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  • • Located at or outside the anal verge

    • Usually well-differentiated, keratinizing tumors

    • Behave similarly to squamous cell carcinomas of skin

    • Lesions may be present for long periods before symptoms develop

    • 4 types

    • -Squamous cell

      -Basal cell

      -Bowen disease

      -Paget disease

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Epidemiology

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  • • Squamous, basal cell carcinoma, and Bowen disease more common in men

    • Paget disease more common in women

    • 50% patients with Paget disease have coexistent GI malignancy

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Symptoms and Signs

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  • • Mass

    • Bleeding

    • Pain

    • Discharge

    • Itching

    • Tenesmus

    • Lesions may be quite large with central ulceration

    Paget disease: Erythematous, eczematoid rash

    Basal cell: Raised edges with central ulcer

    Bowen disease: Scaly, erythematous, sometimes pigmented; often associated with condylomas in younger patients

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Laboratory Findings

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  • • Pap smear screening may be useful to detect dysplasia in immunocompromised patients

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Imaging Findings

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  • CT/MRI: Reveal anal mass

    Endorectal US: Reveals size and depth of invasion and perianal nodes

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  • • Chronic or nonhealing perineal ulcer

    • Anal canal cancer

    • Perianal abscess

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Rule Out

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  • • Biopsy all chronic or nonhealing perineal ulcers

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  • • Physical exam with digital rectal exam

    • Assessment for lymph adenopathy (groins)

    • Exam under anesthesia, anoscopy with biopsy

    • Endorectal US to assess size and depth of invasion

    • Chest film, CT to assess for metastatic disease

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When to Admit

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  • • Intractable symptoms: Pain

    • Severe bleeding with hemodynamic compromise

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  • • Mainstay of treatment is surgical (wide excision)

    • Chemoradiation useful for aggressive lesions

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Surgery

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Indications

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  • • Small, well-differentiated lesions (< 4 cm) may be treated with wide excision

    • Large, deep lesions involving sphincters require abdominoperineal resection (APR)

    • Grossly involved lymph nodes should be resected

    • Recurrences may be treated with reexcision or APR

    For Bowen disease: Wide local excision and 4-quadrant biopsy

    For Paget disease: Wide local excision and multiple perianal biopsies

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Medications

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  • • Chemoradiation may have a role in advanced disease

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Treatment Monitoring

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  • • Surveillance physical exam with rectal exam and lymph node exam

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Complications

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  • • Infection/perianal sepsis

    • Fistula

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Prognosis

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  • Squamous cell carcinoma: T stage determines survival; 5-year survival T1 (100%), T2 (60%)

    Basal cell carcinoma: Metastasis is rare; local recurrence is 30%

    Bowen disease: invasive squamous cell carcinoma develops in fewer than 10% of cases

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References

Peiffert D et al: Conservative treatment by irradiation of epidermoid carcinomas of the anal margin. Int J Radiat Oncol Biol Phys 1997; 39:57.  [PubMed: 9300740]
Pineda CE et al: High-resolution anoscopy targeted surgical destruction of anal high-grade ...

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