Jeremy Van, DO, Joanna Solarewicz, DO, MS, Ioannis Economou, MD; Rush University Medical Center, Chicago, IL
Introduction: Squamous Cell Carcinoma in Situ (SCC IS), also known as Bowen’s Disease, is an early form of SCC involving the epidermis without invasion to deeper layers. The perianal region and anorectal area are the least common locations of disease. This is a case of a patient with vulvar, perianal, and anorectal Bowen’s Disease.
Methods: A 56-year-old female with (w/) past medical history (hx) of AML s/p chemotherapy and allogeneic stem cell transplant on immunosuppression and C. Diff Colitis s/p total colectomy and ileostomy presented w/ 1-year hx of rectal and vaginal bleeding. Hgb 11.5. HIV antigen and antibody neg. On gynecological exam, there was a right vulvar lesion. Wide local excision was completed and pathology revealed SCC IS. Anoscopy demonstrated nodularity 2 cm from the anal verge. Biopsies from the anal verge and anal canal demonstrated SCC IS. CT chest, abdomen, and pelvis (CAP) and MRI pelvis showed no evidence of metastasis or fistula. She was treated with perineal resection and proctectomy. Proctectomy path revealed anorectal SCC IS without further rectum involvement. P16 immunostaining was positive suggesting HPV associated neoplasia. Discussion: Anal Bowen’s disease is associated w/ human papillomavirus (HPV) types 16 and 18. Additional risk factors include hx of receptive anal intercourse, HIV, hx of other anogenital cancers and an immunosuppressed state. Diagnosis is made via anoscopy or lower endoscopy with full thickness bx specimens. Histologically it demonstrates epithelial hyperkeratosis, atypical epithelial cells w/ mitotic figures and full-thickness epidermal involvement. If there is worry the lesions are invasive, local staging w/ pelvic MRI and systemic staging with CT CAP and PET can be completed. If there is rectal involvement, rectal endoscopic ultrasound can be used to determine the depth of invasion and local nodal involvement. The gold standard treatment is surgical excision. To our knowledge, there are few cases of a patient having vulvar, perianal, and anorectal Bowen’s disease.
Sahai A, Kodner IJ. Premalignant neoplasms and squamous cell carcinoma of the anal margin. May 2006. 88-93. Troicki F, Pappas A, Noone R, et al. Radiation therapy of recurrent anal squamous cell carcinoma in-situ: a case report. 24 Feb 2010. 67.
A: Vulvar Squamous Cell Carcinoma in Situ, no evidence of stromal invasion
B: Malignant cytologic features, across the full thickness of the epidermis, such as nuclear hyperchromasia, nuclear pleomorphism (arrowhead), disordered cellular polarity, and loss of cellular maturation (arrow indicates atypical, large nuclei present at the granular layer)
C: White Star-> Perianal Squamous Cell Carcinoma in Situ, no evidence of stromal invasion
D: Anal Canal Squamous Cell Carcinoma in Situ, full thickness loss of maturation and cytological atypia
E: Anorectal Squamous Cell Carcinoma in Situ
F: Strong and diffuse p16 immunostaining within the neoplastic cells
Disclosures: Jeremy Van indicated no relevant financial relationships. Joanna Solarewicz indicated no relevant financial relationships. Ioannis Economou indicated no relevant financial relationships.