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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 13-15

Isolated fungating axillary lymph node metastasis in anal canal carcinoma – A rare case report


Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India

Date of Submission31-Jan-2021
Date of Acceptance06-Jun-2021
Date of Web Publication12-Sep-2022

Correspondence Address:
Dr. Raghav Yelamanchi
Department of Surgery, Ward 17, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcs.ijcs_2_21

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  Abstract 

Anal canal cancer is the least common malignancy of the gastrointestinal tract. Main risk factors include infection with human papillomavirus strains, immunosuppression, multiple sexual partners, and receptive anal intercourse. We present a rare case of anal canal carcinoma with fungating right axillary lymph node metastasis. A 65-year-old farmer had presented to the surgical department with complaints of bleeding per rectum and ulceration around the anus for 6 months. He also gives a history of fecal incontinence and right axillary swelling. On examination, there was an ulcer around the anus circumferentially with everted edges and indurated base. There were multiple enlarged bilateral inguinal lymph nodes and fungating right axillary lymph node. Magnetic resonance imaging of the pelvis revealed features suggestive of neoplastic etiology of anal canal. Biopsy of ulcer margin and axillary lymph node was suggestive of squamous cell carcinoma. Positron emission tomography/computed tomography (PET/CT) of the whole body revealed no other site metastatic foci. The patient underwent diversion sigmoid colostomy and was started on chemoradiation (Nigro regimen). The patient had very good response to the regimen, and follow-up PET/CT scan showed no active uptake in the tumor foci.

Keywords: Anal canal cancer, carcinoma of anal canal, fungating axillary lymph node metastasis, Nigro regimen


How to cite this article:
Yelamanchi R, Mawblei P, Gupta N, Durga C K. Isolated fungating axillary lymph node metastasis in anal canal carcinoma – A rare case report. Indian J Colo-Rectal Surg 2022;5:13-5

How to cite this URL:
Yelamanchi R, Mawblei P, Gupta N, Durga C K. Isolated fungating axillary lymph node metastasis in anal canal carcinoma – A rare case report. Indian J Colo-Rectal Surg [serial online] 2022 [cited 2022 Sep 26];5:13-5. Available from: https://www.ijcrsonweb.org/text.asp?2022/5/1/13/355939


  Introduction Top


Anal canal cancer is the least common malignancy of the gastrointestinal tract.[1] Although squamous cell carcinoma is the predominant histology, other rare possibilities include adenocarcinoma, basal cell carcinoma, melanoma, sarcoma, and lymphoma. Main risk factors include infection with human papillomavirus strains (91% of tumors), immunosuppression, multiple sexual partners, and receptive anal intercourse.[2] It progresses from anal intraepithelial neoplasia to invasive carcinoma over a period of time. Due to the less prevalence of the disease, routine screening of the population is not recommended. However, high-risk population such as human immunodeficiency virus (HIV)-infected patients are to be screened.[3] Bleeding is the most common symptom of anal canal carcinoma. Anal canal carcinoma spreads locally and regionally. Surrounding structures such as anal sphincter are frequently involved. We present a rare case of anal carcinoma with fungating right axillary lymph node metastasis.


  Case Report Top


A 65-year-old farmer had presented to the surgical department with complaints of bleeding per rectum and ulceration around the anus for 6 months for which he was taking treatment from a local quack. There was a history of fecal incontinence for 2 months. The patient also gives a history of swelling in the right axilla for 1 month which was rapidly increasing in size. There was no history of high-risk sexual behavior. On examination, there was an ulcer around the anus circumferentially with everted edges and indurated base [Figure 1]. The induration was extending 2 cm into the anal canal. Anal sphincter tone was absent. There were bilateral multiple hard and mobile palpable inguinal lymph nodes of maximum size 2 cm × 3 cm [Figure 2]. There was a 5 cm × 7 cm fungating growth in the right axilla [Figure 3]. Head, neck, and breast examination were normal. Rest of the examination was within normal limits.
Figure 1: Anal canal ulcer with everted edges

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Figure 2: Enlarged bilateral inguinal lymph nodes

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Figure 3: Enlarged and fungating right axillary lymph node

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Magnetic resonance imaging (MRI) of the pelvis revealed features suggestive of neoplastic etiology of anal canal with growth involving the anal sphincter and extending into the ischiorectal fossa. There were enlarged bilateral inguinal and internal iliac lymph nodes on MRI imaging. Edge biopsy of the anal ulcer revealed moderately differentiated squamous cell carcinoma. Fine needle aspiration cytology of bilateral inguinal lymph nodes was positive for malignant cells. Core needle biopsy of the axillary lymph node was suggestive of squamous cell carcinoma. Positron emission tomography/computed tomography (PET/CT) of the whole body revealed no other site metastatic foci other than bilateral inguinal and right axillary lymph nodes. HIV serology was negative. The patient underwent diversion sigmoid colostomy and was started on chemoradiation (Nigro regimen). The patient had very good response to the regimen, and follow-up PET/CT scan showed no active uptake in the tumor foci. At 6-month follow-up, lymph nodes had regressed, and the anal ulcer had healed with induration but with no regain of sphincter function.


  Discussion Top


Anal carcinoma like all other carcinomas spreads predominantly through the lymphatic route. Commonly involved lymph nodes include the inguinal and iliac group of lymph nodes. Hematogenous metastases are present in only 10% of the patients.[4] Liver is the most common site for distant metastases.[4] Other sites include lung, bone, and rare sites such as bone marrow. Male sex, ulceration, and lymph node involvement are associated with poor prognosis and decreased overall survival in anal canal carcinoma.[5]

The above case is very unique regarding the site of metastasis. Only one case of axillary lymph node metastasis in anal canal cancer has been reported in literature so far.[6] Fungating axillary lymph node in the presence of normally enlarged inguinal nodes of anal carcinoma is not reported so far. Noncontagious distant lymph node metastasis in the absence of any other solid organ metastasis is difficult to explain. Possible explanation may be the deposition of the circulating tumor cells which are now believed to be present even in localized anal canal carcinoma.[7] Evaluation of the head, neck, and chest region should always be done to rule out a second primary tumor metastasizing to the axillary lymph node. Anal canal lymphoma may also be considered as a clinical differential diagnosis but that can be ruled out by histopathology.

Nonregional lymph node metastasis should be considered as Stage IV disease. There are no specific guidelines for the management of oligometastatic disease as the one presented above. Anal canal cancer responds well to chemoradiotherapy. The Nigro regimen consisting of 5-fluorouracil and mitomycin C with radiotherapy is the most commonly used regimen for primary chemoradiotherapy. In case of fully metastatic disease, 5-fluorouracil and cisplatin regimen can be used. In the above case, the patient responded very well to Nigro regimen. There was shrinkage of the primary tumor as well as inguinal and axillary lymph nodes. There is emerging evidence based on few case reports about the role of surgical resection of metastasis after chemoradiotherapy in anal canal cancer.[8]


  Conclusion Top


Fungating axillary lymph node metastasis of anal canal carcinoma is one of the rarest case scenarios. The second primary in head-and-neck region and lymphoma should be ruled out. Anal canal carcinoma responds very well to primary chemoradiotherapy, and there is an emerging role of surgical resection of metastasis in metastatic anal cell carcinoma.

Consent

Consent was taken from patient for publication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Martin FT, Kavanagh D, Waldron R. Squamous cell carcinoma of the anal canal. Surgeon 2009;7:232-7.  Back to cited text no. 1
    
2.
Centers for Disease Control and Prevention: How Many Cancers are Linked with HPV Each Year?HPV and Cancer; 2017. Available from: https://www.cdc.gov/cancer/hpv/statistics/cases.htm. [Last accessed on 2021 Jan 28].  Back to cited text no. 2
    
3.
Leeds IL, Fang SH. Anal cancer and intraepithelial neoplasia screening: A review. World J Gastrointest Surg 2016;8:41-51.  Back to cited text no. 3
    
4.
Salati SA, Al Kadi A. Anal cancer-A review. Int J Health Sci (Qassim) 2012;6:206-30.  Back to cited text no. 4
    
5.
Das P, Crane CH, Eng C, Ajani JA. Prognostic factors for squamous cell cancer of the anal canal. Gastrointest Cancer Res 2008;2:10-4.  Back to cited text no. 5
    
6.
Kumar PR, Kotne SS, Rao PB, Surendra. A rare presentation of carcinoma anal canal presenting with distant axillary lymph node metastasis. Int J Cur Res Rev 2015;7:32-5.  Back to cited text no. 6
    
7.
Carter TJ, Jeyaneethi J, Kumar J, Karteris E, Glynne-Jones R, Hall M. Identification of cancer-associated circulating cells in anal cancer patients. Cancers (Basel) 2020;12:2229.  Back to cited text no. 7
    
8.
Sousa TT, Santos BD, Belotto M, Peixoto RD. Successful hepatectomy for metastatic squamous cell carcinoma of the anal canal-a case report. J Gastrointest Oncol 2016;7:E103-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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