Nonoperative management of squamous-cell carcinoma of the rectum

Rectal squamous cell carcinoma treated with neoadjuvant fluorouracil, oxaliplatin, cetuximab, and radiation: A case report of pathological complete response

RATIONALE

Treatment strategies for rectal squamous cell carcinoma (rSCC) are yet to be established, given its rarity. Although squamous cell carcinoma has been reported to be highly sensitive to cetuximab and radiation, there is no report of combination therapy of cetuximab and radiation for rSCC. In this study, we firstly reported a case of rSCC in which a complete response was achieved with the original chemoradiotherapy comprising oxaliplatin, S-1, cetuximab, and simultaneous radiation.

PATIENT CONCERNS

A 46-year-old women presented to our hospital with lower abdominal pain and fatigue.

DIAGNOSES

Based on tumor marker analyses, histological examination of biopsy specimens, and comprehensive imaging, the patient was diagnosed with rSCC.

INTERVENTIONS

Neoadjuvant chemoradiotherapy (50.4 Gy) was administered in 28 fractions, along with concurrent chemotherapy comprising SOX (S-1: 80 mg/m2, days 1-5 and 8-12, oxaliplatin: 85 mg/m2, day 1) and cetuximab (400 mg/m2, day 1, 250 mg/m2, after day 8).

OUTCOMES

Five weeks after chemoradiation, the patient underwent laparoscopic partial intersphincteric resection, achieving a complete pathological response.

LESSONS

This case firstly highlights the usefulness of SOX plus cetuximab combined with radiation in the treatment of locally advanced rSCC. However, a large-scale study is required to establish safe and effective treatment regimens.

Treatment of metastatic rectal squamous cell carcinoma in a pregnant patient

Rectal squamous cell carcinoma is an exceedingly rare form of rectal cancer, with limited data available regarding its presentation and effective treatment. Rectal cancer occurring during pregnancy is uncommon as well. This is a case of metastatic rectal squamous cell carcinoma presenting in a 22-week pregnant, female patient in her early 30s. The patient was treated with 5-fluorouracil and cisplatin and delivered a healthy male child born via uncomplicated vaginal delivery at 35 weeks. This article demonstrates that despite the rare nature of this cancer, in the already rare context of pregnancy, effective and safe treatment is possible with a multidisciplinary team.

Radiotherapy in the management of rare gastrointestinal cancers: A systematic review

The aim of this analysis is to assess radiotherapy's role and technical aspects in an array of rare gastrointestinal (GI) cancers for adult patients. Collection data pertaining to radiotherapy and digestive rare cancers were sourced from Medline, EMBASE, and Cochrane Library. Preoperative chemoradiotherapy improved outcomes for patients with esophageal undifferentiated carcinoma compared with esophageal salivary gland types of carcinomas. For rare gastric epithelial carcinoma, perioperative chemotherapy is the common treatment. Adjuvant chemoradiotherapy showed no benefice compared with adjuvant chemotherapy for duodenal adenocarcinoma. Small bowel sarcomas respond well to radiotherapy. By analogy to anal squamous cell carcinoma, exclusive chemoradiotherapy provided better outcomes for patients with rectal squamous cell carcinoma. For anal adenocarcinoma, neoadjuvant chemoradiotherapy, followed by radical surgery, was the most effective regimen. For pancreatic neuroendocrine tumors, chemoradiotherapy can be a suitable option as postoperative or exclusive for unresectable/borderline disease. The stereotactic body radiotherapy (SBRT) is a promising approach for hepatobiliary malignancy. Radiotherapy is a valuable option in gastrointestinal stromal tumors (GIST) for palliative intent, tyrosine kinase inhibitors (TKIs) resistant disease, and unresectable or residual disease. Involved field (IF) radiotherapy for digestive lymphoma provides good results, especially for gastric extranodal marginal zone lymphoma (MALT). In conclusion, radiotherapy is not an uncommon indication in this context. A multidisciplinary approach is needed for better management of digestive rare cancers.

Treatment paradigm and prognostic factor analyses of rectal squamous cell carcinoma

Background

Rectal squamous cell carcinoma (rSCC) is a rare pathological subtype of rectal cancer. There is no consensus on the treatment paradigm for patients with rSCC. This study aimed to provide a paradigm for clinical treatment and develop a prognostic nomogram.

Methods

Patients diagnosed with rSCC between 2010 and 2019 were identified in the Surveillance, Epidemiology, and End Results (SEER) database. According to the TNM staging system, Kaplan-Meier (K-M) survival analysis was used to identify the survival benefits of different treatments in patients with rSCC. The Cox regression method was used to identify independent prognostic risk factors. Nomograms were evaluated by Harrell's concordance index (C-index), calibration curves, decision curve analysis (DCA) and K-M curves.

Results

Data for 463 patients with rSCC were extracted from the SEER database. Survival analysis showed that there was no significant difference in median cancer-specific survival (CSS) among patients with TNM stage 1 rSCC treated with radiotherapy (RT), chemoradiotherapy (CRT) or surgery (P = 0.285). In TNM stage 2 patients, there was a significant difference in median CSS among those treated with surgery (49.5 months), RT (24 months), and CRT (63 months) (P = 0.003). In TNM stage 3 patients, there was a significant difference in median CSS among those treated with CRT (58 months), CRT plus surgery (56 months) and no treatment (9.5 months) (P < 0.001). In TNM stage 4 patients, there was no significant difference in median CSS among those treated with CRT, chemotherapy (CT), CRT plus surgery and no treatment (P = 0.122). Cox regression analysis showed that age, marital status, T stage, N stage, M stage, PNI, tumor size, RT, CT, and surgery were independent risk factors for CSS. The 1-, 3-, and 5-year C-indexes were 0.877, 0.781, and 0.767, respectively. The calibration curve showed that the model had excellent calibration. The DCA curve showed that the model had excellent clinical application value.

Conclusion

RT or surgery is recommended for patients with stage 1 rSCC, and CRT is recommended for patients with stage 2, and stage 3 rSCC. Age, marital status, T stage, N stage, M stage, PNI, tumor size, RT, CT, and surgery are independent risk factors for CSS in patients with rSCC. The model based on the above independent risk factors has excellent prediction efficiency.

Modified DCF (Docetaxel, Cisplatin and 5-fluorouracil) chemotherapy is effective for the treatment of advanced rectal squamous cell carcinoma

Background

Advanced rectal squamous cell carcinoma (rSCC) is a very rare and aggressive entity, and the best initial management is crucial for long survival as well as organ preservation and quality of life. Whereas local diseases are treated with chemo-radiotherapy and salvage surgery, data are scarce on how to treat more advanced diseases, and the role of induction chemotherapy is unknown.

Methods

We retrospectively analyzed all consecutive patients with advanced rSCC and treated with modified DCF (docetaxel, cisplatin, 5-fluorouracil; mDCF) regimen, from January 2014 and December 2021 in two French centers. Exploratory endpoints were efficacy (overall survival, recurrence-free survival, response rate, organ preservation rate) and safety.

Results

Nine patients with locally advanced or metastatic diseases received a mDCF regimen and were included for analysis. The median age was 62.0 years, 7 patients (77.8%) were women, and all eight available tumors were positive for HPV, mostly (85.7%) to genotype 16. With a median follow-up of 33.1 months, 77.8% of patients were still alive and disease-free, and the median overall survival was not reached at six years. The objective response rate was 87.5% after mDCF, and the complete response rate was 25.0% after mDCF and was increased to 75.0% after chemoradiotherapy. Only one patient underwent surgery on the primary tumor, with a complete pathological response. The median mDCF cycle was eight over eight scheduled, and all patients received the complete dose of radiotherapy without interruptions.

Conclusions

Induction mDCF chemotherapy followed by chemoradiotherapy is safe and highly effective in patients with advanced rSCC, and should be considered as an option in metastatic stage or locally advanced disease with an organ-preservation strategy.

Demographics, pattern of practice and clinical outcomes in rectal squamous cell carcinoma

AIM

The aim of this study was to describe the baseline clinical features, treatment patterns and outcomes in rectal squamous cell carcinoma (SCC).

METHOD

This is a retrospective study of patients with rectal SCC treated at the Princess Margaret Cancer Centre (Toronto, Canada) between 1 January 1995 and 31 December 2020. Clinical factors associated with locoregional failure (LRF), distant metastases (DM), disease-free survival (DFS) and overall survival (OS), such as age, sex, HIV status, T-category, nodal status, grade and primary treatment, were investigated with univariate analysis (UVA).

RESULTS

Twenty nine patients with rectal SCC were analysed with a median follow-up of 7.4 years (range 0.3-20.4 years). The median age at diagnosis was 52 years, with the majority presenting with clinical T3 disease or higher (n = 21, 72%) and positive regional lymph nodes (n = 16, 55%), while more than quarter of patients (28%) had metastatic disease. Definitive chemoradiation was the treatment modality of choice in more than half of all cases (n = 17, 59%) with a response rate of 100%. The 10-year cumulative incidence of LRF and DM was, respectively, 12% (95% CI 1.8%-32.9%) and 31% (95% CI: 12.0%-52.6%). The 5- and 10-year OS was 82% (95% CI 66.1%-100%). UVA revealed a trend towards an association of male gender (hazard ratio = 4.65, 95% CI 0.9%-24.1; p = 0.067) and primary surgical treatment (hazard ratio = 0.76, 95% CI 0.09-6.34; p = 0.061) with DFS.

CONCLUSION

Definitive chemoradiation is an effective and preferred treatment for rectal SCC allowing for sphincter preservation with complete clinical response observed in all patients.

A primary squamous cell carcinoma of the sigmoid colon in a young patient: A case report and literature review

Colon cancer is among the most common types of cancer with adenocarcinomas being the most common type. Herein we report a young patient who presented with primary colonic squamous cell carcinoma without risk factors. To the best of our knowledge, this is the youngest patient with such diagnosis worldwide.

Primary sigmoid squamous cell carcinoma with liver metastasis: A case report

BACKGROUND

The pathological type of simple squamous carcinoma in colorectal malignancies is rare. Simple squamous cell carcinoma of the colorectum occurs most frequently in the rectum. The clinicopathological features and biological behaviors of squamous colorectal carcinoma are unclear, and its prognosis may be worse than that of simple adenocarcinoma. Studies on squamous colorectal cancer are currently limited to case reports, and there is no standard treatment protocol. Therefore, more case reports are required to fully understand squamous colorectal cancer.

CASE SUMMARY

We reported the case of a 56-year-old woman who complained of constipation for 2 years. Colonoscopy revealed a sigmoid colon tumor, and the pathological result of colonoscopy was squamous carcinoma. After completing the relevant assessment, the patient was clinically diagnosed with cT4aN0M0, stage IIB, and surgery was performed. Based on postoperative pathological results, the patient was diagnosed with pT4bN0M0, stage IIC. Six cycles of adjuvant chemotherapy were administered after surgery. Liver metastasis and abdominal wall mass were found more than 1 mo after the end of the last chemotherapy session. Targeted local treatment was not performed because the liver had multiple metastases, but I¹²⁵ particle implantation of the abdominal wall mass was performed. Two cycles of first-line chemotherapy were administered after the surgery. The patient underwent 14 mo of treatment and eventually died from the tumor.

CONCLUSION

Squamous carcinoma of sigmoid colon is a rare tumor with unclear pathogenesis. Its clinicopathological diagnosis should be paid close attention.

Squamous rectal carcinoma: a rare malignancy, literature review and management recommendations

Squamous cell carcinoma of the rectum is a rare malignancy (0.3% of all rectal cancers), with no known risk factor. These tumours are assessed as rectal cancer using immunohistochemical and radiological tests, and certain criteria (localisation, relationship with neighbouring structures) have to be fulfilled to make the diagnosis. Some clinicians used to stage them with the anal cancer TNM (tumour–node–metastasis), whereas others used the rectal cancer TNM. When localised, the tendency nowadays is to treat those tumours like squamous anal cancers with definitive chemoradiotherapy (5-fluorouracil and mitomycin) and to skip surgery. For metastatic disease there is no clearly validated regimen and treatment should be based on recommendations of squamous anal cancers because of their common histology. Concerning follow-up after a curative approach, techniques should follow those for anal cancer as well, evaluating a delayed response.

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Rectal squamous cell carcinoma (rSCC) is a rare entity for which we have limited knowledge and no clear recommendations.

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Creation of an international registry and a biological repository could increase our understating of this rare entity.

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Definitive chemoradiotherapy (CRT) should be the gold standard treatment of local/locally-advanced rSCC.

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Clarification of clinical and pathologic response rates with CRT or radiotherapy alone and patterns of failure is important.

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Timing for tumour response assessment is paramount. Data tilt towards waiting until 6 months after definitive treatment.

Patterns of Care and Outcomes of Low-Lying Adenocarcinoma and Squamous Cell Carcinoma of the Rectum

PURPOSE

Squamous cell carcinoma (SCC) of the rectum is a unique entity that lacks definitive guidelines regarding prognosis and treatment. This study aimed to analyze patterns of care and survival for SCC and adenocarcinoma (AC) of the rectum.

METHODS

This was a retrospective analysis of patients with stage I-III SCC or AC of the rectum treated from 2004 to 2016 from the National Cancer Database. The treatment groups analyzed were surgery alone (S), chemoradiation followed by surgery (CRT + S), surgery followed by chemoradiation (S + CRT), and definitive chemoradiation (CRT). Patient- and clinical-related factors were compared. Overall survival was assessed with the Kaplan-Meier method and Cox proportional regression models.

RESULTS

Of the patients studied, 21,587 (97.1%) were AC and 640 (2.9%) were SCC. Among patients with AC, most (n = 8549, 59.4%) received chemoradiation followed by surgery; those with SCC (n = 305, 66.4%) received definitive chemoradiation. Among patients who received surgery, the majority (69.2%) with AC histology had a low anterior resection while the majority (52.1%) of SCC had an abdominoperineal resection. Five-year overall survival of AC versus SCC in the entire cohort was 61.6% versus 56.1%, respectively (p < 0.001). On multivariable analysis for AC, CRT + S (HR 0.61, p < 0.001), or S + CRT (HR 0.67, p < 0.001) had improved survival compared to S alone while those who had definitive CRT (HR 1.55, p < 0.001) had worse survival.

CONCLUSIONS

SCC of the rectum tends to be treated like anal cancers with definitive chemoradiation, with similar survival to historical reports of anal cancer. AC of the rectum is most commonly treated under the rectal cancer paradigm.

Primary Squamous Cell Carcinoma of Colon and Rectum: A Systematic Review of the Literature

Background - Objective: Primary colorectal squamous cell carcinoma is an extremely rare neoplasm with an incidence of 0.1 to 0.25 per 1,000 diagnosed colorectal carcinomas.The objective of this study was to evaluate its biological behavior and highlight the role of a surgical approach for its management.Methods: PubMed and Cohrane databases were independently searched (last search: April 10th, 2020) for articles concerning colorectal squamous cell carcinoma in adult population.Results: Seventy-one studies met predefined inclusion criteria and involved 99 patients (54.5% females) with an age of 56.98 ± 12.19 years (mean ± SD). The most frequent site of occurrence was the rectum (63.5%). Open surgery was conducted at 95% of patients, while 21.4% and 30.3% received neoadjuvant and adjuvant therapy respectively.Postoperative complications were developed in 31.3% of patients, while 6.1% died withing the first month following operation. Five-years survival rate was 49.5% (95% CI: 33.7%-63.4%). Female sex (HR: 0.24; 95% CI: 0.11-0.54; p-value: 0.001) and presence of postoperative complications (HR: 4.10; 95%CI: 1.47-1.46; p-value: 0.007) significantly affected the survival.Conclusions: Colorectal Squamous Cell Carcinoma is a rare tumor with an aggressive behavior. Surgery is the standard of treatment for the colontumors, while the role of chemoradiotherapy is promising especially for rectal tumors. Further clinical trials are necessary to determine the preferred treatment approach.

Indications for laparoscopic surgery for older rectal cancer patients with comorbidities

PURPOSE

Given the lack of safety studies concerning laparoscopic surgery for rectal cancer in patients ≥ 80 years old with comorbidities, we sought to investigate this in the current study.

METHODS

Between 2012 and 2019, 24 patients ≥ 80 years old underwent laparoscopic surgery for rectal cancer without preoperative treatment. These patients were divided into those with [comorbidity(+) group, n = 13] and without [comorbidity(-) group, n = 11] comorbidities. The preoperative nutritional status and ASA classification, postoperative complications, time to oral diet, and length of hospital stay were evaluated in each group.

RESULTS

In the comorbidity(+)/comorbidity(-) groups, the average age was 85.9/84.1 years old, respectively. The major comorbidities were heart disease including atrial fibrillation and valvular disorder. The average PNI and CONUT scores in the comorbidity(+)/comorbidity(-) groups were 44.7/44.2 an 3.1/2.2, respectively. Planned surgical procedures were completed in all patients. Postoperative complications occurred in 2/3 cases in the comorbidity(+)/comorbidity(-) groups, respectively, and the average time to oral diet was 3.8/3.7 days, while the average length of hospitalization after surgery was 15.2/16.5 days, respectively. In the comorbidity(+) group, there was no exacerbation of comorbidities in any cases.

CONCLUSION

The safety of laparoscopic surgery is acceptable among older rectal cancer patients with comorbidities.

Evaluating treatment protocols for rectal squamous cell carcinomas: the Duke experience and literature

Background

Colorectal cancer is the third most common cancer in the United States and associated with significant morbidity and mortality. Within colorectal cancer histologies, squamous cell carcinomas (SCC) are rare compared to adenocarcinomas, with only about 200 cases reported to date. Because rectal SCC is rarely encountered, there is a lack of literature and clinical consensus surrounding its optimal treatment approach. Staging and management of SCC can be partly analogous to both rectal adenocarcinoma and anal canal SCC, which leads to a dilemma in how to best approach these patients. As large randomized prospective trials are unrealistic in the setting of this rare malignancy, this study evaluates an institutional experience and reviews the existing literature to help guide future management approaches.

Methods

This retrospective study compared various treatment regimens for rectal SCC patients treated at Duke University Medical Center from January 1, 1980 through December 31, 2016. Patients ≥18 years old with histologically confirmed, nonmetastatic rectal SCC were included. Due to small sample size, all statistical analyses were descriptive. For our systematic review, a comprehensive search of PubMed from 1933 to March 2018 was performed, with selected articles referenced to ensure all relevant publications were included. A qualitative analysis was performed to examine patient diagnoses, treatments, and disease- and treatment-related outcomes.

Results

Eight patients were included. Three patients underwent initial, curative attempt surgery and two of these patients required colostomy. With follow-up ranging from 7.1 to 31.5 months, one patient was alive with no evidence of disease while two developed local/regional recurrences. Five patients received definitive chemoradiation. Of these, three patients developed local/regional and/or metastatic recurrence. Two patients achieved complete response on imaging and currently remain disease-free (follow-up of 31.5 and 33.6 months).

Conclusions

Although the review of our institutional experience is limited by small numbers, our analysis suggests that definitive chemoradiation therapy is the preferred treatment approach to rectal SCC based on improved disease-related outcomes, sphincter preservation and morbidity profiles. This conclusion is supported by a systematic literature review.

Survival and prognostic factors in patients with rectal squamous cell carcinoma

BACKGROUND

Squamous cell carcinoma (SCC) of the rectum is a rare form of gastrointestinal malignancy. The current knowledge on the natural history is primarily derived from case series.

METHODS

Using the National Cancer Data Base (NCDB), we determined the prognostic factors and overall survival (OS) outcomes of rectal SCC reported to NCDB between 2004 and 2015. Kaplan-Meier method and log-rank test were used to perform OS analysis. Propensity matched analysis was undertaken to compare the OS outcomes between rectal and anal SCC.

RESULTS

Of the 3405 cases included in our analysis, 67% were female. Median age at diagnosis was 61 years and did not differ by sex. In stages I-III, patients who received definitive chemoradiation only (108 months) had a better median OS as compared to surgery alone (76 months) (p = 0.012). On multivariate analysis, age <60 years, female sex, and receipt of chemoradiation with or without surgery were independent predictors of better OS in stage I-III disease. Administration of chemoradiation was associated with better OS in stage IV disease. On propensity matched analysis comparing outcomes to anal SCC, OS of rectal SCC was inferior (79 months) to anal SCC (113 months) (p < 0.001), no such difference in OS was noted in the cohorts that received surgery plus post-surgical chemoradiation (p = 0.12).

CONCLUSION

Outcomes of rectal SCC were dependent upon age, sex, comorbidity score, and therapy received. Chemoradiation alone or in combination with surgery was associated with a better median OS in patients with stages I-III.

Comparison of Anal Versus Rectal Staging in the Prognostication of Rectal Squamous Cell Carcinoma: A Population-Based Analysis

BACKGROUND

Rectal squamous cell carcinoma is a rare malignancy with limited data regarding management and prognosis. It is also unknown whether a rectal squamous cell cancer staging system should be based on size, as for anal squamous cell carcinoma, or depth of invasion, as for rectal adenocarcinoma.

OBJECTIVE

The aims of the current study were to determine the optimal management strategy, prognostic factors, and staging system for rectal squamous cell carcinoma.

DESIGN

This was a population-based study.

SETTINGS

The Surveillance, Epidemiology, and End Results database was used to identify patents diagnosed between 1988 and 2013.

PATIENTS

Patients ≥18 years of age undergoing radiation or local excision alone, radiation with local excision, or radiation with radical resection were included. Patients were then staged according to both the American Joint Committee on Cancer classification for rectal adenocarcinoma (American Joint Committee on Cancer-rectum) and anal cancer (American Joint Committee on Cancer-anus).

MAIN OUTCOME MEASURES

The main outcome was 5-year, disease-specific survival.

RESULTS

In both univariate and multivariate survival analyses, the addition of local excision or radical resection to radiation resulted in similar-to-worse outcomes across all of the stages. Among patients staged according to American Joint Committee on Cancer-rectum (n = 1646), although a significant difference in 5-year survival was observed for stage I as compared with higher stages, no difference was noted between stages II and III (80% vs 61% and 62%). However, in the American Joint Committee on Cancer-anus classification (n = 1327), a significant difference was observed across all of the stages (87% vs 72% vs 59%; p < 0.001). In multivariate analysis, the prognostic discrimination based on HRs provided by the American Joint Committee on Cancer-anus was superior to that of the American Joint Committee on Cancer-rectum.

LIMITATIONS

This study was limited by lack of data on chemotherapy and location of positive nodes.

CONCLUSIONS

A treatment approach primarily based on radiation should be considered the optimal management strategy for rectal squamous cell carcinoma. Moreover, a staging system based on size (American Joint Committee on Cancer-anus) rather than on depth of invasion (American Joint Committee on Cancer-rectum) appears to be more accurate in predicting its prognosis. See Video Abstract at http://links.lww.com/DCR/A734.

Effect of oxaliplatin combined with 5-fluorouracil on treatment efficacy of radiotherapy in the treatment of elderly patients with rectal cancer

Efficacy of the combination of oxaliplatin, 5-fluorouracil and radiotherapy on rectal cancer in elderly patients was investigated. Seventy-three elderly patients with rectal cancer confirmed by histopathological examination were randomly divided into 3 groups: oxaliplatin group (25 cases): intravenous infusion of oxaliplatin; fluorouracil group (24 cases): intravenous infusion of fluorouracil; combination group (24 cases), intravenous infusion of oxaliplatin and fluorouracil. All patients were treated with radiotherapy, and efficacy and safety were evaluated after 2 courses of treatment. MTT assay was used to observe the inhibitory effects of the proliferation of human rectal cancer cells. Cell proliferation and sensitization ratios were compared. After 2 courses of treatment, there was no difference in complete remission (CR), partial remission (PR), stable disease (SD), progression disease (PD) and disease control rate (DCR). Remission rate (RR) was higher in the combination group than that in the oxaliplatin and the fluorouracil groups (P<0.05), and there was no difference between the oxaliplatin and the fuorouracil group (P>0.05). Incidence of neutropenia in the combination group was higher than that in the fluorouracil group (P<0.05). OD values of the combination group were lower than those of the oxaliplatin and the fluorouracil groups (P<0.05). Proliferation ability of SW837 cells of the combination group was significantly lower than that of the oxaliplatin and the fluorouracil groups (P<0.05). Intragroup comparison of sensitization ratio showed that sensitization ratios of three groups of cells at 24, 48 and 72 h were all higher than those at 12 h (P<0.05). The combination of oxaliplatin and 5-fluorouracil is safe and effective in the treatment of rectal cancer in elderly patients, and it can be used for sensitization of radiotherapy. So it should be popularized in clinical practices.

Squamous Cancers of the Rectum Demonstrate Poorer Survival and Increased Need for Salvage Surgery Compared With Squamous Cancers of the Anus

BACKGROUND

Squamous cell cancers of the anus are rare GI malignancies for which neoadjuvant chemoradiation is the first-line treatment for nonmetastatic disease. Squamous cancers of the rectum are far less common, and it is unclear to what degree chemoradiotherapy improves their outcomes.

OBJECTIVE

The purpose of this study was to compare stage-specific survival for anal and rectal squamous cancers stratified by treatment approach.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted at Commission on Cancer designated hospitals.

PATIENTS

Patients (2006-2012) identified in the National Cancer Database with pretreatment clinical stage I to III cancers who underwent chemoradiotherapy, with and without subsequent salvage surgical resection (low anterior resection or abdominoperineal resection), ≥12 weeks after chemoradiotherapy were included in the study.

MAIN OUTCOME MEASURES

Overall survival and the need for salvage surgery were measured.

RESULTS

Anal cancers (n = 11,224) typically presented with stage II (45.7%) or III (36.3%) disease, whereas rectal cancer stages (n = 1049) were more evenly distributed (p < 0.001). More patients with rectal cancer underwent low anterior or abdominoperineal resections 12 weeks or later after chemoradiotherapy versus those undergoing abdominoperineal resection for anal cancer (3.8% versus 1.2%; p < 0.001). Stage I and II rectal cancer was associated with poorer survival compared with anal cancer (stage I, p = 0.017; stage II, p < 0.001); survival was similar for stage III disease. Salvage surgery for anal cancer was associated with worse survival for stage I to III cancers; salvage surgery did not significantly affect survival for rectal cancer.

LIMITATIONS

This was a retrospective study without cancer-specific survival measures.

CONCLUSIONS

Squamous rectal cancers are associated with significantly worse survival than squamous cancers of the anus for clinical stage I and II disease. Despite both cancers exhibiting squamous histology, rectal cancers may be less radiosensitive than anal cancers, as suggested by the greater incidence of salvage surgery that does not appear to significantly improve overall survival. See Video Abstract at http://links.lww.com/DCR/A422.

A rare case of primary rectal squamous cell carcinoma diagnosed by endoscopic ultrasound

Primary squamous cell carcinoma (SCC) of the rectum is a very rare entity making up to 0.1-0.25/1,000 cases of all colorectal cancers. Here, we present the case of an otherwise healthy 63-year-old female who presented with progressive pelvic discomfort, new onset constipation and a complex mass in presacral region on imaging which was proved to be poorly differentiated SCC of the rectum. The correct diagnosis was achieved by fine needle aspiration (FNA) via endoscopic ultrasound (EUS-guided FNA) as initial conventional colonoscopy failed to establish the diagnosis. Patient completed neoadjuvant chemo-radiation and her tumor was successfully resected. She is following up with oncology clinic for monitoring and further management.

Gemcitabine-based chemotherapy in colon squamous cell carcinoma: A case report and literature review

Squamous cell carcinoma (SCC) originating from the colon is rare. In terms of its clinicopathological characteristics, this type of cancer has been reported to be more aggressive and have a worse prognosis compared with adenocarcinoma. We herein present a successful therapeutic approach applying neoadjuvant and adjuvant gemcitabine-based chemotherapy in a patient with colon SCC. A 58-year-old male patient received two cycles of neoadjuvant chemotherapy with a regimen including gemcitabine, oxaliplatin and capecitabine, followed by radical excision and six cycles of adjuvant chemotherapy. Contrast-enhanced computed tomography and serum tumor markers were used for reassessment and evaluation was based on the World Health Organization criteria. Following neoadjuvant chemotherapy, the mass had shrunk and the patient was classed as having stable disease. Surgery and adjuvant chemotherapy were then performed and the patient had achieved a progression-free survival of 10 months when this report was submitted. Therefore, gemcitabine may be a treatment option for colon SCC in the neoadjuvant and/or adjuvant chemotherapy setting.

[Rectal squamous cell carcinoma treatment: Retrospective experience in two French university hospitals, review and proposals]

After publishing a retrospective series of 23 patients treated for a rectal squamous cell carcinoma with exclusive curative and conservative intent chemoradiation, we aim to propose a review of the literature about this rare tumour. We identified 11 retrospective studies, on 106 patients, treated between 2007 and 2016. Treatment of rectal squamous cell carcinoma should be similar to anal carcinoma, based on exclusive chemoradiation, displaying a 5-year overall survival rate over 80%, while it was 32% in surgical series. Baseline explorations should be similar as for anal carcinoma, with an interest in PET-CT at diagnosis and monitoring, after a delay over 6 weeks after chemoradiation. Intensity-modulated radiotherapy is legitimate, to a prophylactic dose between 36 and 45Gy, and over 54Gy to the tumour. Concomitant chemotherapy should combine an antimetabolite (5-fluorouracil or capecitabine) and mitomycin C, or cisplatin. This treatment seems well tolerated, associated with grade 2 or above toxicity below 30%. Follow-up should be established on anal squamous cell carcinoma schedule, with endoscopic ultrasonography and PET-CT. Rectal squamous cell carcinoma is a rare tumour; it management should be based on anal curative and conservative intent chemoradiation.

Comparison of outcomes between rectal squamous cell carcinoma and adenocarcinoma

Large, population-based analyses of rectal squamous cell carcinoma (SCC) have not been previously conducted. We assessed patterns of care, prognostic factors, and outcomes of rectal SCC and adenocarcinoma (AC) in population-based cohorts. Surveillance, Epidemiology, and End Results (SEER) registry searches were performed (1998-2011), producing 42,308 nonmetastatic rectal cancer patients (999 SCC and 41,309 AC). Patient, tumor, and treatment characteristics were compared. Based on risk factors, SCC/AC groups were subdivided into low-, intermediate-, and high-risk groups. Overall survival (OS) was compared between histological and risk groups using Kaplan-Meier method and log-rank test. Multivariate logistic regression models evaluated prognostic factors for 5-year survival. Cox regression modeling was performed on propensity-matched data. Rectal SCC, more common in females and associated with larger tumors of higher grade, was more often treated with radiotherapy (RT) than surgery. Surgery was associated with higher OS in AC but not SCC, and RT had proportionally greater benefits in SCC. These effects of RT and surgery were retained when stratified into risk groups (particularly high/intermediate-risk). Favorable prognostic factors for survival included younger age, non-black race, SCC histology, size ≤3.9 cm, localized stage, lower grade, surgery, and RT. For SCC, race, tumor grade, and surgery were not prognostic factors for survival. Cox regression modeling of propensity-matched data showed that AC histology increased risk of death versus SCC. In the largest analysis of rectal SCC to date, and in the notable absence (and unlikelihood) of prospective data, nonsurgical and RT-based treatment is recommended.

Primary squamous cell carcinoma of the rectum: An update and implications for treatment

AIM: To provide an update on the aetiology, pathogenesis, diagnosis, staging and management of rectal squamous cell carcinoma (SCC).

METHODS: A systematic review was conducted according to the preferred reporting items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of Ovid MEDLINE was performed with the reference list of selected articles reviewed to ensure all relevant publications were captured. The search strategy was limited to the English language, spanning from 1946 to 2015. A qualitative analysis was undertaken examining patient demographics, clinical presentation, diagnosis, staging, treatment and outcome. The quantitaive analysis was limited to data extracted on treatment and outcomes including radiological, clinical and pathological complete response where available. The narrative and quantitative review were synthesised in concert.

RESULTS: The search identified 487 articles in total with 79 included in the qualitative review. The quantitative analysis involved 63 articles, consisting of 43 case reports and 20 case series with a total of 142 individual cases. The underlying pathogenesis of rectal SCC while unclear, continues to be defined, with increasing evidence of a metaplasia-dysplasia-carcinoma sequence and a possible role for human papilloma virus in this progression. The presentation is similar to rectal adenocarcinoma, with a diagnosis confirmed by endoscopic biopsy. Many presumed rectal SCC’s are in fact an extension of an anal SCC, and cytokeratin markers are a useful adjunct in this distinction. Staging is most accurately reflected by the tumour-node-metastasis classification for rectal adenocarcinoma. It involves examining locoregional disease by way of magnetic resonance imaging and/or endorectal ultrasound, with systemic spread excluded by way of computed tomography. Positron emission tomography is integral in the workup to exclude an external site of primary SCC with metastasis to the rectum. While the optimal treatment remains as yet undefined, recent studies have demonstrated a global shift away from surgery towards definitive chemoradiotherapy as primary treatment. Pooled overall survival was calculated to be 86% in patients managed with chemoradiation compared with 48% for those treated traditionally with surgery. Furthermore, local recurrence and metastatic rates were 25% vs 10% and 30% vs 13% for the chemoradiation vs conventional treatment cohorts.

CONCLUSION: The changing paradigm in the treatment of rectal SCC holds great promise for improved outcomes in this rare disease.

Chemoradiation in rectal squamous cell carcinoma: Bi-institutional case series

BACKGROUND AND PURPOSE

Primary rectal squamous cell carcinoma (SCC) is an uncommon disease. Early reports stated that surgery is the most effective treatment. However, recent publications suggest conservative strategy with chemoradiation provides satisfactory results.

PATIENTS AND METHODS

We have retrospectively studied the medical charts of 23 patients treated for a rectal SCC in two teaching hospitals in France between 1992 and 2013. Twenty-one patients received an exclusive chemoradiotherapy (CRT) and two a pre-operative CRT followed by a planned surgery. Patients received pelvic irradiation with a dose ranging from 36-45 Gy followed by a boost of 15-23 Gy. Twenty-two patients received a concurrent chemotherapy.

RESULTS

After CRT, the rate of clinical complete response was 83%. With a median follow-up of 85 months, 5-year overall survival rate was 86%. Five patients presented with a relapse. The 5-year disease-free survival rate was 81%. The 5-year colostomy-free survival rate was 65%. Three patients (13%) presented with grade III-IV late rectal toxicity.

CONCLUSIONS

Although retrospective, this is the largest cohort of patients treated with CRT for a rectal SCC. Exclusive CRT could result in high local control rate and prolonged survival in rectal SCC patients with a high rate of organ preservation.

Female perineal diseases: spectrum of imaging findings

The female perineum, which is divided into the anterior urogenital triangle and the posterior anal triangle, is a surface structure often overlooked. Female perineal diseases may present with nonspecific clinical signs due to its close anatomical relationship between the different compartments. Diagnosis of the origin of a perineal disorder may also be a difficult problem encountered in pelvi-perineal imaging. Therefore, a precise knowledge of the female perineal anatomy and the associated disease processes is essential to radiologists, pathologists, and surgeons alike who are involved in the evaluation of the patient who presents with a perineal mass. Cross-sectional imaging plays a crucial role for proper management. Due to the robust contrast resolution of MR, MR imaging is the modality of choice for evaluation of the extent of a complex perineal lesion, its relationship to the adjacent structures. It has a greater sensitivity and specificity for the diagnosis than the other non-invasive imaging techniques and is helpful in guidance for surgical planning. The purpose of this article is to highlight the spectrum of imaging findings of female perineal diseases.

Primary squamous cell carcinoma of the rectum: an atypical histology

Squamous cell carcinoma of the rectum is one of the differential diagnoses of rectal tumors. It represents a low incidence in the population. The etiopathogenesis and the biology of these tumors are unclear, for this reason the gold standard treatment is difficult to establish. We present a 47-years-old woman who had a squamous cell carcinoma in medium rectum. She was treated with radiation therapy and chemotherapy and the treatment was followed by surgical excision.