Abstract
Background
Anal canal high-grade squamous intraepithelial lesion (HSIL) is the precursor to anal cancer. Immunocompromised patients are at increased risk and disease is usually within 3 cm from the anal verge. High-resolution anoscopy (HRA) with an 8-cm anoscope is used to identify and guide cautery treatment of HSIL.
Purpose
We report three patients with a long-term history of ulcerative colitis (UC) treated with systemic immunomodulators who developed proximally located rectal HSIL.
Results/Outcomes
Two patients were HIV-negative women, 63 and 48 years old, and the third was a 51-year-old HIV-positive man with underlying UC for 10, 16, and 3 years, respectively. They each presented with a HPV-positive HSIL visibly extending above the limits of the anoscope used for HRA. None developed cancer. All had episodes of active UC. It is unclear what causative role systemic immunomodulators play in predisposing UC patients to proximal HSIL. HSIL probably developed on a tongue of HPV-infected squamous epithelium growing proximally over the inflamed rectum. Islands developed when areas of squamous epithelium degenerated, creating skip areas.
Discussion
This study highlights the potential for HSIL to extend into the rectum either as a contiguous patch or isolated islands and the need for heightened surveillance in patients with extensive anal canal HSIL treated with immunodulator therapy. HSIL identified at the limit of the anoscope should be investigated further with colonoscopy, and argon plasma coagulation (APC) ablation can serve as an effective treatment option. Patients are at risk for stricture, but it is unclear what role the UC or the ablation played in stricture formation.
References
Seer Cancer Facts (2016) http://seer.cancer.gov/statfacts/html/anus.html. Accessed 23 June 2016
Palefsky JM, Holly EA, Ralston ML, Jay N (1998) Prevalence and risk factors for human papillomavirus infection of the anal canal in human immunodeficiency virus (HIV)-positive and HIV-negative homosexual men. J Infect Dis 177(2):361–367
Goldstone SE, Johnstone AA, Moshier EL (2014) Long-term outcome of ablation of anal high-grade squamous intraepithelial lesions: recurrence and incidence of cancer. Dis Colon rectum 57(3):316–323
Jay N, Berry JM, Hogeboom CJ et al (1997) Colposcopic appearance of anal squamous intraepithelial lesions. Dis Colon rectum 40(8):919–928
Grevenitis P, Thomas A, Lodhia N (2015) Medical therapy for inflammatory bowel disease. Surg Clin North Am 95(6):1159–1182
Al Hallak M, Najeeb GH, Mouchli A (2010) Primary submucosal squamous cell carcinoma of the rectum diagnosed by endoscopic ultrasound: case report and literature review. Case reports in gastroenterology 4(2):243–249
Frizelle FA, Hobday KS, Batts KP et al (2001) Adenosquamous and squamous carcinoma of the colon and upper rectum: a clinical and histopathologic study. Dis Colon rectum 44(3):341–346
Cheng H, Sitrin MD, Satchidanand SK et al (2007) Colonic squamous cell carcinoma in ulcerative colitis: report of a case and review of the literature. Can J Gastroenterol 21(1):47–50
Kulaylat MN, Doerr R, Butler B et al (1995) Squamous cell carcinoma complicating idiopathic inflammatory bowel disease. J Surg Oncol 59(1):48–55
Mir-Madjlessi SH, Farmer RG (1985) Squamous cell carcinoma of the rectal stump in a patient with ulcerative colitis. Report of a case and review of the literature. Cleve Clin Q 52(2):257–261
Greenberg R et al (2008) Squamous dysplasia of the rectum in a patient with ulcerative colitis treated with 6-mercaptopurine. Dig Dis Sci 53(3):760–764
Lam AKY, Ho YH (2006) Primary squamous cell carcinoma of the rectum in a patient on immunosuppressive therapy. Pathology 38(1):74–76
Acknowledgements
Connolly had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis with study supervision from Goldstone.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Connolly, J.G., Goldstone, S.E. Squamous cell dysplasia in the proximal rectum of three patients treated for ulcerative colitis on immunomodulators. Int J Colorectal Dis 32, 753–756 (2017). https://doi.org/10.1007/s00384-016-2745-9
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00384-016-2745-9