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Anal canal NEC is often associated with distant metastases, and prognosis is poor [1]. Due to its rarity, the treatment strategy for anal canal NEC remains unclear. Pagetoid spread (PS) is included in secondary perineal Paget disease, which is one of the extramammary Paget diseases [2]. Herein, we present a case report for the treatment of advanced NEC with PS, inguinal lymph node metastasis and sphincter infiltration. (a) Colonoscopy showed erythema of the mucous membrane from the anal canal to the rectum; (b) MRI showed that the levator ani muscle was ruptured by the tumor. (a) Colonoscopy showed erythema of the mucous membrane from the anal canal to the rectum; (b) MRI showed that the levator ani muscle was ruptured by the tumor.(a) The perineal defect was reconstructed using the gracilis muscle flap; (b, c) PS lesion was excised with a margin of 1 cm or more; (d) the bulbar urethra was exposed from the perineum. (a) The perineal defect was reconstructed using the gracilis muscle flap; (b, c) PS lesion was excised with a margin of 1 cm or more; (d) the bulbar urethra was exposed from the perineum. A 70-year-old man who complained of refractory perianal skin ulcers was referred to our hospital. The condition had spread concentrically around the anus. Colonoscopy revealed erythema of the mucous membrane that was continuous from the anal canal to the rectum (Fig. 1a). Magnetic resonance imaging (MRI) revealed a hyperintense mass in the right wall of the anal canal on T2-weighted images. Tumor invasion of the prostate and levator ani muscle was suspected (Fig. 1b). Enhanced computed tomography (CT) showed a 3-cm wall thickening in the right wall of the anal canal and swelling of the left inguinal lymph node. Fluorine-18 fluorodeoxyglucose positron emission tomography CT (FDG-PET/CT) showed FDG uptake in the anal canal with a maximum standardized uptake value (SUVmax) of 5.4. The left inguinal lymph node had a SUVmax of 2.5. Biopsy was performed on the anal canal and perianal skin lesions. The pathological results indicated adenocarcinoma with severe atypia. Immunohistochemically, the tumor of the perianal skin lesion was positive for cytokeratin 20 (CK20) and caudal homebox transcription factor 2 (CDX2). Based on the above results, the tumor was diagnosed as anal canal adenocarcinoma with PS, inguinal lymph node metastasis and infiltration into the prostate and sphincter. It was decided that radical resection was possible and total pelvic exenteration (TPE) was performed with perianal plastic reconstruction using the gracilis muscle flap and D3 lymphadenectomy. form for each elective experience in order to receive academic credit. The forms are available on the JHUSOM Registrar Self-Service portal. After completing an elective registration form, the student must have it signed by the course director. If the elective is an experience outside of the Hopkins system, the student will need to obtain the signature of the Associate Dean for Medical Student Affairs. Students are expected to consult with their advisors about their academic program at regular intervals. It is the responsibility of the student to see that the Elective Registration Form is completed and submitted to the Registrar's Office in a timely manner. The deadline for submission of the elective registration form is prior to the start of the elective. Effective July 1, 2020, the Office of the Registrar will no longer accept retroactive elective registration forms. Drop Form – within the deadline: The normal deadline for dropping electives is one month prior to the course, with the exception of a two-month deadline for dropping subinternships and certain advanced clerkships. If a student wants to drop a course within the deadline, he or she should submit a drop form to the course director and verify the signed copy has been submitted to the Office of the Registrar prior to submitting a new registration form for that period. Late Drop Form: Changes will not ordinarily be permitted after the deadlines, though students may petition for such changes by submitting a drop form to the Course Director, and the Associate Dean for Medical Student Affairs. The completed form with appropriate signatures should be submitted to the Registrar's Office. Credit will not be given for course work other than that indicated on the most current registration form. If a student fails to 3 GUIDELINES, RULES AND PROCEDURES FOR ELECTIVES attend a course for which they have registered, an incomplete grade will be recorded on the transcript for that course, and the student will not be given credit for any other course during that time period. RULES CONCERNING REQUIRED SUBINTERNSHIPS AND CERTAIN ADVANCED CLINICAL ELECTIVES Certain advanced clinical electives (listed below) are very much in demand. One of the important advantages of these clerkships is the independent responsibility delegated to students so that they play a very active role in patient care. The trade-off is that students registering for these electives must accept the special responsibilities and obligations which they carry to patients, staff, their colleagues, and other members of the health care unit. Last minute dropouts from these courses impose burdens on the clinical unit and often mean lost opportunity for other students who want to participate in the elective. In view of the problems which have resulted from last minute dropouts, the Undergraduate Medical Educational Policy and Curriculum Committee (UMEPCC) adopted the following rules regarding the scheduling process for these rotations: Students registering for advanced electives with significant patient care responsibilities are obliged to participate in such electives. Changes must be made two months prior to the start of such electives. If a drop is necessary past the deadline, the student may petition for a change by submitting a "Request to Drop Course After Deadline" to the Course Director, and the Associate Dean for Medical Student Affairs, and filing the completed form with the Registrar's Office. Credit will not be given for course work other than that indicated on the most current registration form. If student fails to attend a course for which they have registered, an incomplete grade will be recorded on their transcript for that course, and the student will not be given credit for any other course during that time period. The following clinical experiences are governed by these rules: REQUIRED SELECTIVES Approved Subinternship Experience Prerequisite(s): Respective Core Clerkship Availability/Duration: Year-round, 4.5 weeks; follows SOM Academic Calendar quarter dates Drop Period: All scheduling must occur through the Registrar’s Office Subinternships that fulfill graduation requirements (JHH or Bayview only): Gynecology, Benign (JHH-Dr. Silka Patel) Gynecology Oncology (JHH- Dr. Silka Patel) Emergency Medicine (JHH – Dr. Sharon Bord) Medicine (JHH-Dr. Amit Pahwa) Medicine (Bayview – Dr. Janet Record) Medicine-Hospitalist (JHH – Dr. Padmini Ranasinghe) Medicine-Hospitalist (Bayview- Dr. Amteshwar Singh) Obstetrics/GYN (Bayview Dr. Silka Patel) Obstetrics/Maternal Fetal Medicine (JHH Dr. Silka Patel) Pediatrics-Inpatient (JHH-Dr. Amit Pahwa) Pediatrics-Harriet Lane (JHH –Dr. Nakiya Showell) Pediatrics – Emergency Medicine (JHH – Dr. Lauren Kahl) Surgery (JHH – Dr. Alodia Gabre-Kidan) Surgery (Bayview – Dr. Alodia Gabre-Kidan) Thoracic Surgery (JHH – Dr. Richard Battafarano) Adult Orthopaedic Surgery (JHH – Dr. Brian Neuman) Pediatric Orthopaedic Surgery (JHH – Dr. Paul Sponseller) Neurosurgery (JHH – Dr. Tim Witham) Plastic Surgery (JHH – Dr. Robin Yang) Otolaryngology (JHH – Dr. Marietta Tan) Urology (JHH – Dr. Amin Herati) 4 GUIDELINES, RULES AND PROCEDURES FOR ELECTIVES Advanced Clerkship in Critical Care Prerequisite(s): Medicine or Surgery Core Clerkship, except PICU which has a Prerequisite of Pediatrics Availability/Duration: Year-round, 4.5 weeks; follows SOM Academic
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