Fistula-associated anal adenocarcinoma: good results with aggressive therapy

Chronic fistula in ano associated with adenocarcinoma: a case report with a review of the literature

The malignant transformation of chronic fistula in ano is rare, accounting for 3% to 11% of all anal canal malignancies. It results from long-standing inflammation and chronic irritation. No guidelines are available for the management of these cases. We herein present a case report of a 55-year-old man who presented with a history of constipation, perianal pain, and discharging fistula in ano of 4-year duration and underwent fistula surgery with recurrence. Biopsy of the fistulous tract revealed adenocarcinoma. He received neoadjuvant chemoradiotherapy, followed by abdominoperineal excision including excision of the fistulous tract. After 18 months of follow-up, he is free of recurrence. We present this case with a review of the literature, highlighting the management strategies.

The Curious Incidence of Mucinous Adenocarcinoma Masquerading as Perianal Hidradenitis Suppurativa

Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic inflammatory disorder affecting the terminal follicular epithelium within the apocrine skin glands. When these lesions develop in the genital and perianal regions, there is a potential risk of progression to squamous cell carcinoma or mucinous adenocarcinoma. The tumor may appear in the perianal area, perineum, or buttocks. Here, we present a rare case of long-standing perianal HS with associated fistula-related mucinous adenocarcinoma and the challenges we faced in managing this condition.

Adenocarcinoma arising from a chronic perianal fistula in a Crohn's disease patient: case report and review of the literature

Crohn's disease patients frequently develop perianal fistulas during their life. They are also at higher risk to develop cancers. Rarely, those cancers appear within a prior chronic fistula. The main types are adenocarcinoma mostly mucinous and squamous cell carcinoma. They are generally discovered at an advanced stage with a poor prognosis because symptoms are generally the same as those of the fistula itself. Regular follow-up of chronic fistulas is then important for an early diagnosis as well as histological analysis of the fistula during surgery. There is no consensus on the ideal treatment but abdominoperineal resection is the corner stone with or without neo or adjuvant chemo-radiotherapy. This paper presents a rare case of mucinous adenocarcinoma in a chronic perianal fistula in a Crohn's disease female and provides a review of the literature.

Cancer in Anal Fistulas

Fistula-associated anal cancer in Crohn's disease (CD) can be challenging to diagnose and treat. Patients with longstanding fistulas in the setting of CD who present with a sudden change in their symptoms should undergo biopsy under anesthesia with extensive sampling, followed by staging imaging. Pelvic magnetic resonance imaging (MRI) can be helpful in identifying the extent of the disease locally. Patients often present in the later stages due to the challenges associated with diagnosing these patients. Two subtypes of this disease include squamous cell carcinoma and adenocarcinoma, and treatment depends on diagnosis. Small sample size and lack of uniform data on treatments make it difficult to say which treatment modalities are optimal, but aggressive combined therapy is likely the best approach for survival. This will include chemotherapy and radiation and often radical resection as well. Despite this, survival is poor, although more recent data suggest that outcomes are improving.

A case report of anal fistula-associated mucinous adenocarcinoma developing 3 years after treatment of perianal abscess

BACKGROUND

A long-standing (over 10 years) anal fistula is considered a fundamental cause of fistula-associated mucinous adenocarcinoma (FAMC). Perianal abscesses and anal fistulas are two sequential phases of the same anorectal infectious process. We experienced a case of FAMC which developed 3 years after the treatment of a perianal abscess.

CASE PRESENTATION

A 68-year-old woman was admitted to our hospital because of progressive anal pain and a palpable tumor. She had a history of undergoing a drainage operation for a perianal abscess 3 years previously. A 15 × 15-mm tumor at the former drainage site was identified; transanal ultrasonography showed an intersphincteric fistula connecting to the tumor. A biopsy taken from the tumor demonstrated mucinous adenocarcinoma; the tumor was diagnosed as FAMC. Laparoscopic abdominoperineal resection was performed. Histopathology showed highly dysplastic cells lining the lumen of the anal fistula and poorly differentiated mucinous adenocarcinoma proliferating in the dermis and epidermis in the distal aspect of the fistula.

CONCLUSIONS

FAMC can develop within fewer than 3 years after the development of a perianal abscess and anal fistula.

Adjuvant chemoradiotherapy does not improve outcomes in patients with fistula-associated anal adenocarcinoma undergoing abdominoperineal resection

OBJECTIVE

Abdominoperineal resection (APR) is currently established as a standard treatment regimen for fistula-associated anal adenocarcinoma (FAAA), however, the efficacy of chemoradiotherapy (CRT) remains unclear. The aim of this study is to evaluate the role of CRT in patients with FAAA treated with APR through single-center experience and literature review.

METHODS

A retrospective review was performed on patients with FAAA consecutive treated in our institution from 2005 to 2022. In addition, a systematic literature search was performed using PubMed and MEDLINE. All patients with FAAA who received APR in our institution and reported in the literature were included and divided into three categories for statistical analysis: APR alone (APR group), neoadjuvant therapy combined APR (CRT+APR group), and APR combined postoperative therapy (APR+CRT group).

RESULTS

Fifteen patients with FAAA were identified from our retrospective charts review. At a median follow-up time of 18 months, the recurrence-free survival rate was 53.3% and the survival rate was 73.3%. Eight patients underwent APR and 6 received postoperative chemotherapy. Among them, one died, one developed recurrence and the remaining six patients were alive with disease free. We found 37 publications describing 62 patients with FAAA treated with APR. Clinical data from these articles were analyzed together with the 8 cases in our institution. The overall survival rates were 94.1%, 70.8%, and 38.5% at 1-, 3-, 5-years respectively. Combining (neo)adjuvant therapy did not appear to improve outcomes in FAAA treated with APR (CRT+APR vs. APR, p=0.977; APR+CRT vs. APR, p=0.351). Lymph node involvement was shown to be significantly associated with poor outcomes by multivariate analysis (p=0.020).

CONCLUSIONS

For patients with FAAA without lymph node involvement, APR is adequate to control disease and the addition of CRT does not appear to prolong survival.

Non-mucinous adenocarcinomas and squamous cell carcinomas of the anal region masquerading as abscess or fistula: a retrospective analysis and systematic review of literature

PURPOSE

Abscess or fistula of the anal region is an uncommon presentation of malignancy. Under the assumption of a benign condition, diagnostics is often delayed, resulting in advanced tumour stages at first diagnosis. Due to the case rarity, treatment guidelines for cancers of anorectal region masquerading as abscess or fistula are missing.

METHODS

We analysed all patients presenting with an abscess or fistula of the anal region in our department between January 2004 and August 2020. The malignancies were included to our study to acquire data on clinical presentation, treatment and outcome. Furthermore, a systematic review to present adenocarcinomas and squamous cell carcinomas associated to an abscess or fistula was performed.

RESULTS

0.5% of the patients treated for an abscess or fistula of the anal region met the selection criteria. Mean time from the onset of symptoms to diagnosis of malignancy was 100 days. Histology revealed adenocarcinoma and squamous cell carcinoma each in two patients. All patients had locally advanced tumours without distant metastases, in two cases with regional lymph-node metastases. Neoadjuvant chemoradiation was applied in two patients. All patients underwent abdomino-perineal resection of the rectum. The overall outcome reveals a recurrence-free survival of 4.5 and 3 years for two patients. Further two patients died within 5 months after the primary resection.

CONCLUSION

Advanced carcinomas of the anorectal region may masquerade as abscess or fistula, cause diagnostic problems and delay oncologic treatment. However, even in these very advanced situations, surgical therapy with curative intent should be attempted.

A Multi-Disciplinary Approach to Perianal Fistulizing Crohn's Disease

Perianal fistulizing Crohn's disease represents a severe phenotype associated with significant morbidity. Patients with perianal fistulizing disease are more likely to have a severe disease course and have significant reductions in quality of life. Moreover, these patients are at risk for the development of distal rectal and anal cancers. Given the complexity and severity of this patient group, the management of perianal Crohn's disease must be undertaken by a multidisciplinary team. The gastroenterologist and colorectal surgeon play a critical role in the diagnosis and management of perianal fistulizing disease. An examination under anesthesia provides critical information and is an essential part of the work-up of complex perianal fistulas. The radiologist also plays a central role in characterizing anatomy and assessing response to treatment. Several imaging modalities are available for these patients with magnetic resonance imaging as the imaging modality of choice. Perianal disease developing after ileal pouch-anal anastomosis represents a particularly challenging form of fistulizing disease and requires a multidisciplinary clinical and radiologic approach to differentiate surgical complications from recurrent Crohn's disease.

Perianal Fistula-Associated Carcinoma in Crohn's Disease: A Multicentre Retrospective Case Control Study

BACKGROUND AND AIMS

Carcinoma associated with perianal fistula in Crohn's disease is a pending threat for patients. This study aimed to improve understanding and facilitate development of diagnostic and therapeutic strategies.

METHODS

A retrospective case-control study was conducted at four German hospitals. The analysis included 40 patients with proven malignancy associated with perianal Crohn's fistulas and 40 randomly selected controls with fistulizing perianal Crohn's disease. Differences between groups were analysed and multivariate calculations were performed to describe risk factors for oncological outcomes.

RESULTS

Histology revealed adenocarcinoma in 33/40 patients and squamous cell carcinoma in 7/40 patients. Compared to fistula patients without carcinoma, patients with malignancies associated with fistula had a diagnosis of Crohn's disease at younger age. Crohn's disease lasted longer in patients with malignancy [25.8 ± 9.0 vs 19.6 ± 10.4; p = 0.006]. Fistula-related findings differed significantly between the two groups. Signs of complicated and severe fistulation including complex anatomy and chronic activity occurred significantly more often in patients with malignancy associated with fistula. Significant multivariate hazard ratios for overall mortality and progression-free survival were shown for histological type of cancer, metastatic disease and R1 resection. Overall survival was 45.1 ± 28.6 months and the 5-year survival rate was 65%.

CONCLUSIONS

In patients with adenocarcinoma or squamous cell carcinoma associated with perianal fistula in Crohn's disease, fistula characteristics determine the risk of malignancy. Early diagnosis influences outcomes, while treatment of chronic fistula activity may be key to preventing malignancy. Expert multimodal therapy is paramount for successful treatment of perianal fistula-associated malignancies.

Anal Adenocarcinoma: A Rare Malignancy in Need of Multidisciplinary Management

Adenocarcinoma of the anal canal is an uncommon malignancy, making it challenging to perform randomized controlled clinical trials to define best practices in care. For patients with localized disease, there remains a lack of consensus regarding the optimal management, with some physicians advocating for trimodality therapy (similar to the locally advanced rectal adenocarcinoma paradigm) and others advocating for definitive radiation therapy with concurrent chemotherapy (similar to the management of anal squamous cell carcinoma). The objective of this clinical review is to describe the management and outcomes of patients with anal adenocarcinoma to help inform treatment recommendations.

Challenges in Crohn's Disease Management after Gastrointestinal Cancer Diagnosis

Simple Summary

Crohn’s disease (CD) is a chronic inflammatory bowel disease affecting both young and elderly patients, involving the entire gastrointestinal tract from the mouth to anus. The chronic transmural inflammation can lead to several complications, among which gastrointestinal cancers represent one of the most life-threatening, with a higher risk of onset as compared to the general population. Moreover, diagnostic and therapeutic strategies in this subset of patients still represent a significant challenge for physicians. Thus, the aim of this review is to provide a comprehensive overview of the current evidence for an adequate diagnostic pathway and medical and surgical management of CD patients after gastrointestinal cancer onset.

Abstract

Crohn’s disease (CD) is a chronic inflammatory bowel disease with a progressive course, potentially affecting the entire gastrointestinal tract from mouth to anus. Several studies have shown an increased risk of both intestinal and extra-intestinal cancer in patients with CD, due to long-standing transmural inflammation and damage accumulation. The similarity of symptoms among CD, its related complications and the de novo onset of gastrointestinal cancer raises difficulties in the differential diagnosis. In addition, once a cancer diagnosis in CD patients is made, selecting the appropriate treatment can be particularly challenging. Indeed, both surgical and oncological treatments are not always the same as that of the general population, due to the inflammatory context of the gastrointestinal tract and the potential exacerbation of gastrointestinal symptoms of patients with CD; moreover, the overlap of the neoplastic disease could lead to adjustments in the pharmacological treatment of the underlying CD, especially with regard to immunosuppressive drugs. For these reasons, a case-by-case analysis in a multidisciplinary approach is often appropriate for the best diagnostic and therapeutic evaluation of patients with CD after gastrointestinal cancer onset.

Outcomes of surgical treatment in patients with anorectal fistula cancer

Background

No standard treatment for anorectal fistula cancer, such as multidisciplinary therapy, has been established due to the rarity of the disease. Herein, we investigated patients with cancer associated with anorectal fistula who underwent surgery to clarify the clinicopathological characteristics and to propose future perspectives for treatment strategies.

Case presentation

Seven patients with cancer associated with anorectal fistula who underwent rectal amputation in our institute were analyzed with regard to clinical characteristics, pathological findings, surgical results, and prognosis. Four cases had Crohn's disease as an underlying cause. All seven cases were diagnosed as advanced stage. Preoperative [¹⁸F]-fluoro-2-deoxy-d-glucose (FDG)-positron emission tomography/computed tomography (FDG-PET/CT) showed abnormal FDG accumulation in six cases including four mucinous adenocarcinomas. Three cases that received preoperative hyperthermo-chemoradiotherapy achieved pathological R0 resection. Postoperative recurrence was observed in four cases including three with Crohn's disease and one resulting in death.

Conclusions

Anorectal fistula cancer is rare and difficult to be diagnosed at early stages. Mucinous adenocarcinoma associated with anorectal fistula tends to exhibit abnormal FDG accumulation by FDG-PET/CT unlike common colorectal mucinous adenocarcinoma. Preoperative hyperthermo-chemoradiotherapy may be effective in obtaining pathological complete resection.

Perianal mucinous adenocarcinoma with dysplastic polyps of the colon: A case report

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Mucinous adenocarcinoma of the perianal region is extremely rare (6.9% of anal neoplasms and 2–3% of all gastrointestinal malignancies).

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Given the low incidence of this tumor, it is often missed at initial evaluation.

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Association with chronic perianal fistula are common and inflammatory symptoms can be misleading with delay in diagnosis.

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The paucity of publications leads to a lack of consensus on both diagnostic and therapeutic approaches.

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The understanding of the etiopathogenic mechanisms may lead to the development of novel diagnostic and therapeutic protocols.

Introduction

Perianal mucinous adenocarcinoma is rarely encountered in the setting of anal neoplasms. The rarity of the disease and the paucity of publications on this topic are responsible for a lack of diagnostic and therapeutic guidelines.

Presentation of case

An 80-year-old man with mucinous adenocarcinoma of the anal canal associated with dysplastic polyps of the colon was treated by multiple endoscopic polypectomies and abdomino-perineal resection of the rectum. We discuss the management of this rare case from the diagnosis up to one-year follow-up.

Discussion

Perianal mucinous adenocarcinoma is a very rare entity frequently combined with chronic fistulas. Inflammatory symptoms may mislead its diagnosis, which is often delayed. The unique association between perianal mucinous adenocarcinoma and dysplastic polyps of the colon, that we have reported, may suggest a secondary etiology. High clinical suspicion is important for early and correct diagnosis, which should be based on endoanal ultrasound and/or magnetic resonance imaging followed by deep tissue biopsies.

Conclusion

We stress the importance of accumulating such cases in the literature. The understanding of the etiopathogenic mechanisms may lead to the development of novel diagnostic and therapeutic protocols.

Management of large and surrounding tissue infiltrative anal fistula cancer: Two case reports

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We reported two cases of adenocarcinoma originating from anal fistula.

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High degree of clinical suspicion is crucial to diagnose anal fistula cancer.

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Histopathological evaluation should be performed on recurrent, incurable anal fistulas.

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Intensive surgical treatment with neoadjuvant or adjuvant therapy should be considered in advanced cases.

Introduction

Adenocarcinoma originating from chronic perianal fistulas is a rare disease. Due to the lack of evidence of this malignancy, no definitive diagnostic and treatment guidelines have been established. We present two cases of anal fistula cancer and discuss the diagnostic and treatment strategies.

Presentation of case

A 79-year-old man was referred for a perianal mass. The patient had a history of chronic perianal fistula and was diagnosed with adenocarcinoma originating from a long-standing perianal fistula. The patient underwent laparoscopic abdominoperineal resection (APR) without any adjuvant therapy. The second case was a 42-year old man, who was referred for a prolapsed anal mass. The patient had recurrent perianal fistula over several years. He was diagnosed with mucinous adenocarcinoma originating from a long-standing perianal fistula, but he initially refused surgical treatment. Two years later, the patient revisited with a huge overgrown tumor and underwent laparoscopic APR with wide perineal skin excision, wound debridement and coverage with a bilateral V-Y advancement flap via a one-step procedure.

Discussion

High degree of clinical suspicion is crucial to diagnose this rare disease that can easily be missed at an early stage. Depending on the disease stage, surgical treatment, chemotherapy, and radiotherapy can be considered.

Conclusion

Histopathological evaluation should be performed on recurrent and incurable anal fistulas over a long period of time. Intensive surgical treatment with or without neoadjuvant and adjuvant therapy should be considered in advanced cases.

Mucinous adenocarcinoma of the buttock associated with hidradenitis: A case report

BACKGROUND

Mucinous adenocarcinomas of the buttock are rare and have an uncertain etiology and natural course. They are usually related to chronic anal fistulas, hidradenitis suppurativa, or Crohn's disease. Here, we report a case of mucinous adenocarcinoma associated with hidradenitis and contradictory immunochemistry results.

CASE SUMMARY

A 62-year-old man complained of recurrent abscesses of the buttock for 3 years. He had several scars and nodules in bilateral buttocks, with purulent discharge. The skin lesions did not appear to originate from the anus. The patient was diagnosed with recurrent abscesses due to hidradenitis suppurativa at the first visit. He showed purulent and subsequent mucin discharge in the first operation and was diagnosed with mucinous adenocarcinoma. Several examinations were performed to determine disease origin and staging. There were no significant findings or evidence of anal fistulas. Hence, he underwent wide local excision and V-Y advancement flap in the second operation. The final diagnosis was mucinous adenocarcinoma without any evidence of anal fistulas. Additional immunochemistry test results were negative for cytokeratin (CK) 7 and positive for CK20 and CDX2, with a colorectal origin. A pathologist suggested that the disease originated from a chronic anal fistula. The patient has remained free of recurrence for 24 mo.

CONCLUSION

Although the patient with mucinous adenocarcinoma showed an atypical course, immunochemistry helped detect the disease origin.

Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of inflammatory bowel disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the general principles of surgical treatment of inflammatory bowel disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Mucinous adenocarcinoma arising from chronic perianal fistula-a multidisciplinary approach

Mucinous adenocarcinoma (MA) is a rare entity. Indeed, the pathogenesis of fistula-associated perianal MA is still controversial. Due to the lack of informed evidence regarding this malignancy, no guidelines have been established concerning diagnostic and treatment strategies. The aim of this article is to report our experience and outcomes after three cases of large perianal MA treated in our center. From our retrospective chart review, we identified three male patients with chronic perianal fistula-in-ano who progressively developed perianal MA, confirmed by pelvic magnetic resonance (MRI) and histopathological examination performed on biopsy. We hereby, in accordance with the Surgical CAse REport (SCARE) guidelines, describe the management and further follow-up of each patient. The three patients underwent preoperative chemoradiation therapy, followed by ischioanal abdominoperineal resection (APR). Perineal reconstruction was needed in every case, using a vertical rectus abdominis myocutaneous (VRAM) flap and, punctually, a left fasciocutaneous flap was used too. Also, two of three patients completed the treatment with adjuvant chemotherapy. Neither recurrences nor distant metastases have been observed during the follow-up in both cases that finished the multimodal treatment. MA arising from chronic perianal fistula has an indolent growth with locoregional aggressiveness and a high risk of local recurrence. Therefore, although an ischioanal APR remains the surgical treatment of choice, an aggressive multimodal approach combining preoperative chemoradiation and adjuvant chemotherapy may achieve favorable effectiveness and promising response rates.

Adenocarcinoma within anorectal fistulae: different clinicopathological characteristics between Crohn's disease-associated type and the usual type

Adenocarcinoma within anorectal fistulae is rare and is sometimes associated with Crohn's disease. Crohn's disease-associated adenocarcinoma within anorectal fistulae has a poor prognosis; however, little is known about the clinicopathological differences between Crohn's disease-associated adenocarcinoma within anorectal fistulae and usual adenocarcinoma within anorectal fistulae. We retrospectively searched patients' charts and pathology archives at Tokyo Yamate Medical Center and Tokyo Medical and Dental University Hospital for adenocarcinoma within anorectal fistulae. Clinical and pathological data were collected and immunohistochemical examinations were conducted. Overall survival rate was estimated using the Kaplan-Meier method. Prognostic factors of overall survival were assessed using univariate and multivariate Cox regression analyses. We examined 82 cases of adenocarcinoma within anorectal fistulae. Fifty-nine of 82 cases (72%) had usual adenocarcinoma within anorectal fistulae, while the remaining 23 cases (28%) had Crohn's disease-associated adenocarcinoma within anorectal fistulae. Patients with Crohn's disease-associated adenocarcinoma within anorectal fistulae were diagnosed at a younger age and at a more advanced stage than those with usual adenocarcinoma within anorectal fistulae. Macroscopic and histological types were also different between usual adenocarcinoma within anorectal fistulae and Crohn's disease-associated adenocarcinoma within anorectal fistulae. Crohn's disease-associated adenocarcinoma within anorectal fistulae included more ulcerative types and high-grade adenocarcinomas. The rate of lymphovascular invasion was higher in Crohn's disease-associated adenocarcinoma within anorectal fistulae. Immunohistochemically, the expression of E-cadherin, p53, and MUC5AC differed between usual adenocarcinoma within anorectal fistulae and Crohn's disease-associated adenocarcinoma within anorectal fistulae. Patients with Crohn's disease-associated adenocarcinoma within anorectal fistulae exhibited worse overall survival than those with usual adenocarcinoma within anorectal fistulae, and vascular invasion was the strongest significant independent predictor of overall survival in patients with adenocarcinoma within anorectal fistulae. In conclusion, usual adenocarcinoma within anorectal fistulae and Crohn's disease-associated adenocarcinoma within anorectal fistulae have different clinicopathological characteristics and should be considered separate clinical entities.

A CARE-compliant article: a case report of primary adenocarcinoma of the anal glands: Review of literature

RATIONALE

Adenocarcinoma of the anal canal is an uncommon malignancy. Primary adenocarcinoma, in particular, is extremely rare.

PATIENT CONCERNS

A 61-year-old man was referred to our institution with complaints of repeated hematochezia.

DIAGNOSIS

Digital rectal examination revealed a hard palpable ulcer in the anal canal, measuring 2 cm × 2 cm in size, at the 5 o'clock direction (in the lithotomy position). The pelvic enhanced magnetic resonance imaging revealed anal verge occupying mass. A diagnosis of carcinoma of the anal canal was considered. Colonoscopic examination revealed a poorly differentiated adenocarcinoma of the anal canal.

INTERVENTIONS

The patient underwent abdominoperineal resection (APR) of the rectum, and was administered 6 courses of adjuvant chemotherapy with mFOLFOX.

OUTCOMES

The patient was followed up for more than 1 year after operation, and no local recurrence or distant metastasis occurred.

LESSONS

The diagnosis and treatment of this disease is still a huge challenge because its incidence is very low. A study of more cases is required for uniformity in diagnosis and for the development of treatment protocols.

Fistula-associated anal carcinoma in Crohn's disease

Fistula-associated anal carcinoma in patients with Crohn's disease (CD) is a rare condition. More recently, this entity has been increasingly reported likely due to increased recognition, and the incidence may be greater than once appreciated. There remains a paucity of data regarding the incidence, diagnosis, treatment, and outcome of fistula-associated anal carcinoma. Area covered: This review evaluates the clinical features, pathology, treatment, and prognosis of fistula-associated anal carcinoma in patients with CD. A strategy for surveillance of this carcinoma is proposed by the authors based on the evidence obtained from this review. Expert commentary: Clinicians caring for patients with CD and perianal involvement need to be aware of the rare yet extremely important association of long-standing perianal disease and fistula-associated carcinoma. Only through awareness, a high level of suspicion will be diagnosed in a timely manner. This involves a thorough history, a proper, and complete anorectal examination, along with early imaging and examination under anesthesia. Through this approach, it is hoped that early diagnose can be achieved in at-risk patients and change the significant morbidity and mortality associated with this diagnosis.

Endoanal Ultrasonography of Mucinous Adenocarcinoma Arising from Chronic Fistula-in-ano: Three Case Reports

Mucinous adenocarcinoma arising in chronic fistula-in-ano is rare, and diagnosing it at an early stage is difficult. The role of endoanal ultrasonography in diagnosing the condition has not been discussed in the study. Herein, we report three cases of mucinous adenocarcinoma arising from anal fistulas in which endosonography played an important role in diagnosing malignant change. Three male patients with a 5- to 20-year history of anal fistula were referred to our hospital due to perianal induration, progressive anal pain, or mucopurulent secretion. In all three patients, endosonography revealed a multiloculated complex echoic mass with isoechoic solid components communicating with a trans-sphincteric fistula and sonography-guided biopsy under anesthesia revealed mucinous adenocarcinoma. All patients underwent abdominoperineal resection with lymph node dissection. One patient with a local recurrence died 3 years after surgery and two have remained disease-free for >6 years. These observations suggest that endosonography may be a reliable technique for the diagnosis of mucinous adenocarcinoma arising from chronic fistula-in-ano. Sonography-guided biopsy is useful for the definitive diagnosis of malignancy. Therefore, periodic endosonography assessment should be recommended for patients with persistent anal fistula, especially those with progressive clinical symptoms. Once malignancy is suspected, aggressive sonography-guided biopsy under anesthesia should be performed, which may enable an early diagnosis, curative treatment, and favorable long-term results.

Mucinous adenocarcinoma arising from chronic perianal fistula mimicking horseshoe abscess

Perianal fistulae are commonly seen clinical entity. Development of malignancy within a perianal fistula is rare. Even rarer is the development of mucinous adenocarcinoma in a chronic fistula-in-ano. Only a handful of such cases have been reported in the past. A case of mucinous adenocarcinoma arising in chronic perianal fistula in a 34-year-old woman is being described. She presented with complaints of perineal fullness, pain and recurrent pus discharge from perianal fistula for 4 years. On radiological workup, a large solid-cystic pelvic mass was seen in relation to the fistula. On MRI, the lesion was mimicking a large horseshoe abscess. Transrectal ultrasound-guided biopsy and subsequent histopathological examination confirmed the presence of mucinous adenocarcinoma with tumour cells immunopositive for CK7 and CK20.

Mucinous adenocarcinoma on perianal fistula. A rising entity?

INTRODUCTION

Mucinous adenocarcinoma on perianal fistula is a rare entity; it could be underdiagnosed because it behaves often as a regular perianal fistula.

MATERIALS AND METHODS

We have recently treated four cases in our unit. We present them and review the literature, emphasizing on clinical characteristic and therapeutic options. The four patients were male with a mean age of 64. Three of them were classified as locally advances cases and therefore treated with neoadjuvant therapy.

RESULTS

All of them underwent laparoscopic abdominoperineal escisión. Surgical specimens are described and clinical characteristic specified. Review of the literature shows that this disease has a very high potential risk of local recurrence and we must be aggressive with the resection. Sometimes plastic surgery is needed to reconstruct the perianal wound.

CONCLUSIONS

Mucinous adenocarcinoma associated with anal fistula is a rare disease. Neoadjuvant chemoradiotherapy followed by an adequate abdominoperineal excision may result in favourable outcomes.

Mucinous adenocarcinoma of perianal region: an uncommon disease treated with neo-adjuvant chemo-radiation

Mucinous adenocarcinoma of the perianal region is an oncologic rarity posing a diagnostic and therapeutic dilemma for treating oncologists due to very few reported cases without definite therapeutic guidelines. It accounts for 2% to 3% of all gastrointestinal malignancies and are historically known to arise from chronic anal fistulas and ischiorectal or perianal abscesses. We hereby report a sporadic and interesting case of perianal mucinous adenocarcinoma in a 56-year-old male initially treated with alternative medicines and local surgery for recurrent fistula in ano of 2 years duration. He presented with complaints of discharging growth in perianal region, painful defecation associated with occasional blood mixed stools of 6 months duration. Incisional biopsy from the ulcer revealed mucinous adenocarcinoma. Contrast enhanced computed tomography (CT) scan and whole body positron emission tomography (PET) scan showed a localized perianal growth which was further confirmed with colonoscopy. With no pre-set treatment protocol for this rare entity, he was managed with neo-adjuvant concurrent chemo-radiation (CCRT) followed by abdominoperineal resection (APR) and adjuvant chemotherapy. Presently he is on 3 monthly follow-up since last 1 year post APR and adjuvant chemotherapy without any evidence of recurrence or distant metastasis. To the best of knowledge, our report may be one of the rarest cases of this disease entity where the duration of anal fistula was merely 2 years in contrast to the established criteria that the fistula precedes carcinoma by at least 10 years.

Clinicopathological characteristics of cancer associated with Crohn's disease

Purpose

We examined the clinicopathological characteristics and prognosis of patients with cancer associated with Crohn’s disease (CD).

Methods

The subjects of this study were patients with cancer confirmed in a resected specimen of bowel, who were treated at our institution between September, 1974 and December, 2014.

Results

We analyzed 34 patients (26 men, 8 women, median age at cancer diagnosis 43.5 years, duration of illness 18 years) and found that the number of those with CD complicated with cancer began to drastically increase after 2005. The site of onset of cancer was in an anorectal lesion in 24 (70.6 %) patients. In 17 (50 %) patients, the cancer was diagnosed before surgery; in 3 patients (8.8 %), it was based on pathological findings during surgery; and in 14 patients (41.2 %), it was based on postoperative pathological findings. Mucinous carcinoma was the dominant histological type, seen in 15 patients (44.1 %), while the special type of signet-ring cell carcinoma was found in 4 patients. The cumulative overall 5 year survival rate was 46.2 %.

Conclusion

In this group of Japanese CD patients, an anorectal lesion was the most frequent site of origin of cancer. As cancer was diagnosed preoperatively in only 50 % of these patients, the overall prognosis was poor, with a cumulative 5 year survival rate of just 46.2 %.

Case report of an anal adenocarcinoma arising from a perineal lump

Anal adenocarcinoma is a rare condition and can arise in chronic inflammatory states such as in Crohn's disease, or in a chronic fistula-in-ano. We report our diagnosis and management of a patient who presented with a large perineal lump with a long-standing history of perianal fistulous disease. This was initially evaluated with a Magnetic Resonance Imaging, and the diagnosis was confirmed with biopsy. Multimodality treatment with chemoradiotherapy and surgery should be offered to achieve the best outcomes.

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Although anal adenocarcinoma is rare, it can arise from chronic inflammatory states such as long standing perianal fistulae.

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MRI can be helpful in delineating the underlying aetiology, but histology is ultimately required for definitive diagnosis.

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Radical surgery with either neoadjuvant or adjuvant chemoradiotherapy appears to be most effective.

Anal Adenocarcinoma: Outcomes in an Uncommon Malignancy

Adenocarcinoma is an uncommon malignancy of the anal canal. Although it is recognized as an aggressive disease, optimal management and long-term outcomes are not well established. Patients diagnosed with anal adenocarcinoma were identified from a cancer database. Their charts were reviewed for patient and disease characteristics, management, and outcomes. Eighteen patient charts from 1997 to 2012 were reviewed. Nine patients presented with stage II disease, five with stage III, three with stage IV, and one was inadequately staged before chemoradiation. One patient refused treatment, one patient went straight to abdominoperineal resection, 13 patients underwent initial chemoradiation therapy, and three underwent palliative chemotherapy. Of the 13 patients who received neoadjuvant therapy, eight underwent subsequent radical resection; three progressed during neoadjuvant and became unresectable, one had complete pathologic response and was observed, and one did not complete neoadjuvant and was lost to follow-up. Two patients with stage II disease were disease free over eight years, and one was disease free after 26 months; four patients had persistent or recurrent local disease, and 10 developed metastatic disease. Seven patients died with disease at a median 16 months, and the other seven were alive with disease at a median follow-up of 10 months. Patients with anal adenocarcinoma present at advanced stages, and cure is rare. Although chemoradiation followed by abdominoperineal resection is the most common management strategy, the potential for curative resection and long-term disease free survival is minimal, regardless of stage at presentation.

Multidisciplinary management of colorectal adenocarcinoma associated with anal fistula: an Indian series

AIM

Adenocarcinomas associated with anal fistula are rare and often present at an advanced stage. They are often mistaken for commonly occurring benign diseases, leading to delayed diagnosis. Previous reports have predicted inferior oncological outcomes for these cases compared with sporadic rectal cancers. We are presenting our series of patients with colorectal adenocarcinoma associated with anal fistula who were treated with multimodality therapy at a tertiary cancer centre in India.

METHOD

This was a retrospective review of a prospectively maintained database of patients treated at our centre between 1 July 2013 and 31 March 2015. Of the 15 patients included in the study, 11 had prior intervention in the form of seton placement or fistulotomy. Fourteen patients had circumferential resection margin (CRM) involvement at initial workup and hence were given neoadjuvant chemoradiotherapy (NACRT). None of the patients had distant metastasis and only 15% had regional nodal involvement.

RESULTS

All 13 patients included in the final analysis underwent abdominoperineal excision (APE). Ten patients (73%) underwent extralevator APE. Plastic reconstruction in the form of a V-Y advancement flap for perineal closure was required in six patients (46%). On histopathological examination, a mucinous component was found to be present in 11 patients (73%). The quality of total mesorectal excision was complete in 92% patients. The CRM was free in 92% of patients. Median overall survival and disease-free survival were not reached.

CONCLUSION

Colorectal adenocarcinomas associated with fistula are locally aggressive malignancies with a low incidence of lymph node involvement and distant metastasis. NACRT, wider resection in the form of extralevator APE, and liberal use of plastic reconstruction may result in favourable outcomes.

Anal adenocarcinoma complicating chronic Crohn's disease

INTRODUCTION

Colorectal adenocarcinoma and Crohn's disease are known to be associated entities. However, a carcinoma arising within a chronic perianal fistulous tract in a patient with Crohn's disease is a rare complication.

PRESENTATION OF CASE

We present a case of a 40-year-old male patient with a long-standing perianal Crohn's disease who developed an anal mucinous adenocarcinoma within the fistulous tracts.

DISCUSSION

Although, Crohn's disease and colorectal carcinoma association is well established, few cases have been reported where the cancer has originated within a perianal fistula. Constant mucosal regeneration occurring within a fistula seems to be the predominant pathogenetic mechanism, while immunosuppressants and anti-TNF agents may also contribute to the malignant transformation. Unfortunately, the lack of suspicion and the inadequate physical examination or colonoscopy due to exacerbation of the perianal symptoms could lead to delayed diagnosis; and thus, a poor prognosis.

CONCLUSION

Albeit a rare complication, clinicians should maintain a high degree of vigilance about the possible development of adenocarcinoma in patients with long-standing perianal Crohn's disease. Thus, these patients should be kept under regular surveillance with examination under anaesthesia and biopsies or curettage of the tracts.

Metachronous adenocarcinoma of the anal canal after anterior resection for sporadic primary rectal adenocarcinoma: A rare case report

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We present a case of metachronous anal canal adenocarcinoma.

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A short discussion on the subtypes of anal adenocarcinoma and their management is provided.

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Immunohistology of anal canal adenocarcinoma is highlighted.

Introduction

Anal canal adenocarcinoma is an extremely rare malignancy with poorly defined diagnostic and treatment criteria.

Presentation of case

A 42-year-old women was diagnosed with primary anal canal adenocarcinoma 11 months after undergoing anterior resection for primary sporadic rectal adeocarcinoma. Transanal excision was performed and additional adjuvant chemotherapy was given. Immunohistology showed positivity for cytokeratin (CK) 20 and CDX2, and negative CK7, which is compatible with colorectal subtype anal adenocarcinoma. At 6 months follow-up the patient has no evidence of recurrent or metastatic disease.

Discussion

Diagnosis of primary anal adenocarcinoma is typically delayed because of its rarity, and vague clinical presentation. Exact histologic criteria remain poorly defined but the use of immunohistology has improved the overall diagnostic accuracy of anal adenocarcinoma and it also helps define its correct origin. Reports on the management and outcomes of this cancer consist mainly of retrospective studies with no consistent treatment strategy and limited comparison data. Most authors currently recommend neoadjuvant chemoradiotherapy and radical resection. Despite aggressive therapy, rates of local failure and distant recurrence remain high.

Conclusion

Diagnosis of adenocarcinoma of the anal canal is difficult but specific immunohistolgic patterns help to correctly identify its correct origin and subtype. Defining the correct subtype of anal adenocarcinoma may impact treatment strategies of this rare cancer.

Mucinous adenocarcinoma arising in chronic perianal fistula: good results with neoadjuvant chemoradiotherapy followed by surgery

Chronic perianal fistulas are a common clinical condition. However, their evolution to adenocarcinoma is rare. We report the case of a 48-year-old man with perianal chronic fistulas, who developed two perianal ulcerated lesions near the external orifices of the fistulas, which extended proximally as a pararectal tumor. No intestinal lesion was seen at endoscopic examination. Histopathological biopsy indicated mucinous adenocarcinoma. Staging was performed by pelvic magnetic resonance imaging (MRI) and thoracoabdominal CT scan. The patient underwent a laparoscopic colostomy followed by neoadjuvant chemoradiotherapy and then laparoscopic abdominoperineal resection followed by adjuvant therapy. We have seen a favorable outcome with no recurrence at 3 years of follow-up.

Multidisciplinary and evidence-based management of fistulizing perianal Crohn's disease

Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial to improve outcomes.

Anal abscess and fistula

Benign anorectal diseases, such as anal abscesses and fistula, are commonly seen by primary care physicians, gastroenterologists, emergency physicians, general surgeons, and colorectal surgeons. It is important to have a thorough understanding of the complexity of these 2 disease processes so as to provide appropriate and timely treatment. We review the pathophysiology, presentation, diagnosis, and treatment options for both anal abscesses and fistulas.

Primary and secondary adenocarcinomas associated with anal fistulae

PURPOSE

The purpose of this study was to evaluate the clinical features, pathology, and etiology of adenocarcinoma in patients with anal fistulae.

METHODS

We identified seven patients diagnosed with adenocarcinoma associated with anal fistulae from a retrospective chart review.

RESULTS

Five patients were diagnosed with primary adenocarcinoma associated with anal fistulae. Two patients were diagnosed with secondary adenocarcinoma associated with anal fistulae originating from rectal cancer on the proximal side. The primary adenocarcinomas included cancers arising from long-standing anal fistulae fulfilling established diagnostic criteria in two patients, and cancer arising from short-duration anal fistulae in three patients. Excision of the fistula was performed based on the initial diagnosis of the anal fistula for all five patients. Increased suspicion of cancer was due to the existence of gelatinous material in the anal fistula in three patients and induration in the resected specimens in two patients. The etiologies of the secondary adenocarcinomas associated with anal fistulae included implantation in the anal fistula from rectal cancer and fistula formation originating due to the progression of rectal cancer.

CONCLUSION

Anal fistulae are commonly seen in the coloproctology clinic, but special attention to similar conditions associated with malignant disease is needed.

A case of perianal mucinous adenocarcinoma arising from an anorectal fistula successfully resected after preoperative radiotherapy

A case of mucinous adenocarcinoma arising on a long-standing anorectal fistula is described. A 60-year-old man with a long history of mucinous discharge, pain and perianal induration underwent a biopsy of the external opening of the fistula that showed a mucinous infiltrating adenocarcinoma. Due to the large size of the tumor and the fact that it had extended into the surrounding tissue, preoperative radiotherapy was performed. Radiotherapy was given with 40 Gy in 25 fractions for 5 weeks through posterior and bilateral portals. After radiotherapy the tumor was markedly shrunk and the serum level of carcinoembryonic antigen was also improved. Abdominoperineal resection was performed 8 weeks after the termination of radiotherapy. Histological examination of the resected specimen revealed that the invasion of the tumor remained within the sphincter muscle and that no cancer cells were present on the surgical margin. The histological effect of radiotherapy was judged as grade 1b. This treatment can result in downstaging and R0 resection, which also has a possibility to prevent local recurrence. This case suggests that preoperative radiotherapy may play an important role in the definitive treatment of locally advanced perianal mucinous adenocarcinoma.

Cryptoglandular anal fistulas

BACKGROUND

Cryptoglandular anal fistula arises in 2 per 10 000 persons per year and is most common in young men. Improper treatment can result in fecal incontinence and thus in impaired quality of life.

METHOD

This S3 guideline is based on a systematic review of the pertinent literature.

RESULTS

The level of evidence for treatment is low, because relevant randomized trials are scarce. Anal fistulae are classified according to the relation of the fistula channel to the sphincter. The indication for treatment is established by the clinical history and physical examination. During surgery, the fistula should be probed and/or dyed. Endo-anal ultrasonography and magnetic resonance imaging are of roughly the same diagnostic value and may be useful as additional studies for complex fistulae. Surgical treatment is with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter, and occlusion with biomaterials. Only superficial fistulae should be laid open. The risk of postoperative incontinence is directly related to the thickness of sphincter muscle that is divided. All high anal fistulae should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterials yields a lower cure rate.

CONCLUSION

This is the first German S3 guideline for the treatment of cryptoglandular anal fistula. It includes recommendations for the diagnostic evaluation and treatment of this clinical entity.

Fistula-associated anal adenocarcinoma in Crohn's disease

BACKGROUND

Adenocarcinoma arising from perianal fistulae in patients with Crohn's disease (CD) is rare. The literature consists mainly of case reports and small series making characterization of this clinical entity difficult. We present 6 patients with CD and fistula-associated anal adenocarcinoma (FAAA) and a systematic review of published series.

METHODS

Retrospective charts were reviewed of 6 consecutive patients with FAAA in CD treated from 1992 through 2007. All available variables of our patients and of all available published cases were included for statistical analysis.

RESULTS

All patients treated at our institution had severe perianal CD at presentation. The average age at time of diagnosis was 45.5 years. All patients underwent abdominoperineal resection (APR) and 4 received chemoradiation. Four patients died with metastatic disease, 1 is alive with pelvic recurrence at 55 months, and 1 is alive without evidence of disease at 19 months follow-up. A total of 23 publications including 65 patients (37 female, mean age 53 years) with FAAA were reviewed in our systematic review. The average fistula duration was 14 years. Mean delay of cancer diagnosis was 11 months. APR was performed in 56 patients with an overall 3-year survival rate of 54%. Thirteen of 15 patients with node-positive tumors died with recurrent disease following surgery.

CONCLUSIONS

Adenocarcinoma arising from long-standing perianal CD fistulae is being increasingly reported. The outcome is poor following operative treatment, especially if perirectal lymph nodes are involved. Periodical cancer surveillance should be performed in all patients with long-standing perianal CD fistulae.

Surgical management of pyogenic complications of Crohn's disease

Patients with Crohn's disease are prone to the development of pyogenic complications. These complications are most commonly in the form of perianal or intraabdominal abscesses and/or fistulas. Complications in these 2 distinct areas are managed differently; however, they are similar in the fact that initial treatment relies on medical or minimally invasive management to achieve a nonacute condition prior to definitive surgical procedure. This article reviews the current surgical management of obtaining pyogenic control in both anorectal and intraabdominal Crohn's disease.

The value of routine histopathological analysis in patients with fistula in-ano

OBJECTIVE

To determine the positive yield of routine histopathology in patients undergoing surgery for fistula in-ano.

METHOD

Histopathology reports of all the patients who underwent surgery for fistulae-in-ano over a period of 36 months were reviewed.

RESULTS

Analysis included 84 patients of which 73 (87%) were male subjects. The mean age was 39.4 years (range 11-68). Forty-one (49%) had recurrent fistulae. Granulomatous diseases such as Crohn's disease and tuberculosis (TB) were suspected in six patients. However, of the six patients, confirmation of the disease status was obtained only in three patients: stains for acid-fast bacilli confirmed TB in two (2.4%) patients and colonoscopy and biopsy confirmed Crohn's disease in one (1.2%) patient. All three patients had recurrent fistulae.

CONCLUSION

As the positive yield of routine histopathology is minimal, we do not recommend routine histopathology for fistula in-ano, except for those presenting with recurrent fistulae and those with clinical suspicion of an underlying disease such as TB, HIV or Crohn's disease.

Epigenetic inactivation of tumor suppressor SFRP2 and point mutation in KRAS proto-oncogene in fistula-associated mucinous type anal adenocarcinoma: report of two cases

The secreted frizzled-related proteins (SFRPs) genes are unmethylated in normal colorectal mucosa tissue but aberrant methylation profiles can be detected in colorectal cancer (CRC), adenomas, and in aberrant crypt foci. The aim of the current study was to clarify whether SFRP2 methylation and K-ras structural mutation in fecal DNA can be found in stool and tumoral tissues of individuals with fistula-associated mucinous type anal adenocarcinomas (MTAA).Two man patients (68 and 56 years old) were treated for anorectal fistula in the surgical department. Patients were evaluated for clinical findings, tumoural tissue samples were examined histopathologically and DNA from fecal and tumoral tissue samples were isolated. K-ras mutation and promoter hypermethylation of SFRP2 gene in tumoral tissues were assessed by methylation-specific PCR based stripAssay hybridisation technique (Me-PCR) and compared to the healthy controls. Fecal and tumoural tissue samples from both patients were found to be fully hypermethylated profiles for SFRP2 gene and combined point mutations were detected in codon 12 and 13 of K-ras proto-oncogene. The current results showed that the combined effects of somatic mutations in K-ras and epigenetic alterations in SFRP2 genes may play an active role in the development of mucinous type anal adenocarcinoma.

Perianal mucinous adenocarcinoma arising from chronic anorectal fistulae: a review from single institution

BACKGROUND

Mucinous adenocarcinoma arising from a chronic anorectal fistula is rare, with few reports in the literature. Such lesions can be misdiagnosed for the more common benign perianal abscess or fistula.

METHODS

From our retrospective chart review, we identified three patients with chronic perianal fistula-in-ano who were subsequently found to have developed perianal mucinous adenocarcinoma on biopsy. We recorded the symptomatology, subsequent management and further follow-up of each patient.

RESULTS

Two of three patients who received irradiation and chemotherapy were still alive during 28 and 24 months of follow-up, respectively without any evidence of distant metastasis. One patient with inguinal lymph node metastases died due to distant metastasis 6 months after diagnosis.

CONCLUSIONS

Fistula-associated perianal mucinous adenocarcinoma is an uncommon malignant transformation of chronic fistula-in-ano. MRI can provide important diagnostic information on patient with this suspicious inflammatory condition. Although radical resection of the tumour with abdominoperineal resection remains the surgical treatment of choice. Combined chemoradiotherapy may be appropriate for these patients with promising results.

Diagnosis and treatment of perianal fistulas in Crohn's disease

Perianal fistulas secondary to Crohn's disease may destroy the sphincter musculature after years of development. Meticulous anorectal examination is often needed to identify the location of abscesses and fistulas. Combined medical and surgical therapy is the optimal treatment for perianal fistulas secondary to Crohn's disease. Drug therapy is also necessary for patients with active gastrointestinal inflammation. Patients with complex fistulae must be treated on an individual basis. However, choosing the appropriate surgical and medical interventions is often quite difficult. In this article, we will review the diagnosis and treatment of perianal fistulas in Crohn's disease.