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Presented by Dr. Ashley Cimino-Mathews and prepared by Dr. Yembur Ahmad
This case talks about a 60-year-old female with an anal mass.
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1. Question
Clinical history: A 60 year-old female with an anal mass
Choose the correct diagnosis:
Correct
Diagnosis: D. Hemorrhoid
Histology: The polypoid fragment of tissue is lined by benign squamous epithelium with normal maturation and foci of underlying anorectal glands without significant atypia. Within the center of the polypoid fragment are large, dilated vascular spaces lined by flattened endothelium with no appreciable atypia. The vascular spaces are not anastomosing.
Discussion: The resection specimen shows classic histologic features of a hemorrhoid, which are the presence of dilated veins (perianal venous plexuses). Internal hemorrhoids occur above (proximal to) the dentate line and are lined by anorectal glandular mucosa. External hemorrhoids occur below (distal to) the dentate line and are lined by squamous mucosa. Why on earth am I showing you a hemorrhoid? It is important to remember to evaluate the hemorrhoids for the presence of any low or high grade squamous intraepithelial lesions (LSIL or HSIL), also known as anal intraepithelial neoplasia 1 (AIN 1) or anal intraepithelial neoplasia 2-3 (AIN 2-3), respectively. In addition, in situ or invasive squamous cell carcinoma can involve hemorrhoids. These features are not present in this case, but you should always remember to look for atypia. For this reason, it is prudent to ink the resection margin of the hemorrhoids, just in case there is any atypia seen microscopically. Ink, don’t think. It only takes 2 seconds.
Incorrect
Diagnosis: D. Hemorrhoid
Histology: The polypoid fragment of tissue is lined by benign squamous epithelium with normal maturation and foci of underlying anorectal glands without significant atypia. Within the center of the polypoid fragment are large, dilated vascular spaces lined by flattened endothelium with no appreciable atypia. The vascular spaces are not anastomosing.
Discussion: The resection specimen shows classic histologic features of a hemorrhoid, which are the presence of dilated veins (perianal venous plexuses). Internal hemorrhoids occur above (proximal to) the dentate line and are lined by anorectal glandular mucosa. External hemorrhoids occur below (distal to) the dentate line and are lined by squamous mucosa. Why on earth am I showing you a hemorrhoid? It is important to remember to evaluate the hemorrhoids for the presence of any low or high grade squamous intraepithelial lesions (LSIL or HSIL), also known as anal intraepithelial neoplasia 1 (AIN 1) or anal intraepithelial neoplasia 2-3 (AIN 2-3), respectively. In addition, in situ or invasive squamous cell carcinoma can involve hemorrhoids. These features are not present in this case, but you should always remember to look for atypia. For this reason, it is prudent to ink the resection margin of the hemorrhoids, just in case there is any atypia seen microscopically. Ink, don’t think. It only takes 2 seconds.
