Surgical Procedures: Surgery and Staging for Anal Cancer

Cancerous cells in the anus are called anal cancer. The anus is found at the end of the bowel. It helps move stool out of the body. 

Often, anal cancers start in the inner lining of the anus or mucosa and are called squamous cell carcinoma. Other types of anal cancers include:

• Adenocarcinoma.
• Basal cell carcinoma.
• Melanoma.
• Gastrointestinal stromal tumors (GIST).

What is staging and how is it performed?

Staging is a way to find out how far the cancer has spread in your body. Your provider will have you get a few tests to figure out the stage of your cancer. For anal cancers, these tests may include:

Physical Exam: This is a general exam to look at your body and to talk about past health issues. This will include an exam of the anal canal and rectum (digital rectal exam). At times, an anal Pap test may be done to look for HPV (human papillomavirus).

Imaging: Radiology tests can look inside your body at the cancer and see if it has spread. These tests can include:  

• X-ray. 
• CAT scan (CT scan).
• Ultrasound. 
• Positron emission tomography scan (PET scan).
• Magnetic resonance imaging (MRI).

Procedures: Each case of anal cancer is different. Talk with your care team about which procedures may be part of your treatment plan. These options may include:

• Endoscopy: An endoscope, or a lighted tube, is used to look for any abnormal areas. The endoscope can take tissue for a biopsy.
• Anoscopy: Using an anoscope (a short and hollow-lighted tube), your healthcare provider can place this into the anus and rectum to see these areas better.
• Proctoscopy: Using a proctoscope (a short, lighted tube), your provider can take a closer look at your rectum.
• Rigid proctosigmoidoscopy: A rigid proctosigmoidoscope is a longer version of the anoscope, allowing your provider to see the rectum and lower part of the sigmoid colon.
• Biopsy: A biopsy takes cells from the cancer, or a piece of the cancer, to see what type of cancer it is and how it behaves. A doctor called a pathologist looks at the sample in a laboratory. 
  • Sentinel Lymph Node Biopsy: A radioactive or blue dye is injected near the cancerous tumor and is absorbed into the cells. Any lymph nodes with blue dye or radioactive material present are removed and sent for testing.
  • Fine Needle Aspiration: A small sample of lymph node fluid and/or tissue is aspirated (removed) through a hollow needle.

Anal cancer spreads to other parts of the body through the tissue, lymph, and blood systems. Cancer stage determines how extensive the cancer is, how far it has spread, and what treatment course will be recommended. Anal cancer is staged using the American Joint Committee on Cancer (AJCC) staging system and includes stages 0 (called carcinoma-in-situ) through stage IV disease.

Often, anal cancer is treated with surgery.

There are two surgical procedures used to treat anal cancer, depending on your stage and situation, including:

• Local Resection: Removal of the tumor, as well as a small amount of surrounding normal-appearing tissue. This is used in cases where the tumor is small and has not spread to other parts of the body. Bowel control is not often affected using this method.
• Abdominoperineal Resection (APR): Abdominal and anal incisions (cuts) are made to remove the anus, rectum, and sigmoid colon. A colostomy (opening in the belly where stool can exit the body) will be needed. The opening where the anus was will be closed with sutures. Lymph nodes may also be removed.

What are the risks associated with anal surgery?

As with any surgery, there are risks and possible side effects. These can be:

• Reaction to anesthesia (Anesthesia is the medication you are given to help you sleep through the surgery, to not remember it and to manage pain. Reactions can include wheezing, rash, swelling and low blood pressure).
• Injury to nearby organs.
• Bleeding.
• Blood clots.
• Infection.

Side effects that are specific to an abdominoperineal resection include:

• Scar tissue in the belly. 
• Issues with digestion. 
• Need for a permanent colostomy.
• Changes in sexuality for men, including erectile dysfunction, inability to achieve orgasm or decreased orgasmic pleasure/intensity in men.
• Scar tissue may cause painful intercourse in women.
• Changes in body image. 

What is recovery like?

Recovery from anal cancer surgery depends on the extent of the procedure you have had. For those who have undergone an abdominoperineal resection, a hospital stay is needed. You will be taught how to care for your incision before leaving the hospital.

Your medical team will discuss with you the medications you will be taking, such as those for pain, blood clot prevention, and/or other conditions.

Common activity restrictions and instructions for abdominoperineal surgery include:

• Walking, the night of or day following surgery is often suggested.
• Shower 48-72 hours after surgery. 
• Do not lift, bend or twist until you have been told that you can. 
• Do not drive while taking narcotic pain medication. 
• Do not sit for long periods of time as this can delay healing. 
• Follow the recommended diet given to you. 

Contact your healthcare team if you experience:

• Fever. Your care team will tell you at what temperature they should be notified. 
• Redness or drainage at the incision. 
• Nausea, vomiting, or abdominal bloating.
• Leg swelling and/or shortness of breath.
• Blood in stool or continued rectal bleeding with or without lightheadedness or dizziness.
• Any new or worsening pain. 

How can I care for myself?

You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that you can go back to your normal activity.

Be sure to take your prescribed medications as directed to prevent pain, infection, and/or constipation. Call your team with any new or worsening symptoms.

There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation. 

Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.

• Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.