine i proširio se na limfne čvorove u blizini rektuma ili oko obližnjih područja, poput mjehura, uretre ili vagine. - Stadij III B – rak je bilo koje veličine i proširio se do obližnjih područja i limfnih čvorova ili se proširio na druge limfne čvorove u zdjelici. - Stadij IV – rak se proširio na dijelove tijela koji se nalaze dalje od zdjelice. Liječenje raka anusa i rektuma Liječenje ovisi o stadiju raka, sveukupnom zdravlju i osobnim preferencijama. Kombinirana kemoterapija i zračenja Liječnici obično liječe rak anusa kombinacijom kemoterapije i zračenja. U kombinaciji, ova dva tretmana poboljšavaju šanse za izlječenje. - Kemoterapija – lijekovi za kemoterapiju se ubrizgavaju u venu ili uzimaju u obliku tableta. Lijekovi putuju kroz tijelo i ubijaju brzorastuće stanice, kao što su stanice raka. Nažalost, oni također oštećuju i zdrave stanice koje rastu brzo, uključujući i one u probavnom traktu i folikulu kose. Uzrokuje nuspojave kao što su mučnina, povraćanje i gubitak kose. - Zračenje – koristi se za ubijanje stanica raka. Zračenje može oštetiti zdravo tkivo u blizini mjesta zračenja. Nuspojave mogu uključivati crvenilo kože i čireve oko anusa, kao i otvrdnuće i smanjenje analnog otvora. Obično zračenje za rak anusa traje pet ili šest tjedana. Kemoterapija se obično provodi tijekom prvog tjedna i peti tjedan. Vaš liječnik će odrediti terapiju na temelju karakteristika raka i cjelokupnog zdravlja. Iako kombinacija ovih terapija povećava njihovu učinkovitost, ona također čini nuspojave češćima. Razgovarajte s vašim liječnikom o nuspojavama koje vas očekuju. Osobe s HIV-om imaju veću vjerojatnost da dožive nuspojave kemoterapije i zračenja, budući da tretmani mogu oslabiti njihov već ugrožen imunološki sustav. Nuspojave mogu otežati liječenje te iz tog razloga, liječnik može preporučiti niže doze kemoterapije i zračenja, ako je prisutan HIV. Kirurško liječenje Liječnici obično koriste različite postupke za uklanjanje raka anusa. - Operacija za uklanjanje ranog stadija raka anusa – koristi se kod vrlo malog raka anusa koji se nije proširio izvan analnog kanala i može biti uklonjen operacijom. Tijekom ovog postupka, kirurg uklanja tumor i malu količinu zdravog tkiva koje ga okružuje. Budući da su tumori mali, u ranoj fazi raka ponekad se mogu ukloniti bez oštećenja analnog sfinktera, tj. mišića koji okružuju analni kanal i koji kontroliraju stolicu. Ovisno o raku, liječnik može preporučiti kemoterapiju i zračenje nakon operacije. - Ako rak ne može biti uklonjen bez oštećenja analnog sfinktera, liječnik može preporučiti kombinaciju kemoterapije i zračenja. Kombinirani tretman može smanjiti rak na veličinu koja omogućuje kirurgu da izvede operaciju bez utjecaja na sfinkter. - Abdominalna resekcija – ako rak nije reagirao na kemoterapiju i zračenje, ili ako je brzo napredovao, liječnik može preporučiti opsežniju operaciju koja se zove abdominoperinealna resekcija. Tijekom ovog postupka kirurg uklanja analni kanal, rektum i dio debelog crijeva. Kirurg tada preostali dio debelog crijeva spaja na otvor (stomu) na trbuhu, kroz koji će otpadne tvari napustiti tijelo. ImunoBran tablete Prirodna podrška imunitetu. Pilex protiv hemoroida Brzo ublažava hemoroide. od 369 kn