Adenocarcinoma del canal anal. Revisión de conjunto

Synchronous occurrence of HPV-associated cervical squamous cell carcinoma (FIGO IIA) in prolapsed uterus and adenocarcinoma of the anal canal cT1N0M0: Case report

RATIONALE

Guidelines of rare synchronous tumours treatment are often unavailable due to lack of wide prospective studies. Additionally, their management is not just a simple sum of coexisting tumours management and has to regard many circumstances like symptoms, age, comorbidities, advancement.

PATIENT CONCERNS

Herein, we report a case of an 81-year-old woman who presented with bleeding from the prolapsed uterus.

DIAGNOSES

Based on physical examination, that is, speculum examination, bimanual, and per rectum, followed by rectoscopy and histopathology, the diagnosis of cervical squamous cell carcinoma FIGO IIA2 in prolapsed uterus with anal canal adenocarcinoma cT1N0M0 was made.

INTERVENTIONS

Dominating complaint of bleeding from prolapsed cervix was managed with radical vaginal hysterectomy in conjunction with wide colpectomy preceded by laparoscopic pelvic and paraaortic lymphadenectomy. Due to the lack of consent for removal of the anus, only radiotherapy was applied instead.

OUTCOMES

The patient underwent magnetic resonance image follow-up. No recurrence was found at 18 months.

LESSONS

Imaging is useful method of synchronous cancers diagnostics. These cancers may vary in aetiology and stage. Cervical cancer may be co-existing with another anogenital cancer. Therapy of synchronous cancers should be individualized taking into account patient's consent, age, physical condition, and comorbidities.

Cancer of the anal canal, a reality in the Colombian coffee region. Clinical-epidemiological review 2000-2019

INTRODUCTION

Anal cancer is a rare pathology which has increased over the last few decades, and, therefore, gained importance for the quality of life of affected individuals. Thus, a review has been conducted in the Colombian coffee region (Departments of Caldas, Quindío y Risaralda) describing its behaviour and clinical-epidemiological profile.

MATERIALS AND METHODS

Descriptive review of 437 patients of Western SAS Oncologists between January 2000 and December 2019 with a diagnosis of anal cancer.

RESULTS

62% of cases presented in women with a median age of 62 years, 30% in the sixth decade; centred at 65% in three main cities designated as capitals (Manizales, Pereira and Armenia); 62% as localised disease, with 40% stage II-A and 6% as initial metastasis; 29% presented positive ganglia, particularly N1a; squamous cell or epidermoid histology in 90%; 16% poorly differentiated; 5% related to Human Immunodeficiency Virus infection; localisation in the medial area of the anal canal in 63% of cases; 83% completed treatment, and 92% of them received chemotherapy/radiation therapy with 87% based on the Nigro protocol; finally, 11% presented with relapse in the liver in 10% of cases and 55% local.

CONCLUSION

Four hundred and thirty-seven patients evaluated over 20 years with follow up at median 34.13 months (standard deviation 41.75) with median survival at later ages decreasing to 62% in patients older than 80 years, and differences in survival in localised disease at 78% in comparison to 46% in advanced metastasis. Finally, the overall 5-year survival rate is 69% with a median survival of 191 months in the study.

An Exceptional Adenocarcinoma in a Girl

Anal adenocarcinoma is very rare and usually occurs in the elderly. We present a case of a 12-year-old girl with an anal margin painful tumor infiltrating the lower rectum, with perineal and vulvar permeation nodules and bilateral fixed inguinal and iliac lymph nodes. Histology showed anal adenocarcinoma with mucosecreting component and independent cells. She had no extra pelvic metastasis on CT scan. She underwent a colostomy and palliative care. This exceptional case challenges us on the diversity of forms of anal cancers that require a multidisciplinary approach. The precarious social context and the age of onset make it difficult to manage this rare cancer.

A dualistic model of primary anal canal adenocarcinoma with distinct cellular origins, etiologies, inflammatory microenvironments and mutational signatures: implications for personalised medicine

Background

Primary adenocarcinoma of the anal canal is a rare and aggressive gastrointestinal disease with unclear pathogenesis. Because of its rarity, no clear clinical practice guideline has been defined and a targeted therapeutic armamentarium has yet to be developed. The present article aimed at addressing this information gap by in-depth characterising the anal glandular neoplasms at the histologic, immunologic, genomic and epidemiologic levels.

Methods

In this multi-institutional study, we first examined the histological features displayed by each collected tumour (n = 74) and analysed their etiological relationship with human papillomavirus (HPV) infection. The intratumoural immune cell subsets (CD4, CD8, Foxp3), the expression of immune checkpoints (PD-1, PD-L1), the defect in mismatch repair proteins and the mutation analysis of multiple clinically relevant genes in the gastrointestinal cancer setting were also determined. Finally, the prognostic significance of each clinicopathological variable was assessed.

Results

Phenotypic analysis revealed two region-specific subtypes of anal canal adenocarcinoma. The significant differences in the HPV status, density of tumour-infiltrating lymphocytes, expression of immune checkpoints and mutational profile of several targetable genes further supported the separation of these latter neoplasms into two distinct entities. Importantly, anal gland/transitional-type cancers, which poorly respond to standard treatments, displayed less mutations in downstream effectors of the EGFR signalling pathway (i.e., KRAS and NRAS) and demonstrated a significantly higher expression of the immune inhibitory ligand-receptor pair PD-1/PD-L1 compared to their counterparts arising from the colorectal mucosa.

Conclusions

Taken together, the findings reported in the present article reveal, for the first time, that glandular neoplasms of the anal canal arise by HPV-dependent or independent pathways. These etiological differences leads to both individual immune profiles and mutational landscapes that can be targeted for therapeutic benefits.