CLOACOGENIC CARCINOMA
ABSTRACT:Cloacogenic
carcinoma originates from persistent remnant of
cloacal membrane of embryo.This is a case of 70 yr old female who presented
with mass in anorectal and vulvar region and bleeding per rectum.Inguinal
nodes were palpable.Clinically it was diagnosed as Vulvar /anal carcinoma
.Histopathologically diagnosis confirmed as cloacogenic carcinaoma.
KEY WORDS: cloacogenic carcinoma ,anorectal region, basaloid .
INTRODUCTION:
Cloacogenic Carcinoma accounts for 2 - 3% of all anorectal carcinoma found
in all age groups but predominantly in 5th to 6th decade. Females are affected 2-3
times more frequently than in males. (5)(9)
It is a rare tumour of anorectal region originating from persistant remnant of
cloacal membrane . Cloacogenic carcinoma arise from the mucosa of transitional
or cloacogenic zone separating the rectal and anal mucous membranes.(10)
CASE REPORT:
A 60 Year old lady presented with the growth in external genitalia and
anal region of 7 months duration. She complained of pain over swelling , pain
during defaecation and bleeding per rectum. She had spontaneous defaecation
of 4 months duration.
On local examination a ulcero proliferative growth over anal region and
2x2 cm growth over left side labia majora .
Inguinal nodes were palpable and FNA was attempted which revealed
Cytologically , poorly differentiated tumour cells with vague papillary
configuration.
After carrying out necessary investigations ,wedge biopsy from both
vulval and anal growth is performed under spinal anaesthesia.
Two containers were received one labelled as vulvar growth and other
labelled as anal growth.
Grossly vulvar growth appeared as multiple grey white ,grey brown skin
covered soft tissue pieces altogether measuring 1 ml in aggregate all embedded in
single block A.
Anal growth appeared as grey white , grey brown soft tissue pieces
altogether measuring 0.3 ml in aggregate all embedded in single block B
Histology -Section studied from both the specimen shows a malignant tumour
composed of markedly anaplastic and pleomorphic cells arranged in nests and
sheets. They tend to form vague glandular units. Some cells look basaloid as well.
Clumps of poorly differentiated hyperchromatic cells present.
Diagnosis – Features are consistent with cloacogenic carcinoma.
DISCUSSION:
The common symptoms are rectal bleeding ,rectal pain and perineal
discomfort. Approximately one third of patients notice an anal mass. Most
tumours present as fungating or ulcerating lesions but the tumour may arise in
anal ducts and present as submucosal mass. A small number of patients have no
intra luminal mass.(8)
Predominant histologic pattern varies because of complex epithelium from
which they arise but many resemble transitional cell neoplasm of urinary
bladder.(4)(5)(7)(8)(9)(11)
Most common growth pattern is nests of cells that are elongated and
angulated and grow invasively in long finger like extensions .In the more well
differentiated lesions , distinct palisading is present in periphery.(10)
Most common variation is presence of various degree of squamoid
differentiation. This generally takes the form of centrally located epithelial pearls
surrounded by well differentiated squamous cells.(10)
Squamous cells located in central portion of epithelial cells are usually
uniform , frequently appearing deceptively benign .However peripherally located
portions of invading squamous cells are less uniform with irregular hyper
chromatic nuclei, numerous mitotic figures and occasional multinucleated
neoplastic giant cells.(10)
Basaloid carcinoma shows formation of islands of small cells with basophilic
cytoplasm and distinctive pattern of nuclear palisading at the periphery of clumps
of tumor cells. It may show presence of masses of eosinophilic necrosis
surrounded by relatively narrow rim of tumor cells giving a SWISS CHEESE
appearance under low power microscope.(3)
In moderately differentiated basaloid carcinoma, the preceding feature
especially the palisading are less prominent ,while in poorly differentiated cases
cells are formed into small highly infiltrative clumps and there is considerable
nuclear pleomorphism and mitotic activity.(3)
Basaloid carcinoma often show a mixed picture with areas of squamous
differentiation .On occasion they also demonstrate a micro cystic pattern and
contain isolated mucus secreting cells.(2)
One third of patients had nodal metastases .Most commonly involved are
perirectal nodes followed by inguinal nodes .Hepatic metastasis have occurred in
20% of patients .Most common adjacent structures involved is vagina which is
seen in 20% of women of this tumor.(8)
Organs most frequently involved are liver, lungs ,bones and peritoneum.(6)(10)
ACKNOWLEDGEMENT
We take the previlege of thanking the Medical Superintendent and Dean, Faculty
of Medicine, Dr. L. Lakshamana Rao, H.O.D. Department of Pathology and the
patient, for allowing us to take on this case for presentation.
REFERENCES:
1 .Lewin KJ, Riddell RH, Weinstein WM :Gastrointestinal Pathology and Its Clinical
Implications.New York,Igaku-Shoin,1992,pp 1319-1330
2 .Kalogeropoulos NK, Antonakopoulos GN , MB, et al : Spindle cell carcinoma
(pseudo sarcoma) of anus :a light , electon microscopic and immunocytochemical
study of a case. Histopathology 9:987-994,1985.
3 .Boman B, Moertel CG, O’Connell MJ, et al:Carcinoma of anal canal: a clinical
and pathological study of 188 cases. Cancer 54:114-125,1984
4.Gillespie JJ, MacKay B : Histogenesis of cloacogenic carcinoma .Hum Pathol
9:580,1978
5 .Fogler R , Lanter B ,Stern G ,et al : Mucoepidermoid carcinoma in an “anal
fistula” with associated adenocarcinoma of descending colon :Report of a case in
a villous adenoma .Dis Colon Rectum 20:428,1977
6 .Levin SE .Cooperman H, Freilich M, et al :Transitional cloacogenic carcinoma of
anus .Dis Colon Rectum 20:1,1977
7 .Hickey RC, Martin RG, Kheir S ,et al :Anal cancer : With special reference to the
cloacogenic variety . Surg Clin North Am 52:943,1972
8 .Kheir S , Hickey PC, Martin RG, et al : Cloacogenic carcinoma of anal canal. Arch
Surg 104:407,1972
9 . Fisher ER :The basal cell nature of the so-called transitional claocogenic
carcinoma of anus as revealed by electon microscopy. Cancer 24:312 ,1969
10 .Klotz RG , Pamukcoglu T, Souilliard DH: Transitional cloacogenic carcinoma of
the anal canal: Clinicopathologic study of three hundred and seventy three
cases.Cancer 20:1727-1745,1967
11 .Grinvalsky HT, Helwig EB:Carcinoma of anorectal junction. Cancer 9;480,1956
FIG 1 H & E STAINING 10X
FIGURE 1 SHOWS BASALOID CELLS
FIG 2 H & E STAINING 10X
FIGURE 2 SHOWS SQUAMOUS CELLS
FIG 3
H & E STAINING 10X
.FIGURE 3 SHOWS GLANDULAR UNITS
FIG 4.H&E STAINING 20X
FIGURE 4 SHOWS TUMOUR CELLS FORM GLANDULAR UNITS.STROMA SHOWS
HYPERCHROMATIC OAT CELL LIKE MORPHOLOGY.
FIG 5
GIEMSA STAINING 10X
FIG 6
GIEMSA STAINING 20X
FIGURE 5 & 6 SHOWS POORLY DIFFERENTIATED TUMOR CELLS WITH VAGUE PAPILLARY
CONFIGURATION.
All the microscopic pictures were taken using Nikon Coolpix Model
8400
X - Indicates the power of objective
Stain used is Haemotoxylin and Eosin