Anorectal smear in the diagnosis of anorectal adenocarcinoma
A 64-year-old man presented to the general surgery outpatient clinic with a 3 months' history of anal bleeding and pain during the defecation. Anal examination revealed the presence of hemorrhoids and subsequently the patient was treated by hemorrhoidectomy. Unfortunately, radiological studies, tumor marker blood tests and colonoscopy were not performed prior to hemorrhoidectomy. Postoperatively, the patient continued to suffer from constipation and severe pain during defecation. Therefore, he visited another hospital 1.5 1½ months later, where physical examination revealed the presence of an anal stricture. Colonoscopy could not be performed at this time either, because of pain, but he underwent operative dilation of the stricture. The patient returned to the general surgery clinic 1 month after the procedure because of persistent pain and a rectoscopy was performed. This procedure revealed a fragile, fungating tumor at the posterior wall of the rectum 5 to 7 cm above the dentate line and obstructing the lumen. Histologic examination of a biopsy from this tumor demonstrated a well differentiated adenocarcinoma. The patient had laparoscopic low anterior resection (LAR), followed by radiotherapy and chemotherapy. Pathologic examination of the resected tumor revealed a 4 × 4 × 3 cm well differentiated adenocarcinoma, invading the muscularis, and extending into rectal subserosa. All surgical margins were free of disease and there was no evidence of metastasis in the regional lymph nodes.\nRectal bleeding recurred 18 months after the operation and the patient returned to the clinic. At this time, an anorectal smear was procured as the initial procedure, using an endocervical brush. The smears were fixed in 95% ethanol and stained with Papanicolaou stain. Cytologic examination of the smears revealed a mucinous and necrotic background in which numerous neutrophils, squamous, and glandular cells were identified. Many of the glandular cells were in the form of sheets of reactive columnar cells with thin cytoplasm and uniform oval to round nuclei. In addition, there were several atypical glandular cells with large hyperchromatic nuclei and thick cytoplasm []. These cells were either single or in the form of three dimensional clusters, straps, and glands. Cellular strips with nuclear pseudostratification, reminiscent of short “bird tail like” arrangements were also seen [].[] Some tumor cells were spindle shaped similar to a high-grade anal intraepithelial neoplasia or squamous cell carcinoma []. These cytologic findings were interpreted as diagnostic of adenocarcinoma.\nRectoscopy was performed following the procurement of the smear. This revealed a 3 cm ulcero-papillary mass at the level of dentate line. Microscopic examination of the biopsy showed a well differentiated adenocarcinoma, and an abdominoperineal resection was performed. Histologic examination of the resected material demonstrated invasion of the muscularis propria by neoplastic glands []. Some dysplastic, but not frankly malignant, glands were seen in the mucosa adjacent to the adenocarcinoma. The tumor did not have any continuity with the area of the initial anastomosis, thus hindering the ability to determine if it was a recurrence or a new primary. There was no evidence of involvement of any lymph nodes or perianal soft tissue by the tumor. The patient received postoperative chemotherapy and has been living with no evidence of disease for 17 months after the second operation.