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Anal Pain






Anal Pain
Piles / Hemorrhoid

A 39 year old Caucasian with serious bleeding from external piles was seen by a general surgeon who operated on him in February 2005. Following surgery, he continued to have severe pain two months after surgery.

He was seen and re-operated by the same surgeon for piles but continued to have severe pain even on sitting three months after surgery and was referred to see me. Clinical examination showed that he had a previously unrecognized chronic anal fissure with large external skin tags.

He underwent an excision of the skin tags and a simple procedure called a lateral sphincterotomy to cure the chronic fissure and was totally well the following day. Expert examination and accurate diagnosis and surgery will ensure prompt healing and minimal complications in all cases undergoing surgery.

Difficult Rectal Cancer
Rectal Cancer

A 50 year old Caucasian man first complained of anal symptoms including bleeding and anal pain in May 2005. He was seen in Russia initially and was diagnosed to have a very low rectal cancer about 2 cm from the anal verge. Complete removal including removal of the anus was advised in Russia. The patient was adamant against this and sought treatment with me. Clinical examination showed a very muscular and large man who was otherwise very fit for his age.

As the cancer was indeed 2 cm from the outside skin edge an abdominal-perineal excision or removal of the rectum and anus was discussed with him. He was firmly fixed against the idea that he will have a permanent colostomy bag on his abdomen. As all scanning showed that the tumour was localized without spread to other parts of his body, it was felt that it might be possible to attempt an inter-sphincteric dissection of his anus and remove the cancer totally by this method and allow him to preserve anal function.

This operation was performed successfully on the 3rd August. The cancer was removed with a good margin and no chemotherapy or radiotherapy was needed. He remains very well with good ability to control his anus on follow up.

Advanced Rectal Cancer
Cancerous Polyp Cancerous Polyp

A 39 year Chinese man with locally advanced rectal cancer. Mr Chia first presented with difficulty in motion in Jan 2005. He was then in severe pain and had bleeding whenever he went to the toilet. He also passed motion with difficulty and pain. Clinical examination showed a huge rectal mass fixed to the pelvis and protruding into the anal canal. The lower end of the cancer was only 2 cm from the bottom of the anus. He saw a surgeon elsewhere and he was advised that no treatment was possible and that he should go home and await the end.

Mr Chia became desperate until a friend recommended him to see me at Mt Elizabeth Hospital. Clinical examination showed Mr Chia to be a well built man in his late 30’s. He was fit and physical examination showed no abnormality except for the huge fixed cancer in the pelvis and rectum. CT films showed gross infiltration outside the rectum and a huge mass was immediately clearly seen. The cancer was clearly not completely respectable at this stage. He was advised to undergo chemotherapy and radiotherapy in an effort to shrink the cancer. This strategy worked well.

Six weeks of chemo and radiotherapy shrunk the mass completely. After 6 weeks, no residual cancer was felt on rectal examination. Further X rays showed spread elsewhere and Mr Chia was advised for rectal surgery. An ultra-low anterior resection was done on Oct 2006. Histological examination of the resected specimen showed complete clearance of cancer. Mr Chia is expected to have a good prognosis.

Redo of Blotched Up Surgery
Cancerous Polyp

A 63 year old man in another country had a colonoscopy and removal of a colonic polyp on the 10th Jan 2003. The following day, he complained of severe abdominal pain and was hospitalized and underwent emergency surgery on the 13th January 2003. Surgery was performed during which the perforated removal of polyp site was sutured closed and a tube inserted into his caecum.

Unfortunately this too perforated and a second operation was performed on the 19th Jan 2005. However, this was not done in proper fashion and again, an emergency surgery had to be done. The patient became frightened of surgery in his own country and flew to see me on the 11 Jan 2005. Examination showed that he had two stomas(intestinal openings) on his abdomen, one on the right and one on the left. There was also a very large anterior hernia. A complete repair and restoration of all his stomas was suggested by me.

The patient was anxious about more surgery but after consideration, underwent surgery by me on the 15 July 2005. This difficult surgery was successful as the two stomas were restored back to the abdomen and the hernia repaired. The patient made a good recovering and flew home.

Intra-Abdominal Cancer Up Surgery
Cancerous Polyp Cancerous Polyp
Cancerous Polyp Cancerous Polyp

A 28 year old man with huge intra-abdominal cancer. Mr TF first presented in April 2005 in his own country with a problem of a large intra-abdominal swelling. X rays revealed a very large intra-abdominal tumour and he was operated upon. Although 2.5 kg of tumour was removed, the surgery was evidently incomplete. Histological examination showed this to be a desmoplastic small cell tumour. The patient was given a combination of adriamycin, ifosfamide, vincristine, dacarbazine and mesna. However, after 5 cycles, residual mesenteric thickening was still evident. The patient relapsed in Feb 2006. CT scan then showed large soft tissue mass in the pelvis invading the rectum, sigmoid colon, prostate, seminal vesicles and numerous intra-abdominal nodules with a larger mass in the upper abdomen.

He received further chemotherapy but the masses increased in size. In July 2006 he developed severe pain in the buttocks and constipation and examination showed a very large abdominal mass arising from the pelvis. Palliative radiotherapy was given in an attempt to shrink the tumour and he received a total of 4500 cgy in 25 fractions. However repeat CT scans on 17 August 2006 showed further increase in the size of the masses. He was told to go elsewhere for treatment and was finally referred to see me at Mt Elizabeth Hospital.

I first saw Mr TF on the 12 Oct 2006. Physical examination showed a very large abdominal mass up to the level of the umbilicus. Rectal examination showed a hard fixed pelvic mass. CT scans showed a 20 cm large pelvic tumour, a 13 cm abdominal tumour, a 5 cm splenic hilar mass and multiple smaller abdominal masses. He was initially tried on further chemotherapy but no response was noted.

Finally as the pain and constipation became progressively worse, surgery was performed on the 15 Feb 2007. During surgery, despite the hugeness of the mass, expert dissection and manipulation enabled all the masses to be totally removed. Mr TF now has a very good chance of complete cure.

Multimodal treatment of mesothelioma

Doctors specializing in mesothelioma treatment frequently adopt a multimodal approach: they treat a patient with a combination of therapies. Due to the relative lack of effectiveness of single-modality treatment in affecting patient survival, the multimodal combination of treatments holds more promise for survival of malignant mesothelioma patients. For an over view of single-mode and multimodal treatment regimens, see the abstract of "Treatment of Malignant Mesothelioma" by M.T. Jaklitsch, S.C. Grondin, and D.J. Sugarbaker and published in the World Journal of Surgery in 2001.

The December 1999 issue of the medical journal, Chest, published a clinical case presentation that illustrates a fairly typical multimodal treatment. The patient was a 52-year-old man with an early diagnosis of Stage I pleural mesothelioma. Doctors performed a pleurectomy (i.e. surgery) and then delivered intrapleural doses of chemotherapy drugs. Then he received additional localized radiation and chemotherapy. Two years after the surgery he did not show evidence of the tumor.

The author concluded that "Aggressive trimodality therapy for mesothelioma is presented as a successful treatment option." (R. Buono - "Mesothelioma Clinical Presentation", Chest 1999; 116:444S-445S)

In recent years, there has been some progress made in the management of malignant mesothelioma, particularly in the area of combination of agents and treatment methods used. More details can be found in this interview with mesothelioma medical expert, Dr. Nicholas Vogelzang: "New Directions for the Treatment of Mesothelioma: An Expert Interview" (Oncology 6(1), 2003).

The following discussion of mesothelioma treatments is organized into separate sections (surgery, photodynamic therapy, radiation, etc.) so that each component of a combination of treatments (multimodality therapy) can be better understood.

Further Information:

"Multimodality Treatments for Mesothelioma?" by W. Eberhardt, (27th Annual congress of the European Society for Medical Oncology).

Two presentations evaluating multimodal treatment of mesothelioma were part of the program of the 37th Annual Meeting of the American Society of Clinical Oncology, May 12-15, 2001 (San Francisco). The first study, by M. Keohan, et al., used an agressive regimen for their phase II study of trimodal therapy for peritoneal mesothelioma. The second study, by J.V. Juturi, et al., investigated intracavitary paclitaxel in a multimodality management of malignant pleural mesothelioma; two earlier cooperative group studies using this treatment method yielded response rates of 0% and 9%, respectively, in patients with mesothelioma. For information about obtaining ASCO asbstracts, check their webpage.

A.M. Boylan - "Mesothelioma: new concepts in diagnosis and management" in Current Opinion in Pulmonary Medicine, March 2000; 6(2):157-163. An interesting discussion about the difficulties of diagnosing mesothelioma; the controversies about staging mesothelioma; and whether the improved survival rates of some new treatments indicate that these treatments are more effective or are explained by patient selection.

D. H. Sterman, MD, et. al. - "Advances in the Treatment of Malignant Pleural Mesothelioma" in Chest 1999; 116:504-520; (see abstract) This article discusses the roles of chemotherapy, radiotherapy, surgery and combined modality approaches in the treatment of pleural mesotheliomas. Promising new avenues may modify the therapeutic nihilism that is rampant among clinicians dealing with mesothelioma.

Types of Mesothelioma Treatment:

Other Mesotheliomas

While the great majority of mesotheliomas are in either the pleura or the peritoneum, malignant mesotheliomas sometimes occur in other parts of the body, including the testicles (a variety of peritoneal mesothelioma) and the heart (a variety of pleural mesothelioma.) These are also caused by exposure to asbestos fibers.

Benign mesotheliomas occur less frequently than malignant mesotheliomas. They are generally thought to be unrelated to asbestos exposure. Two thirds of benign mesotheliomas occur in females. (Kittle: Mesothelioma Diagnosis and Management, Year Book Medical Publishers, 1987)

Unfortunately, cystic benign mesotheliomas have a high incidence of local recurrence. (Katsube: Cystic Mesothelioma of the Peritoneum; Cancer 1982, 50:1615; Moore: Benign Cystic Mesothelioma; Cancer 1980, 45:2395) A July 1998 article by G.S. Letterie in the journal "Gynecology and Obstetrics" describes therapy with anti-estrogen tamoxifen as a non-surgical option for cases of symptomatic recurrent cystic mesotheliomas.

other Types of cancer:

Peritoneal mesothelioma

Many of the organs in the abdomen are enveloped by a thin membrane of mesothelial cells, known as the peritoneum.

Peritoneal mesothelioma is a tumor of this membrane. Its only known cause in the U.S. is previous exposure to asbestos, but it can be many years after exposure before the disease appears. Peritoneal mesotheliomas account for about one-fifth of all mesotheliomas.

Like pleural mesothelioma, peritoneal mesothelioma can be either benign or malignant. This discussion is only about malignant peritoneal mesothelioma.

Mesothelioma is sometimes diagnosed by coincidence, before any symptoms have appeared. For example, the tumor is sometimes seen on a routine abdominal x-ray for a check-up or before surgery.

When the symptoms of peritoneal mesothelioma appear, they typically include abdominal pains, weakness, weight loss, loss of appetite, nausea, and abdominal swelling. Fluid often accumulates in the peritoneal space, a condition known as ascites. Over time the wasting symptoms can become more and more severe.

The growing tumor can exert increasing pressure on the organs in the abdomen, leading to bowel obstruction and distention. If the tumor presses upward, it can impair breathing capacity. If the tumor pushes against areas with many nerve fibers, and the bowel distends, the amount of pain can increase.

X-rays and CT scans are, typically, the first step towards detecting peritoneal mesothelioma. The actual diagnosis is typically achieved by obtaining a piece of tissue. The medical procedure of looking at the peritoneum is known as a peritoneoscopy. It is a hospital procedure and requires anesthesia. If an abnormality is seen, the doctor will attempt to obtain a tissue sample - this is known as a biopsy. The tissue sample will be examined by a pathologist who makes a diagnosis using microscopic analysis of specialized stains.

There are at least two explanations for how asbestos fibers can get into the peritoneum. The first is that fibers caught by the mucus of the trachea and bronchi end up being swallowed. Some of them lodge in the intestinal tract and from there they can move through the intestinal wall into the peritoneum. The second explanation is that fibers that lodge in the lungs can move into the lymphatic system and be transported to the peritoneum.

Medical science does not know exactly how or why, at a cellular level, a carcinogen like asbestos causes a cell to become malignant (cancerous.) Thus it is not known whether only one fiber can cause a tumor to develop or whether it takes many fibers, or what the exact conditions and predispositions are for this change to happen.

At this time there are treatments, but no known cure, for peritoneal mesothelioma. The prognosis depends on various factors, including the size and stage of the tumor, its extent, the cell type, and whether or not the tumor responds to treatment.

However, the options for relief and treatment of people with peritoneal mesothelioma have improved, especially for those whose cancer is diagnosed early and treated vigorously. Many people receive a combination of therapies, sometimes known as multimodal therapy. Specific types of treatment include:

There are also clinical trials and various experimental treatments like gene therapy and immunotherapy, and antiangiogenesis drugs.

Pleural mesothelioma

Pleural mesothelioma is of two kinds: (1) diffuse and malignant (cancerous), and (2) localized and benign (non-cancerous.)

Benign mesotheliomas can often be removed surgically, are generally not life-threatening, and are not usually related to asbestos exposure. Malignant mesotheliomas, however, are very serious. Fortunately, they are rare - about two thousand people are diagnosed with mesothelioma in the U.S. each year.

The remainder of this section is about diffuse malignant pleural mesothelioma.

Pleural mesothelioma is a cancer of the cells that make up the pleura or lining around the outside of the lungs and inside of the ribs. Its only known cause in the U.S. is previous exposure to asbestos fibers, including chrysotile, amosite or crocidolite. This exposure is likely to have happened twenty or more years before the disease becomes evident, since it takes many years for the disease to "incubate." It is the most common type of mesothelioma, accounting for about 75% of all cases.

Mesothelioma is sometimes diagnosed by coincidence, before there are any symptoms. For instance, tumors have been discovered through routine chest x-rays. However, when symptoms occur, they may include shortness of breath, weakness, weight loss, loss of appetite, chest pains, lower back pains, persistent coughing, difficulty in swallowing, alone or in combination. An initial medical examination often shows a pleural effusion, which means an accumulation of fluid in the pleural space - the area between the lungs and the chest wall.

The first step in detecting pleural mesothelioma is, typically, a chest x-ray or CT scan. This is often followed by a bronchoscopy, using a viewing scope to look inside the lungs.

The actual diagnosis usually requires obtaining a piece of tissue through a biopsy. This could be a needle biopsy, an open biopsy, or through a tube with a camera (thoracoscopy or chest scope.) If an abnormality is seen through the camera then a tissue sample can be taken at the same time, using the same tube. This is a hospital procedure that requires anesthesia, but is not usually painful. The tissue sample is tested by a pathologist.

Fluid build-up from the pleural effusion can generally be seen on a chest x-ray and heard during a physical examination, but a firm diagnosis of mesothelioma can only be made through a biopsy and pathological testing. This is important because there are also benign pleural effusions and other tumors that have a similar appearance to mesothelioma. Diagnosing mesothelioma can be quite difficult; it requires special lab stains, and much experience in understanding them.

The spread of the tumor over the pleura causes pleural thickening. This can reduce the flexibility of the pleura and encase the lungs in an increasingly restrictive girdle. With the lungs restricted, they get smaller and less functional, and breathing becomes more difficult. At first a person with mesothelioma may be breathless only when he or she exercises, but as lung function drops, he or she can become short of breath even while resting.

The tumor spreads by direct invasion of surrounding tissue. As it spreads inward it can compress the lungs. As the tumor spreads outward it can invade the chest wall and ribs, and this can be extremely painful.

Current medical science does not know exactly how and why, at a cellular level, asbestos fibers cause mesothelial cells to become abnormal (malignant or cancerous.) Thus it is not known whether only one fiber causes the tumor or whether it takes many fibers. It seems that asbestos fibers in the pleura can start a tumor as well as promote its growth; the tumor does not depend on any other processes for its development.

There is as yet no known cure for malignant mesothelioma. The prognosis depends on various factors, including the size and stage of the tumor, the extent of the tumor, the cell type, and whether or not the tumor responds to treatment. The Firm has represented many clients who lived for five to ten years after diagnosis, most of them in good health for a majority of those years. Some mesothelioma victims succumb within a few months; the average survival time is about a year.

The treatment options for people with mesothelioma have improved significantly, especially for those whose cancer is diagnosed early and treated vigorously. Many people are treated with a combination of therapies, sometimes known as multimodal therapy.

Specific types of treatment include:

There are also experimental treatments like gene therapy and immunotherapy, angiogenesis inhibitors, and clinical trials for various new treatments and combinations of treatments.

Treatments that reduce pain and improve lung function, are becoming more successful (although they cannot cure mesothelioma.) Pain control medications have become easier to administer. Debulking is a surgical process of removing a substantial part of the tumor and reducing the pleural thickening; this can provide significant relief. X-ray therapy has also been successfully used to control the tumor and the pain associated with it for a while.

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