Yes, anal cancer can initially present as a sore or non-healing ulcer
Anal squamous cell carcinoma commonly presents as a non-healing ulcer, and this is explicitly recognized as one of the key presenting features in current clinical practice guidelines 1, 2.
Clinical Presentation
According to ESMO guidelines, anal cancer may present with any combination of:
- A non-healing ulcer (specifically mentioned as a presenting feature)
- Bleeding (most common, ~45% of patients)
- Mass or sensation of rectal mass (~30%)
- Pain
- Itching
- Discharge
- Faecal incontinence
- Fistulae 1, 2
The EORTC 22861 trial identified skin ulceration as an independent prognostic factor for worse survival and local control, further confirming that ulceration is a recognized presentation of anal cancer 2.
Critical Diagnostic Pitfall: Misdiagnosis as Benign Conditions
The most important caveat is that anal cancers presenting as ulcers or sores are frequently misdiagnosed as benign anorectal disorders, particularly:
A case series specifically documented anal carcinomas initially misdiagnosed as idiopathic chronic anal fissures, emphasizing that small and early cancers commonly masquerade as benign conditions 3. Another case report described a patient with recurrent perianal abscesses where multiple biopsies initially showed only chronic inflammation before ultimately revealing squamous cell carcinoma 4.
When to Suspect Malignancy
Clinical suspicion for anal cancer should be heightened in patients with:
- Non-healing ulcers or fissures despite 8-12 weeks of appropriate treatment
- Fissures in atypical positions (not posterior midline)
- Indurated or ulcerated anal tags
- Risk factors for HPV-related disease (HIV infection, history of anogenital warts, prior lower genital tract malignancies, immunosuppression, smoking) 1, 3
Diagnostic Approach
The diagnostic algorithm requires:
- Digital anorectal examination (essential low-cost clinical tool) 1
- Biopsy for histological confirmation (mandatory - diagnosis cannot be made without tissue) 1, 2
- Anoscopy/proctoscopy 1
Important note: Diagnosis may be delayed because bleeding and ulceration are commonly attributed to hemorrhoids 1. Multiple repeat biopsies may be necessary, as underlying malignancy can initially show only reactive mucosal changes 6.
The key message: Any persistent anal ulcer or sore that does not heal with standard treatment warrants biopsy to exclude malignancy, as anal cancer frequently presents this way and is commonly misdiagnosed initially.