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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. vol.110 no.10 Madrid oct. 2018

http://dx.doi.org/10.17235/reed.2018.5657/2018 

SCIENTIFIC LETTERS

Adenocarcinoma of the anal canal with an exceptional immunohistochemistry in a patient with serrated polyposis syndrome: a diagnostic challenge

Adriana Ruano-Campos1  , Jaime Zuloaga1  , María-Jesús Fernández-Aceñero2 

1Services of General Surgery and Digestive Diseases. Hospital Clínico San Carlos. Madrid, Spain

2Services of Pathology. Hospital Clínico San Carlos. Madrid, Spain

Key words: Anal adenocarcinoma; Immunohistochemistry; Serrated polyposis syndrome

Dear Editor,

In relation to the article published in this journal by Alberto Herreros de Tejada et al. 1, we recently diagnosed a case of adenocarcinoma of the proximal anal canal with an exceptional immunohistochemistry. This was identified as an incidental finding after a hemorrhoidectomy in a patient with serrated polyposis syndrome (SPS).

Case report

We present the case of a 48-year-old female, current smoker, with a history of endoscopically controlled SPS. The patient was assessed for grade III hemorrhoids, and a hemorrhoidectomy in accordance with the Milligan-Morgan technique was performed. Pathological analysis of the specimen revealed a poorly differentiated infiltrating adenocarcinoma that originated from a tubular-villous adenoma with high-grade dysplasia at the squamocolumnar junction (Fig. 1A and B). The superficial adenomatous lesion and the infiltrating component were identical and expressed cytokeratin 7 intensely, and were negative for cytokeratin 20 (Fig. 1C). A multidisciplinary committee decided to widen the previous resection margins after a computed tomography (CT) scan confirmed the absence of distant or lymph node disease. No residual tumor infiltration was found in the surgical specimen. PET-CT after three months follow-up showed lymphadenopathy at the sigmoid colon mesenterium. Given these findings and the history of SPS, a proctocolectomy with end ileostomy was performed. Histopathological analysis identified multiple serrated adenomas with low-grade dysplasia with metastasis of poorly differentiated carcinoma that was morphologically the same as that observed in the anal canal in 2/109 lymph nodes analyzed (pT0N1bM0). The patient started adjuvant chemotherapy.

Fig. 1 A. Microscopic image of the epithelium in the squamocolumnar transition zone (arrow); the polyp mucosa is cranial to it (hematoxylin-eosin). B. Microscopic image of infiltrating tumor foci in the submucosa, with poorly differentiated and disorganized cells with nuclear pleomorphism (hematoxylin-eosin). C. Immunohistochemistry of the polyp at the hemorrhoid. Submucosal tumor clusters in the center and on the right (arrows), both reaching the limit of the resection plane, hindering a proper assessment of the deeper margin. 

Discussion

Anal adenocarcinomas account for up to 10% of anorectal tumors 2. They are more commonly located proximal to the dentate line and are histologically and immunohistochemically similar to rectal carcinomas (CK7- and CK20+). The main clinical implication is regional lymphatic dissemination 3. Intense CK7 expression makes it necessary to rule out both ductal anal carcinoma and metastatic lesions. In rare cases with a high-grade and poorly differentiated colorectal phenotypes, expression of CK20 may be replaced by CK7 4. As a T1 lesion with no evidence of lymphatic or distant disease was identified via a CT scan, we opted for close surveillance following margin extension. With regard to SPS, factors associated with malignancy are serrated adenomas with dysplasia and their multiplicity 1.

References

1. Herreros de Tejada A, González-Lois C, Santiago J. Lesiones serradas y síndrome de poliposis serrada. Rev Esp Enferm Dig 2017;109(7):516-26. DOI: 10.17235/reed.2017.4065/2015 [ Links ]

2. Anwar S, Welbourn H, Hill J, et al. Adenocarcinoma of the anal canal - A systematic review. Colorectal Dis 2013;15(12):1481-8. DOI: 10.1111/codi.12325 DOI: 10.1111/codi.12325 [ Links ]

3. Ferrer Márquez M, Velasco Albendea FJ, Belda Lozano R, et al. Adenocarcinoma del canal anal. Revisión de conjunto. Cir Esp 2013;91(5):281-6. DOI: 10.1016/j.cireng.2013.10.017 [ Links ]

4. Zhang PJ, Shah M, Spiegl GW, et al. Cytokeratin 7 immunoreactivity in rectal adenocarcinomas. Appl Immunohistochem Mol Morphol 2003;11(4):306-10. PMID: 14663355. DOI: 10.1097/00129039-200312000-00005 [ Links ]

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