Synchronous anal mucinous adenocarcinoma and anal tuberculosis presenting as chronic anal fistula: Challenging management

Sarah Benammi, Youness Bakali, Mouna Alaoui, Farid Sabbah, Mohamed Raiss, Abdelmalek Hrora


Metachronous anal tuberculosis to an anal adenocarcinoma is an exceptional condition. The aim of our study was to report management of the first case of synchronized anal canal adenocarcinoma and anal canal tuberculosis and report our multidisciplinary approach. A 71-year-old man was admitted for non-healing anal fistula. Rectal examination at supine position showed an ulcerative growth at the medio-superior quadrant on a radius of 2cm from the anal verge. Digital rectal examination assessed no tumor in the anorectum. Biopsy of fistulae confirmed diagnosis of anal mucinous adenocarcinoma with coexisting anal tuberculosis. Further exploration confirmed diagnosis with no distal metastasis, no active pulmonary tuberculosis and no immunodepression. Adjuvant anti-bacillary chemotherapy was initiated 1 month prior to adjuvant radio-chemotherapy. Patient was re-admitted at the 6th week following the last dose of radio-chemotherapy for surgery. On long-term evaluation at 10 months, the patient reported absence of symptoms with weight gain. Association of both entities is rare. Chronic inflammatory damage may possibly initiate a sequence of metaplasia and dysplasia, resulting in neoplastic transformation. Anal canal adenocarcinoma treatment follows same guidelines as rectal cancer. Extra-pulmonary tuberculosis treatment follows anti-bacillary protocol with consequent side effects. Therefore, our case is a unique clinical challenge for physicians. Management decision was multidisciplinary process. Their pathophysiology relationship is yet to be understood. Moreover, each entity has defined and individual therapeutic protocols and indications. All this taken into consideration, such case presents a clinical and therapeutic challenge for physicians.


Anal mucinous adenocarcinoma; Anal tuberculosis; Extrapulmonary tuberculosis; Metachronous; Anal fistula

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Young AN, Jacob E, Willauer P, et al. Anal Cancer. Surg Clin North Am. 2020;100(3):629-634. doi: 10.1016/j.suc.2020.02.007. PMID: 32402305.

Grange JM. Koch's Tubercle Bacillus - a centenary reappraisal. Zentralbl Bakteriol Mikrobiol Hyg A Med Mikrobiol Infekt Parasitol. 1982;251(3):297-307. PMID: 6805153.

Azadi A, Jafarpour Fard P, Sagharjoghi Farahani M, Khodadadi B, Almasian M. Anal tuberculosis: A non-Healing anal lesion. IDCases. 2018;12:25-28. doi: 10.1016/j.idcr.2018.02.012. PMID: 29942741; PMCID: PMC6010925.

Erhan Y, Sakarya A, Aydede H, et al. A case of large mucinous adenocarcinoma arising in a long-standing fistula-in-ano. Dig Surg. 2003;20(1):69-71. doi: 10.1159/000068857. PMID: 12637812.

Ibáñez J, Erro JM, Aranda F, et al. Adenocarcinoma mucinoso en fístula perianal de largo tiempo de evolución tratado mediante QT-RT neoadyuvante y amputación abdominoperineal laparoscópica [Mucinous adenocarcinoma on chronic perianal fistula treated by neoadjuvant chemoradiotherapy and laparoscopy-assisted abdominoperineal amputation]. Cir Esp. 2006;79(3):184-5. Spanish. doi: 10.1016/s0009-739x(06)70847-8. PMID: 16545286.

Leong FQ, Chan DKH, Tan KK. Anal Adenocarcinoma Can Masquerade as Chronic Anal Fistula in Asians. Ann Coloproctol. 2019;35(1):47-49. doi: 10.3393/ac.2018.03.15. PMID: 30509019; PMCID: PMC6425245.

Kline RJ, Spencer RJ, Harrison EG Jr. Carcinoma associated with fistula in ano. Arch Surg 1964;89:989–94.

Benson AB, Venook AP, Al-Hawary MM, et al. Rectal Cancer, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2018;16(7):874-901. doi: 10.6004/jnccn.2018.0061. PMID: 30006429; PMCID: PMC10203817.

Chakinala RC, Khatri AM. Gastrointestinal Tuberculosis. 2022 May 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 32310575.

Chakravartty S, Chattopadhyay G, Ray D, Choudhury CR, Mandal S. Concomitant tuberculosis and carcinoma colon: coincidence or causal nexus? Saudi J Gastroenterol. 2010;16(4):292-294. doi: 10.4103/1319-3767.70619. PMID: 20871197; PMCID: PMC2995101.

Ghanem S, Kim CJ, Dutta D, Salifu M, Lim SH. Antimicrobial therapy during cancer treatment: Beyond antibacterial effects. J Intern Med. 2021;290(1):40-56. doi: 10.1111/joim.13238. PMID: 33372309.

Joshi JM. Tuberculosis chemotherapy in the 21 century: Back to the basics. Lung India. 2011;28(3):193-200. doi: 10.4103/0970-2113.83977. PMID: 21886955; PMCID: PMC3162758.


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