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Anal adenocarcinoma complicating chronic Crohn's disease.

Papaconstantinou I, Mantzos DS, Kondi-Pafiti A, Koutroubakis IE - Int J Surg Case Rep (2015)

Bottom Line: Constant mucosal regeneration occurring within a fistula seems to be the predominant pathogenetic mechanism, while immunosuppressants and anti-TNF agents may also contribute to the malignant transformation.Albeit a rare complication, clinicians should maintain a high degree of vigilance about the possible development of adenocarcinoma in patients with long-standing perianal Crohn's disease.Thus, these patients should be kept under regular surveillance with examination under anaesthesia and biopsies or curettage of the tracts.

View Article: PubMed Central - PubMed

Affiliation: 2nd Department of Surgery, Aretaieion Hospital, Medical School, University of Athens, 76 V. Sofias Avenue, 11528, Athens, Greece. Electronic address: johnpapacon@hotmail.com.

No MeSH data available.


Related in: MedlinePlus

MRI of adenocarcinoma developing within fistulous tracts (high signal intensity on T2-weighted image).
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fig0010: MRI of adenocarcinoma developing within fistulous tracts (high signal intensity on T2-weighted image).

Mentions: A 40-year-old male patient with ileocolonic CD and perianal fistulising lesions, diagnosed 23 years ago, was referred to our institution for a new finding of soft tissue within a perianal fistula. His past medical history included loop sigmoidostomy and seton insertion 3 years ago for control of his perianal disease. Three months later, due to ileus caused by terminal ileitis, he underwent emergency right colectomy. At the same time, the loop sigmoidostomy was converted to end colostomy with closure of the peripheral stump; since, the perianal disease was still uncontrollable. At this time, taking into account the benign nature of the disease, as well as patient’s age, it was decided to give to the patient a second chance to keep his sphincter mechanism rather than to perform an abdominoperineal resection. The patient had received in the past, either in conjunction or consequently, corticosteroids, antibiotics (metronidazole, ciprofloxacin), immunosuppressants (azathioprine, methotrexate) and anti-TNF agents (infliximab) for the control of the frequent flare-ups. On referral, he was on adalimumab and mercaptopurine. Physical examination revealed mild perianal inflammation with muco-purulent discharge from two sore-like fistulous orifices, located at 7 and 11 o’clock in supine position (Fig. 1). Pelvic magnetic resonance imaging (MRI) demonstrated pathological tissue development within one fistulous tract (Fig. 2) suggesting a mucinous cancer arising within the fistula. The rectosigmoidoscopy depicted mild lesions compatible with moderately active CD, without any other sign of obvious malignancy. Mucosal biopsies were obtained from the lesions and the underlying fistulous tracts; granulomatous tissue infiltrated by mucus-producing adenocarcinoma was found on pathology. Staging with computed tomography did not reveal any metastatic disease. Thus, the patient underwent abdominoperineal resection, where a 37 cm segment of colon with the mesorectum, anal canal of 7 cm and the corresponding overlying soft tissue of the perineum was resected. On histopathology, a T4N1 moderately/poorly differentiated mucinous adenocarcinoma was detected (Fig. 3). According to the referrer, his last physical examination, six months prior to admission, was unremarkable. Unfortunately, three months postoperatively the patient developed multiple bone metastases and he is currently receiving chemotherapy.


Anal adenocarcinoma complicating chronic Crohn's disease.

Papaconstantinou I, Mantzos DS, Kondi-Pafiti A, Koutroubakis IE - Int J Surg Case Rep (2015)

MRI of adenocarcinoma developing within fistulous tracts (high signal intensity on T2-weighted image).
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4430134&req=5

fig0010: MRI of adenocarcinoma developing within fistulous tracts (high signal intensity on T2-weighted image).
Mentions: A 40-year-old male patient with ileocolonic CD and perianal fistulising lesions, diagnosed 23 years ago, was referred to our institution for a new finding of soft tissue within a perianal fistula. His past medical history included loop sigmoidostomy and seton insertion 3 years ago for control of his perianal disease. Three months later, due to ileus caused by terminal ileitis, he underwent emergency right colectomy. At the same time, the loop sigmoidostomy was converted to end colostomy with closure of the peripheral stump; since, the perianal disease was still uncontrollable. At this time, taking into account the benign nature of the disease, as well as patient’s age, it was decided to give to the patient a second chance to keep his sphincter mechanism rather than to perform an abdominoperineal resection. The patient had received in the past, either in conjunction or consequently, corticosteroids, antibiotics (metronidazole, ciprofloxacin), immunosuppressants (azathioprine, methotrexate) and anti-TNF agents (infliximab) for the control of the frequent flare-ups. On referral, he was on adalimumab and mercaptopurine. Physical examination revealed mild perianal inflammation with muco-purulent discharge from two sore-like fistulous orifices, located at 7 and 11 o’clock in supine position (Fig. 1). Pelvic magnetic resonance imaging (MRI) demonstrated pathological tissue development within one fistulous tract (Fig. 2) suggesting a mucinous cancer arising within the fistula. The rectosigmoidoscopy depicted mild lesions compatible with moderately active CD, without any other sign of obvious malignancy. Mucosal biopsies were obtained from the lesions and the underlying fistulous tracts; granulomatous tissue infiltrated by mucus-producing adenocarcinoma was found on pathology. Staging with computed tomography did not reveal any metastatic disease. Thus, the patient underwent abdominoperineal resection, where a 37 cm segment of colon with the mesorectum, anal canal of 7 cm and the corresponding overlying soft tissue of the perineum was resected. On histopathology, a T4N1 moderately/poorly differentiated mucinous adenocarcinoma was detected (Fig. 3). According to the referrer, his last physical examination, six months prior to admission, was unremarkable. Unfortunately, three months postoperatively the patient developed multiple bone metastases and he is currently receiving chemotherapy.

Bottom Line: Constant mucosal regeneration occurring within a fistula seems to be the predominant pathogenetic mechanism, while immunosuppressants and anti-TNF agents may also contribute to the malignant transformation.Albeit a rare complication, clinicians should maintain a high degree of vigilance about the possible development of adenocarcinoma in patients with long-standing perianal Crohn's disease.Thus, these patients should be kept under regular surveillance with examination under anaesthesia and biopsies or curettage of the tracts.

View Article: PubMed Central - PubMed

Affiliation: 2nd Department of Surgery, Aretaieion Hospital, Medical School, University of Athens, 76 V. Sofias Avenue, 11528, Athens, Greece. Electronic address: johnpapacon@hotmail.com.

No MeSH data available.


Related in: MedlinePlus