Evolving perineal lesion in a smoking patient: What diagnosis to consider?

 Corresponding author: yousra elkirami Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Evolving perineal lesion in a smoking patient: What diagnosis to consider? Yousra elkirami , Rajae bounour, soukayna allali, Dafr Allah benajah, Sidi Adil Ibrahimi and Mohammed El Abkari Department of Hepato-gastroenterology, CHU Hassan II, Fez. Sidi Mohamed Ben Abdellah University, Fez, Morocco. World Journal of Advanced Research and Reviews, 2025, 26(02), 794-797 Publication history: Received on 28 March 2025; revised on 03 May 2025; accepted on 06 May 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.26.2.1711 Abstract Chronic perineal lesions, especially when progressive and associated with weight loss, should raise concern for serious conditions, particularly malignancies. We report the case of a 59-year-old male, a chronic smoker and regular cannabis user, who presented with a progressive ulcerative perineal lesion evolving over four years without medical evaluation and treated exclusively with traditional remedies. Clinical examination revealed a large, painful, inflammatory ulceration with necrotic areas. Histopathological analysis confirmed a moderately differentiated, infiltrating squamous cell carcinoma. Staging investigations classified the tumor as T4N1aM0 (stage IIIb). A diverting sigmoidostomy was performed, followed by concomitant chemoradiotherapy. Clinical course was favorable, with marked symptomatic improvement and radiological regression of the tumor mass. This case highlights the importance of early diagnosis of suspicious lesions, particularly in patients with risk factors, and underlines the critical role of multidisciplinary management in improving the prognosis of perineal squamous cell carcinomas. Keywords: Perineal lesion; Squamous cell carcinoma; Smoking; Ulcerative lesion; Chemoradiotherapy; Multidisciplinary management 1. Introduction Chronic perineal lesions are particularly concerning due to their potential severity. The progressive nature of these lesions, especially when associated with weight loss, immediately raises suspicion of serious underlying conditions, particularly malignancies. Among the first diagnoses to consider are squamous cell carcinoma and melanoma, two highly aggressive cancers that may present with similar ulcerative features. The potentially life-threatening nature of these conditions mandates thorough and prompt diagnostic investigation. The aim of this article is to present a clinical case of a patient with a progressive perineal lesion, highlighting the clinical findings and differential diagnoses, with a particular focus on the importance of considering malignant tumors. 2. Case presentation Mr. A.D., a 59-year-old man, has a long-standing history of heavy smoking (40 pack-years) and daily cannabis use. For the past four years, he had been suffering from a progressively enlarging perineal ulcerative lesion, associated with serosanguinous discharge and unquantified weight loss. The patient had not sought any medical advice during this time, relying exclusively on traditional treatments. Clinical examination revealed a patient in generally good condition, with no palpable abdominal masses and no lymphadenopathy. Proctological examination showed a large perineal tissue loss, approximately 4 cm in its longest World Journal of Advanced Research and Reviews, 2025, 26(02), 794-797 795 dimension (Figure 1), painful, with irregular borders, marked inflammatory signs, and a necrotic base in places interspersed with bright red granulation tissue. A biopsy was performed, and histopathological analysis revealed a moderately differentiated and infiltrating squamous cell carcinoma. Staging investigations showed a locally advanced anal canal tumor, classified as T4N1aM0, corresponding to stage IIIb. The case was discussed in a multidisciplinary tumor board, where the decision was made to proceed with a protective intestinal diversion (sigmoidostomy), followed by concomitant radiochemotherapy with fluoropyrimidines. The clinical course following treatment was marked by a significant improvement in the patient’s general condition. He became asymptomatic, reporting neither pain nor local discomfort. On proctological examination, the anal margin appeared mostly healed, as shown in Figure 2. The previously ulcerative and proliferative lesion had regressed substantially. A residual erythematous and indurated area remained near the anal orifice, without signs of superinfection or bleeding. This appearance suggests a favorable clinical course, with ongoing healing under treatment. Radiologically, a thoraco-abdomino-pelvic CT scan showed regression of the anal canal tumor. The right inguinal lymph nodes had decreased in size, and the mesorectal lymph nodes were replaced by residual lymphatic formations. No evidence of distant recurrence was observed. Figures 1 and 2 show the aspect of the anal margin before and after radiochemotherapy, demonstrating clear local improvement and regression of the lesion. Figure 1 Clinical appearance of the anal margin prior to initiation of chemoradiotherapy - World Journal of Advanced Research and Reviews, 2025, 26(02), 794-797 796 Figure 2 Clinical appearance of the anal margin following completion of chemoradiotherapy 3. Discussion Squamous cell carcinoma is a type of skin cancer that typically arises in sun-exposed areas, but it can also develop in less exposed regions such as the perineum [1]. Tobacco use is a well-established risk factor for many types of cancer, including squamous cell carcinomas [2, 4]. Furthermore, chronic cannabis use may also contribute to the pathogenesis of such lesions, although direct evidence remains limited. The rapid progression of the lesion and the absence of medical consultation for four years led to a diagnosis at an advanced stage (T4N1M0), highlighting the critical importance of early detection and management of suspicious lesions. The presence of necrotic areas and vivid red granulation tissue within the lesion is characteristic of invasive tumors [1, 3], reinforcing the need for aggressive treatment and close follow-up. The prognosis of squamous cell carcinoma largely depends on the stage at diagnosis and the tumor’s response to treatment [3]. A multidisciplinary treatment approach including surgery, radiotherapy, and potentially chemotherapy is often necessary to manage the disease effectively [3]. Regular monitoring is crucial to detect any recurrence or metastasis. 4. Conclusion This clinical case highlights the importance of vigilance regarding progressive perineal lesions, especially in patients with risk factors such as smoking. Early diagnosis and prompt intervention are essential to improve survival outcomes and reduce complications associated with perineal cancers. Regular medical consultations and the evaluation of cutaneous lesions—even in less visible areas—should be encouraged to enable early detection of malignant conditions. Compliance with ethical standards Disclosure of conflict of interest The authors declare that they have no competing interests. Statement of ethical approval World Journal of Advanced Research and Reviews, 2025, 26(02), 794-797 797 Ethical approval was not required for this case report, as per the policies of our institution. The work complies with the ethical standards of the Declaration of Helsinki. Statement of informed consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. References [1] Ackerman, A. B. (2009). Carcinoma of the Skin. In Ackerman's Surgical Pathology, 5th Edition, pp. 707–732. Elsevier. [2] Grembowski, D., & Wagner, E. H. (2007). "Risk Factors for Squamous Cell Carcinoma of the Skin." Journal of Dermatological Treatment, 18(4), 215–222. [3] Kawai, K., & Itami, J. (2012). "Management of Squamous Cell Carcinoma of the Skin: A Review." Japanese Journal of Clinical Oncology, 42(6), 489–494. [4] Shapiro, M., & Smith, S. (2018). "The Role of Tobacco in the Development of Carcinomas." Journal of Clinical Oncology, 36(15_suppl), e19045