Anal Cancer
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Malignancy- A 67-year-old man with anal cancer involving anterior rectal wall and dentate line and prostate, staged T4N1aM0, had undergone chemoradiation and presents for evaluation 8 weeks after therapy completion. He reports that discomfort is nearly gone from the anal canal and that his bowel movements are normal. On examination, there is a shallow 1-cm ulcer. What is the best next option?
- A 53-year-old man with rectal cancer starting at 2 cm from anorectal ring presents to the office to discuss further management. He has undergone chemoradiation and consolidation FOLFOX chemotherapy for cT3N1aM0 microsatellite proficient tumor. He has a partial response with a residual palpable mass. He normally has up to five bowel movements per day with urgency and fecal leakage. What is the best next surgical treatment for him?
- A 58-year-old patient presents to the clinic reporting anal pain and bleeding with bowel movements. Examination shows an ulcer at the anal verge measuring 1.5 cm. Biopsy shows invasive squamous cell carcinoma. Pelvic magnetic resonance imaging (MRI) shows the lesion invades the external sphincter. What is the patient’s T stage?
- A 62-year-old woman presents to the office with a 1-month history of rectal pain, bleeding, and perianal mass. On digital rectal examination and anoscopy, a 3-cm firm mass is noted at the left lateral anal canal. Inguinal examination is unremarkable. Biopsy of the mass shows moderately differentiated squamous cell carcinoma. Staging computed tomography (CT) of the chest and abdomen and magnetic resonance imaging (MRI) of the pelvis demonstrate a T2N1M0 tumor. What is the best next step in her management?
- A 33-year-old man presents to your office for evaluation of numerous bilateral 2–5 mm perianal lesions. Biopsies show high-grade squamous intraepithelial lesions, and high-resolution anoscopy shows no intraanal lesions. Which of the following is the best initial management for this patient?
- A 38-year-old HIV-positive male patient is diagnosed with a cT3N1M0 squamous cancer of the anal canal. The patient’s CD4 count is 250 cells/mm3. What is the most appropriate next step in management?
- A 45-year-old man is seen in the clinic for persistent perianal itching. Examination of the perianal skin revealed a 1.5-cm plaque-like lesion at the left lateral position, approximately 2 cm from the anal verge. Punch biopsy of the lesion demonstrates basal cell carcinoma. There is no distant metastatic disease. What is the most appropriate next step in treatment?
- A 64-year-old man presents with a lesion on the perianal skin, as shown in the figure. Biopsy in the office demonstrates verrucous carcinoma. The most definitive management in this patient is
- A 22-year-old female patient presents to your office with rectal bleeding and family history of colon cancer in her sister who was diagnosed at age 28 years. Esophagogastroduodenoscopy demonstrates three gastric and duodenal adenomas. Colonoscopy demonstrates hundreds of polyps throughout her colon. Pathology demonstrates tubular adenomas. You perform a flexible sigmoidoscopy that confirms nine polyps in her rectum; the polyps range from 4 mm to 9 mm in size. She is interested in having children in the near future. What is the recommended next step in her management?
- A healthy 51-year-old man has a poorly differentiated right colon adencarcinoma with mucinous features and mismatch repair (MMR) deficient protein expression. After germline testing was performed, a diagnosis of Lynch syndrome made. The patient reports no issues with incontinence to gas or stool. What is the recommended surgery in this patient?
- A 47-year-old woman presents with rectal pain and feculent discharge from her vagina. A digital rectal exam (DRE) in the office reveals a 4-cm, firm, palpable mass starting just below the dentate line; it is immobile and contiguous with the posterior vaginal wall. You perform a biopsy that confirms squamous cell carcinoma. After completing the staging workup, you find she has T4N0, stage IIIB disease. The recommended treatment is
- A 61-year-old patient presents to clinic with a newly diagnosed rectal adenocarcinoma biopsy proven on colonoscopy. You perform a digital rectal examination (DRE) in the office and find a bulky circumferential tumor at approximately 6 cm from the anal verge that is not mobile. What is the best imaging modality to assess the local characteristics of the tumor?
- A 61-year-old man is found to have a 2-cm mass in the mid-rectum (8 cm from the anal verge) on diagnostic colonoscopy. Biopsy reveals moderately differentiated adenocarcinoma. Computed tomography (CT) reveals no evidence of metastatic disease, and magnetic resonance imaging (MRI) demonstrates a cT3, node-negative cancer. After presentation at a multidisciplinary tumor board, the patient agrees to total neoadjuvant therapy. The patient has a complete clinical response to treatment and opts for close radiologic and endoscopic surveillance in an effort to avoid surgery. On a surveillance proctoscopy 6 months after treatment, the patient is found to have a 7-mm recurrence at the original cancer site. Which of the following is the best next step in management?
- A 45-year-old man undergoes a screening colonoscopy, which shows a 1.5-cm polyp in the rectum located 5 cm from the anal verge. Biopsy reveals well-differentiated invasive adenocarcinoma without lymphovascular invasion, perineural innovation, or tumor budding. Staging computed tomography (CT) does not show any evidence of metastatic disease, and his carcinoembryonic antigen (CEA) level is normal. Magnetic resonance imaging (MRI) of the pelvis reveals the polyp to be a T-1 lesion without any evidence of lymph node metastasis. What is the most appropriate next step in treatment?
- A 63-year-old otherwise healthy woman comes to see you for chafing and ulceration related to a perianal skin tag. It has been present ever since she was pregnant years ago; however, in the past 6 months, there is an area that has been bleeding persistently. On examination, she has a large 3-cm perianal skin tag, with a small area of ulceration at the base measuring about 1–2 mm. You take her for excision of this tag, and the pathology comes back as invasive, well-differentiated squamous cell carcinoma, 6 mm in width, with margins negative at least 1 cm from the edge of the specimen. Staging workup and imaging are negative. The recommended next step in treatment is
- A 63-year-old woman is diagnosed with a poorly differentiated microsatellite–stable rectal cancer 7 cm from the anal verge on screening colonoscopy. She denies trouble with continence. Staging computed tomography (CT) of the chest/abdomen/pelvis does not demonstrate distant disease; a mass is confirmed in the mid rectum with evidence of lymphadenopathy. Rectal magnetic resonance imaging (MRI) demonstrates this tumor is a T4aN2M0 with threatened circumferential radial margin. The multidisciplinary tumor board recommends total neoadjuvant chemotherapy with FOLFOX and long-course chemoradiation therapy. Six weeks after completing neoadjuvant therapy, flexible sigmoidoscopy demonstrates persistent tumor. Restaging MRI after total neoadjuvant therapy is consistent with persistently threatened posterior radial margin with tumor extending to the presacral fascia. The multidisciplinary tumor board’s best recommendation for her is
- A 55-year-old male patient presents to the clinic for evaluation of intermittent fecal incontinence and fecal urgency. The patient has a history of stage III rectal cancer for which he completed total neoadjuvant therapy (TNT) and low anterior resection (LAR) with diverting loop ileostomy. He is now 3 months status post ileostomy reversal. Despite fiber supplementation and intermittent antidiarrheal medication use, he experiences stool stacking and incomplete evacuation 3 days per week. The patient’s symptoms are consistent with
- A 40-year-old woman is referred to you because of a 6-month history of painful hemorrhoids that have not been responsive to topical therapy and stool softeners. A 3-cm, ulcerated, hard mass extending into the anal canal is found on perianal examination and biopsied. Pathology comes back as anal squamous cell cancer. What is the most appropriate next step?
- A 47-year-old female patient presents 28 weeks after completing chemoradiation therapy for P16-positive HPV-associated squamous cell carcinoma of the anus. The patient continues to report intermittent bleeding and pain, which has continued to slowly improve. On physical examination, she has evidence of residual disease. The best next step in management for this patient is
- Anorectal Disease
- A patient presents with persistent anal pain despite use of fiber and bowel regimen. On examination, the patient has a linear 2-cm tear in the right lateral position of the anal canal with exposure of the underlying internal sphincter. The most appropriate next step in the management of this patient is
- The anal transition zone (ATZ) transitions from
- A 60-year-old male patient with a history of radiation for prostate cancer presents with pneumaturia and recurrent urinary tract infections. Workup reveals a 1-cm defect in the anterior rectum just above the dentate line, corresponding to a urethral defect on cystoscopy. There is evidence of radiation damage to the rectum but no active infection and no evidence of cancer recurrence. Which of the following is the most definitive management?
- A 60-year-old patient is reevaluated for pruritus ani. Symptoms did not improve after topical steroid, barrier cream, and anal hygiene measures. Examination shows dry leathery scaly perianal skin without ulceration. The best next step is in her management is
- A 34-year-old male who engages in anal receptive intercourse presents to the clinic with a 2-week history of rectal pain, bright red bleeding, tenesmus, and persistent diarrhea. He has family history of Crohn’s disease. Urgent colonoscopy reveals normal ileum and colon but moderate proctitis with patchy ulcerations and copious amounts of mucus. Rectal cultures and biopsy results are pending. The most appropriate next step in management is
- A 51-year-old man is undergoing a screening colonoscopy during which a partially circumferential mass at the level of the upper rectal valve is found. On rigid proctoscopy, the mass is found to be located 11 cm from the anal verge. On pathologic evaluation, the lesion is identified as a moderately differentiated invasive adenocarcinoma. Pelvic magnetic resonance imaging (MRI) with and without contrast showed a T3N1 mass without extramural venous invasion (EMVI) and a radial margin of 7 mm. What is the immediate lymphatic drainage of the lesion?
- A 36-year-old man who is HIV-positive presents to your clinic with a 6-week history of perianal burning and itching. Rectal examination reveals multiple small condylomata within the anal canal. Intraoperative excisional biopsies of the condylomata confirm human papillomavirus (HPV). Which of the following HPV subtypes confers the highest risk of anal high-grade dysplasia and squamous cell carcinoma?
- A 45-year-old man, who reports sex only with men (MSM), has been referred to you for evaluation of a whitish anorectal lesion identified on initial screening colonoscopy. Biopsies confirmed high-grade squamous intraepithelial lesion (HSIL), for which he ultimately underwent excision and fulguration. What is the recommended surveillance?
- A screening anal pap was performed on a 33-year-old male patient with well-controlled human immunodeficiency virus (HIV). Cytology is consistent with high-grade squamous intraepithelial lesion (HSIL). The most appropriate next step in management is
- A 64-year-old woman with history of cervical cancer treated with radical hysterectomy presents with anal itching and burning. Examination demonstrates a well-circumscribed hyperkeratosis/lichenification rash. Which of the following is the best next step in her management?
- A 41-year-old patient presents to your clinic with anal pain for the past 2 months. On anoscopy and examination, a 1-cm ulcer is seen at the dentate line. The patient is sexually active with a single partner and received a kidney transplant 10 years ago. What is the most likely diagnosis of the anal lesion?
- You are performing a high-resolution anoscopy on a patient referred for high-grade squamous intraepithelial lesion (HSIL) seen on an anal pap. You identify two areas with high-grade dysplasia. What is the treatment of choice?
- A 56-year-old patient is diagnosed with rectal cancer just above the dentate line. What is the lymphatic drainage of this lesion?
- Miscellaneous
- Pelvic Floor
- A 75-year-old man with a remote history of fistulotomy and radiation therapy for prostate cancer presents for evaluation of his worsening fecal incontinence. He has poor sphincter tone and a palpable muscular defect. Anal manometry confirms diminished resting and squeeze pressures that do not improve after pelvic floor physical therapy with biofeedback. His symptoms persist despite bowel habit optimization and sacral nerve stimulator implantation. The best next option for ths patient is
- A 38-year old woman presents to your clinic with chronic constipation and intermittent anal bleeding. During a rigid proctoscopy, a well-circumscribed ulcer is visualized on the anterior wall of the rectum, located at 8-cm from the anal verge. A biopsy is obtained, revealing minimal inflammation, with fibrosis of the lamina propria, and with a thickened muscularis mucosa. The most appropriate next step is
- Perioperative
- Benign Disease
- A 30-year-old female patient undergoes proctocolectomy and ileal pouch anal anastomosis (IPAA) for familial adenomatous polyposis. What surveillance is recommeded for her?
- A 65-year-old man with Crohn’s disease presents with intermittent bleeding from a long-standing anal fistula. He is on infliximab with good endoscopic control. On examination, there are large skin tags and an external fistula opening with irregular, heaped up, and friable edges. There is no evidence of abscess. Which of the following would be the most appropriate next step?
- A 55-year-old man with a history of ulcerative colitis (UC) diagnosed in his early 20s presents with a new diagnosis of distal rectal moderately differentiated adenocarcinoma. Mismatch repair (MMR) protein expression is intact; routine surveillance endoscopy showed a mass starting ~2 cm from the anal verge with all other biopsies negative for dysplasia. Laboratory results reveal unremarkable levels of carcinoembryonic antigen (CEA), comprehensive metabolic panel (CMP), and complete blood count (CBC). Systemic staging is negative for metastatic disease. Local staging with magnetic resonance imaging (MRI) reveals a T3N1 lesion. Based on a multidisciplinary tumor board discussion, the patient is planned for total neoadjuvant chemotherapy with upfront chemoradiation followed by consolidation chemotherapy. After this therapy is completed, what is the optimal surgical course for this patient?
- A 22-year-old woman with medically refractory ulcerative colitis presents for consideration of total abdominal proctocolectomy with ileal pouch-anal anastomosis (IPAA). Which of the following should be part of her preoperative evaluation?
- Colon and Rectal Surgery Educational Program (CARSEP)