Chemo-radiotherapy: an alternative to surgery for squamous cell carcinoma of the rectum--report of six patients and literature review

The Enigma That is Rectal Squamous Cell Carcinoma: A Case Series

INTRODUCTION

Colorectal cancer is the third most common cancer and the third leading cause of cancer deaths in the United States. As rectal squamous cell carcinoma (SCC) is an uncommon colorectal cancer, there is limited data on this clinical entity. We aimed to evaluate the tumor characteristics, treatment, and clinical outcomes of this rare deadly disease.

METHODS

Pathological specimens from 2017 to 2022 at a single National Cancer Institute-designated cancer center were screened for all rectal cases with a diagnosis of SCC. All patients with a primary rectal SCC were included. Patients who had extension to the dentate line or evidence of an anal mass, and those who were treated at an outside institution, were excluded. Demographic, treatment, outcome, and surveillance data was extracted.

RESULTS

There were 56 specimens identified, nine of which met inclusion criteria. Most patients were White (78%), Hispanic (78%), and female (67%). The average age at diagnosis was 57 y [52-65]. All patients had nodal involvement at the time of clinical staging. All patients were treated with Nigro protocol, with one patient treated with surgery first. The median time of follow-up was 12 mo after initial treatment, 33% had recurrence, with median time to recurrence of 25 mo. Overall, mortality from rectal SCC was 33% at a median time of 37 mo from initial diagnosis.

CONCLUSIONS

Rectal SCC is a colorectal cancer that is not fully understood. Our findings showed that treatment mirrors that of anal SCC, with similar rates of survival to both rectal adenocarcinoma and anal SCC.

Comprehensive CT Imaging Analysis of Primary Colorectal Squamous Cell Carcinoma: A Retrospective Study

The aim of this study was to evaluate the findings of CT scans in patients with pathologically confirmed primary colorectal squamous-cell carcinoma (SCC). The clinical presentation and CT findings in eight patients with pathologically confirmed primary colorectal squamous-cell carcinoma were retrospectively reviewed by two gastrointestinal radiologists. Hematochezia was the most common symptom (n = 5). The tumors were located in the rectum (n = 7) and sigmoid colon (n = 1). The tumors showed circumferential wall thickening (n = 4), bulky mass (n = 3), or eccentric wall thickening (n = 1). The mean maximal wall thickness of the involved segment was 29.1 mm ± 13.4 mm. The degree of tumoral enhancement observed via CT was well enhanced (n = 4) or moderately enhanced (n = 4). Necrosis within the tumor was found in five patients. The mean total number of metastatic lymph nodes was 3.1 ± 3.3, and the mean short diameter of the largest metastatic lymph node was 16.6 ± 5.7 mm. Necrosis within the metastatic node was observed in six patients. Invasions to adjacent organs were identified in five patients (62.5%). Distant metastasis was detected in only one patient. In summary, primary SCCs that arise from the colorectum commonly present as marked invasive wall thickening or a bulky mass with heterogeneous well-defined enhancement, internal necrosis, and large metastatic lymphadenopathies.

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.

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.

Primary squamous cell carcinoma of the colon: A rare case report

INTRODUCTION AND IMPORTANCE

Squamous cell carcinoma (SCC) of the colon is an extremely rare pathologic entity, accounting for less than 1 % of all colorectal cancer cases. They tend to be very aggressive with poor outcomes and treatment strategies are still controversial due to the paucity of data available to guide management.

CASE PRESENTATION

A case of a cecal mass with metastatic liver lesions. Initially diagnosed as an adenocarcinoma, the patient underwent resection with metastasectomy. Despite achieving negative surgical margins and undergoing adjuvant chemotherapy, the patient relapsed and presented with a new mass in the descending colon. The patient underwent resection with subsequent follow-up revealing distant metastasis. The patient passed away soon after.

CLINICAL DISCUSSION

Primary colorectal SCC has similar presentation to adenocarcinoma of the colon. Unfortunately, it usually presents at a late stage. Diagnosis of colorectal SCC requires histologic confirmation of SCC plus exclusion of possible causes. Management is predominantly definitive radical resection followed by adjuvant chemotherapy and radiotherapy. Surgical margins should be at least 5 cm, preferably 10 cm. Lymph node yield greater than 20 was associated with improved survival. Studies assessing the prognosis of primary colorectal SCC following chemo-radiotherapy have not been done.

CONCLUSION

Surgery remains the most vital important step in the management of colonic SCC. The role of chemotherapy and/or radiation remains questionable. Depending on the aggressiveness of this disease the need for further frequent.

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.

Case Report: Management of rectal squamous cell carcinoma - a treatment dilemma

Primary rectal squamous cell carcinoma is rare compared to adenocarcinoma, which is the predominant histologic type most commonly discovered at the time of colorectal carcinoma diagnosis. Due to the infrequent nature of this malignancy, data on tumor pathogenesis and risk factors remains sparse. Moreover, no standardized therapeutic regimen exists. This report describes a case of advanced rectal squamous cell carcinoma diagnosed in a 46-year-old female who initially presented with abdominal pain. Her clinical course was uncomplicated and she responded well to the selected therapy. Much work remains to be accomplished for patients with rectal squamous cell carcinoma.

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.

Nomogram predicting overall survival of rectal squamous cell carcinomas patients based on the SEER database: A population-based STROBE cohort study

We aimed to evaluate the prognostic value of clinical and pathologic factors in rectal squamous cell carcinomas (SCC) and to construct a nomogram for their outcome prediction.The study cohort was selected from Surveillance, Epidemiology, and End Results (SEER) program between January 2004 and December 2013. Univariate and multivariate analyses were performed using Cox proportional hazards regression model to evaluate the prognostic value of involved variables. All prognostic factors were combined to construct a nomogram to predict the overall survival (OS), followed by discrimination as well as calibration plots and receiver operating characteristic (ROC) curves for assessing the predictive accuracy of the nomogram.We identified 806 patients with a median follow-up time of 35 months. Multivariate analyses revealed that marital status (P < .001), age (P < .001), T stage (P = .008), M stage (P < .001), surgery (P = .004), chemotherapy (P = .003) and radiotherapy (P = .016) were independent prognostic factors of OS. Finally, the 7 variables were combined to construct a 3-year and 5-year OS nomogram. The concordance indexes (C-indexes) of OS were 0.756 (95% CI, 0.726-0.786) for the internal validation and 0.729 (95% CI, 0.678-0.780) for the external validation. Additionally, there was superior discrimination power of the nomogram over the SEER stage or the 8th edition AJCC TNM staging classification (P < .001). Calibration plots further showed good consistency between the nomogram prediction and actual observation. The area under the curve (AUC) of ROC curves for 3-year OS was 0.811 (95% CI: 0.769-0.853) in the training cohort and 0.748 (95% CI: 0.681-0.815) in the validation cohort. The AUC for 5-year OS was 0.770 (95% CI: 0.721-0.819) in the training cohort and 0.797 (95% CI: 0.731-0.863) in the validation cohort. Finally, Kaplan-Meier analysis further validates the predictive potential of the nomogram.Marital status, age, T stage, M stage, surgery, chemotherapy and radiotherapy were significantly associated with OS of patients with rectal SCC. This predictive model has the potential to provide an individualized risk estimate of survival in patients with rectal SCC.

Anal squamous cell carcinoma with metastasis to duodenum causing duodenal stricture and gastric outlet obstruction

Squamous cell carcinoma (SCC) of the anal canal is a rare entity encompassing only 2-4 percent of all colon, rectal, and anal cancers. SCC of the anal canal tends to be loco-regional, and in the event of distant metastasis, a most common site of spread is to liver and lung. We report an unusual case of SCC of the anal canal with duodenal metastases in a 49-year-old female who had presented with symptoms of abdominal pain, nausea, and vomiting eight months after the primary diagnosis of SCC of the anal canal. Esophagogastroduodenoscopy (EGD) revealed duodenal stricture with subsequent biopsy revealing duodenal mucosa with scattered malignant cell clusters within lymphatic spaces, consistent with metastatic carcinoma. Immunohistological staining demonstrated malignant cells positive for CK7, p16, p63 favoring a metastatic SCC.

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.

Definitive Chemoradiation for Squamous Cell Carcinoma of the Rectum

OBJECTIVES

Squamous cell carcinoma (SCC) of the rectum is a rare disease with <80 cases reported in the English literature. We reviewed outcomes in patients with SCC of the rectum treated with definitive chemoradiation at a single institution.

MATERIALS AND METHODS

We identified 14 patients treated definitively with chemoradiation for SCC of the rectum. All patients were female and the median age was 56 years at presentation. Patients were treated with external beam radiation therapy with a median dose of 54 Gy (range, 38 to 58.8 Gy). All patients received concurrent chemotherapy, with 5-flourouracil and cisplatin in 10 patients and capecitabine and cisplatin in 4 patients.

RESULTS

The median follow-up was 4.5 years (range, 1.8 to 16.3 y). Only 3 of the 14 patients had relapse or persistent disease, and 2 of these underwent successful salvage surgery. The remaining 11 patients had no evidence for local or distant relapse after chemoradiation. Only 1 patient died of SCC of the rectum, 1 died of a second primary, and 12 are alive with no evidence of disease. The 5-year actuarial overall survival, disease-free survival, and disease-specific survival rates were 81%, 72%, and 88% respectively.

CONCLUSIONS

Chemoradiation is an ideal strategy for definitive therapy of SCC of the rectum with excellent disease-free survival and overall survival. In patients with local failure, salvage surgery can provide excellent outcomes.

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.

Squamous Cell Carcinoma of the Anal Transitional Zone after Ileal Pouch Surgery for Ulcerative Colitis: Systematic Review and Treatment Perspectives

BACKGROUND

Few cases of pouch-related cancers have been reported in ulcerative colitis (UC), and squamous cell carcinoma (SCC) is very rare.

METHOD

A systematic review of the literature was performed to identify all unequivocal cases of pouch-related SCC in UC patients.

RESULTS

Eight cases of SCC developing after ileal pouch-anal anastomosis (IPAA) have been observed since 1978. Two arose from the pouch mucosa and 6 from below. The pooled cumulative incidence of SCC is below 0.06% after IPAA. Many patients had neoplasia on the preoperative specimen, but squamous metaplasia of the pouch or anorectal mucosa may have an important role in SCC. These patients are rarely offered chemoradiation therapy and the outcome is poor. Selected patients with SCC located close to the pouch outlet can be treated with chemoradiation prior to consideration of surgery and salvage their pouch. A chemoradiation regimen is suggested to avoid pouch excision in these patients.

CONCLUSIONS

SCC is rare after pouch surgery but associated with extremely poor survival. Very low SCC can be managed with chemoradiation treatment, preserving the pouch and avoiding surgery, even in older patients. The role of pouch metaplasia, surveillance frequency, and treatment modalities after IPAA need further studying.

Complete pathologic response after chemoradiotherapy in a patient with rectal squamous cell carcinoma: a case report

Squamous cell carcinoma (SCC) of the rectum is a rare disease. A 59-year-old man presented with SCC of the middle rectum located 10 cm from the anus. The stage of the tumor was revealed to be T3N+M0. The patient received a combined treatment with cisplatin and fluorouracil in concomitance with external radiation therapy. He then underwent an anterior resection of the rectum. The postoperative histopathological findings classified the tumor as ypT0N0 with cancer-free margins and lymph nodes. Treatment of SCC remains very challenging, and the acquisition of more consistent data is needed.

[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.

Efficacy of Immunohistochemical Staining in Differentiating a Squamous Cell Carcinoma in Poorly Differentiated Rectal Cancer: Two Case Reports

A rectal carcinoma, including primary an adenosquamous and a squamous cell carcinoma (SCC), is a very rare disease, accounting for 0.025% to 0.20% of all large-bowel malignant tumors. Because SCCs have a higher mortality than adenosquamous carcinomas, determining whether the primary rectal cancer exhibits an adenomatous component or a squamous component is important. While differentiating between these 2 components, especially in poorly differentiated rectal cancer, is difficult, specific immunohistochemical stains enable accurate diagnoses. Here, we report the use of immunohistochemical stains to distinguish between the adenomatous and the squamous components in 2 patients with low rectal cancer, a 58-year-old man and a 73-year-old woman, who were initially diagnosed using the histopathologic results for a poorly differentiated carcinoma. These data suggest that using these immunohistochemical stains will help to accurately diagnose the type of rectal cancer, especially for poorly differentiated carcinomas, and will provide important information to determine the proper treatment for the patient.

Primary squamous cell carcinoma of the rectum: a case report and literature review

Squamous cell carcinoma (SCC) of the rectum is a rare occurrence with an incidence rate of 0.1–0.25% per 1,000 cases. Herein, we report a case of a 52-year-old female who presented with a 2-month history of diffuse lower abdominal pain and hematochezia. Abdominal CT scan revealed a 7-cm irregular rectal mass, and the biopsy showed SCC.

Squamous cell carcinoma of the rectum: a consequence of immunosuppression resulting from inhibiting tumour necrosis factor (TNF)?

Treatment with tumour necrosis factor (TNF) antagonists may lead to enhanced susceptibility to certain malignancies. In particular, an association is seen emerging between TNF antagonists and development of squamous cell carcinomas (SCCs) of the skin (in association with psoriasis), the oral cavity, and in the anogenital areas (possibly related to prior human papilloma virus infection). We present here a case of a 53-year old woman with a history of severe rheumatoid arthritis (RA), most recently treated with the TNF antagonist etanercept plus methotrexate, presented to our service after several months of increasing left pelvis and buttock pain. Evaluation with a computerised tomography (CT)-directed biopsy of a pelvic side wall mass revealed a metastatic SCC. On a fluorodeoxyglucose (FDG) positron-emission tomography (PET) an additional area of uptake was identified in the left posterior rectum corresponding to a 1 cm nodule palpable on digital exam. Colonoscopic biopsy revealed a basaloid SCC of the rectum as the likely primary site. Immunosuppression following TNF antagonist therapy may have given arise to this unrestrained neoplastic growth. It thereby underscores the need for an initial baseline study of risk factors and identification of patients who are at higher risk for development of a malignancy, in order to achieve a diagnosis at an early stage.

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.

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.

Radiochemotherapy Versus Surgery in Nonmetastatic Anorectal Neuroendocrine Carcinoma: A Multicenter Study by the Association des Gastro-Entérologues Oncologues

Neuroendocrine carcinomas (NEC) of the anus or the rectum are a rare disease, accounting for less than 1% of all digestive malignancies. Most are metastatic at diagnosis and treated with a platinum-based chemotherapy. No guidelines for localized tumors exist. The purpose of this study was to describe the characteristics of anorectal localized NEC, their management and their outcomes.We retrospectively reviewed patients from 11 French centers with anorectal localized NEC. We compared 2 therapeutic managements: surgery (group A) versus chemotherapy with or without radiation (group B). Progression-free survival (PFS) and overall survival (OS) were estimated with the Kaplan-Meier method.A total of 24 patients were identified with a median follow-up of 25 months (3-60 months). Median age was 63 years old and 17 had a rectal tumor (71%). Mean Ki-67 was 72% (range: 20-100), and 75% of the tumors had a high proliferative index (Ki-67 > 50%). Global PFS and OS were 13.1 and 44.1 months, respectively. Thirty-seven percent of patients were in group A and 63% in group B. There was no difference between group A and group B, whether in terms of PFS (13.0 months vs. 13.2 months, P = 0.75) or OS (49.1 months vs. 39.2 months, P = 0.42).In patients with anorectal localized NEC, chemotherapy with or without radiation obtained a similar outcome as surgery and this conservative approach could be deemed a reasonable option.

Adenosquamous Cell Carcinoma of the Rectum in a Girl: First Case Reported and Review of the Literature

Adenosquamous carcinoma is a rare colorectal tumor with few cases described in the literature; no children have been reported. A 12-year-old-girl presented tenesmus, diarrhea, and iron deficiency anemia. Intestinal bowel disease was suspected, colonoscopy and biopsy were performed and the diagnosis was a squamous cell carcinoma. Chemoradiation therapy based on last colorectal cancer guidelines was started. Complete regression of the primary tumor was observed with lymph node progression. The pathology report of the lymphadenectomy revealed metastasis of adenosquamous carcinoma, although there was not any adenomatous component in the first biopsy. The patient presented progression with liver metastases, despite stable local disease due to response to first-line treatment of the squamous component.

Squamous Cell Carcinoma of Rectum: How to Treat?

Squamous cell carcinoma (SCC) of rectum is an uncommonly seen malignancy. It has been difficult to establish the precise etio-pathogenesis due to paucity of cases. For the same reason, the rigorous treatment protocol has not been defined. The available compendium of knowledge about this pathology is based on isolated case reports and case series. We report a case of SCC of rectum who was treated with chemo-radiotherapy.

Squamous cell carcinoma of the rectum: The treatment paradigm

PURPOSE

This study was planned to clarify the optimal treatment for squamous cell carcinoma of the rectum, an histological entity extremely rare.

METHODS

Ten patients with histologically proven squamous cell carcinoma of the rectum were treated with concomitant radiochemotherapy. Radiation therapy was delivered with a 3Dconformational multiple field technique to a dose ranging from 45 to 76.5 Gy, with 6-15 MV energy photons. Chemotherapy consisted of an antimetabolite drug in association with mitomycin C or oxaliplatin. Overall survival and disease free survival were considered in months from the end of the concomitant treatment.

RESULTS

All patients completed programmed radiochemotherapy treatment but two patients were excluded to the analysis. Six patients (75%) presented negative biopsy 6 months after the end of radiochemotherapy. Seven patients (87.5%) showed a tumour regression after initial treatment. Only 1 patient underwent salvage surgery. Considering a mean follow-up of 41.75 months, 7 patients are still disease free survivors. Only 1 patient developed local recurrence at 6 months and he died 14 months after abdomino-perineal resection.

CONCLUSION

Primary radio chemotherapy, with a curative intent, could be considered the treatment modality of choice for squamous carcinoma of the rectum.

Chemoradiation therapy with S-1 for primary squamous cell carcinoma of the rectum: report of three cases

Purpose

Although successful treatment of squamous cell carcinoma (SCC) of the rectum using chemoradiation therapy (CRT) has been reported, a standard protocol has yet to be established. The aim is to ascertain the effectiveness of CRT with S-1 for three patients with SCC of the rectum.

Case presentation

We treated three female patients complaining of rectal bleeding. The patients were diagnosed as having primary SCC of the rectum by means of routine examinations; one of them was a very rare case because of the presence of two lesions in the lower rectum. We treated the patients using CRT with S1 at a radiation dose of 1.8 Gy/fraction given five times weekly (Monday to Friday) to a median dose of 59.4 (45 to 59.4) Gy; S-1 (80 mg/m²/day) was administered orally during radiation therapy. One of three patients had an adverse event involving massive hemorrhage from the tumor. All patients exhibited an excellent response to CRT with S-1; two patients had a complete response, and one patient had a partial response and underwent a posterior pelvic exenteration with advancement flap reconstruction as a salvage treatment. Pathological examination of the resected specimen and lymph nodes revealed no tumor cells indicating a pathological complete response. In this series, the response rate was 100%.

Conclusions

We suggest that CRT with S-1 be chosen as the first-line therapy for SCC of the rectum. However, a large study will be required to establish a safe and effective regimen.

Nonoperative management of squamous-cell carcinoma of the rectum

BACKGROUND

Radiochemotherapy without surgical resection has become the treatment of choice for anal squamous-cell carcinoma. The optimal treatment for rectal squamous-cell carcinoma is not well established.

OBJECTIVE

The purpose of this work was to assess the efficacy of nonoperative strategies in the management of primary rectal squamous-cell carcinoma.

DESIGN

We retrospectively reviewed data from all of the patients with documented rectal squamous-cell carcinoma who were treated with conservative strategies in a single institution. Concomitant radiochemotherapy was proposed to all except 1 patient. The remaining patient was treated by radiotherapy alone given his impaired functional status. All of the patients were treated with conformal or intensity-modulated radiation therapy. Surgical resection was reserved for persistent disease or relapse.

SETTING

This study was conducted in a single tertiary institution.

MAIN OUTCOME MEASURES

After a mean follow-up of 56 months, 2 patients experienced relapse and no patients died.

RESULTS

Eleven patients were included in the series. The clinical response to radiotherapy was complete for 7 patients. The remaining 4 patients underwent salvage surgery. The pathologic response was incomplete for 2 of the 4 patients. One recurrence occurred outside the field of radiotherapy and was successfully treated by radiotherapy. The second was a local recurrence, which occurred on a patient who was treated with radiotherapy alone.

LIMITATIONS

The number of patients included in this retrospective series was limited because of the rarity of the disease. Patients were treated with nonhomogeneous conservative strategies because of modification in the therapeutic strategy for anal squamous-cell carcinoma and of the adaptation of the treatment to patient comorbidities and functional status.

CONCLUSIONS

This series demonstrates that good results can be obtained by using a rectum-conserving strategy. Close follow-up should be maintained, with the use of salvage surgery reserved only for persistent disease or relapse (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A155).

Squamous cell carcinoma of the middle rectum: Report of a case and literature overview

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We report a case of squamous cell carcinoma of middle rectum, with literature review (International Journal of Surgery Case Reports 2014; 5: 86–90).

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The report we describe was characterized by the presence of a squamous cell carcinoma of the middle rectum and a synchronous ureteral tumor.

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The patient had undergone pelvic irradiation for prostate cancer seven years before, thus suggesting aforementioned treatment as possible cause.

INTRODUCTION

Squamous-cell carcinoma (SCC) of the middle rectum is a rare disease with an estimated incidence of 0.1–0.25/1000 colorectal neoplasms. Literature is represented essentially by case report and short series, and only seventy-six cases of colorectal squamous carcinoma have been documented in literature.

PRESENTATION OF CASE

We report the case of a SCC of the middle rectum, associated to an ureteral inverted papilloma, occurred in a patient with a past history of prostate cancer treated with prostatectomy and radiotherapy.

DISCUSSION

Colorectal squamous-cell carcinoma is a rare disease. This localization is more frequent than the right colon, but no more epidemiological informations are actually available apart from a slight predominance of the female sex. Risk factors for SCC of the rectum are unknown and many hypotheses have been evocated. Because of its rarity, the interpretation of available information is clouded by a lack of uniformity in diagnosis and treatment.

CONCLUSION

Treatment of SCC remains very challenging, and the acquisition of more consistent data is needed.

An interesting case of primary squamous cell carcinoma of the colon with synchronous metastatic adenocarcinoma

KEY CLINICAL MESSAGE

We present a case of primary squamous cell carcinoma of the colon with synchronous metastatic adenocarcinoma. This case highlights the poor prognosis of these late presenting cancers. Furthermore, the unusual dual pathology raises questions about its potential etiology.

Primary rectal squamous cell carcinoma treated with surgery and radiotherapy

Primary squamous cell carcinoma of the rectum is a rare malignancy, and the discrete dual lesions of rectum are even rarer. There is currently no effective and satisfactory treatment for this disease. Here we report a case of an elderly female with bi-primary squamous cell carcinoma of the rectum treated with radical resection and radiotherapy. The patient is still alive 43 mo after the initial curative resection of the tumor. We suggest that surgery as the primary treatment followed by concomitant radiotherapy may be an effective protocol for elderly patients with rectal squamous cell carcinoma.

Primary squamous cell carcinoma of the most distal rectum: a dilemma in origin and management

Squamous cell carcinoma (SCC) of the rectum is a rare malignant entity that has been classically managed with a surgery-based approach, which included abdominoperineal resection for distal lesions. Recently there have been reports on the favourable outcomes achieved with the non-surgical management of these patients. We report a case of a 52-year-old woman who was diagnosed with a stage IIIa SCC located on the distal rectum. The patient was managed conservatively with a chemoradiation regime with mitomycin and 5-fluorouracil. Complete remission was achieved and she is currently alive, asymptomatic and disease-free after 30 months. This case adds to the existing evidence that supports the role of chemoradiation as a first-line curative treatment for the rare rectal SCC.

Rare tumors of the rectum. Narrative review

Most rectal neoplasms are adenocarcinomas, but there is a small percentage of tumors which are of other histological cell lines such as neuroendocrine tumors, sarcomas, lymphomas and squamous cell carcinomas, which have special characteristics and different treatments. We have reviewed these rare tumors of the rectum from a clinical and surgical point of view.

Squamous cell carcinoma of middle rectum: Literature review

INTRODUCTION

Squamous cell carcinoma SCC of the rectum is a distinct entity. We report a very rare case of squamous cell carcinoma of the middle rectum.

PRESENTATION OF CASE

The patient was a 62-year-old woman who presented with a history of rectal bleeding and discomfort. Colonoscopy revealed a polypoid tumour of the middle rectum. Biopsies of this mass revealed a poorly differentiated SCC of the rectum. CT scan of the chest, abdomen and pelvis was negative for distal metastases. The patient received combined chemo-radiation followed by surgical excision. The postoperative period was uncomplicated.

DISCUSSION

The pathogenesis of rectal SCC remains unclear and diagnosis is often delayed. Diagnostic criteria have been proposed. MRI of the rectum and trans-rectal endoscopic ultrasound R-EUS provide essential information to plan a therapeutic approach. The squamous cell carcinoma antigen level is not suitable for initial diagnosis of rectal SCC. Most authors conclude that the surgery is the gold standard treatment. Tumour stage is the most important prognostic predictor of SCC.

CONCLUSION

Squamous cell carcinoma of the rectum is a distinct entity. Before the final choice of treatment is made, digestive surgeons should bear in mind this rare tumour.

Early recurrence and progression of a rare rectal squamous cell carcinoma after initial response to primary chemoradiotherapy

Rectal squamous cell carcinomas represent an extremely rare malignancy which carries a significant morbidity and mortality. Diagnosis requires distinction from squamous cell carcinoma of the anus and colonic adenocarcinoma by endoscopy and histopathological examination of a biopsy. Due to the rarity of the pathology, available evidence is limited and optimum management has yet to be elucidated. Older reports favored radical surgical management, but recent reports in the literature recommend judicious use of primary chemoradiotherapy. We herein report the diagnosis and management of a male patient with an aggressive, locally advanced rectal squamous cell carcinoma treated with good results with primary chemoradiotherapy. Six months after completion of therapy, however, extensive recurrence and metastases were diagnosed. This case highlights the need for stringent clinical and radiological follow-up.

Squamous cell carcinoma of the rectum: a single institution experience

BACKGROUND

Squamous cell carcinoma (SCC) of the rectum is a rare disorder. There is currently no effective method as to how best treat patients with this condition. The purpose of this study was to review a single tertiary institution's experience.

METHODS

A retrospective chart review was conducted of all patients who presented with documented SCC of the rectum over a 10-year period (2000-2010). During the study period, all patients were offered chemoradiation as an initial treatment modality [a fluorouracil (5-FU)-based regimen in conjunction with mitomycin or cisplatin].

RESULTS

Six patients presented with primary rectal SCC. Mean patient age was 60 years. The majority of patients were female (83 %). The most common presenting symptom was rectal bleeding (67 %). The mean distance from the inferior tumor margin to the anal verge was 6 cm. Two patients (33 %) presented with stage II disease, and 4 (67 %) were stage III. Five patients (83 %) received chemoradiation therapy initially, and 1 patient underwent abdominoperineal resection after refusing chemoradiation. Two additional patients (33 %) underwent salvage surgery. During a mean follow-up of 44 months, 4 patients (66 %) were alive without evidence of disease.

CONCLUSIONS

Based on the results of this cases series, chemoradiation as an initial primary therapy appears to be beneficial for patients with primary SCC of the rectum. A 5-FU chemotherapy-based regimen in conjunction with fractionated radiotherapy appears to be effective for local control of the disease.

Rectal squamous cell carcinoma treated with chemoradiotherapy: report of six cases

PURPOSE

Squamous cell carcinoma (SCC) of the colon and rectum is a rare pathologic entity. From May 2006 to August 2008 six consecutive patients with SCC of the rectum were treated at our institution. A retrospective analysis of these cases was performed in order to evaluate the role of chemoradiotherapy as an alternative to surgery.

METHODS

All tumors were locally advanced and the clinical stage was T3N0M0 in three cases, T3N1M0, T4N1M0 and T3N2M1 in the other three cases. All patients received primary chemoradiation reserving surgery for unresponsive or recurrent tumors except in one of complete responders. Radiation treatment was given to standard pelvic volume up to 50.4 Gy in 28 fractions, with a boost to the primary tumor up to 59.4 Gy in two patients.

RESULTS

A complete clinical response with a negative endoscopic biopsy was achieved in four patients and a partial response in two. Surgery as a part of the primary treatment was performed in the non-metastatic patient with partial response and in the first patient with complete response. At a median follow-up of 39 months (range, 24-41) from the end of chemoradiotherapy, five out of six patients remain alive and free of recurrence, three of them without having undergone surgery.

CONCLUSION

Our data, though from a small series, give support to the hypothesis that concomitant chemoradiation may be considered a safe and effective therapeutic approach for patients with rectal SCC.

Squamous cell carcinoma of rectum presenting in a man: a case report

BACKGROUND

Primary squamous cell carcinomas of the colorectum are very uncommon. Until now, to the best of our knowledge, only 114 cases of squamous cell carcinoma in the colorectum exist in the reported literature. Here we report a case of squamous cell carcinoma of the rectum in the ethnic Kashmiri population in northern India.

CASE PRESENTATION

The case of a 60-year-old male patient (Asian) with a pure squamous cell carcinoma of the rectum is presented here. The patient underwent a curative surgery with concomitant chemotherapy. Two years after the initial curative resection of the tumor he is still alive.

CONCLUSION

The prognosis for squamous cell carcinoma of the colorectum is worse than for that of adenocarcinoma, because of the delayed diagnosis. The etiopathogenicity of squamous cell carcinoma of the colorectum is discussed. Surgical resection of the lesion seems to be the treatment of choice. Chemotherapy also helps in improvement of the prognosis.

Chemoradiation as definitive treatment for primary squamous cell cancer of the rectum

In this report, we present a case of advanced squamous cell cancer located in the rectum of a 78-year-old woman treated with chemoradiation with curative intent. The patient showed a complete clinical response to chemoradiation; multiple biopsies were performed at the site of the previous mass 5 mo after the end of treatment and histological examination showed no residual tumour in the specimens. Surgical intervention was avoided and the patient was free of disease 12 mo after the diagnosis of cancer. Primary chemoradiation should be considered as the treatment of choice for this rare malignancy.