IJCRR - 7(3), February, 2015
Pages: 32-35
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A RARE PRESENTATION OF CARCINOMA ANAL CANAL PRESENTING WITH DISTANT AXILLARY LYMPH NODE METASTASIS
Author: P. Ravindra Kumar, Siva Sankar Kotne, P. B. Ananda Rao, Surendra
Category: Healthcare
Abstract:Introduction: Anal carcinomas present as a locoregional disease with regional lymph node metastases. Distant vascular metastasis to liver, lung , etc. is less than 10% and distant lymphatic spread to supraclavicular, paraaortic or mediastinal lymph nodes is less than 1%. Axillary lymph node metastasis is extremely unusual in anal carcinomas and we couldn't find any literature review. Case Report: Here we report a 34 years old female who was diagnosed to have moderately differentiated squamous cell carcinoma of anal canal with bilateral inguinal lymph nodes. Regular general examination revealed a left axillary lymph node which on cytology showed squamous cell carcinomatous deposits. Possibility of lymphoma, second primary and contiguous lymphatic spread was ruled out on thorough examination and investigations. Treatment Policy: In view of unusual rare presentation of carcinoma anal canal with distant solitary lymph node metastasis, the case is staged as stage IV disease. We planned as a case based planning and started with chemotherapy (neoadjuvant) followed by concurrent chemo radiotherapy and then by surgery if essential. Patient presently had good response after two cycles of neoadjuvant chemotherapy. Conclusion: In conclusion, although local lymph nodes in anal carcinomas are common and initial sites of spread, distant metastasis to axillary lymph node is unlikely without involvement of para aortic or mediastinal or supraclavicular lymph nodes. Hence, this case is an unusual presentation of carcinoma anal canal with skipped lymph node metastasis.
Keywords: Anal carcinoma, Metastatic axillary lymph node, Squamous cell carcinoma
Full Text:
INTRODUCTION
In accordance with the American Joint Committee on Cancer (AJCC)1 and the International Union Against Cancer (UICC)2 , the anal canal can be defined as the anatomic region located between the anorectal ring, which is a palpable area corresponding to the puborectalis muscle, and the anal verge, which is visible spontaneously on clinical examination of the perineum. The dentate line subdivides the anal canal into two parts:-
(1) Leisons occurring below the true mucocutaneous junction and at the anal margin are usually well differentiated keratinizing squamous carcinomas with inguinal lymph node metastases and are called anal margin cancers
. (2) Lesions arising near or above the dentate line are generally highly anaplastic nonkeratinizing squamous carcinomas (cloacogenic, basaloid, transitional) with rapid growth characteristics demonstrating early invasion of contiguous soft tissue and early spread to regional lymph nodes and are called anal canal cancers. Anal carcinomas3,4 present as a locoregional disease with regional lymph node metastases5,6. Distant vascular metastasis to liver, lung , etc. is less than 10% and distant lymphatic spread to supraclavicular, paraaortic or mediastinal lymph nodes is less than 1%. Axillary lymph node metastasis is extremely unusual in anal carcinomas and we couldn’t find any literature review.
INITIAL PRESENTATION
We report a 35 year old female presented with complaint of right ulcerated inguinal swelling since 8 months and left inguinal swelling since 10 days. She has no other associated systemic complaints. Past history and family history did not contribute any further information. On regular general examination a left solitary axillary lymph node was found and on per rectal examination ulceroproliferative hard mass can be felt 5cm away from the anal verge. Haematological profile was within normal limits. Trucut biopsy of anal canal showed moderately differentiated squamous cell carcinoma. FNAC of right and left inguinal lymph node showed metastatic squamous cell carcinomatous deposits. FNAC was also done for left axillary lymph node which showed metastatic squamous cell carcinomatous deposit. Ultrasound abdomen is normal, no abdominal or pelvic lymph nodes can be felt. CT scan of thorax and abdomen is normal with only left axillary lymph node 1.5*1.5cm and bilateral inguinal lymph nodes present. Possibility of lymphoma is excluded by doing cytokeratin(CK) and leucocyte common antigen(LCA) which showed positivity for CK and negativity for LCA. Second primary and contiguous lymphatic spread is excluded by thorough general examination, ultrasound abdomen and CT scan of thorax and abdomen.
DIAGNOSIS
Patient was finally diagnosed as carcinoma anal canal with bilateral inguinal lymph nodes and with an solitary axillary lymph node.
TNM STAGING-cT1N3M1-STAGEIV
Treatment Policy: Carcinoma of the anal canal is a relatively rare gastrointestinal tract malignancy. The historical standard of treatment was an abdominoperineal resection7 and it has evolved over years and now chemoradiation therapy has become the treatment of choice. Nigro et al8 . demonstrated that it was possible to control disease and preserve anal sphincter function with chemoradiation9 . In view of unusual rare presentation of carcinoma anal canal with distant solitary lymph node metastasis, the case is staged as stage IV disease. We planned as a case based planning and started with chemotherapy (neoadjuvant) followed by concurrent chemo radiotherapy and then by surgery if possible. Patient presently had good response after two cycles of neoadjuvant chemotherapy.
DISCUSSION
Because of the rarity of this disease and the confusion regarding its diagnosis and treatment, little attention to anal cancer has been paid in the literature. In particular, there has been a paucity of studies after the use of chemoradiation in the primary management of anal canal cancers became widespread. Many histologic types of anal canal cancer are described, including squamous cell carcinoma, adenocarcinoma, cloacogenic or basaloid carcinoma, melanoma, leiomyosarcoma, and carcinoid tumors. Nearly 80% of anal canal tumors are squamous cell carcinomas. Cloacogenic, basaloid, or transitional tumors are considered variants of squamous cell carcinoma as they all exhibit a similar natural history, response to treatment, and prognosis. Another 10% of anal cancer tumors are adenocarcinomas. Nigro et al. demonstrated that anal carcinoma could be cured without the morbidity and functional consequences of an APR. Since their report in 1974, concurrent 5-FU and mitomycin-C has been established as the standard by several randomized trials. However, this regimen is associated with significant acute toxicity in 25–50% of patients and a mortality rate of 1–3%10,11. Anal cancers are rare tumours; however, the incidence is increasing in both men and women. Changing trends in sexual behaviour, smoking, and infection with the human papillomavirus are thought to be responsible for the increase. Patients with metastatic disease have a poor prognosis, with 5-year median overall survival rates of 10% in men and 20% in women. The standard systemic treatment of metastatic disease remains cisplatin and 5-fluorouracil.
CONCLUSION
In conclusion, although local lymph nodes in anal carcinomas are common and initial sites of spread, distant metastasis to axillary lymph node is unlikely without involvement of para aortic or mediastinal or supraclavicular lymph nodes. Hence, this case is an unusual presentation of carcinoma anal canal with skipped lymph node metastasis
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