Cloacogenic Polypoidal Tumor in a 51 Year Old Woman with Colitis

Abstract

Purpose: Anorectal cancer accounts for 1-6% of colon malignancies, of which cloacogenic cancer seen in ˜2% of anorectal malignancies. Cloacogenic cancer is a non keratinizing tumor that originates from the cloacal remnant cells at the level of or below the pectinate line in the region of the anal sphincter. This cancer often accompanies genital cancer as the cloacal cells give rise to the hind gut and the part of the genital system. This cancer has a female preponderance and is frequently seen in the fifth and seventh decade of life. Proposed etiologies include chromosomes 3 and 11 deletions, chronic anorectal disease as is seen in colitis, immunosuppression, human papilloma virus infection and smoking. Patients can present with a wide variety of symptoms that include abdominal discomfort, bloody stools, and diarrhea. Direct visualization with colonoscopy generally reveals plaque like lesion with histopathology leading to the final diagnosis. Polypoidal manifestations are unusual. Colposcopy and prostate cancer screening is recommended to rule out concomitant genital cancer. Full body CT scans help in staging and detecting recurrences and is generally more aggressive than the common squamous cell cancers and adenomas. Management is by local excision with chemoradiation for localized tumors and abdominoperineal resection for more extensive tumors. A 52-year-old woman with a family history of polyps presented with complaints of bloody diarrhea and lower abdominal discomfort for 4 weeks. Review of systems was otherwise negative. She denied any recent travels, but did report having similar symptoms following a trip to Costa Rica 8 to 9 years ago. At this time, she underwent a colonoscopy that was reported normal and her diarrhea responded to antibiotics. She is an ex-smoker and social drinker. Physical exam was significant for tenderness in the left upper and lower quadrants. Rectal exam revealed 1.5 cm rectal polyp, 0-1 cm from the anal verge. Labs were non-revealing. Colonoscopy revealed a 1.5 cm rectal polyp and mild pancolitis. Biopsies were obtained and sent for pathology. Pathology revealed invasive cloacogenic cancer in the polyp and chronic colitis in the remainder of the colon. Colorectal surgery consult was obtained and full body CT scan for staging and chemoradiation is being planned. Conclusion: Cloacogenic cancer is a relatively rare anorectal malignancy and further research on the etiology and pathogenesis may help in proposing effective management strategies. This report also emphasizes biopsying polyps near the anorectal verge. In addition, the close embryologic correlation with genital malignancies may warrant a rethinking for earlier screening if patients are diagnosed with genital malignancies.