Int J Colorectal Dis DOI 10.1007/s00384-015-2123-z
LETTER TO THE EDITOR
Mucinous anal adenocarcinoma invading the perianal region Laura Iliescu & Mugur Grasu & Vlad Herlea & Constantin D. Ungureanu & Letitia Toma
Accepted: 8 January 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor, Anal adenocarcinoma is a rare form of anorectal neoplasia, accounting for about 5 % of the cases [1]. Regarding the histopathology aspect, adenocarcinomas are very rare and more aggressive than epidermoid cancers [2]. The size of the tumor is the most important prognostic factor [3]. Furunculosis is an infection affecting the skin and soft tissues, located in the hair-baring parts of the body. The most frequent etiologic agent is Staphylococcus aureus, but it can also be caused by a series of gram positive or negative bacteria [4]. The diagnosis is based on the clinical aspect and bacteriologic confirmation of the infection. Severe cases may have the appearance of ulcerated skin tumors. A 63-year-old man presented to our clinic for perianal tumors developing for the past 6 months. The patient had no previous medical history and did not describe any changes in bowel movement or GI bleeding. Three months earlier, he had presented to another clinic where he had been diagnosed with perianal furunculosis and had been given local antibiotics, without any improvement. On admission, the patient was stable, without fever, with L. Iliescu (*) : L. Toma Department of Internal Medicine, Fundeni Clinical Institute, Sos Fundeni nr 258, sector 2, 022328 Bucharest, Romania e-mail: [email protected] M. Grasu Department of Radiology, Fundeni Clinical Institute, Bucharest, Romania V. Herlea Department of Pathology, Fundeni Clinical Institute, Bucharest, Romania C. D. Ungureanu Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
normal heart and lungs sounds, without tenderness in the abdomen, and normal bowel sounds. Clinical evaluation revealed multiple perianal tumors, the largest being of about 9/9 cm, located on the left side, with several areas of ulceration. Blood tests revealed mild leukocytosis with neutrophilia, inflammatory syndrome, and increased CA19-9 levels. Microscopic examination of the secretion from the tumors showed fibrin deposits, conjunctive tissue, and atypical polygonal cells with hyperchromatic nuclei and irregular contour. There was no growth on bacterial cultures. The patient remained stable throughout the hospitalization under antibiotic treatment. Pelvic CT scan showed polilobular formations with multiple septations located bilateral perianal, predominantly on the left side, invading the muscles and connecting to the anal canal. Pelvic MRI revealed a large T2-hyperintense solid tissue infiltrating the anatomic layers from the anal canal to the skin. Microscopy aspect of biopsies from the tumor, in hematoxylin-eosin stain, showed large mucin deposits (more than half of the tumor mass), containing tumor cells. The diagnosis was moderately well differentiated (G1–G2) hypersecretant mucinous extracellular adenocarcinoma. The patient underwent colostomy and will be referred to a radiotherapist to reduce the size of the tumor and consecutively attempt resection. Adenocarcinomas are very rare and aggressive; typically, they have a high rate of recurrence. Furthermore, mucinous adenocarcinomas are even more rare, accounting for about 3 % of all anal carcinomas [2]. Clinical presentation includes anal pruritus, pain in the perianal region, hematochezia, and discharge. Our patient presented none of these symptoms, except perianal pain which can be attributed to the skin lesions. Clinical aspect of the tumors had initially provoked the confusion with extensive perianal furunculosis. Moreover,
Int J Colorectal Dis
the digital rectal examination did not reveal any masses. On the other hand, microscopic examination of secretions taken from the lesions did not reveal any bacteriologic infection. Typically, Staphylococcus aureus or less frequent germs are present in such examinations in furunculosis [4]. The extent of the lesions and the lack of response to local means of antiseptics and antibiotics were the signs to suggest a neoplastic pathology. Due to late diagnosis, anal carcinomas generally have a poor prognosis [2]. Treatment options include surgery, chemotherapy, and radiotherapy [2]. Consensus on treatment protocols has not been reached, due to the low number of causes and lack of clinical trials. A common option is radiotherapy and chemotherapy prior to surgery. In our patient, we decided that resection and colostomy followed by radiotherapy was the best choice. This is consistent with other literature data.
We would like to draw the attention toward the uncommon presentation of a rare tumor and the diagnostic and therapeutic challenges that it imposes.
References 1. Belkacémi Y, Rouanet P, Jafari M (2009) Primary adenocarcinoma of the anal canal. In: Belkacémi Y, Mirimanoff RO, Ozsahin M (eds) Management of rare adult tumours. Springer-Verlag France, Paris, pp 167–173 2. Bharucha AE, Wald A (2009) Anorectal diseases. In: Yamada T (ed) Textbook of Gastroenterology, 5th edn. Blackwell Publishing Ltd, UK, pp 1717–1745 3. Ryan DP, Compton CC, Mayer RJ (2000) Carcinoma of the anal canal. N Engl J Med 342:792–800 4. Demos M, McLeod MP, Nouri K (2012) Recurrent furunculosis: a review of the literature. Br J Dermatol 167(4):725–732
LETTER TO THE EDITOR
Mucinous anal adenocarcinoma invading the perianal region Laura Iliescu & Mugur Grasu & Vlad Herlea & Constantin D. Ungureanu & Letitia Toma
Accepted: 8 January 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor, Anal adenocarcinoma is a rare form of anorectal neoplasia, accounting for about 5 % of the cases [1]. Regarding the histopathology aspect, adenocarcinomas are very rare and more aggressive than epidermoid cancers [2]. The size of the tumor is the most important prognostic factor [3]. Furunculosis is an infection affecting the skin and soft tissues, located in the hair-baring parts of the body. The most frequent etiologic agent is Staphylococcus aureus, but it can also be caused by a series of gram positive or negative bacteria [4]. The diagnosis is based on the clinical aspect and bacteriologic confirmation of the infection. Severe cases may have the appearance of ulcerated skin tumors. A 63-year-old man presented to our clinic for perianal tumors developing for the past 6 months. The patient had no previous medical history and did not describe any changes in bowel movement or GI bleeding. Three months earlier, he had presented to another clinic where he had been diagnosed with perianal furunculosis and had been given local antibiotics, without any improvement. On admission, the patient was stable, without fever, with L. Iliescu (*) : L. Toma Department of Internal Medicine, Fundeni Clinical Institute, Sos Fundeni nr 258, sector 2, 022328 Bucharest, Romania e-mail: [email protected] M. Grasu Department of Radiology, Fundeni Clinical Institute, Bucharest, Romania V. Herlea Department of Pathology, Fundeni Clinical Institute, Bucharest, Romania C. D. Ungureanu Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
normal heart and lungs sounds, without tenderness in the abdomen, and normal bowel sounds. Clinical evaluation revealed multiple perianal tumors, the largest being of about 9/9 cm, located on the left side, with several areas of ulceration. Blood tests revealed mild leukocytosis with neutrophilia, inflammatory syndrome, and increased CA19-9 levels. Microscopic examination of the secretion from the tumors showed fibrin deposits, conjunctive tissue, and atypical polygonal cells with hyperchromatic nuclei and irregular contour. There was no growth on bacterial cultures. The patient remained stable throughout the hospitalization under antibiotic treatment. Pelvic CT scan showed polilobular formations with multiple septations located bilateral perianal, predominantly on the left side, invading the muscles and connecting to the anal canal. Pelvic MRI revealed a large T2-hyperintense solid tissue infiltrating the anatomic layers from the anal canal to the skin. Microscopy aspect of biopsies from the tumor, in hematoxylin-eosin stain, showed large mucin deposits (more than half of the tumor mass), containing tumor cells. The diagnosis was moderately well differentiated (G1–G2) hypersecretant mucinous extracellular adenocarcinoma. The patient underwent colostomy and will be referred to a radiotherapist to reduce the size of the tumor and consecutively attempt resection. Adenocarcinomas are very rare and aggressive; typically, they have a high rate of recurrence. Furthermore, mucinous adenocarcinomas are even more rare, accounting for about 3 % of all anal carcinomas [2]. Clinical presentation includes anal pruritus, pain in the perianal region, hematochezia, and discharge. Our patient presented none of these symptoms, except perianal pain which can be attributed to the skin lesions. Clinical aspect of the tumors had initially provoked the confusion with extensive perianal furunculosis. Moreover,
Int J Colorectal Dis
the digital rectal examination did not reveal any masses. On the other hand, microscopic examination of secretions taken from the lesions did not reveal any bacteriologic infection. Typically, Staphylococcus aureus or less frequent germs are present in such examinations in furunculosis [4]. The extent of the lesions and the lack of response to local means of antiseptics and antibiotics were the signs to suggest a neoplastic pathology. Due to late diagnosis, anal carcinomas generally have a poor prognosis [2]. Treatment options include surgery, chemotherapy, and radiotherapy [2]. Consensus on treatment protocols has not been reached, due to the low number of causes and lack of clinical trials. A common option is radiotherapy and chemotherapy prior to surgery. In our patient, we decided that resection and colostomy followed by radiotherapy was the best choice. This is consistent with other literature data.
We would like to draw the attention toward the uncommon presentation of a rare tumor and the diagnostic and therapeutic challenges that it imposes.
References 1. Belkacémi Y, Rouanet P, Jafari M (2009) Primary adenocarcinoma of the anal canal. In: Belkacémi Y, Mirimanoff RO, Ozsahin M (eds) Management of rare adult tumours. Springer-Verlag France, Paris, pp 167–173 2. Bharucha AE, Wald A (2009) Anorectal diseases. In: Yamada T (ed) Textbook of Gastroenterology, 5th edn. Blackwell Publishing Ltd, UK, pp 1717–1745 3. Ryan DP, Compton CC, Mayer RJ (2000) Carcinoma of the anal canal. N Engl J Med 342:792–800 4. Demos M, McLeod MP, Nouri K (2012) Recurrent furunculosis: a review of the literature. Br J Dermatol 167(4):725–732
