8,588

Anal Canal Basaloid Carcinoma Treated with Local Resection and Radiation: A Case Report

Yoshifumi Nakayama, Masaki Akiyama, Yusuke Sawatsubashi, Noritaka Minagawa, Takayuki Torigoe, Yasuhiro Kantake, Keiji Hirata

Yoshifumi Nakayama, Masaki Akiyama, Yusuke Sawatsubashi, Noritaka Minagawa, Takayuki Torigoe, Keiji Hirata, Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health. 1-1 Iseigaoka, Yahata-nishi-ku, Kitakyushu 807-8555, Japan
Yoshifumi Nakayama, Masaki Akiyama, Yusuke Sawatsubashi, Department of Gastroenterological and General Surgery, Wakamatsu Hospital of University of Occupational and Environmental Health, 1-17-1 Hamamachi, Wakamatsu-ku, Kitakyushu 808-0024, Japan
Yasuhiro Kantake, Kantake Proctologic Clinic. 3-1-13 Einomaru, Yahata-nishi-ku, Kitakyushu, 807-0851, Japan
Correspondence to: Yoshifumi Nakayama, Department of Gastroenterological and General Surgery, Wakamatsu Hospital of University of Occupational and Environmental Health, Japan.

Email: nakayama@med.uoeh-u.ac.jp
Telephone: +81-93-761-0090
Fax: +81-93-588-3904
Received: October 22, 2015
Revised: November 26, 2015
Accepted: November 28, 2015
Published online: December 21, 2015

ABSTRACT

We herein report a case of anal canal basaloid carcinoma that received consecutive treatments. A 61-year-old Japanese female suffered from a hemorrhage with prolapse for five years. As this symptom worsened, she underwent hemoroidectomy at another clinic. At that time, a little-finger tumor near the hemorrhoid located at 4 o’clock was identified and the patient underwent combined resection. The pathological diagnosis of this tumor was basaloid carcinoma invaded to the submucosal layer, with positive lymphatic invasion and a positive horizontal tumor margin. She was referred to the surgical outpatient clinic for a detailed examination and consecutive treatments. Additional resection was performed at the previous operative scar. This specimen pathologically indicated that a small residuary tumor of basaloid carcinoma was located in the mucosal layer. Radiotherapy was additionally performed at the pelvic cavity and bilateral inguinal area. The patient has survived without recurrence for approximately 13 years after the consecutive treatments.

© 2015 ACT. All rights reserved.

Key words: Anal canal; Basaloid carcinoma; Consecutive treatments; Resection; Radiothrapy

Nakayama Y, Akiyama M, Sawatsubashi Y, Minagawa N, Torigoe T, Kantake Y, Hirata K. Anal Canal Basaloid Carcinoma Treated with Local Resection and Radiation: A Case Report. Journal of Gastroenterology and Hepatology Research 2015; 4(12): 1877-1879 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/1440

Introduction

Anal canal carcinomas include several histological types, such as squamous cell carcinoma, basaloid/cloacogenic carcinoma and adenocarcinoma, due to the existence of several types of epithelial cells in the anal canal. The most common subtype is squamous cell carcinoma[1,2], and basaloid carcinoma is considered to be an aggressive variant of squamous cell carcinoma[3].

The incident of anal canal carcinoma in Japan is 2% of all colorectal carcinomas and basaloid carcinoma accounts for 1.6% of all anal canal neoplasms reported to the Japanese Society for Cancer of the Colon and Rectum[4]. Therefore, anal canal basaloid carcinoma is a comparatively rare disease.

In the present case, the anal canal basaloid carcinoma was limited to the submucosal layer with lymphatic vessel invasion and a positive horizontal margin in the mucosal layer. Additional resection was performed at the previous operative scar. Moreover, radiotherapy was performed at the pelvic cavity and bilateral inguinal area. This report presents a therapeutic case of anal canal basaloid carcinoma with consecutive treatments.

CASE REPORT

A 61-year-old Japanese female suffered from a hemorrhage with prolapse for five years. As this symptom worsened, she underwent hemoroidectomy at another clinic. At that time, a little-finger tumor nearby the hemorrhoid located at 4 o’clock was identified and the patient underwent combined resection. The pathological diagnosis of this tumor was basaloid carcinoma invaded to the submucosal layer (Figure 1a), with positive lymphatic invasion (Figure 1c) and a positive horizontal tumor margin (Figure 1b).

She was referred to the surgical outpatient clinic for a detailed examination and consecutive treatments. The laboratory data showed that she had a white blood cell count of 6.200/mm3, hemoglobin of 13.7 g/dl, hematocrit of 41.0%, platelets count of 234,000/mm3, normal electrolytes, as well as normal blood urea nitrogen levels and a normal liver function. The patient’s CEA was 1.5 ng/ml and SCC was 1.3 U/ml. Operative scars located at 4-5 o’clock, 7 o’clock and 11 o’clock were identified. No tumor was macroscopically identified in these scars.

An additional resection was performed at the previous operative scar located at 4-5 o’clock (Figure 2a and 2b).

This specimen pathologically indicated a small residuary tumor of basaloid carcinoma in the mucosal layer (Figure 3a and 3b).

Radiotherapy was performed at the pelvic cavity and bilateral inguinal area (1.8 Gy x 28, total 50.4 Gy). The patient had an uneventful recovery and was discharged from the hospital on the 14th day after the operation. She has been followed up in the outpatient clinic without recurrence for approximately 13 years since undergoing the consecutive treatments.

Discussion

Anal canal basaloid/cloacogenic carcinomas are thought to arise from cloacogenic remnants[5]. That is, basaloid carcinoma of the anal canal is considered to be a poorly differentiated variant of the cloacogenic tumors arising in the basal layer of the transitional zone epithelium[6]. Basaloid carcinoma currently belongs in the squamous cell carcinoma group as a variant according to the second edition of the WHO classification system of anal carcinomas[7]. In this classification system, the variants of anal canal squamous cell carcinoma, including large cell keratinizing, large cell nonkeratinizing (cloacogenic) and basaloid type, are grouped by a similar nature history, response to treatment and prognosis[8,9].

Anal canal basaloid carcinoma exhibits a highly malignant potential[10]. The incidence of lymph node metastasis is reportedly 40~52.3% at the diagnosis[1,2] and the incidence of inguinal lymph node metastasis was approximately 20%[2]. Moreover, the rate of distant metastasis is reportedly 13.3-19.0% at the diagnosis[1,5].

The incidence of anal cancer is increasing due to its risk factors[11], such as anal-genital human papillomavirus (HPV) infection, immunosuppression associated with human immunodeficiency virus or transplantation and smoking[12,13]. In the present patient, there was no symptom of anal-genital HPV infection or immunosuppression. Although the result of HTLV-I testing was negative, an HPV examination was not performed.

In Japan, abdominoperineal resection (APR) was generally performed for the patients with anal canal basaloid carcinoma until several years ago. Conversely, nearly all patients with anal canal squamous cell carcinoma, including basaloid carcinoma, are initially treated with chemoradiation therapy in Western Countries and subjected to subsequent APR only if a residual tumor remained at the time of a postradiation biopsy[14,15]. The treatment of anal canal basaloid or squamous cell carcinoma in Japan has recently changed to chemoradiation therapy as the first-line treatment due increased the patient’s quality of life.

The NCCN guidelines currently indicate that concurrent chemoradiation therapy is the recommended primary treatment for patients with nonmetastatic anal canal cancer[7]. The NCCN guidelines also indicate that the primary treatment for patients with T1, N0 and well-differentiated squamous cell carcinoma of anal cancer is local excision with adequate margins[7]. Patients with inadequate margins are advised to undergo re-excision or to consider the local radiation therapy with or without 5-FU based chemotherapy[7]. In the present case, the patient (T1, N0) with basaloid carcinoma underwent consecutive treatments as recommended by the NCCN guidelines.

CONCLUSION

This report described a therapeutic case of anal canal basaloid carcinoma with the consecutive treatments. It is important to undergo the suitable treatments for the patients with anal canal basaloid carcinoma depending on the situation.

CONFLICT OF INTERESTS

There are no conflicts of interest with regard to the present study.

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Peer reviewer: Ilker Etikan, Department of Biostatistics, Faculty of Medicine, University of Gaziosmanpasa, Tokat, Turkey.

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