Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 15  |  Issue : 3  |  Page : 196-198
Squamous cell carcinoma of the rectum 21 years after radiotherapy for cervical carcinoma


1 Department of Gastroenterology, The University of Texas Health Science Center, Houston, TX 77030, USA
2 Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center, Houston, TX 77030, USA

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Date of Submission08-May-2008
Date of Acceptance04-Aug-2008
Date of Web Publication24-Jul-2009
 

   Abstract 

Squamous cell carcinoma (SCC) of the rectum is an extremely rare malignancy, accounting for 0.1-0.2% of rectal malignancies. It is associated with ulcerative colitis, prior radiation, schistosomiasis, ovarian cancer, endometrial cancer, human papilloma virus, colocutaneous fistulas and colonic duplication. Prior reported cases of SCC of the rectum have involved treatment with brachytherapy and external beam radiation. This case is particularly interesting because of the remote exposure of radiation (21 years previously) and the subsequent development of SCC of the rectum. Although extremely rare, SCC of the rectum can occur decades after radiation exposure.

Keywords: Human papilloma virus, radiotherapy, rectum, squamous cell carcinoma, surgery

How to cite this article:
Leung KK, Heitzman J, Madan A. Squamous cell carcinoma of the rectum 21 years after radiotherapy for cervical carcinoma. Saudi J Gastroenterol 2009;15:196-8

How to cite this URL:
Leung KK, Heitzman J, Madan A. Squamous cell carcinoma of the rectum 21 years after radiotherapy for cervical carcinoma. Saudi J Gastroenterol [serial online] 2009 [cited 2020 Nov 26];15:196-8. Available from: https://www.saudijgastro.com/text.asp?2009/15/3/196/54745


Squamous cell carcinoma (SCC) of the rectum is extremely rare, accounting for approximately 0.1-0.2% of all rectal malignancies. [1] It was first described in 1919 by Schmidtmann. [2] Based on previous case reports, other conditions have been associated with this rare malignancy, such as colocutaneous fistula, [3] prior radiation, [4],[5] ulcerative colitis, [6],[7],[8] schistosomiasis, [9] ovarian cancer, [4] ovarian teratoma, [10] endometrial carcinoma, [11] human papilloma virus (HPV) [12] and colonic duplication. [13],[14] Previously reported cases of SCC with a history of radiotherapy have involved brachytherapy for the treatment of prostate cancer [5] and for the treatment of ovarian adenocarcinoma. [4] We present a very rare case of SCC of the rectum that, to our knowledge, is the first reported case in which this tumor was diagnosed 21 years after radiotherapy for cervical carcinoma.


   Case Report Top


A 63-year-old Hispanic woman was admitted to the hospital for urosepsis. She had a past medical history of cervical cancer treated with radical hysterectomy and radiotherapy in 1986. There was no evidence of residual cervical cancer or a history of inflammatory bowel disease. Because of her history of malignancy, complaints of pneumaturia of 2 months duration, polymicrobial blood and urine culture results and 30 lb weight loss over 1 year, an abdominal computed tomography (CT) was performed. It revealed a 9 cm pelvic mass with vesicocolonic fistulization, multiple hepatic lesions consistent with metastatic disease and local bony invasion of the pelvis [Figure 1]. A colonoscopy was performed, which revealed a large circumferential ulcerated and friable mass with the distal aspect located 3 cm proximal to the dentate line [Figure 2]. There was no involvement of the anorectal junction. Pathology showed a well-differentiated invasive SCC [Figure 3]a and b. Immunohistochemistry was negative for HPV and cytokeratin 7. Chest CT was negative and no other source for malignancy was identified. Because of her metastatic disease and refusal of palliative chemotherapy, a diverting colostomy was successfully performed and she was subsequently transferred to home hospice.


   Discussion Top


In 1919, Schmidtmann reported the first case of SCC of the colon. [2] Given the rarity of this malignancy, a majority of the published cases are case reports. However, a few case series from large institutions involving a small number of patients have been published. Frizelle et al. [15] reviewed the Mayo Clinic tissue registry spanning 85 years and identified only 11 cases of SCC.

In 1979, Williams et al. [16] proposed three criteria that should be met before establishing a diagnosis of SCC: (1) metastasis from other sites to the colon must be excluded, (2) squamous-lined fistula tract must not involve the affected bowel because it may be a source of SCC and (3) SCC of the anus with proximal extension must be excluded.

The etiology of SCC is unclear. Several theories have been proposed to explain the development of SCC, including: (1) proliferation of uncommitted stem cells into squamous cells that subsequently undergo malignant transformation, (2) squamous metaplasia resulting from chronic inflammation, (3) squamous differentiation of adenomas and adenocarcinomas and (4) pleuripotent stem cells capable of multidirectional differentiation. [17]

Traditionally, surgical resection has been the most appropriate and effective treatment. [17] Because of the rarity of this malignancy, the role of chemoradiation has not been clearly defined. [10],[18],[19] The prognosis is similar to rectal adenocarcinoma for Stage I and II node-negative disease; however, nodal involvement is associated with a worse prognosis than adenocarcinoma of a similar stage. [7] Adjuvant chemotherapy or chemoradiation, although unproven, should be considered in conjunction with surgical resection.

There have been limited reports of SCC of the colon arising after radiotherapy. [4],[5] In this patient, she was previously treated with radiation 21 years ago for cervical carcinoma. Late recurrence of cervical cancer has been reported 26 years after initial therapy. [20] However, our case unlikely represents a late recurrence. Immunohistochemical staining for HPV was negative, virtually excluding a recurrence of cervical carcinoma. [21],[22] Furthermore, cytokeratin 7 immunohistochemical staining should be positive if the malignancy was of gynecological origin. [23] Replacement of the rectal lining with squamous epithelium has been reported following repeated exposure to radiation. [24]

One of the patient's initial symptoms was pneumoturia. Vesicovaginal fistulization is a well known complication from radiotherapy, occurring between 4% and 47.8%. [25],[26],[27] However, given the long time period between radiotherapy and presentation of pneumoturia, the fistula tract was probably caused by bladder invasion by the SCC of the rectum.

In conclusion, this case highlights a rare and interesting case of SCC of the rectum resulting from radiotherapy 21 years earlier. Although extremely rare, SCC of the rectum can occur decades after radiation exposure.

 
   References Top

1.Pikarsky AJ, Belin B, Efron J, Woodhouse S, Weiss EG, Wexner SD, et al . Squamous cell carcinoma of the rectum in ulcerative colitis: Case report and review of the literature. Int J Colorectal Dis 2007;22:445-7.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Schmidtmann M. Zur kenntnis seltener Krebsformen. Virchows Archiv 1919;226:110-8.  Back to cited text no. 2    
3.Balsano NA. Squamous cell carcinoma of the cecum. Arch Surg 1985;120:1176-7.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Pemberton M, Lendrum J. Squamous-cell carcinoma of the caecum following ovarian adenocarcinoma. Br J Surg 1968;55:273-6.  Back to cited text no. 4  [PUBMED]  
5.Yurdakul G, de Reijke TM, Blank LE, Rauws EA. Rectal squamous cell carcinoma 11 years after brachytherapy for carcinoma of the prostate. J Urol 2003;169:280.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Petrelli M, Tetangco E, Reid JD. Carcinoma of the colon with undifferentiated, carcinoid, and squamous cell features. Am J Clin Pathol 1981;75:581-4.  Back to cited text no. 6  [PUBMED]  
7.Comer TP, Beahrs OH, Dockerty MB Primary squamous cell carcinoma and adenocanthoma of the colon. Cancer 1971;28:1111-7.  Back to cited text no. 7    
8.Michelassi F, Montag AG, Block GE. Adenosquamous-cell carcinoma in ulcerative colitis. Report of a case. Dis Colon Rectum 1988;31:323-6.  Back to cited text no. 8    
9.Wiener MF, Polayes SH, Yidi R. Squamous carcinoma with schistosomiasis of the colon. Am J Gastroenterol 1962;37:48-54.  Back to cited text no. 9  [PUBMED]  
10.Lyttle JA. Primary squamous carcinoma of the proximal large bowel. Report of a case and review of the literature. Dis Colon Rectum 1983;2:279-82.  Back to cited text no. 10    
11.Rubio CA, Collins VP, Berg C. Mixed adenosquamous carcinoma of the cecum: Report of a case and review of the literature. Dis Colon Rectum 1981;24:301-4.  Back to cited text no. 11  [PUBMED]  
12.Audeau A, Han HW, Johnston MJ, Whitehead MW, Frizelle FA. Does human papilloma virus have a role in squamous cell carcinoma of the colon and upper rectum? Eur J Surg Oncol 2002;28:657-60.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Larizadeh R, Powell DE. Neoplastic Change in a Duplicated Colon. Br J Surg 1965;52:666-8.  Back to cited text no. 13  [PUBMED]  
14.Hickey WF, Corson JM. Squamous cell carcinoma arising in a duplication of the colon: Case report and literature review of squamous cell carcinoma of the colon and of malignancy complicating colonic duplication. Cancer 1981;47:602-9.  Back to cited text no. 14  [PUBMED]  
15.Frizelle FA, Hobday KS, Batts KP, Nelson H. Adenosquamous and squamous carcinoma of the colon and upper rectum: A clinical and histopathologic study. Dis Colon Rectum 2001;44:341-6.  Back to cited text no. 15  [PUBMED]  
16.Williams GT, Blackshaw AJ, Morson BC. Squamous carcinoma of the colorectum and its genesis. J Pathol 1979;129:139-47.  Back to cited text no. 16  [PUBMED]  
17.Anagnostopoulos G, Sakorafas GH, Kostopoulos P, Grigoriadis K, Pavlakis G, Margantinis G, et al. Squamous cell carcinoma of the rectum: A case report and review of the literature. Eur J Cancer Care (Engl) 2005;14:70-4.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Lundquest DE, Marcus JN, Thorson AG, Massop D. Primary squamous cell carcinoma of the colon arising in a villous adenoma. Hum Pathol 1988;19:362-4.  Back to cited text no. 18  [PUBMED]  
19.Juturi JV, Francis B, Koontz PW, Wilkes JD. Squamous-cell carcinoma of the colon responsive to combination chemotherapy: Report of two cases and review of the literature. Dis Colon Rectum 1999;42:102-9.  Back to cited text no. 19  [PUBMED]  
20.Van Herik M, Decker DG, Lee RA, Symmonds RE. Late recurrence in carcinoma of the cervix. Am J Obstet Gynecol 1970;108:1183-6.  Back to cited text no. 20  [PUBMED]  
21.Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, et al . Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 1999;189:12-9.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]
22.Bosch FX, Lorincz A, Muρoz N, Meijer CJ, Shah KV. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol 2002;55:244-65.  Back to cited text no. 22    
23.Varadhachary GR, Abbruzzese JL, Lenzi R. Diagnostic strategies for unknown primary cancer. Cancer 2004;100:1776-85.  Back to cited text no. 23  [PUBMED]  [FULLTEXT]
24.Dukes CE. The significance of the unusual in the pathology of intestinal tumours. Ann R Coll Surg Engl 1949;4:90-103.  Back to cited text no. 24  [PUBMED]  [FULLTEXT]
25.Kramer C, Peschel RE, Goldberg N, Kohorn EI, Chambers JT, Chambers SK, et al . Radiation treatment of FIGO stage IVA carcinoma of the cervix. Gynecol Oncol 1989;32:323-26.  Back to cited text no. 25  [PUBMED]  
26.Million RR, Rutledge F, Fletcher GH. Stage IV carcinoma of the cervix with bladder invasion. Am J Obstet G ynecol 1972;113:239-46.  Back to cited text no. 26    
27.Moore KN, Gold MA, McMeekin DS, Zorn KK. Vesicovaginal fistula formation in patients with Stage IVA cervical carcinoma. Gynecol Oncol 2007;106:498-501.  Back to cited text no. 27  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Anand Madan
Division of Gastroenterology, The University of Texas Health Science Center, 6431 Fannin Street, MSB 4.234, Houston, TX 77030
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.54745

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  [Figure 1], [Figure 2], [Figure 3]

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