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Wang M, Xiang Y, Wang Y, Zhang J, Zhao H, Wang C, Qiao L, Yang B. Adjuvant chemoradiotherapy does not improve outcomes in patients with fistula-associated anal adenocarcinoma undergoing abdominoperineal resection. Front Oncol 2022; 12:1061513. [PMID: 36439430 PMCID: PMC9682013 DOI: 10.3389/fonc.2022.1061513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/24/2022] [Indexed: 08/30/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - Bolin Yang
- Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
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Muacevic A, Adler JR, Karimi S, Mehta V, Perez-Tamayo A, Chaudhry V. Anal Adenocarcinoma Arising From a Fistula-in-Ano: A Case Report. Cureus 2022; 14:e31339. [PMID: 36514648 PMCID: PMC9733786 DOI: 10.7759/cureus.31339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 11/12/2022] Open
Abstract
Crohn's disease (CD) is an inflammatory disease that can affect any portion of the gastrointestinal tract (GIT). Although it can present with a number of complications, perianal fistulae are among the most common consequences in patients with CD. In very rare cases, these patients can develop fistula-associated anal adenocarcinoma (FAAA). In this case report, we discuss a 72-year-old man with a long-term history of CD complicated by perianal fistulae, which failed medical and surgical management, ultimately presenting with acute anal pain in the outpatient setting. The physical examination revealed a seton traversing through a fistula surrounded by circumferential granulation tissue suspicious for malignancy. A biopsy of the tissue confirmed grade 3 mucinous-type infiltrating adenocarcinoma of the perianal skin. The patient was diagnosed with an anal verge malignancy associated with a fistula in the context of long-standing CD, and MRI staging demonstrated a T3N1 lesion with potential left inguinal node involvement. He completed neoadjuvant chemo-radiotherapy using capecitabine for five weeks with minimal tumor response, and subsequently, an abdominoperineal resection (APR) was performed with patient discharge on the fifth post-procedure day. Post-operative chemotherapy with oxaliplatin/leucovorin/fluorouracil was administered with minimal complications. Although rare, this report demonstrates the importance of consistent follow-up and mitigation of risk factors in patients with CD, along with the significance of prompt multimodal treatment in the event of developing FAAA.
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Sekar A, Rana SS, Bardia A. SMILE-like lesion in the anal canal. AUTOPSY AND CASE REPORTS 2021; 11:e2021289. [PMID: 34249793 PMCID: PMC8214893 DOI: 10.4322/acr.2021.289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/12/2021] [Indexed: 12/02/2022] Open
Abstract
Stratified mucin-producing intraepithelial lesion (SMILE) is an intraepithelial lesion with overlapping features of the high-grade squamous intraepithelial lesion (HSIL) and adenocarcinoma in situ (AIS). Currently, it is well described in the cervix. We present a case showing similar SMILE-like lesions in the polypectomy specimen from the anal canal along with invasive adenocarcinoma components. This lesion showed an immuno-profile characteristic of a SMILE lesion described in the cervix, such as p63 negativity, high ki67 index, and nuclear positivity for p16. It might be arising from the Human papillomavirus prone transitional region of the anal canal as described in the cervix. However, we could not assure this association and etiological link due to insufficient material in the formalin-fixed paraffin-embedded block. Notwithstanding, we strongly suggest that the HPV is the main driver for this SMILE-like lesion similar to what is described in the cervix. To our knowledge, this is the first case report of a SMILE lesion in the anal canal. Further studies will be required to elucidate the underlying pathogenetic mechanism of SMILE-like lesions described in the anal canal.
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Affiliation(s)
- Aravind Sekar
- Post Graduate Institute of Medical Education and Research Department of Histopathology, Chandigarh, India
| | - Surinder Singh Rana
- Post Graduate Institute of Medical Education and Research Department of Gastroenterology, Chandigarh, India
| | - Anand Bardia
- Post Graduate Institute of Medical Education and Research Department of Histopathology, Chandigarh, India
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Spiridakis KG, Sfakianakis EE, Flamourakis ME, Intzepogazoglou DS, Tsagataki ES, Ximeris NE, Rachmanis EK, Gionis IG, Kostakis GE, Christodoulakis MS. Synchronous mucinous adenocarcinoma of the recto sigmoid revealed by and seeding an anal fistula. (A case report and review of the literature). Int J Surg Case Rep 2017. [PMID: 28641190 PMCID: PMC5479962 DOI: 10.1016/j.ijscr.2017.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The diagnosis of such conditions remains difficult when the colonic tumor is unknown and the chronic lesion of anal fistula seems to be a benign condition. The management of these cases remain controversial. The aim of this study highlights the importance of high suspicion with further investigation and the need of biopsy in all anal fistulas.
Introduction There are few cases of synchronous rectal adenocarcinoma revealed by an anal fistula. The diagnosis of synchronous mucinous adenocarcinoma of the recto sigmoid and anal canal remains difficult. The chronic anal fistula can be mistaken as the common manifestation of a benign perianal abscess or fistula. Case presentation We present a rare case of a Greek Caucasian 79 year old male patient with anal fistula and a recurrent perianal abscess who subsequently was found to have developed synchronous rectosigmoid and perianal mucinous adenocarcinoma on biopsy. The histological exam revealed mucinous adenocarcinoma in two sites, representing two tumors, cells were immunopositive for cytokeratin 20 and negative in cytokeratin 7. The patient underwent “laparoscopic extralevator abdominoperineal excision ” with both lesions being resected. There is no recurrence after four years of follow up. Conclusions This case highlights the importance of high suspicion, further investigation and the need of biopsy in all anal fistulae.
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Affiliation(s)
| | | | | | | | - Eleni S Tsagataki
- Venizeleio General Hospital, Department of Surgery, Heraklion, Crete, Greece.
| | - Nikolaos E Ximeris
- Venizeleio General Hospital, Department of Surgery, Heraklion, Crete, Greece.
| | | | - Ioannis G Gionis
- Venizeleio General Hospital, Department of Surgery, Heraklion, Crete, Greece.
| | - Giorgos E Kostakis
- Venizeleio General Hospital, Department of Surgery, Heraklion, Crete, Greece.
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Mukai N, Pinheiro LV, Ayrizono MDLS, Barreiro GC, Kharmandayan P, Akinaga MH, Bento AM, Martinez CAR, de Carvalho RB, Ward M, Coy CSR, Leal RF. Mucinous adenocarcinoma associated with chronic suppurative hidradenitis: Report of a case and review of the literature. Int J Surg Case Rep 2016; 26:12-6. [PMID: 27424105 PMCID: PMC4949808 DOI: 10.1016/j.ijscr.2016.06.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 06/24/2016] [Accepted: 06/25/2016] [Indexed: 02/08/2023] Open
Abstract
Mucinous adenocarcinoma associated with suppurative hidradenitis is extremely rare. Magnetic resonance imaging findings help in the diagnosis of mucinous adenocarcinoma. The surgery is highly complex, and even in a tertiary hospital, complications may occur.
Introduction Chronic suppurative hidradenitis (CSH) is a benign condition that can affect the perineal region and often leads to the formation of abscesses and fistulas. It is rare for CSH to undergo malignant degeneration into mucinous adenocarcinoma. Presentation of case We report a case of a 55-year-old male patient with perineal CSH who suffered worsening long-term pain despite multiple surgical procedures to alleviate his symptoms. Pelvic magnetic resonance imaging (MRI) showed multiloculated cystic lesion on the left side wall of the distal rectum with gluteal extension. Pathological examination revealed mucinous adenocarcinoma. The patient underwent an abdominoperineal resection (APR) of the rectum with cutaneous muscle flap reconstruction. Although histopathological sections showed clear margins, the tumor recurred 6 months following surgery. Discussion Perineal mucinous adenocarcinoma arising in a patient with CSH is an extremely rare condition. This diagnosis is often difficult, due to the paucity of signs of malignant degeneration as well as the rarity of the disease itself. Surgical resection of the lesions is a well-established approach. In this case, diagnosing the tumor at such a late stage likely compromised his outcome. Conclusion Malignant degeneration to mucinous adenocarcinoma must be suspected in patients with a history of long-term CSH. In such cases, local biopsies and a radiological examination, such as MRI can help in the diagnosis.
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Affiliation(s)
- Natalia Mukai
- Coloproctology Unit, Department of Surgery, University of Campinas, UNICAMP, Campinas, Sao Paulo, Brazil
| | - Lílian Vital Pinheiro
- Coloproctology Unit, Department of Surgery, University of Campinas, UNICAMP, Campinas, Sao Paulo, Brazil
| | | | | | - Paulo Kharmandayan
- Plastic Surgery Unit, Department of Surgery, University of Campinas, UNICAMP, Campinas, Sao Paulo, Brazil
| | - Mariana Hanayo Akinaga
- Plastic Surgery Unit, Department of Surgery, University of Campinas, UNICAMP, Campinas, Sao Paulo, Brazil
| | - Adriano Mesquita Bento
- Plastic Surgery Unit, Department of Surgery, University of Campinas, UNICAMP, Campinas, Sao Paulo, Brazil
| | | | - Rita Barbosa de Carvalho
- Department of Pathology, Gastrocenter, University of Campinas, UNICAMP, Campinas, Sao Paulo, Brazil
| | - Marc Ward
- University of Chicago Medical Center, Chicago, IL, United States
| | | | - Raquel Franco Leal
- Coloproctology Unit, Department of Surgery, University of Campinas, UNICAMP, Campinas, Sao Paulo, Brazil.
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Yang BL, Shao WJ, Sun GD, Chen YQ, Huang JC. Perianal mucinous adenocarcinoma arising from chronic anorectal fistulae: a review from single institution. Int J Colorectal Dis 2009; 24:1001-6. [PMID: 19205706 DOI: 10.1007/s00384-009-0657-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2009] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Bo-Lin Yang
- Department of Coloproctology, Nanjing T.C.M. University Hospital, Nanjing, China
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Seya T, Tanaka N, Shinji S, Yokoi K, Oguro T, Oaki Y, Ishiwata T, Naito Z, Tajiri T. Squamous cell carcinoma arising from recurrent anal fistula. J NIPPON MED SCH 2007; 74:319-24. [PMID: 17878704 DOI: 10.1272/jnms.74.319] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Here, we report on a patient with squamous cell carcinoma (SCC) arising from recurrent anal fistula. The patient was a 57-year-old woman who had 32-year history of having a recurrent perianal abscesses that ruptured spontaneously. Six months before her admission to our hospital, anal pain developed. She had no history of inflammatory bowel disease. Physical examination revealed three external fistulous openings at the two o'clock position, 2 cm from the anal verge. One internal opening in the lower rectum was found with proctoscopy. The patient underwent fistulectomy. Microscopic examination showed SCC arising from the anal fistula, which was accompanied by vessel invasion. The tumor was observed to be continuous from the external opening but was not exposed to the internal opening of the rectal mucosa. Because human papillomavirus (HPV) infection was suspected, immunohistochemical analysis was performed, but showed no HPV infection. Two weeks after fistulectomy, abdominoperineal resection with lymph node dissection was performed. Histopathological examination revealed no remnant cancer tissue or lymph node metastasis. She was discharged after surgery without complications. Eight years after the operation, she complained of constant pain during micturition. Urological examination revealed urinary bladder cancer, and transurethral resection of the bladder tumor was performed. Histopathological examination revealed transitional cell carcinoma of the urinary bladder. Two years later, the patient died of metastatic urinary bladder cancer, without recurrence of the fistula cancer. Because the patients mother had died of urinary bladder cancer and she herself had metachronous urinary bladder cancer in addition to fistula cancer, we investigated whether microsatellite instability (MSI) and chromosomal instability correlated with fistula cancer development. Immunohistochemical analysis of formalin-fixed, paraffin-embedded surgical tumor specimens for p53, MLH1, and MSH2 was performed. The tumor specimens showed no MLH1 expression but did show normal MSH2 expression. p53 was not expressed. Five microsatellite loci were examined using the tumor specimens to detect MSI, namely two loci with mononucleotide runs (i.e., BAT25 and BAT26) and three loci with dinucleotide repeats (i.e., APC, Mfd15, and D2S123). The tumor specimens showed alternations in the repeated sequences of two loci (i.e., BAT26 and D2S123). As a result, the tumor was classified as MSI-H (high) according to the Bethesda criteria. Our patient had MSI and one of the smallest reported SCCs arising from recurrent anal fistulae.
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Affiliation(s)
- Tomoko Seya
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School, and Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Japan.
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Williams JG, Farrands PA, Williams AB, Taylor BA, Lunniss PJ, Sagar PM, Varma JS, George BD. The treatment of anal fistula: ACPGBI position statement. Colorectal Dis 2007; 9 Suppl 4:18-50. [PMID: 17880382 DOI: 10.1111/j.1463-1318.2007.01372.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- J G Williams
- McHale Centre, New Cross Hospital, Wolverhampton, UK.
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Leal RF, Ayrizono MLS, Coy CSR, Fagundes JJ, Góes JR. Mucinous adenocarcinoma derived from chronic perianal fistulas: report of a case and review of the literature. Tech Coloproctol 2007; 11:155-7. [PMID: 17510737 DOI: 10.1007/s10151-007-0348-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2005] [Accepted: 05/19/2006] [Indexed: 11/30/2022]
Abstract
Chronic perianal fistulas are a common clinical condition. However, their evolution into adenocarcinoma is rare. We report the case of a 68-year-old man with perineal and perianal chronic fistulas, who developed a perineal mass that extended proximally as a pararectal tumor. Diagnosis was confirmed by magnetic resonance imaging (MRI). Histopathological sections indicated extramucosal mucinous adenocarcinoma. No intestinal lesion was seen at endoscopic examination. The patient underwent abdominal perineal excision of the rectum without neoadjuvant or adjuvant therapy, and had a good postoperative outcome.
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Affiliation(s)
- R F Leal
- Coloproctology Unit, Department of Surgery, Universidade Estadual de Campinas, UNICAMP, Rua Antônio Augusto de Almeida, n. 37 Cidade Universitária, CEP 13084-070, Campinas, São Paulo, Brazil
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Raiss M, Hrora A, Menfaa M, Sabbah F, Ahallat M, al Baroudi S, Hosni K, Benamar A, Oudanane M, Mjahed A, Kettani F, Halhal A, Tounsi A. [Adenocarcinoma of the anal glands]. ANNALES DE CHIRURGIE 2001; 126:452-5. [PMID: 11447798 DOI: 10.1016/s0003-3944(01)00529-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The study aim was to report an adenocarcinoma of the anal glands revealed by an anal abscess in a 64-year-old man. Malignant transformation of an anal fistula is discussed in the genesis of this disease. Clinical symptoms are not specific. Abdomino-perineal resection of the rectum is the usual surgical treatment and adjuvant radiation therapy didn't prove its efficiency.
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Affiliation(s)
- M Raiss
- Clinique chirurgicale C, hôpital Ibn Sina Rabat, Maroc.
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