Premalignant neoplasms and squamous cell carcinoma of the anal margin

Anal carcinoma - exploring the epidemiology, risk factors, pathophysiology, diagnosis, and treatment

Anal carcinoma is a relatively rare tumor that accounts for approximately 2% of gastrointestinal malignancies and less than 7% of anorectal cancers. Most anal tumors originate between the anorectal junction and the anal verge. Risk factors for the disease include human papillomavirus infection, human immunodeficiency virus, tobacco use, immunosuppression, female sex, and older age. The pathogenesis of anal carcinoma is believed to be linked to human papillomavirus-related inflammation, leading to dysplasia and progression to cancer. Squamous cell carcinoma is the most common type of anal tumor, with an annual incidence of approximately 1 to 2 per 100000 persons. Treatment regarding anal cancer has emerged over time. However, chemoradiation therapy remains the mainstay approach for early localized disease. Patients with metastatic disease are treated with systemic therapy, and salvage surgery is reserved for disease recurrence following chemoradiation. This article aims to provide background information on the epidemiology, risk factors, pathology, diagnosis, and current trends in the management of anal cancer. Future directions are briefly discussed.

From benign to malignant: unveiling invasive squamous cell carcinoma following resection of perianal condyloma acuminatum: a case report

This case illustrates the surgical management of a perianal mass, initially misdiagnosed as condyloma acuminatum in a male patient in his late 50s, later identified as invasive squamous cell carcinoma following excision. Despite extensive preoperative evaluation, the lesion's malignancy was confirmed through histopathology. The significant, fungating mass required a multidisciplinary approach, culminating in a pT3 staging and additional wide excision with inferior gluteal artery perforator flap reconstruction. This case underscores the critical importance of surgical diligence and adaptability, highlighting the role of comprehensive surgery in both diagnosis and treatment of complex perianal malignancies, and reaffirms the value of a multidisciplinary team in achieving favourable outcomes.

Nodal Elective Volume Selection and Definition during Radiation Therapy for Early Stage (T1-T2 N0 M0) Perianal Squamous Cell Carcinoma: A Narrative Clinical Review and Critical Appraisal

Distinction between anal canal and perianal squamous cell carcinomas (pSCCs) is essential, as these two subgroups have different anatomical, histological, and lymphatic drainage features. Early-stage true perianal tumors are very uncommon and have been rarely included in clinical trials. Perianal skin cancers and aCCs are included in the same tumor classification, even though they have different lymphatic drainage features. Furthermore, pSCCs are treated similarly to carcinomas originating from the anal canal. Radiation therapy (RT) is an essential treatment for anal canal tumors. Guidelines do not differentiate between treatment volumes for perianal tumors and anal cancers. So far, in pSCC, no study has considered modulating treatment volume selection according to the stage of the disease. We conducted a narrative literature review to describe the sites at higher risk for microscopic disease in patients with early-stage perianal cancers (T1-T2 N0 M0) to propose a well-thought selection of RT elective volumes.

Radiation Treatment for Cancer of the Anal Margin

OBJECTIVE

To identify best treatment practices by examining outcomes of anal margin cancer patients treated with radiotherapy.

METHODS

Relevant literature was compared with 38 patients at our institution treated 1979 to 2019 with curative radiotherapy. Median age was 51. Four patients had T1, 22 had T2, and 12 had T3 disease based on the American Joint Committee on Cancer (AJCC) staging at time of diagnosis. Nodal staging distribution was: N0=33; N1=2; N2=2; N3=1. Median radiation dose was 56 Gy/30 fractions. Five received nodal radiation for node positivity, 29 received elective nodal radiation, and 29 had perineal boost. Twenty-seven received concurrent chemotherapy.

RESULTS

Three patients experienced isolated local recurrence, 2 had isolated inguinal node recurrences, and 2 developed distant metastases, 1 of whom also had local and regional recurrence. Ten-year disease-free survival (DFS), cause-specific survival, and overall survival were 87%, 92%, and 68%, respectively. One patient did not complete radiation, and 4 had unexpected treatment breaks. Two received salvage abdominoperineal resections. At last follow-up, 17 were alive with no evidence of disease, 2 were alive with anal margin cancer present, 3 had died with anal margin cancer present at 11, 18, and 21 months from radiation therapy, and 16 had died from intercurrent disease. Median follow-up was 6.6 years (range 0.9 to 29.0 y). Age ≥51 was associated with worse locoregional control ( P =0.018) and DFS ( P =0.0233), males had worse DFS ( P =0.0311), and HIV-positive patients had worse overall survival ( P =0.006).

CONCLUSIONS

Radiation provides high locoregional control of anal margin cancer with good long-term outcomes.

Perianal Bowen's disease treated with radiotherapy preserving anal function with a unique skin reaction considered as 'tumoritis'

Bowen's disease (BD) is a form of intraepidermal squamous cell carcinoma (SCC), and it occasionally occurs on the perianal site. BD is often treated with surgical excision; however, sometimes surgical excision for perianal BD cannot preserve anal function. We report the case of a 72-year-old man presenting with perianal pain and BD. He was treated with Radiotherapy (RT) and preserved his normal anal sphincter function without any recurrence or late adverse event. Moreover, we observed the unique skin reaction called 'tumoritis', which is characterized by mucosal inflammation. Tumoritis indicates the true extent of the tumor and evaluating the tumor or lesion size based on the extent of tumoritis when performing RT is important.

Perineal body squamous cell carcinoma treated with radical radiotherapy - a case report

Introduction

Perianal tumours are a rare site of malignancy, and tumours primarily involving the perineal body without vaginal and anal canal involvement are uncommon.

Case summary

A 67-year-old woman presented with a lesion involving the perineum and rectovaginal septum without extension into vaginal or anorectal mucosa and with skip lesions in the vulva. Biopsy was confirmative of squamous cell carcinoma, with p16 positive. A complete metastatic workup with MRI of the pelvis and CECT thorax and abdomen was done. She was diagnosed with perianal carcinoma stage cT2N0M0 Stage II (American Joint Committee on Cancer 8th Edition of Cancer Staging) since the lesion reached the anal verge. Given the location of the tumour (perineal body), comorbidities and advanced age, she received radical radiotherapy with an intensity-modulated radiotherapy technique - 56 Gy in 28 fractions with the intention of organ preservation. The response assessment with MRI at 3 months showed a complete tumour response. She has been disease-free for 3 years and is on regular follow-ups.

Conclusion

Isolated perineal body squamous cell carcinomas are unusual, and synchronous vulvar skip lesion makes this case unique. Radical radiotherapy achieved organ preservation with tumour control and minimal toxicity in an elderly frail patient.

Perianal squamous cell carcinoma: A case report

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Perianal squamous malignancies are often misdiagnosed leading to delay in treatment.

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Surgical management aims to preserve sphincter function.

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Chemoradiation is preferred in cases of suspected sphincter involvement.

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Some superficial muscle fibers may be resected in select cases without loss of function.

Introduction and importance

Perianal carcinomas, though rare, are usually squamous cell carcinoma. Current literature recommends surgical excision for tumors staged T1-T2, N0 without external anal sphincter involvement, however our case demonstrated that tumors with superficial involvement of external sphincter fibers can be resected completely.

Case presentation

A 45-year-old Caucasian male presented with a perianal mass found to be squamous cell carcinoma. Initial imaging suggested the anal sphincter was spared, however intraoperatively tumor cells were found involving superficial external sphincter fibers and a portion was excised to ensure complete removal.

Clinical discussion

Perianal squamous malignancies are often misdiagnosed as more benign conditions. Treatment aims to preserve sphincter function and depends on tumor stage along with anatomical involvement.

Conclusion

Despite superficial muscle infiltration, the T2N0 perianal lesion was curable with surgical resection alone without recurrence or functional deficits reported one year later. This suggests surgical management may be possible in some cases with sphincter involvement.

Bilateral V-Y flap for a perianal basal cell carcinoma: A case report

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We describe basal cell carcinoma in the perianal area.

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Complete resection of perianal tumor with reconstruction of the area.

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Surgical management of perianal basal cell carcinoma.

Background

Basal cell carcinomas are rare in non-sun-exposed skin, and are even rarer in the perianal region. Alertness to the unusual occurrence of this tumor at perianal site, with understanding of its clinical course, can prevent delay in its diagnosis and morbid aggressiveness in the management of the disease.

Presentation of case

A 93 year old female, referred to our hospital because of a three month bleeding ulcerative lesion, with a diameter approximately of 4.5 × 3.2 cm, located in the perianal region.

Discussion

Tumors of the anus and perianal are infrequent neoplasms of the digestive tract. There are many diseases that can be confused with this diagnosis and it is commonly delayed because the tumor is rarely thought of in this particular cutaneous topography. Suspicion and early diagnosis, give the opportunity for a timely and appropriate treatment and also prevent tumor extension.

Conclusion

Treatment modalities include early wide local excision to clear margins, ensuring further local recurrence and distant metastasis. The use of local V-Y advancement fasciocutaneous flaps may be another valid option for the reconstruction of perianal skin defects, with less morbidity than other flaps described in the literature.

Perianal Paget's Disease Co-Associated with Anorectal Adenocarcinoma: Primary or Secondary Disease?

Perianal Paget's disease (PPD) represents a skin neoplasm which can be either primary or secondary to carcinoma from an adjacent internal organ. PPD with underlying colorectal adenocarcinoma is usually looked upon as a secondary disease. We report a rare case of co-associated PPD and anorectal adenocarcinoma. The PPD was found to be located near the anorectal adenocarcinoma with normal tissues between them. Immunohistochemical stains demonstrated that the Paget's cells were CK7+/GCDFP-15–/CK20–/MUC2–/CDX2–, whereas the anorectal adenocarcinoma was shown to be CK7+/GCDFP-15–/CK20+/MUC2+/CDX2+. This immunological phenotypic profile supported the notion that PPD and anorectal adenocarcinoma were of different origins, but could not define the exact origins of PPD. In our determination, this case was a primary PPD with anorectal adenocarcinoma. PPD remains a heterogeneous and complex pathology, and additional studies are required to differentiate between the various possible origins.

Neoplasms of anal canal and perianal skin

Tumors of the anus and perianal skin are rare. Their presentation can vary and often mimics common benign anal pathology, thereby delaying diagnosis and appropriate and timely treatment. The anatomy of this region is complex because it represents the progressive transition from the digestive system to the skin with many different co-existing types of cells and tissues. Squamous cell carcinoma of the anal canal is the most frequent tumor found in the anal and perianal region. Less-frequent lesions include Bowen's and Paget's disease, basal cell carcinoma, melanoma, and adenocarcinoma. This article aims to review the clinical presentation, diagnostic evaluation, and treatment options for neoplasms of the anal canal and perianal skin.