A 40-year-old married, nulliparous female with retro-positive status presented in April 2022 with complaints of difficulty and painful defecation, which progressively increased in severity for two months. She was on antiretroviral treatment for two years with a CD4 count of 127 cells/µL.
On physical examination, her performance status was ECOG 1. On per-rectal examination, a hard circumferential wall thickening was felt approximately three cm from the anal verge.
MRI of the pelvis revealed a concentric wall thickening for an approximate length of 5.7 cm involving the anorectum with its lower end at approximately 2.7 cm from the anal verge (Fig. 1). There was suggestion of infiltration by the mass lesion of the posterior wall of the vagina for an approximate length measuring 5.0 cm, with the lesion extending in the vaginal canal, extending intra-luminally. There is infiltration of the right-sided levator ani muscle and both internal and external anal sphincters. MRI also suggested enlarged lymph nodes in the bilateral internal iliac, right inguinal and perirectal region, and uterine fibroids in the posterior myometrium.
PET-CT scan correlated with the MRI findings but also additionally revealed increased FDG uptake in multiple polypoidal lesions in the stomach (size 1.3 x 1.2 cms, SUVmax 7.7 in the greater curvature) and in left gastric lymph nodes (size 1.2 x 0.7 cms, SUVmax 3.4), Fig. 2.
The biopsy from anal canal growth was Squamous Cell Carcinoma (Fig. 3).HPE from the stomach lesion showed Poorly differentiated malignant neoplasm (Fig. 4). Immunohistochemistry (IHC) showed CD45 positive, CD 20 Positive, BCL2 20% positive, BCL16 50% Positive, MUM1 40% positive, Cmyc 50% positive, Ki 67 70%. CK, CD3, and CD 10 were negative. Biopsy plus IHC revealed DLBCL-non-GCB type.
The final diagnosis was synchronous SCC of the anal canal, cT4N1M0 (Stage IIIC disease) and DLBCL (non-GCB type) of the stomach was established in the background of HIV-positive.
The case was discussed in institutional multidisciplinary tumour board, and the plan of management was decided as upfront definitive chemoradiation for anal SCC, which would be followed by chemotherapy management for gastric Lymphoma.
She received external beam radiotherapy to the pelvis using 6 MV Photons to a dose of 60 Gy in 30 fractions using VMAT technique along with two cycles of reduced dose Concurrent doublet chemotherapy included 5-FU (500 mg/m2) for four days and Mitomycin-C (6mg/m2) on 2nd fraction radiotherapy (cycle-1) and from 23rd fraction radiotherapy (cycle-2). She tolerated the treatment well with grade-I radiotherapy-induced skin toxicity.
Her CD4 count during radiotherapy was 106 cells/µL. However, at radiotherapy completion, it fell to 56 cells/µL, due to which Rituximab was omitted, and CHOP chemotherapy was started in standard doses.
After three cycles of CHOP, she developed a perianal abscess, which was managed conservatively. This led to a gap of three weeks from the 3rd cycle of chemotherapy (CHOP) for the management of the ischio-anal abscess. At this time, a Follow-up MRI of the pelvis was suggestive of residual disease along with trans-sphincteric perianal tract in the right-sided ischio-anal fossa.
Her CD + T cell count was 50/µL and cycle four was planned. It was decided that further chemotherapy (Cycles 5 & 6) would be scheduled only if she tolerated cycle 4. It was further planned for an assessment for pelvic exenteration if she tolerated chemotherapy.
Further chemotherapy was omitted as the patient defaulted and went back home. On telephonic follow-ups, it was known that she gradually developed severe anaemia (Hb 6.2 g/dl) and deranged renal status (Serum Urea 90 mg/dl and Creatinine 3.1 mg/dl). She succumbed to her disease at her home a month later.