Anal Malignant Melanoma: Report
of a Case ~
H. L. CItULANI, M.S. Honorary Assistant Proctologist, G. T. Hospital, Bombay, India
next seven months. He attempted self-treatment with Ayurvedic and h o m e o p a t h i c drugs, w i t h o u t relief. T h e patient was seen again in March 1976. T h e symptoms were increasing discomfort, continuous pain, and a foul smelling discharge. On examination an ulcer was seen extending outside the anal verge for 5-6 cm. T h e margins of the ulcer were raised in some places and felt firm to the touch. Rectal examination revealed invasion of the lower rectmn. Proctoscopic examination was deferred due to pain. A biopsy taken from the ulcer edge was interpreted as malignant m e l a n o m a (Fig. 1). A closer clinical examination (retrospective) showed that in two piaces the floor of the ulcer was discolored gray, the area of discoloration being 3--4 m m in size (Fig. 2) . T h e right inguinal glands were not palpable. T h e left inguinal glands were enlarged, firm and tender, b u t mobile. T h e liver was not enlarged. T h e rest of the physical examination was noncontributory. Results of laboratory investigations were normal, W h e n the subject of operation was broached, the patient again refused surgical treatment and returned to his village against medical advice.
the a n u s a r e u n compared with malignant tumors of the rest of the large intestine. Tumors o1: the anus are generally squamous-cell carcinomas. Other tumors seen are adenocarcinoma of the rectmn invading the anus, basal-cell carcinoma, Paget's disease of the anus, and rarely, an adenocarcinoma arising from the anal glands. Malignant melanoma is the most malignant form of cancer of the bowel. It accounts for only a very small percentage of tumors arising in this region. T h e purpose of this article is to report one such case, in which the lesion was seen very early in its existence and again seven months later when it had ulcerated outside the anal verge and invaded the lower rectum. ~{ALIGNANT TUMORS Of
common
Report of a Case Discussion A 42-year-old man, peon in an office, was first admitted to a Surgical Unit in J n n e 1975 complaining of pain on defecation and a watery discharge. He was diagnosed as having anal fissure and operated on. He was discharged in July 1975. In August 1975 he was seen by the author, after referral by a medical colleague. T h e symptoms at this time were pain on defecation, lasting for some hours afterwards and discharge. Examination revealed a healed scar outside the anal verge in the posterior midline. On rectal examination an indurated nodule was felt posteriorly 1 cm inside the anal ~erge. T h e nodule was exquisitely tender. A malignant lesion was suspected and admission to the hospital for necessary treatment was advised. T h e patient refused and was not seen again for the
That malignant melanoma is uncommon in the anal region is evidenced by the fact that the largest series reported until 1960 is that of Pack and Martins 12 (26 cases). Ouan e t aI. I3 reported 25 cases in 1959. Other investigators each have fewer than a dozen: Berkley, 4 11 cases; Mikal,8 four cases; Mirajkar and Sachdeva,9 one case, and Burns~ one case. Over a 28-year period (1928-1956), when more than 4,000 cases of malignant tumors of the anorectum were seen at St. Mark's Hospital, only ten were cases of malignant m e l a n o m a 7 From the Memorial Center, N e w York, 21 cases were reported over a period of 25 years from a
* Received for publication August 6, 1976. Address reprint requests to Dr. Chulani: Consulting Surgeon and Proctologist, 4, Mirabelle, Linking Road, Bandra, Bombay-400050, India.
517 Dis. Col. & Rect. Sept. 1977
Volume 20 Number {5
5 18
tt. L. CHULANI
Dis. CoL & Rect. Sept. 1977
Fla. 1. Above, melanin pigment (X 10). Below, higher-power view (hematoxylin and eosin; X 40).
Volume 20 Number 6
ANAL MALIGNANT
FIG. 2.
MELANOMA
519
A r l o w s p o i n t to p i g m e n t e d areas. C e n t r a l d a r k color is d u e to b l o o d .
total of 4,500 malignant tumors of the anorectum by Q u a n et al. la I n 21 years, Bacon3 saw only two cases. T h e tumor generally arises as a small polypoid mass. Gabriel6 has stressed that the tumor is invariably protuberant. In this instance the tumor was ulcerative and was therefore mistaken for an anal fissure initially. W h e n protuberant, it may suggest the diagnosis of a thrombosed internal hemorrhoid, 10 since the tumor spreads upwards into the lower rectum. Its true nature may be revealed only when the specimen is submitted to histologic examination. Spread of the tumor may occur upward and downward, as in this case. Rectal spread may be continuous with the anal tumor or may appear as discontinuous submucosal nodules, which may be dark in color. Pigmentation is often scanty (amelanotic melanoma), and then the diagnosis may be difficult to make. T h e tumor has a high
metastasizing potential and is justifiably considered the most malignant form of intestinal cancer. 1, 2 Lymphatic spread may occur in three directions: upward to involve the inferior mesenteric glands, along the middle hemorrhoidal vessels to the internal iliac glands, and to the inguinal lymph nodes. In "this case the left inguinal glands were enlarged, though not hard or fixed. T r e a t m e n t should be carried out as soon as the diagnosis is established.6 T h e preferred form of treatment is abdominoperineal resection with bilateral groin dissection and deep pelvic node disectionA 1 Radiotherapy and chemotherapy are of no value. It would be interesting to follow the natural course of this disease in this case, since the patient has refused treatment. Personal follow u p is impossible, since the patient has gone to his native village.
H. L. CHULANI
520
H o w e v e r , his e m p l o y e r s have i n f o r m e d the author
t h a t w h e n last h e a r d f r o m h e w a s
u n a b l e to d efecate a n d the ulcer h a d g r o w n larger. H e was in c o n t i n u o u s pain: References 1. Ackerman LV, Butcher HR Jr: Surgical Pathology. Ed. 3. St. Louis, Mosby, 1964, 1244 pp 2. Anderson W: Boyd's Pathology for the Surgeon. Ed. 8. Philadelphia, W. B. Saunders, 1967, 842 pp 3. Bacon HE: Cancer of the Colon, Rectum and Anal Canal. Philadelphia, J. B. Lippincott, 1964, 956 pp 4. Berkley JL: Melanoma of the anal canal: Report of a case of five-year survival after ahdominoperineal resection. Dis Colon Rectum 3:159, 1960 5. Burns FJ: Melanoma of the rectum: Report of a case. Dis Colon Rectum 3:241, 1960
Dis. Col. & Rect. Sept. 1977
6. Gabriel WB: The Principles and Practice of Rectal Surgery. Ed. 5, Springfield, Ill., Charles C Thomas 1963, 739 pp 7. Goligher JC: Surgery of the Anus, Rectum and Colon. Ed 2. Springfield, Ill., Charles C Thomas, 1967, 1110 pp 8. Mikal S: Malignant melanoma of the anus and rectum. Am J Surg 103:191, 1962 9. Mirajkar VR, Sachdeva YV: Malignant melanoma of the rectum: A case report. Indian J Surg 7:50, 1945 10. Morson BC (editor): Diseases of the Colon, Rectum and Anus (Tutorials in Postgraduate Medicine). London, Heinemann, 1969, vol 1, 314 pp I1. Nealon TF: Management of the Patient with Cancer. Philadelphia, W. B. Saunders, 1965, 1067 pp 12. Pack GT, Martins FG: Treatment of anorectal malignant melanoma. Dis Colon Rectum 3:15, 1960 13. Quan SH, White JE, Deddish MR: Malignant melanoma of the anorectum. Dis Colon Rectum 2:275, 1959
of a Case ~
H. L. CItULANI, M.S. Honorary Assistant Proctologist, G. T. Hospital, Bombay, India
next seven months. He attempted self-treatment with Ayurvedic and h o m e o p a t h i c drugs, w i t h o u t relief. T h e patient was seen again in March 1976. T h e symptoms were increasing discomfort, continuous pain, and a foul smelling discharge. On examination an ulcer was seen extending outside the anal verge for 5-6 cm. T h e margins of the ulcer were raised in some places and felt firm to the touch. Rectal examination revealed invasion of the lower rectmn. Proctoscopic examination was deferred due to pain. A biopsy taken from the ulcer edge was interpreted as malignant m e l a n o m a (Fig. 1). A closer clinical examination (retrospective) showed that in two piaces the floor of the ulcer was discolored gray, the area of discoloration being 3--4 m m in size (Fig. 2) . T h e right inguinal glands were not palpable. T h e left inguinal glands were enlarged, firm and tender, b u t mobile. T h e liver was not enlarged. T h e rest of the physical examination was noncontributory. Results of laboratory investigations were normal, W h e n the subject of operation was broached, the patient again refused surgical treatment and returned to his village against medical advice.
the a n u s a r e u n compared with malignant tumors of the rest of the large intestine. Tumors o1: the anus are generally squamous-cell carcinomas. Other tumors seen are adenocarcinoma of the rectmn invading the anus, basal-cell carcinoma, Paget's disease of the anus, and rarely, an adenocarcinoma arising from the anal glands. Malignant melanoma is the most malignant form of cancer of the bowel. It accounts for only a very small percentage of tumors arising in this region. T h e purpose of this article is to report one such case, in which the lesion was seen very early in its existence and again seven months later when it had ulcerated outside the anal verge and invaded the lower rectum. ~{ALIGNANT TUMORS Of
common
Report of a Case Discussion A 42-year-old man, peon in an office, was first admitted to a Surgical Unit in J n n e 1975 complaining of pain on defecation and a watery discharge. He was diagnosed as having anal fissure and operated on. He was discharged in July 1975. In August 1975 he was seen by the author, after referral by a medical colleague. T h e symptoms at this time were pain on defecation, lasting for some hours afterwards and discharge. Examination revealed a healed scar outside the anal verge in the posterior midline. On rectal examination an indurated nodule was felt posteriorly 1 cm inside the anal ~erge. T h e nodule was exquisitely tender. A malignant lesion was suspected and admission to the hospital for necessary treatment was advised. T h e patient refused and was not seen again for the
That malignant melanoma is uncommon in the anal region is evidenced by the fact that the largest series reported until 1960 is that of Pack and Martins 12 (26 cases). Ouan e t aI. I3 reported 25 cases in 1959. Other investigators each have fewer than a dozen: Berkley, 4 11 cases; Mikal,8 four cases; Mirajkar and Sachdeva,9 one case, and Burns~ one case. Over a 28-year period (1928-1956), when more than 4,000 cases of malignant tumors of the anorectum were seen at St. Mark's Hospital, only ten were cases of malignant m e l a n o m a 7 From the Memorial Center, N e w York, 21 cases were reported over a period of 25 years from a
* Received for publication August 6, 1976. Address reprint requests to Dr. Chulani: Consulting Surgeon and Proctologist, 4, Mirabelle, Linking Road, Bandra, Bombay-400050, India.
517 Dis. Col. & Rect. Sept. 1977
Volume 20 Number {5
5 18
tt. L. CHULANI
Dis. CoL & Rect. Sept. 1977
Fla. 1. Above, melanin pigment (X 10). Below, higher-power view (hematoxylin and eosin; X 40).
Volume 20 Number 6
ANAL MALIGNANT
FIG. 2.
MELANOMA
519
A r l o w s p o i n t to p i g m e n t e d areas. C e n t r a l d a r k color is d u e to b l o o d .
total of 4,500 malignant tumors of the anorectum by Q u a n et al. la I n 21 years, Bacon3 saw only two cases. T h e tumor generally arises as a small polypoid mass. Gabriel6 has stressed that the tumor is invariably protuberant. In this instance the tumor was ulcerative and was therefore mistaken for an anal fissure initially. W h e n protuberant, it may suggest the diagnosis of a thrombosed internal hemorrhoid, 10 since the tumor spreads upwards into the lower rectum. Its true nature may be revealed only when the specimen is submitted to histologic examination. Spread of the tumor may occur upward and downward, as in this case. Rectal spread may be continuous with the anal tumor or may appear as discontinuous submucosal nodules, which may be dark in color. Pigmentation is often scanty (amelanotic melanoma), and then the diagnosis may be difficult to make. T h e tumor has a high
metastasizing potential and is justifiably considered the most malignant form of intestinal cancer. 1, 2 Lymphatic spread may occur in three directions: upward to involve the inferior mesenteric glands, along the middle hemorrhoidal vessels to the internal iliac glands, and to the inguinal lymph nodes. In "this case the left inguinal glands were enlarged, though not hard or fixed. T r e a t m e n t should be carried out as soon as the diagnosis is established.6 T h e preferred form of treatment is abdominoperineal resection with bilateral groin dissection and deep pelvic node disectionA 1 Radiotherapy and chemotherapy are of no value. It would be interesting to follow the natural course of this disease in this case, since the patient has refused treatment. Personal follow u p is impossible, since the patient has gone to his native village.
H. L. CHULANI
520
H o w e v e r , his e m p l o y e r s have i n f o r m e d the author
t h a t w h e n last h e a r d f r o m h e w a s
u n a b l e to d efecate a n d the ulcer h a d g r o w n larger. H e was in c o n t i n u o u s pain: References 1. Ackerman LV, Butcher HR Jr: Surgical Pathology. Ed. 3. St. Louis, Mosby, 1964, 1244 pp 2. Anderson W: Boyd's Pathology for the Surgeon. Ed. 8. Philadelphia, W. B. Saunders, 1967, 842 pp 3. Bacon HE: Cancer of the Colon, Rectum and Anal Canal. Philadelphia, J. B. Lippincott, 1964, 956 pp 4. Berkley JL: Melanoma of the anal canal: Report of a case of five-year survival after ahdominoperineal resection. Dis Colon Rectum 3:159, 1960 5. Burns FJ: Melanoma of the rectum: Report of a case. Dis Colon Rectum 3:241, 1960
Dis. Col. & Rect. Sept. 1977
6. Gabriel WB: The Principles and Practice of Rectal Surgery. Ed. 5, Springfield, Ill., Charles C Thomas 1963, 739 pp 7. Goligher JC: Surgery of the Anus, Rectum and Colon. Ed 2. Springfield, Ill., Charles C Thomas, 1967, 1110 pp 8. Mikal S: Malignant melanoma of the anus and rectum. Am J Surg 103:191, 1962 9. Mirajkar VR, Sachdeva YV: Malignant melanoma of the rectum: A case report. Indian J Surg 7:50, 1945 10. Morson BC (editor): Diseases of the Colon, Rectum and Anus (Tutorials in Postgraduate Medicine). London, Heinemann, 1969, vol 1, 314 pp I1. Nealon TF: Management of the Patient with Cancer. Philadelphia, W. B. Saunders, 1965, 1067 pp 12. Pack GT, Martins FG: Treatment of anorectal malignant melanoma. Dis Colon Rectum 3:15, 1960 13. Quan SH, White JE, Deddish MR: Malignant melanoma of the anorectum. Dis Colon Rectum 2:275, 1959
