LAUSR

A 55-year-old man with a history of fistulizing Crohn’s colitis (CC) was evaluated in the emergency department with a complaint of new perineal drainage. He had experienced rectal bleeding and diarrhea since his late teenage years, having first undergone colonoscopy with evidence of colitis 17 years prior to his current presentation for which he was treated with ileal-release budesonide and azathioprine for presumed Crohn’s colitis. Four months after his initial diagnosis, he reported developing a perianal fistula. Five years before his current presentation, an MRE revealed no evidence of small bowel disease. Four months later, although he was switched to infliximab and methotrexate for symptomatic control, 1 year thereafter he self-discontinued these medications as he did not believe they were helpful. Approximately 2 years before his current presentation, he developed abdominal cramping. Repeat colonoscopy demonstrated colitis, after which he was started on adalimumab, 6-mercaptopurine, and oral mesalamine. Several months later he developed swelling in the rectal area for which he was treated with antibiotics for a presumed perirectal abscess. Nevertheless, 3 months later, an examination under anesthesia revealed a left-sided anal mass. Biopsies revealed invasive squamous cell carcinoma (SCC) which was p16 positive that was treated with radiation and chemotherapy, after which he was restarted on adalimumab and 6-mercaptopurine 1 month later. Two months after completing his cancer therapy, he was considered to be in full remission on the basis of a normal PET-CT scan. Unfortunately, a colonoscopy performed 2 months later at an outside facility was significant for an “anal wart,” which was then confirmed to be recurrent SCC, suspicious for invasive carcinoma, which was again p16 positive. Nonetheless, his outside oncologist considered this to be residual disease that would presumably slowly regress over time, and therefore, these findings were not considered concerning. About 1 year prior to his current presentation, about 4 months after that colonoscopy, he established care with the gastroenterology service at our facility. At the time, he described perianal pain with pus and oily discharge and reported that his Crohn’s disease medications were not effective. Repeat colonoscopy at our facility showed an anal stricture and a large, partially circumferential and partially obstructive colonic mass in the distal rectum (Fig. 1). Biopsy revealed p16 positive invasive SCC; a second review of the biopsies from his previous colonoscopy by our pathologists confirmed that at the time he had anal intraepithelial neoplasia, grade 3 (AIN3) with foci of invasive SCC. Our oncology and colorectal surgery teams recommended abdominoperineal resection (APR) with total proctocolectomy and endileostomy with gracilis flap to the perineum. None of 92 lymph nodes were positive, but intraoperatively the patient was noted to have tumor abutting the prostate. Pathology could not determine if margins around the prostate were clear. Unfortunately, a PET-CT obtained 6 months after his APR showed worsening disease burden, with extensive hypermetabolic soft tissue in the pelvis. He was started on docitaxel, cisplatin, and 5-fluorouracil. Two months later, he was evaluated in the emergency department for drainage from his perineal flap. CT demonstrated a large necrotic pelvic mass (Fig. 2). He was treated with a 2-week course of ciprofloxacin and metronidazole for * Alexa R. Weingarden [email protected]