Although none of the editors of InsideSurgery are participating in her care, we have noted the reports that Farrah Fawcett has been hospitalized in Los Angeles. The actress has been suffering from anal cancer since 2006 and was initially treated with chemotherapy with a short period of remission. Reportedly, the cancer returned in May, 2007.
Fawcett entered the hospital after returning from Germany where she was undergoing unspecified experimental treatment. She was photographed in a wheelchair and is variously described as awake and in good spirits and in critical but stable condition. Some reports intimate that Fawcett is dying.
Her physician Dr. Lawrence Piro is quoted as saying that she suffered a small abdominal wall hematoma that was painful after a minor procedure, causing her to use the wheelchair for comfort, but that she is able to ambulate.
When discussing anal cancer and its diagnosis, treatment, and prognosis, it is important to distinguish the two areas in question: the anal margin and the anal canal. The anal canal is roughly the length of the internal anal sphincter, from the upper to the lower edge. It measures approximately 4 cm in length.
The anal margin is distal to the anal canal and extends from the anal verge to the skin of the buttocks. Cancers in the anal margin are less invasive and have a better outcome than cancers of the anal canal.
Anal canal cancers are most prevalent in women in their late 50’s and in HIV patients. Risk factors include smoking, anal sex, promiscuous sex, human papillovirus (HPV) infection, prior radiation to the area, and chronic anal fistula. Anal cancers are easily detected on routine screening colonoscopy.
Unlike the tumors of the more proximal gastrointestinal tract, anal canal tumors are usually squamous cell in origin. They have a characteristic rolled edge with a center crater when viewed with an anoscope. For definitve diagnosis, endoluminal ultrasound (an ultrasound probe placed into the anus) is used to measure the depth of the tumor and the presence of metatastic lymph nodes in the perirectal or pelvic regions.
If endoluminal ultrasound is not available or can not be tolerated by the patient, computed tomography (CT) or magnetic resonance imaging (MRI) can be used.
Once the presence of anal cancer is suspected, a biopsy is taken from the edge of the tumor. The size and the degree of fixation of the tumor to the rectal wall is determined.
Anal cancers are classified as follows: stage 1- confined to the sphincter, stage 2 – extending into the perirectal fat, stage 3 – involving the lymph nodes, stage 4 – distant metastases.
Anal canal lesions that are less than 2 cm, well-differentiated on biopsy, and superficial can be removed by local excision with a 1 cm marging. For these lesions, sometimes a partial excision to save the sphincter and preserve continence is done with subsequent chemoradiation.
For lesions larger than 2 cm and disease confined to the pelvis, the Nigro treatment protocol is used. This consists of intravenous 5-fluorouracil on days 1 to 5 and days 31 to 35 and intravenous mitomycin C on day 1.
Radiation is administered over a 3 to 4 week course and usually consists of 45 Gy to the pelvic region.
Patients are checked 4-6 weeks after completion of the above for the presence of remaining disease and then every three months for two years. Patients who have remaining or recurring disease can have a second course of chemotherapy or a radical surgery called an abdominoperineal resection (APR).
For disease confined to the pelvis, five year survival is quite good and ranges from 70% to 85%.
Patients with widespread metastatic disease on presentation have a very poor survival. Metastases are most typical to the liver, lungs, and bone. For these patients, surgery may be required for local control of the tumor. The conventional chemotherapy is cisplatin.
It is likely that a patient with a course similar to that reported for Fawcett likely had advanced disease on presentation. The recurrence at 4 months is an ominous sign and the continuing treatment attempts with the use of “experimental therapy” in Germany might indicate that conventional treatment had failed.
Reports that Fawcett is in too much pain because of a small abdominal wall hematoma are confusing. Generally, a hematoma here does not prevent ambulation and while slightly uncomfortable does not cause so much pain that walking is difficult.
In addition, a small hematoma would not require a hospitalization.
It is not clear what the minor procedure that Fawcett had that would cause the hematoma is. A laparoscopic procedure with placement of ports through the abdominal wall might cause a hematoma. However, that would not be classified as a minor procedure as it would require the use of general anesthesia.