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The perianal skin lesion was excised with a margin of 1 cm or more (Fig. 2b and c), and simple closure was challenging. The bulbar urethra was pulled out from the perineum to secure a urethral stump (Fig. 2d). The pathological results revealed that the surgical margin was negative. The tumor cells of the anal canal had nuclei with a high nuclear cytoplasmic ratio and infiltrative proliferation with compact nests (Fig. 3a) and were positive for CD56, chromogranin A and synaptophysin. The majority were NEC, and only a few were tubular adenocarcinoma. The Ki-67 labeling index was greater than 70%. The tumor cells of the perianal skin lesions were adenocarcinoma and had no NEC features and were negative for chromogranin A and synaptophysin and positive for CK20 and CDX2 (Fig. 3b–d). In addition, sphincter infiltration and inguinal lymph node metastasis were observed. Accordingly, a diagnosis of anal canal NEC with PS, inguinal lymph node metastasis and sphincter infiltration was made. Although debridement and local flap was required 17 days after the operation because necrosis was observed in a part of the flap, the course after that was generally good. The patient was discharged 42 days postoperatively. At the 7-month follow-up after resection, the patient did not show any recurrence. (a) The tumor cells with a high nuclear cytoplasmic ratio nuclei proliferated with compact nests in the anal canal (×100); (b) the tumor cells did not show neuroendocrine differentiation and were only components of tubular adenocarcinoma in the perianal lesions (×200); (c, d) The tumor cells were positive for CK20 and CDX2, respectively (×100). (a) The tumor cells with a high nuclear cytoplasmic ratio nuclei proliferated with compact nests in the anal canal (×100); (b) the tumor cells did not show neuroendocrine differentiation and were only components of tubular adenocarcinoma in the perianal lesions (×200); (c, d) The tumor cells were positive for CK20 and CDX2, respectively (×100). DISCUSSION NEC is present in only approximately 1% of anal canal malignant tumors [3]. To the best of our knowledge, there have been very few reports of PS associated with anal canal carcinoma and only one report of anal canal NEC [4]. Therefore, treatment strategies for anal canal NEC remain unclear due to its rarity, especially for those with PS. Aytac et al. reported on the prognosis and treatment of 25 cases of NEC of the colon, rectal and anal canal. Calendar quarter dates Drop Period: All scheduling must occur through the Registrar’s Office Site Assignments: Surgical Intensive Care (SICU) (JHH – Drs. Pamela Lipsett and Brad Winters) Weinberg Intensive Care (WICU) (JHH – Drs. Pamela Lipsett and Brad Winters) Medical Intensive Care (MICU) (JHH – Dr. Roy Brower) Medical Intensive Care (MICU) (Bayview – Dr. Souvik Chatterjee) Coronary Intensive Care (CICU) (Bayview – Dr. Marlene Williams) Coronary Intensive Care (CICU) (JHH – Dr. Steve Schulman) Pediatric Intensive Care (PICU) (JHH – Dr. Amanda Levin) Neurocritical Care (NCCU) (JHH and Bayview – Dr. Marek Mirski) Cardiac Surgery Intensive Care (CSICU) (JHH – Dr. Glenn Whitman) Advanced Ambulatory Clerkship Course Type: Advanced Clinical Clerkship Department/Division: Internal Medicine Course Director: Dr. Sharon Dlhosh Contact: Ms. Susan Shultz, 410-955-8336; sshultz@jhmi.edu Faculty: Drs. Sharon Dlhosh, Sujay Pathak, Naomi Cutler, Sara Mixter, Holly Dahlman, and others Availability/Duration: Available year-round, every half-quarter Prerequisite(s): At least the Medicine Core Clerkship is required; 2-3 clerkships, including Medicine, Pediatrics, or Women’s Health preferred. Drop Period: 1 month Description: The Advanced Ambulatory Clerkship combines patient care experience in an outpatient primary care practice with additional experiences in the JH Bayview Geriatric Clinics, Memory Clinic, and Home Care visits. In their assigned outpatient primary care practice, students will work directly under the supervision of one (or more) preceptors in the field of General Internal Medicine or Family Practice. There is a curriculum of online modules that provides background in a number of topics that are relevant to primary and preventive care. Each student learns fundamental broad topics necessary to assess and provide care for adult patients along the continuum of aging. ADVANCED ELECTIVES Women’s Health Subinternship in Gynecology Subinternship in Gynecology and Obstetrics Subinternship in Reproductive Endocrinology Subinternship in Obstetrics/Maternal Fetal Medicine Medicine Advanced Clinical Clerkship in Internal Medicine Advanced Clinical Clerkship in Medical ICU/CCU Advanced Clinical Clerkship in Medicine/Rheumatology Advanced Clinical Clerkship in Medicine-Bayview Advanced Clinical Clerkship: CICU, Bayview Endocrinology Clinical Clerkship Subinternship in Infectious Disease-AIDS Service Clinical Clerkship in Cardiology- Consult Service Clinical Clerkship in Nephrology 5 GUIDELINES, RULES AND PROCEDURES FOR ELECTIVES Clinical Clerkship in Infectious Disease Neurology Advanced Neurology Clerkship Oncology Subinternship in Oncology Pathology Subinternship in Autopsy Pathology - JHH Subinternship in Surgical Pathology - JHH Subinternship in Autopsy and Surgical Pathology at Bayview and Sinai Pediatrics Pediatric Hematology Consultation Service Subinternship in Neonatal Intensive Care Unit Pediatric Pulmonary Subinternship Clinical Clerkship in Adolescent Medicine Neonatal Pediatrics Subinternship-Bayview Psychiatry Subinternship in Psychiatry Radiology Interventional Radiology Subinternship Surgery Subinternship in Surgery General Surgery Subinternship-Bayview Subinternship and Preceptor Program-Sinai Advanced Clerkship in Burns (Subinternship)-Bayview Subinternship in the Surgical Intensive Care Unit Subinternship in Cardiac Surgery Subinternship in Neurosurgical Surgery Subinternship in Pediatric Surgery Plastic Surgery Subinternship-Shock Trauma Subinternship in Plastic Surgery Subinternship in Transplantation Surgery If you have any questions about these rules and procedures, please do not hesitate to contact Dr. Katherine Chretien, Associate Dean for Medical Student Affairs, (410-955-3416), or William Bryant Faust IV, EdD Associate Dean and Registrar, (410-955-3080). GLOSSARY OF TERMS TO DESCRIBE ELECTIVES SUBINTERNSHIP: A rotation in which the student assumes the role of an intern, including primary care of patients and sharing night call CLINICAL CLERKSHIP: A rotation similar to a Core clerkship but with more responsibility for patient care and teaching CONSULT SERVICE: A rotation in which the student participates in the daily consultative activities of a particular division; may include the selected care of inpatients and outpatients of that division 6 RESIDENCY ADVISORS TUTORIAL: A rotation in which the student works with one or a very few faculty members in tutorial and didactic settings. May be in a clinical or basic science department BASIC RESEARCH: A rotation in which the student is engaged in laboratory research in a basic science department or in a clinical department CLINICAL RESEARCH: A rotation in which the student is engaged in research in clinical medicine. May sometimes include laboratory work RESIDENCY ADVISORS Anesthesiology & Critical Care Medicine Dr. Tina Tran Bloomberg 6220 Ttran32@jhmi.edu 410-955-7615 Dermatology Dr. Daren Simkin Dsimkin1@jhmi.edu Family Practice Dr. Nancy Barr Franklin Square Hospital nancy.b.barr@medstar.net Medicine Dr. Sanjay V. Desai sanjayvdesai@jhu.edu Dr. Danelle Cayea dcayea1@jhmi.edu 410-955-7910 Neurology Dr. Raf Llinas rllinas@jhmi.edu Dr. Michael Kornberg michael.kornberg@jhmi.edu Dr. Elisabeth Marsh ebmarsh@jhmi.edu
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