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Thread: Colonic Squamous Cell Carcinoma Pictures - Atlas of Colon and Ileum

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    Default Colonic Squamous Cell Carcinoma Pictures - Atlas of Colon and Ileum

    The Multidisciplinary Approach (For effective solutions in cancer treatment)
    The most effective solutions in the treatment of cancer are obtained under a multidisciplinary approach because oncology is an area that requires the collaboration and co-decision of many branches of science. The consultation of physicians in different branches is extremely important in the diagnosis and treatment of cancer and requires close teamwork. In multidisciplinary structures, specialists in different branches come together, reach a joint decision and share the responsibility. As a result, centers working under a multidisciplinary structure obtain more successful results in the treatment and follow-up of cancer that is in the field of oncology.Multidisciplinary-Approach

    The Multidisciplinary approach in Acibadem Hospitals The diagnosis and treatment of all cancers is evaluated under a multidisciplinary approach in Acibadem Cancer Centers. The services offered in the centers include scanning programs for the early diagnosis of cancer, identifying people who are healthy but at risk of cancer and informing these people and their relatives about cancer prevention.

    Acibadem Hospitals – serving cancer patients with world class technology.
    Acibadem Healthcare Group has brought the latest technology to Turkey. With its developed technology, its technological devices and wealth of knowledge and experience, Acibadem Hospitals offers its patients state-of-the-art technologies the world has reached on the diagnosis and treatment of cancer.

    Acibadem Healthcare Group carries radiation oncology treatment in 5 hospitals. These hospitals are as follows: Maslak and Kozyatağı Hospitals in Istanbul, Bursa, Adana and Kayseri Hospitals outside of Istanbul.

    gamma-knife-deviceThe Gamma Knife device, used for the treatment of brain tumors, offers service in Acibadem Kozyatağı Hospital and the CyberKnife device, used for the treatment of tumors in the brain and in other parts of the body, offers service in Acibadem Maslak Hospital. In addition, cancer patients are treated with the first and only Rapidarc device, which reduces the treatment duration to 1-2 minutes, again in Acibadem Maslak Hospital.

    INTRODUCTION
    Squamous cell carcinoma of the gastrointestinal (GI) tract is a rare malignancy. When encountered, it usually involves the esophagus or the anal canal. Occasionally it can be associated with a GI tract fistula, lined by squamous mucosa. Squamous cell carcinoma of the rectum is extremely unusual and unlike squamous cell carcinoma of the esophagus and anal canal, little is known about the etiology, prognosis, and optimal treatment. This review will examine and summarize the available information regarding this disease from the perspective of the practicing gastroenterologist.
    Colonic Squamous Cell Carcinoma Pictures attachment.php?s=85655477efe8fcb798cb5a68484014fc&attachmentid=2062&d=1442182424

    EPIDEMIOLOGY
    Squamous cell carcinoma of the rectum is a rare entity and only case reports and relatively small case series have been published(Table ​(Table1).1). Schmidtmann in 1919 described the first case of squamous cell carcinoma of the large intestine localized to the cecum. It was not until 1933 that the first case involving the rectum was subsequently described by Raiford. Since that time, 73 cases have been reported in the English language literature. Based on a review of this literature, the incidence of the disease is approximately 0.10 to 0.25 per 1000 colorectal cancers. Of all cases of squamous cell carcinoma of the large intestine, the rectum is the most frequent location for the disease, followed by the right colon. This is likely an underestimation due to reporting bias and histologic variability.

    Squamous cell carcinoma of the rectum appears to affect individuals between the ages of 39 to 93 years old, with a mean age of 57 years. The disease tends to occur more frequently in women than in men. A review of available reports shows that 66% of cases occurred in women and 34% in men. Patients often present with advanced disease, Dukes C or Stage III This might be due to a reporting bias based on the fact that most of these case reports come from tertiary care centers. There is no geographic or ethnic predilection that has been established for this disease, but it is interesting to note that Mel'nikov et al reported 107 cases of squamous cell cancer of the rectum in Russia in one center alone. The details of the study are unavailable, and it is unclear why this population would have such a seemingly high incidence of this malignancy. One plausible explanation is that some cases of anal squamous cell carcinoma might have been misclassified as originating in the rectum.

    While no clear set of risk factors can be established, several associations have been observed. Some case reports have found squamous cell carcinoma in association with inflammatory processes involving the colon and rectum. Several cases have been reported in patients with ulcerative colitis while others have been in found in association with infections including Schistosomiasis, Entamoeba histolytica and human papilloma virus (HPV) Adenocarcinoma has also been associated with squamous cell cancer of both the colon and rectum. Multiple studies have described either synchronous[ or metachronous lesions of adenocarcinoma occurring in the large intestine of patients with squamous cell cancer of the rectum. Additional coexisting diseases have been described including colonic duplication, ovarian cancer prostate cancer, endometrial cancer, and breast cancer

    PATHOGENESIS
    With so few cases described, the exact mechanism behind the development of squamous cell cancer of the rectum remains elusive. Over the years, four hypotheses have developed regarding the pathophysiology of the disease. Some suggest that inflammation or irritation, secondary to inflammatory bowel diseaseinfection or radiation, results in squamous metaplasia from which carcinoma develops Hicks and othershave described the possibility of pluripotent stem cells capable of squamous differentiation. This theory is supported by the fact that squamous carcinoma is often found in the midst of poorly differentiated cells; Michelassi et alhave suggested that epithelial damage causes proliferation of uncommitted basal cells into squamous cells, which then undergo malignant transformation; Histological reviews of adenocarcinomas have demonstrated areas of squamous differentiation, suggesting the possibility that these carcinomas may arise out of preexisting adenomas or adenocarcinomas.
    Colonic Squamous Cell Carcinoma Pictures attachment.php?s=85655477efe8fcb798cb5a68484014fc&attachmentid=2063&d=1442182438

    A clear association between HPV and squamous cell cancer of the anus has been established. Furthermore, HPV has been associated with many squamous cell cancers including: skin, oral, vaginal, penile, esophageal and anal. The subclasses most commonly associated with virulent disease include HPV-and 33. The studies relating to HPV and squamous cell cancer of the rectum however, are few and varied in the methods of detection and the results obtained. Frizelle et aland Nahas et al evaluated a total of 11 squamous cell carcinoma patients for HPV using in situ hybridization and detected no HPV deoxyribonucleic acid (DNA) in any of the specimens. Audeau et all used immunohistochemistry to evaluate 20 patients with squamous cell cancer, adenosquamous cancer, and squamous metaplasia of the rectum, none of whom had detectable HPV. Polymerase chain reaction (PCR) has been considered the gold standard for detection of HPV. In two studies, a total of four patients, have been evaluated via this methodology. All of those evaluated via PCR were HPV-16 positive. There have been concerns that the use of PCR for detection of HPV may lead to false positive results secondary to cross contamination. Indeed, two out of the above four patients with squamous cell cancer of the rectum evaluated via PCR were noted to have a history of cervical dysplasia, a condition known to be associated with HPV. At present we do not have firm evidence for a cause/effect relationship between infection with HPV and squamous cell cancer of the rectum.

    DIAGNOSIS
    Patients with squamous cell carcinoma of the rectum present with symptoms similar to those with adenocarcinoma of the rectum. The symptoms most frequently encountered are rectal bleeding, abdominal pain, change in bowel habits and weight loss. Patients usually experience symptoms for several weeks to months.

    Proctoscopy or colonoscopy with forceps biopsies of any visible abnormalities are the primary modalities for definitive diagnosis of rectal squamous cell carcinoma. The endoscopic appearance can range from a polyp to an ulcerated obstructing mass. Recent advances in endoscopy have been utilized to detect more subtle lesions. An example of this is narrow band imaging (NBI), a new endoscopic technique that highlights mucosa and underlying capillary networks. Fu et al describe the use of this technique in detection of squamous metaplasia in a patient with ulcerative colitis. If the metaplasia-dysplasia-carcinoma pathway is established as for other cancers, then NBI might play an important role in detecting premalignant lesions.

    Occasionally, there can be difficulty either in distinguishing squamous cell cancer of the rectum from that of the anus or other small cell, poorly differentiated tumors on biopsy specimens. Immunohistochemistry has proved useful in characterizing these lesions. The most useful cytokeratins are CAM 5.2, AE1/AE3, and 34B12. CAM 5.2 helps to differentiate rectal from anal lesions. It characteristically stains rectal squamous cell and adenocarcinoma but not anal squamous cell lesions The cytokeratins AE1/AE3 stain positively for cells of squamous origin, helping to delineate less well-characterized lesion.

    In 1979, Williams et all established diagnostic criteria for squamous cell cancer involving the rectum which included: absence of evidence of squamous cell carcinoma of any other part of the body, indicating possible metastasis; careful proctoscopy to exclude proximal extension of anal squamous cell carcinoma; and lack of a fistulous tract lined by squamous cells. The above criteria are required in conjunction with histology consistent with a squamous carcinomawithout glandular differentiation.

    Squamous cell carcinoma antigen (SCC Ag) is a tumor marker that has been found to be associated with squamous carcinoma of the anus. Rasheed et al, found SCC Ag to be elevated in three out of six patients with squamous cell carcinoma of the rectum. It was noted that after treatment with chemo- and/or radiation therapy, the SCC Ag normalized. In 2001, Comer et all found an elevated SCC Ag along with metastatic disease in a patient previously treated for rectal squamous cell cancer. Retreatment with chemotherapy and radiation resulted in an improvement in SCC Ag levels. Based on these observations, it appears that SCC Ag level is not suitable for initial diagnosis of squamous cell carcinoma of the rectum, but might be helpful to monitor disease response and progression.
    Colonic Squamous Cell Carcinoma Pictures attachment.php?s=85655477efe8fcb798cb5a68484014fc&attachmentid=2064&d=1442182455

    Once the diagnosis of squamous cell carcinoma of the rectum has been established, the work-up should focus on staging of the tumor and evaluation for regional and distant metastasis. Trans-rectal endoscopic ultrasound (R-EUS) has become an integral part of the staging process of rectal cancer of all types. Accurate staging helps to determine appropriate surgical treatment (local excision vs radical resection) and the need for adjuvant therapy. The stage of the disease as determined by R-EUS is also predictive of patient survival. In squamous cell cancer of the anus, an increase in stage is associated with a decrease in five-year survivalWhile there are no large studies to support this for squamous cell cancer of the rectum, a review of available case reports supports a similar trend. R-EUS helps to determine the depth of tumor invasion. Superficial T1 lesions involve one or more of the first three echo layers (superficial mucosa, deep mucosa, and submucosa) of the rectal wall. Extension into the muscularis propria, the 4th echo layer, denotes a T2 lesion. Transmural invasion through the muscularis propria into the perirectal fat characterizes a T3 lesion, and T4 lesions involve invasion of surrounding organs. In addition to depth of tumor invasion, local nodal involvement can also be assessed. Size, echogenicity, shape and demarcation are felt to be helpful in distinguishing benign from malignant lymph nodes, although this concept has yet to be validated in rectal cancer. Park et al evaluated the accuracy of R-EUS with fine needle aspiration (FNA) in the detection of rectal cancer. They found nodal involvement via only R-EUS in 33% of histologically confirmed nodes. When FNA was added to the endosonographic examination, the accuracy of the test increased to 87%.

    R-EUS should be performed in conjunction with computed tomography (CT) for complete staging. Several studies have compared the two modalities with regards to the staging of rectal cancer. The accuracy of R-EUS was superior to CT for evaluation of wall invasion (T staging), with a sensitivity of 67% to 93% vs 53% to 83%, respectively. R-EUS also outperformed CT for nodal staging, sensitivity 80% to 87% vs 57% to 72%[55,58,59]. The current consensus is that R-EUS and CT are complimentary. R-EUS provides better tumor and local lymph node evaluation and CT has the advantage of detecting distant metastasis. Endorectal magnetic resonance imaging (MRI) has also been used for evaluation of local disease, allowing a larger area of view than R-EUS. In the limited studies available, endorectal MRI has yet to be shown to be superior to R-EUS

    References:
    Squamous cell cancer of the rectum
    Cancer Treatment (Oncology) | Acibadem Hospitals Group











    Last edited by Medical Photos; 09-13-2015 at 10:14 PM.

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