A 48 year old man presented with invasive adenocarcinoma in the wall of a non-healing anal fistula. The subsequent abdomino-perineal resection specimen showed residual invasive carcinoma coexisting with in situ carcinoma of anal glands as well as in situ squamous carcinoma of the anal canal. The epithelium of the anal canal had koilocytotic features. DNA hybridisation studies by the dot blot technique showed weak positivity for human papillomavirus (HPV) subtypes 16, 18. This case illustrates a number of important points--namely, anal fistulas, particularly non-healing fistulas should be biopsied to exclude malignancy; some adenocarcinomas of the anal arise in anal glands; the coexistence of glandular and squamous carcinoma with evidence of HPV infection is highly reminiscent of similar synchronous lesions of the uterine cervix and suggests that HPV may have an aetiological role in both squamous and glandular carcinomas of the anal canal.
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