ANAL NEOPLASMS

Jonathan S. Viernes
Squamous Cell Carcinoma of the Anal
Margin
A major consideration in managing anal cancers
involves the precise anatomic location of the lesion
Squamous cancer of the skin at the anal margin:
behaves similarly to other cutaneous squamous cell
cancers
Squamous (or transitional) cancer of the anal
canal: a high-grade cancer with significant risk of
metastasis and death
Squamous Cell Carcinoma of the Anal
Margin
Squamous cell carcinomas of the anal margin arise
between the dentate line and the outer limit of
perianal skin
5 cm from the anal verge
These tumors are well-differentiated keratinizing
lesions similar to squamous carcinoma of the skin
Squamous Cell Carcinoma of the Anal
Margin
Diagnosis:
These cancers are more common in men
Patients frequently present with complaints of a palpable
mass, bleeding, itching, pain, or tenesmus
The lesions have rolled, everted edges and a central
ulceration
Associated anal condylomata or chronic fistula-in-ano may
be found in up to 15 percent of patients
Any chronic, nonhealing ulceration in the perianal area
should be biopsied to rule out squamous carcinoma
These cancers are slow-growing and metastasize late
Most patients present 12 to 24 months after the onset of
symptom
Squamous Cell Carcinoma of the Anal
Margin

Squamous Cell Carcinoma of the Anal Canal

Basal Cell Carcinoma
Basal cell carcinoma: a rare tumor of the anal margin
and behaves like basal cell carcinoma elsewhere on the
skin
It is more common in men and presents as a lesion with
raised edges and central ulceration
Treatment:
It is treated by wide local excision with adequate margins
and primary closure or skin grafting
Large lesions may require abdominal-perineal resection

Note: These cancers rarely metastasize (30% local recurrence

rate)
Recurrences are treated by reexcision.
Basal Cell Carcinoma
Bowens Disease
Bowen's disease: an intraepidermal squamous cell
carcinoma (carcinoma in situ) that is a rare, slow-
growing cancer
It usually presents in the elderly but has been reported
in association with anal condyloma in young and
sexually active patients
Diagnosis:
Patients often complain of perianal itching, burning, or
bleeding
Many lesions go unnoticed but may be found incidentally
during histologic examination of tissues removed during
minor anal procedures
Bowens Disease
Discrete, erythematous, scaly plaques are found on
examination
Lesions may have the appearance of eczema or chronic
irritation due to pruritus ani
The presence of ulceration may indicate the
development of an invasive carcinoma
Less than 10% of untreated lesions go on to develop
invasive squamous cell carcinoma, and 35% of these
develop metastases
Bowens Disease
Pagets Disease
Extramammary, perianal Paget's disease is a rare
pathologic entity
It arises from the intraepidermal portion of the
apocrine gland
It is frequently but not always associated with an

underlying carcinoma
Note: If left untreated, adenocarcinoma of the
apocrine glands may develop after a long
preinvasive phase
Pagets Disease
Diagnosis:
Patients usually are 60 to 70 years old, and there is a
female predominance
Severe, intractable pruritus is characteristic of this
disease
Examination reveals an erythematous, eczematous rash

Diagnosis often is delayed because lesions frequently

are treated with a variety of topical medications
without success before biopsy
Pagets Disease
A biopsy should be obtained from any nonhealing,
pruritic anal lesion
Histologic examination reveals Paget cells
Paget cells: large pale cells with eccentric nuclei
A detailed physical examination and complete
evaluation of the gastrointestinal tract should be
performed

Note: Patients with extramammary Paget's disease are at

increased risk of developing noncontiguous
malignancies
Pagets disease
Anal Canal Cancer: Epidermoid Carcinoma

Cloacogenic or transitional zone of the anal

canal: located 6 to 12 mm above the dentate line
Carcinomas of this area may be referred to as:
nonkeratinizing squamous
basaloid

cloacogenic

transitional
Anal Canal Cancer: Epidermoid Carcinoma

Basaloid carcinomas: have the characteristic histologic

appearance of palisading nuclei
Squamous carcinomas in this region are generally
nonkeratinizing
Note: Although these cancers have different histologic
features, they exhibit similar biologic behavior and
are grouped together as epidermoid carcinomas of
the anal canal
Anal Canal Cancer: Epidermoid Carcinoma

Diagnosis:
These are more common in women
Many patients have only minor symptoms and are often
erroneously diagnosed as having benign anorectal
disorders
These lesions can present as an indurated, bleeding
mass that may itch or cause discomfort (some patients
present with a painless mass lesion)
Digital rectal examination reveals the size, location,
and degree of fixation of these tumors
Anal Canal Cancer: Epidermoid Carcinoma

Proctosigmoidoscopy verifies the exact location of

the tumor relative to the dentate line
Biopsies of the mass are necessary for diagnosis

Evaluation of the remainder of the colon should be

done with colonoscopy or barium enema
Examination of both inguinal regions determines if
there is any suspicious nodal enlargement
Chest radiograph and CT scan of the liver are
performed to search for distant metastatic disease
Anal Canal Cancer: Epidermoid Carcinoma

Between 30% and 40% of these patients have

metastatic disease at the time of diagnosis
The risk of metastasis increases with the depth of
invasion, the size of lesion, and the histologic grade of
the lesion
When located below the dentate line, these cancers
metastasize to the inguinal nodes
Those above the dentate line will spread to the
superior rectal, internal pudendal, hypogastric, or
obturator lymph nodes
Note: The most common site of distant metastatic
disease is the liver.
Adenocarcinoma
It may rarely arise from the columnar epithelium of
the anal glands or within a long-standing anorectal
fistula
Patients complain of perianal pain, swelling, and
frequently have an abscess or fistula-in-ano
Abdominal-perineal resection is indicated in these
carcinomas, sometimes after preoperative radiation
therapy
Many of these patients have distant metastases at
the time of diagnosis
Melanoma
It represents 1 to 3% of anal canal cancers
It is the third most common site for melanoma,
following the skin and the eye
The majority arise from the epidermoid lining of the
anal canal adjacent to the dentate line
They spread submucosally, and by the time they
cause symptoms, the extent of invasion is usually
beyond surgical cure
Melanoma
Diagnosis:
The average age at presentation is between the fifth
and sixth decades of life, the male-to-female ratio is
equal and the majority of patients reported in the
literature are Caucasian
Patients commonly present with bleeding, pain, or an
anal mass
They may complain of alteration in bowel habits and
are often misdiagnosed as having a thrombosed
hemorrhoid
Note: Most melanomas in this region are nonpigmented or
lightly pigmented polypoid lesions.
Melanoma
Metastases occur via lymphatic and hematogenous
routes, with lymphatic spread to the mesenteric
nodes being more common than to inguinal nodes
38% of patients have metastatic disease at the time
of diagnosis, with lung, liver, and bone the most
frequent sites of hematogenous spread
Melanoma

Melanoma of the Anal Canal