Perianal Paget's disease as spread from non-invasive colorectal adenomas.

AIMS: Paget's disease of the perianal skin is a rare form of extramammary Paget's disease, and may be a primary intraepithelial adnexal neoplasm or secondary due to spread from an underlying colorectal lesion, nearly always colorectal adenocarcinoma. Secondary perianal Paget's disease associated with non-invasive colorectal adenomas is exceedingly uncommon, with only a few reported cases. METHODS AND RESULTS: Herein, we present the clinical and pathological features of the largest series of secondary perianal Paget's disease arising in association with colorectal adenomas. There was gender parity and the median age was 72 years (range = 68-76 years). In all cases, perianal Paget's disease was associated with colorectal adenomas, including three (75%) conventional tubular adenomas and one (25%) tubulovillous adenoma with serrated foci. All adenomas had high-grade dysplasia and one had intramucosal adenocarcinoma (lamina propria invasion; Tis), but all lacked submucosal invasion. The intraepithelial Paget's cells showed a colorectal phenotype by immunohistochemistry in all cases. At follow-up, two patients had no evidence of disease at 6 and 87 months, one had residual perianal Paget's disease at 8 months and one developed invasive adenocarcinoma of the perianal tissue at 36 months. CONCLUSIONS: Similar to its mammary analogue, secondary perianal Paget's disease may arise in association with invasive and/or in-situ colorectal lesions. Although the latter is an uncommon presentation of a recognised rare disease, knowledge of this phenomenon is important to forestall overdiagnosis of invasion and potential overtreatment. The clinical course is variable, such that close follow-up is required.

Anal Metastasis from Lung Cancer: Report of a Case and Systematic Review of the Literature.

Background: Lung cancer is the most frequent cancer, accounting for over 2 million new cases per year worldwide. In Romania, the cancers with the highest incidence are lung cancer for men and breast cancer for women. Cancer-related deaths follow the same pattern. More than 50% of the patients with lung cancers have distant metastases at the time of diagnosis. Metastases from lung cancer occur mainly in the brain, bones, liver, and adrenals. Anal metastases from primary lung cancer are extremely uncommon. As far as we know there are only 12 cases reported in the literature until now. Case report: Case report and systematic review. We performed a systematic literature search in PubMed using the following MeSH terms: "lung cancer metastasis" AND "anal" OR "anus" OR "perianal". The search was conducted from the beginning of the database onwards. No language exclusion criteria were used. We report the case of a patient with advanced lung adenocarcinoma presenting with a painful, ulcerated and bleeding anal tumor. The anal tumor was excised with primary wound closure in spinal anesthesia. The pathology report and the immunohistochemistry of the specimen revealed metastasis of the lung adenocarcinoma. The review included 12 papers reporting 12 cases. The male/female ratio was 3/1. The average age was 62,16 years. Among these 12 patients, one had a SCLC. From the remaining 11 cases with NSCLC, 4 were adenocarcinomas, 4 squamous cell carcinomas, two anaplastic carcinomas and one mucoepidermoid carcinoma. The anal metastases were synchronous in 4 cases and metachronous in the rest of 8 cases. Since 2006 immuno-histochemistry plays an important role in the diagnosis of these metastases. Conclusions: Our patient presented an anal metastasis of a lung adenocarcinoma that was masquerading as a complicated hemorrhoidal disease. Because anal masses can be easily misdiagnosed, patients with lung cancers and anal or perianal complaints should be evaluated for metastatic disease. Medical teams that are managing such cases must be aware of this rare but possible situation. Immunohistochemistry plays an important role in establishing the diagnosis for the anal or perianal tumours in patients with lung cancer.

Prostate cancer solitary metastasis to anal canal: case report and review of literature.

BACKGROUND: Here we present the first cases of prostate cancer solitary metastasis to anal canal. CASE PRESENTATION: A 67-year-old male patient underwent radical prostatectomy with ilio-obturator lymphonodectomy in 2016 due to poorly differentiated ductal adenocarcinoma (Gleason 4 + 5(40%) = 9) pT3bN0. Two months later increasing PSA rate was noted and the patient started adjuvant intermittent androgen deprivation therapy combined with radiotherapy. Year after patient was admitted to the hospital complaining of dyschezia, pain in anal canal, and bloody stool. Digital rectal examination revealed an anal fissure with ulceration. A biopsy from ulcerated area showed poorly differentiated ductal adenocarcinoma of the prostate. Because there was no evidence of distant metastases on abdominal computed tomography (CT) scan and pelvic magnetic nuclear resonance imaging (MRI) and the only metastasis was in anal canal patient underwent laparoscopic abdominoperineal resection (APR). Postoperative course was uneventful and patient was discharged at postoperative day 7. CONCLUSIONS: Our presented case is the first to describe prostate cancer solitary metastasis to anal canal and we always have to be aware of possible rare disease while assessing the patient with rectal bleeding. Biopsy most of the time is the only and the most reliable test to differentiate between the diseases.

Anorectal metastasis from breast carcinoma: a case report and review of the literature.

BACKGROUND: Gastrointestinal metastasis from primary breast carcinoma is uncommon, anorectal involvement is extremely rare. CASE PRESENTATION: We present the case of a 65-year old woman who underwent treatment for an infiltrative lobular carcinoma of the left breast with bone metastases and who developed metastasis of the rectum and anal canal 4 years later. CONCLUSIONS: A patient with a history of breast cancer, especially lobular carcinoma, presenting with anorectal symptoms, should raise the suspicion of metastatic disease.

[A Case of Metastatic Carcinoma of Anal Fistula].

A 58-year-old man underwent rectal resection(D2 dissection)for rectal cancer and liver/lung metastases in August 2009. Histopathological findings were Ra, type 2, 70×80mm, tub1>tub2, int, pSI(peritoneum), INF b, ly1, v1, pN1(2/13), pPM0, pDM0, M1a(H1, PUL1), fStage IV . The lung metastasis had disappeared on chest CT after postoperative chemotherapy and we were able to perform radical resection of the liver metastasis by performing hepatectomy twice. In October 2013, anal pain appeared and a painful tumor approximately 2 cm in size was found in the 5 o'clock direction of the anus. Biopsy revealed a well-differentiated tubular adenocarcinoma similar to rectal cancer, and it was diagnosed as a fistula metastasis of rectal cancer.We performed chemoradiotherapy(S-1 120mg/day plus RT 60 Gy/30 Fr)as surgery was recommended but refused. As a result, the tumor reduced markedly in size. In December 2015, the tumor enlarged in size and the patient and family requested surgery. We, therefore, performed abdominoperineal resection. Currently, the patient is alive at 18 months after surgery with no recurrence.

[A Case Report of Anal Canal Squamous Cell Carcinoma with Poor Prognosis That Occurred Nine Years after Subtotal Colectomy for Ulcerative Colitis].

Ulcerative colitis(UC)is a chronic inflammatorydisease. Since it is known to be a risk factor for colorectal cancer, severe cases, refractorycases, or cases with cancer are often treated with surgery. We report a case of anal canal squamous cell carcinoma(SCC)found 9 years after subtotal colectomy for UC. A 32-year-old man underwent subtotal colectomyand ileorectum anastomosis 9 years ago for fulminant UC. Anemia was detected during treatment with infliximab, which was initiated 2 years ago. Endoscopic findings revealed a type 3 tumor at the anal canal in the anastomotic region, and he presented to our department. Further examination confirmed the diagnosis of anal SCC. Multimodalitytherapywas performed; however, the patient died 9 months after the first presentation to our hospital. UC has a high incidence of juvenile onset and is associated with increased risk for developing cancer; therefore, considering this case, we want to emphasize on the importance of long- term surveillance.

[Abdominoperineal Resection for Anal Metastasis of Rectal Cancer].

Anal metastasis of colorectal cancer is rare, and no standardized effective therapeutic strategy exists. We report a case of abdominoperineal resection for anal metastasis of rectal cancer. A 65-year-old man underwent laparoscopic low anterior resection for rectal cancer in August 2013. Histopathological examination revealed a moderately differentiated adenocarcinoma( tub2, pSS, ly3, v2, pN1, H0, P0, M0, Stage III a, Cur A). In February 2015, he complained of anal discomfort, and tumor markers were elevated. Enhanced CT revealed a 15-mm high-density solid tumor in the anal canal. The results of needle biopsy indicated a moderately differentiated adenocarcinoma. This tumor was suspected to be metastasis from rectal cancer, and we performed abdominoperineal resection. Histopathological examination revealed a moderately differentiated adenocarcinoma, which was the same histological type as the primary rectal cancer and was covered with normal anal epithelium. Collectively, the findings indicated anal metastasis from rectal cancer. The patient is alive without recurrence for 18 months after resection. Anal metastasis should be considered as a differential diagnosis in patients with anal discomfort who have a history of colon/rectal cancer. Abdominoperineal resection may be an effective treatment modality for this condition.

Anal metastasis from rectal adenocarcinoma.

The metastasis of rectal cancer to the anus is rare. Here, we report a case of advanced rectal cancer, which had a diffuse venous invasion with anal metastasis and multiple lymph node and liver metastases. The patient was a 72-year-old woman who complained of perianal pain and fresh blood in the stools for 6 months. She had neither history of fistula-in-ano nor anal surgery. Digital examination revealed a 2-cm tumor at the 7 o'clock position, and the barium enema and colonoscopy confirmed advanced rectal cancer. Abdominal computed tomography revealed thickness of the upper rectum wall, right inguinal lymph node of 10 mm and multiple liver metastases. Laparoscopically assisted anterior resection, anal tumor resection, and right inguinal lymph node resection were performed, and the histopathological examination of the resected primary and metastatic tumors confirmed similar findings of moderately differentiated adenocarcinoma, suggestive of metastasis of the rectal cancer to the anal region. In the next procedure, she had the liver lesions resected. This case suggested the importance of the careful examination of the anus during colonoscopy, or digital examination for the detection of anal metastasis.

Rare occurrence of metastasis from lung cancer to the anus: case report and review of the literature.

BACKGROUND: Anal metastases from lung cancer are infrequent, and there are only 10 published cases. Life expectancy is no longer than 1 year after diagnosis because of the typically advanced stage of disease. Treatment, which is typically inefficient, is administered with the intent to cure or avoid local complications. CASE PRESENTATION: We report a case of a patient with non-small cell lung cancer presenting with perianal metastasis mimicking an abscess. CONCLUSIONS: Because perianal masses may be misdiagnosed, patients with lung and other cancers should be evaluated for metastatic disease.

Non-small cell lung carcinoma metastasis to the anus.

A 70-year-old man presenting with a lung mass was investigated and treated with pneumonectomy for adenocarcinoma of the lung. He re-presented 3 months later with a large perianal abscess and mass. Subsequent investigations and biopsies showed disseminated metastases from the lung primary. Immunohistochemical staining confirmed the nature of the anal metastasis from the lung adenocarcinoma. Lung cancer is notorious for metastases, hence it is important to be aware of the uncommon modes of spread, which will help obtain early diagnosis and optimise treatment.

Preliminary Suggestion about Staging of Anorectal Malignant Melanoma May Be Used to Predict Prognosis.

PURPOSE: Anorectal malignant melanomas (AMM) are rare and have poor survival. The study aims to evaluate the clinicopathologic characteristics and outcomes of patients with AMM, and to devise a staging system predictive of survival outcome. MATERIALS AND METHODS: This was a retrospective study of 28 patients diagnosed with, and treated for AMM. Patients classified by clinical staging of mucosal melanoma (MM) were reclassified via rectal and anal TNM staging. Survival outcomes were compared among patients grouped by the three different staging systems. RESULTS: The three staging systems were equated with similar figures for 5-year overall survival (OS) and 5-year disease-free survival (DFS) of patients diagnosed with stage I disease. Patients (n=19) diagnosed with MM stage II disease were reclassified by rectal TNM staging into three subgroups: IIIA, IIIB, and IIIC. For these patients, both 5-year OS and 5-year DFS differed significantly between the subgroups IIIA and IIIC (OS: IIIA vs. IIIC, 66.7% vs. 0%, p=0.002; DFS: IIIA vs. IIIC, 51.4% vs. 0%, p < 0.001). CONCLUSION: The accuracy of prognosis in patients diagnosed with AMM and lymph node metastasis has improved by using rectal TNM staging, which includes information regarding the number of lymph node metastases.

Primary colonic adenocarcinoma diagnosed with cutaneous shave biopsy.

A 67-year-old man presented to the emergency department with chronic weakness, fatigue and failure to thrive. On physical examination, he was found to have multifocal exophytic cutaneous masses in the pubic and scrotal regions. We obtained a shave biopsy, and subsequent histopathology demonstrated non-native tissue consistent with metastasis from a primary adenocarcinoma. We report this novel case of anogenital cutaneous metastases of colorectal adenocarcinoma.

KIT genetic alterations in anorectal melanomas.

BACKGROUND: Mucosal melanomas (MM) represent a heterogeneous tumour population that exhibits site-specific molecular profiles. AIMS: In a multicentre retrospective study, we investigated KIT aberrations in primary anorectal (AR) melanomas compared with melanoma metastatic to the gastrointestinal (GI) tract. METHODS: Primary AR MM (n=31) and GI metastatic melanoma (n=27) were studied for KIT mutations on exons 11, 13, 17 and 18 by high-resolution melting analysis, direct sequencing and c-KIT expression by immunohistochemistry. Selected cases were also investigated for increased KIT gene copy number by fluorescent in situ hybridisation. RESULTS: Functional KIT mutations were demonstrated in 11/31 (35.5%) of AR melanomas and in 1/26 (3.8%) of GI melanoma metastases (p=0.004). A significant difference emerged between primary and metastatic MM with regards to KIT-positive immunostaining (p=0.002). Immunohistochemical c-KIT protein overexpression did not correlate with KIT mutational status. Increased KIT copy number was demonstrated in 5/20 AR primary cases. CONCLUSIONS: The rate of functional mutations in KIT is significantly higher in AR MM than in GI metastatic melanoma. KIT protein overexpression does not correlate with KIT mutations and cannot be used for screening purposes. Recognising the molecular heterogeneity of MM helps to identify patients who require a different therapeutic approach.

Perianal metastasis of non-small cell lung cancer.

We herein present the case of a 36-year-old woman who developed perianal metastasis of non-small cell lung cancer that was diagnosed based on the presence of symptoms mimicking a hemorrhoid. The patient initially underwent radiotherapy for a left superior sulcus tumor, then subsequently complained of a perianal mass that had prolapsed and bled. The tumor was removed via resection. Histologically, the mass was diagnosed as poorly differentiated carcinoma and considered to be a metastatic lesion arising from the primary lung cancer.

Colonic and anal metastases from pancreato-biliary malignancies.

Pancreato-biliary malignancies often present with locally advanced or metastatic disease. Surgery is the mainstay of treatment although less than 20% of tumours are suitable for resection at presentation. Common sites for metastases are liver, lungs, lymph nodes and peritoneal cavity. Metastatic disease carries poor prognosis, with median survival of less than 3 mo. We report two cases where metastases from pancreato-biliary cancers were identified in the colon and anal canal. In both cases specific immunohistochemical staining was utilised in the diagnosis. In the first case, the presenting complaint was obstructive jaundice due to an ampullary tumour for which a pancreato-duodenectomy was carried out. However, the patient re-presented 4 wk later with an atypical anal fissure which was found to be metastatic deposit from the primary ampullary adenocarcinoma. In the second case, the patient presented with obstructive jaundice due to a biliary stricture. Subsequent imaging revealed sigmoid thickening, which was confirmed to be a metastatic deposit. Distal colonic and anorectal metastases from pancreato-biliary cancers are rare and can masquerade as primary colorectal tumours. The key to the diagnosis is the specific immunohistochemical profile of the intestinal lesion biopsies.

[Trans-anal resection for recurrence of a very low rectal anastomosis at the suture line after colorectal cancer surgery].

When a relatively small anastomotic recurrence of colorectal cancer is detected in the low rectum, trans-anal resection (TAR) might be an option both for curative intent and for preservation of anal function. We report 3 such cases. Case No. 1: A 58-year-old woman presented with an anastomotic recurrence of sigmoid colon cancer. Low anterior resection(LAR)was performed. Two small recurrent nodules were detected at the suture line 1 year after LAR, which were successfully treated with TAR. The depth of the nodules indicated T2 cancer. The patient remained cancer free 5 years after TAR. Case No. 2: A 56-year-old man developed a severe anastomotic stenosis and an anastomotic recurrence 6 months after LAR for low rectal cancer. TAR was performed circumferentially to resect both the stricture and the recurrence. The depth of the nodule indicated T2 cancer. The patient was cancer free for 7 years after TAR. Case No. 3: A 54-year-old man developed 2 small recurrent nodules at the suture line after LAR for low rectal cancer. TAR was performed. The depth of the nodule indicated T1 cancer. One of the nodules was not resected, which necessitated intersphincteric resection (ISR) 10 months later. In conclusion, in cases of a relatively small recurrence of low rectal anastomosis after colorectal cancer surgery, TAR is an effective treatment option.

[A case of rectal cancer treated with aggressive surgery for liver and anal metastases].

A 64-year-old man underwent laparoscopic surgery for rectal cancer and lateral lymph node dissection. The histopathological findings indicated adenocarcinoma (moderate>well), pA, pN3(4/25No 263 1/1), pM0, Stage IIIb. After the surgery, he received 12 courses of adjuvant chemotherapy with modified 5-fluorouracil Leucovorin oxaliplatin (mFOLFOX6). Liver metastasis( S8)was present, and open hepatectomy was performed 1 year after the first surgery. Three months after the second surgery, the carcinoembryonic antigen (CEA) level increased and chemotherapy TS-1 was started. However, the CEA level continued to increase, and positron emission tomography-computed tomography revealed peritoneal dissemination, and multiple lymph node, bone, and local metastases(in the liver and rectum). Accordingly, 11 courses of chemotherapy with 5- fluorouracil Leucovorin irinotecan (FOLFIRI) and bevacizumab was administered. The patient recently experienced anal bleeding during each bowel evacuation, which developed owing to the recurrence of the cancer in the anus. To improve his quality of life, the anal tumor was excised 2 years 6 months after the first surgery. Chemotherapy with FOLFIRI and bevacizumab was restarted. The CEA level stopped increasing. We think that the anal surgery did not affect our patient's prognosis but helped improve his quality of life.