Adenocarcinoma and Crohn's disease. A report of 2 cases and analysis of the literature

Primary Adenocarcinoma of Terminal Ileum with Clinical and Gross Morphologic Features Simulating Crohn's Disease. A Case Report

We report a case of primary adenocarcinoma of the terminal ileum, which presented with clinical, radiologic and surgical findings indistinguishable from Crohn's disease. The age of the patient and the rapidly progressing symptoms were the only preoperative clues to the diagnosis of an occult malignancy. Frozen sections of an intraoperative biopsy established the correct diagnosis and led to a radical change in the treatment. This is the third report of adenocarcinoma of the small bowel simulating Crohn's disease.

Small bowel adenocarcinoma and Crohn's disease: Any further ahead than 50 years ago?

This review of the literature on small bowel carcinoma associated with Crohn’s disease specifically addresses the incidence, risk factors, and protective factors which have been identified. It also reviews the clinical presentation, the current modalities of diagnosis, the pathology, treatment, and surveillance. Finally, the prognosis and future direction are addressed. Our experience with small bowel adenocarcinoma in Crohn’s disease is reported. Readers will be provided with a better understanding of this rare and often poorly recognized complication of Crohn’s disease.

Cancer in Crohn's disease

There has been a multitude of case reports, case series, hospital-based, and population-based studies that link CD to various types of cancers. When each of these studies is scrutinized, however, there is only enough evidence to support a link between colorectal adenocarcinoma, SBA, and squamous and adenocarcinomas that are associated with perianal fistulizing disease. All of the studies of large bowel adenocarcinoma or SBA follow patients in an era during which there were far fewer effective medicines to treat CD and surgery was more commonplace. The only surveillance study of patients who had extensive, long-duration Crohn's colitis showed a 22% risk for developing neoplasia (low-grade, high-grade, or cancer) after four surveillance examinations. Overall results from this study and the multitude of the other studies show that the risk for cancer in Crohn's colitis is equal to that in UC given equal extent and duration of disease. Patients who have Crohn's colitis that affects at least one third of the colon and with at least 8 years of disease should undergo screening and surveillance, just as in UC. Although the absolute risk for SBA in CD is low (2.2% at 25 years in one study), we should not rule out screening and surveying for this complication that is associated with significant morbidity and mortality in patients who have long-standing, extensive, small bowel disease. The risk for lymphoma and leukemia in CD is low, but immunomodulators and biologics may increase this risk. The evidence that links carcinoid tumors to CD is weak, and population-based studies need to be done. The study of cancers that are associated with CD is an evolving field that surely will change given that immunomodulators and biologics are being used with greater frequency.

The surgical management of Crohn's disease

The surgical management of patients with CD can be complex and fraught with complications. Thorough preoperative evaluation by a multidisciplinary management team should delineate the indications for surgery and allow formulation of an operative strategy. Although surgery is not a cure for CD, approximately three quarters of patients require an operation. Until better postoperative maintenance strategies are developed, many CD patients eventually require a reoperation.

The American College of Surgeons Commission on Cancer and the American Cancer Society. Adenocarcinoma of the small bowel: review of the National Cancer Data Base, 1985-1995

BACKGROUND

Small bowel adenocarcinoma (SBA) accounts for 2% of gastrointestinal (GI) tumors and 1% of GI cancer deaths. The objective of this study was to review the National Cancer Data Base (NCDB) to identify case-mix characteristics, patterns of treatment, and factors influencing survival of patients with SBA.

METHODS

NCDB data from patients diagnosed with primary SBA between 1985-1995 were analyzed. Chi-square statistics were used to compare differences between groups. Disease specific survival (DSS) was calculated using the life table method for patients diagnosed between 1985-1990; univariate differences in survival were compared using the Wilcoxon statistic, and multivariate analyses were performed using a Cox regression model.

RESULTS

There were 4995 SBA cases reported to the NCDB between 1985-1995, 55% of which occurred in the duodenum, 18% in the jejunum, 13% in the ileum, and 14% in nonspecified sites. The overall 5-year DSS was 30.5%, with a median survival of 19.7 months. By multivariate analysis, factors significantly correlated with DSS included patient age, tumor site, disease stage, and whether cancer-directed surgery was performed.

CONCLUSIONS

SBA is found most commonly in the duodenum, and patient DSS is reduced at this site compared with those patients with jejunal or ileal tumors. This reduction in survival was associated with a lower percentage of cancer-directed surgery. Patients age > 75 years had a reduced DSS and more duodenal tumors, and were less frequently treated by cancer-directed surgery than their younger counterparts. This study reflects the experience with SBA from a large cross-section of U.S. hospitals, allowing for the identification of prognostic factors and providing a reference with which results from single institutions may be compared.

The relationship between infliximab treatment and lymphoma in Crohn's disease

The relationship between chronic inflammatory conditions and malignancy is complex. We describe the clinical course of 2 patients with Crohn's disease (CD) in whom lymphoma was diagnosed after treatment with infliximab. The first patient was a 61-year-old man with a 30-year history of fistulizing CD in whom B-cell non-Hodgkin's lymphoma was diagnosed 9 months after treatment with infliximab. The second is a 29-year-old man with CD in whom nodular sclerosing Hodgkin's lymphoma was diagnosed 3 weeks after infusion with infliximab. The lymphoma presented with pleural effusions, mediastinal and cervical adenopathy, and no gastrointestinal lesion. We describe the implications of these cases for the use of immunomodulatory therapy in CD and the questionable association between CD and lymphoma.

Colorectal adenocarcinoma in Crohn's disease

OBJECTIVE

The authors' aim was to review the clinical features and estimate the long-term survival of patients with colorectal carcinoma complicating Crohn's disease.

SUMMARY BACKGROUND DATA

Recent studies have demonstrated a significantly increased risk of colorectal carcinoma in patients with Crohns disease.

METHODS

The authors reviewed retrospectively the medical records of 30 patients with Crohn's disease admitted to The Mount Sinai Hospital between 1960 and 1989 in whom colorectal adenocarcinoma developed. All patients were operated on and follow-up was complete for all patients to 10 years after operation, to the time of death, or to the closing date of the study in December 1989.

RESULTS

The 30 patients in the series had 33 colorectal adenocarcinomas; three patients (10%) presented with two synchronous cancers. The patients were relatively young (mean age, 53 years) and had long-standing Crohn's disease (duration >20 years in 87%). The 5-year actuarial survival was 44% for the overall series: 100% for stage A, 86% for stage B, 60% for stage C. All five patients with excluded bowel tumor died of large bowel cancer within 2.4 years; by contrast, the actuarial 5-year survival for patients with in-continuity tumors was 56%.

CONCLUSIONS

The incidence, characteristics, and prognosis of colorectal carcinoma complicating Crohn's disease are similar to the features of cancer in ulcerative colitis, including young age, multiple neoplasms, long duration of disease, and greater than a 50% 5-year survival rate (without excluded loops). These observations suggest the advisability of surveillance programs for Crohn's disease of the colon similar to those for ulcerative colitis of comparable duration and extent.

Similarity of colorectal cancer in Crohn's disease and ulcerative colitis: implications for carcinogenesis and prevention

Colorectal cancer is the most frequent malignant complication in patients with inflammatory bowel disease. Eighty patients with colorectal cancer complicating Crohn's disease (CD) or ulcerative colitis (UC) with median ages at diagnosis of colorectal cancer of 54.5 years and 43.0 years respectively were studied. The median duration of disease to the diagnosis of cancer was long (CD 15 years; UC 18 years). Most cancers developed after more than eight years of disease (CD 75%; UC 90%). Patients with multiple carcinomas at diagnosis were equally common (CD 11%; UC 12%). Carcinoma occurred in the area of macroscopic disease in most patients (CD 85%; UC 100%). Mucinous and signet ring histological features were equally common (CD 29%; UC 21%). Dysplasia was present with similar frequency in both diseases (CD 73%; UC 79%). The overall five year survival rates were also similar (CD 46%; UC 50%). These findings show that carcinomas complicating CD and UC have strikingly similar clinicopathological features and suggest that a common underlying process, such as chronic inflammation, maybe important in the pathogenesis of colorectal carcinoma.

Adenocarcinoma complicating Crohn's disease

We report on 14 cases of intestinal adenocarcinoma complicating Crohn's disease, seven occurring in the small bowel and seven in the large bowel. In both locations, two-thirds of patients were male. The average ages at the time of diagnosis of Crohn's disease and of cancer were similar between the two groups of patients: 28 and 48 years, respectively. The diagnosis of cancer was suspected or obtained preoperatively in only four cases of large bowel cancer; in two patients with large bowel cancer and five with small bowel cancer, the diagnosis was made at laparotomy. In the remaining cases, only careful histologic examination revealed the carcinoma. Six small bowel cancers were located in the ileum, and five colonic cancers were distal to the splenic flexure. Two small bowel and one large bowel cancer were multifocal and had surrounding mucosal dysplasia. All tumors, except one small bowel cancer, underwent resection. Survival correlated with stage of tumor at resection; no patient with regional or distant metastasis survived five years, in comparison with an 83 percent five-year actuarial survival rate of patients with tumor confined to the intestinal wall. Mean survival was six months for patients with small bowel cancer in comparison with 65 months for patients with large bowel cancer, reflecting a tendency toward more advanced lesions in the small bowel cancer group.

Risk factors for small bowel cancer in Crohn's disease

Suspected risk factors for adenocarcinoma of the small bowel in Crohn's disease include surgically excluded small bowel loops, chronic fistulous disease, and male sex. Review of all seven University of Chicago cases failed to confirm any suspected risk factor. A case-control study was performed to identify possible alternatives. Each case was matched to four randomly selected controls from an inflammatory bowel disease registry matched for year of birth, sex, and confirmed small bowel Crohn's disease. Three factors were significantly associated with the development of cancer: (1) Four cancers developed in the jejunum, and jejunal Crohn's disease was associated with the development of cancer [odds ratio (OR) 8.0, 95% confidence interval (CI) 1.6-39.3]. (2) There was an association between the development of cancer and occupations known to be associated with an increased colorectal cancer risk (OR 20.3, CI 2.7-150.5). Three cases (a chemist with exposure to halogenated aromatic compounds and aliphatic amines, a pipefitter with exposure to asbestos, and a machinist with exposures to cutting oils, solvents, and abrasives) and one of 28 controls (a fireman with multiple hazardous exposures) had an occupational risk factor. (3) Among medications taken for at least six months, only 6-mercaptopurine use was associated with cancer (OR 10.8, CI 1.1-108.7). In conclusion, proximal small bowel disease, 6-mercaptopurine use, and hazardous occupations are associated with cancer of the small bowel in patients with Crohn's disease and can be added to the list of suspected risk factors.

Gastrointestinal malignancies in Crohn's disease. A 20-year experience

The relationship between gastrointestinal neoplasms and Crohn's disease is poorly defined. The purpose of this study was to characterize the features of gastrointestinal malignancies that developed in Crohn's patients. In this retrospective review the authors identified six patients with Crohn's disease who developed such lesions over a 20-year period: four patients had colorectal cancers and two had ileal malignant neoplasms. Patients averaged 52.7 years of age (range, 21 to 61 years). Three patients were men and three women. Five of the six patients had endured Crohn's disease for more than 20 years. Only two lesions were diagnosed before surgery. The colorectal lesions were predominantly right-sided and all occurred in bowel segments with active Crohn's disease. The lesions demonstrated aggressive histologic features: three of six tumors were poorly differentiated, one of the five adenocarcinomas was mucinous, and three of the colorectal cancers were Dukes' B or C lesions. Four of six patients survived five or more years. There was a single malignant carcinoid, which represents the seventh case report of a carcinoid tumor occurring in a patient with Crohn's disease. This study indicates that patients with Crohn's disease develop a wide variety of small bowel and colorectal cancers. Furthermore, it suggests that Crohn's patients with colonic disease should periodically undergo surveillance colonoscopy.

Primary malignant lymphoma of the large intestine complicating chronic inflammatory bowel disease

Ten cases of malignant lymphoma of the colon and rectum complicating chronic inflammatory bowel disease are presented. Seven patients had chronic ulcerative colitis with a history varying from 6 to 20 years. There was extensive colitis in six of these patients and left-sided colitis in one. All seven lymphomas showed the pathological and immunohistological features of primary B-cell tumours of the gastrointestinal tract with a predominance of high-grade tumours. Three patients had Crohn's disease of the large intestine complicated by malignant lymphoma of the sigmoid colon or rectum. The history of Crohn's disease varied from 30 months to 20 years and in each case there was fissuring and fistulae. There was extensive anal involvement in two cases. Histologically the three lymphomas were heterogeneous: one was of 'granulomatous' T-cell type and the other two were markedly polymorphic and of equivocal phenotype. They were also characterized by numerous multinucleate tumour giant cells. Primary colorectal malignant lymphoma should be regarded as a rare, but significant, complication of ulcerative colitis. Immunosuppression may be an additional factor in the genesis of intestinal lymphoma in Crohn's disease. The prognosis appears to be dependent on factors already known to be of prognostic significance in primary gut lymphomas: a predominance of high-grade tumours suggests that the outlook is generally worse than that for idiopathic primary large intestinal lymphoma.

Bowel cancer characteristics in patients with regional enteritis

We report 10 carcinomas in 8 patients with regional enteritis. Five of the cancers were in the ileum, 4 in the right colon, and 1 in the rectum. The visualized small bowel cancers appeared as benign strictures in small bowel involved by regional enteritis. Most were poorly differentiated. The colon cancers had a more typical radiographic appearance of malignancy. In some patients with small bowel cancer the malignancy was discovered only on histologic evaluation; the malignant nature of the lesion was not appreciated by radiography or gross examination at surgery.

Increased populations of endocrine cells in Crohn's ileitis

Hyperplasia of nerves has been described previously in Crohn's disease. To determine whether similar alteration of the enteric endocrine system occurs, endocrine cells of the ileal epithelium were quantified in typical cases of the disease. In the ileum from patients with Crohn's disease, there was an increase in the endocrine cell population, as visualised by immunostaining of chromogranin. Quantification of endocrine cell numbers showed significant increases in both macroscopically uninvolved (i.e. histologically normal) (35.0 +/- 3.8, cells per unit length of muscularis mucosae mean +/- SEM, P less than 0.05) and involved (44.5 +/- 5.5, P less than 0.01) Crohn's disease samples, compared with normal controls (23.7 +/- 3.4). Although individual types of endocrine cell showed slight increases in Crohn's samples, only the enterochromaffin cells in abnormal bowel showed a significantly greater population (normal controls 10.5 +/- 2.3; involved Crohn's 21.3 +/- 4.4, P less than 0.05).

Malignancy in Crohn's disease

The incidence of cancer in Crohn's disease has been evaluated in 473 patients admitted to Rigshospitalet during the period 1 April 1964 to 1 January 1983. The patients' condition at the end of the survey, their survival, and the number and location of cancers were registered. During the survey period 23 cancers (4.9%) were found. Five were intestinal (1.1%) and were split evenly among the two sexes, whereas among 18 patients with extraintestinal cancers there was only 1 man. There was no increased risk of developing cancer inside the gastrointestinal tract compared with a background population matched for age, sex, and calendar time. Extraintestinal cancer in women was, however, significantly in excess.

A study of histochemical changes in mucus from patients with ulcerative colitis, Crohn's disease, and diverticular disease of the colon

The colonic mucosa produces a protective and lubricating layer of mucus. In certain conditions, the quantity and quality of this mucus is impaired. This study assessed the histochemical changes in mucus in inflammatory bowel disease compared with the severity and extent of the condition. Biopsy specimens were taken from 62 patients (32 with ulcerative colitis; ten with colonic Crohn's disease; ten with diverticular disease; ten with normal controls) and sections stained with high iron diamine-alcian blue to distinguish sulphated mucins from sialomucins. Normal subjects showed a predominance of sulphated mucins. The patients with Crohn's and diverticular disease also demonstrated this normal pattern. Of the 20 patients with ulcerative colitis, and without demonstrable dysplastic changes, only one showed a moderate increase in sialomucins. However, of the 12 patients with extensive colitis and dysplastic changes, ten had an increase in sialomucins. Thus, the predominant sialomucin pattern was seen mainly in patients with dysplasia. It may, therefore, indicate patients at high risk of malignancy.

Hodgkin's disease complicating Crohn's disease in a child

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Colorectal carcinoma in patients with Crohn's disease

Epidemiologic studies have shown a fourfold to 20-fold increased risk of colorectal carcinoma in patients with Crohn's disease as compared with the general population, but management for this risk is controversial. This paper presents a series of 10 patients with Crohn's disease and colorectal carcinoma from one institution and a review of the literature. Compared with 118 consecutive patients having colorectal carcinoma of the usual type at the same institution, the 10 patients were younger (mean age 55 vs. 65 yr, p less than 0.05) and had a higher prevalence of mucinous carcinoma (50% vs. 9%, p less than 0.01), providing evidence in addition to the previous epidemiologic results that Crohn's disease is a predisposing (premalignant) condition for colorectal carcinoma. Eight of the 10 patients had an antecedent history of Crohn's disease, ranging from 4 to 51 yr (mean 24 yr); 2 patients presented with colorectal carcinoma and were found to have Crohn's disease. Of particular note, 9 of the 10 patients had colitis or ileocolitis, and carcinoma occurred in bypassed rectum in 2 patients. One patient had two carcinomas. Three of the 11 carcinomas were not recognized preoperatively. The anatomic sites of the cancers were not significantly different from usual colorectal carcinoma, with 7 of the 11 tumors (64%) in the sigmoid colon and rectum. Dysplasia was identified in all 10 patients, and all of the 10 resected carcinomas were found to be contiguous with high-grade dysplasia. The findings in this study support the proposals based upon epidemiologic data that surveillance should be considered for patients with clinically evident colorectal involvement by Crohn's disease or a bypassed segment of colorectum.

Small bowel adenocarcinoma and Crohn's disease: report of a case with differing histogenetic patterns

This paper presents a case of Crohn's disease with associated small bowel adenocarcinoma. A polypoid area of gastric metaplasia was present and showed both fundic and pyloric features, the latter showing increasingly severe dysplasia and infiltrating adenocarcinoma containing many enterochromaffin cells, in which serotonin was demonstrated. At foci of granulomatous inflammation one observed a well differentiated sulfomucin secreting adenocarcinoma. Away from the metaplastic or inflammatory lesions there arose both a poorly and well differentiated sialomucin secreting adenocarcinoma. Multiple microfoci of adenocarcinoma and dysplastic changes of the ileal epithelium were present in the absence of any gross abnormality.

Small intestinal adenocarcinoma complicating regional enteritis

Three new cases of small intestinal adenocarcinoma complicating Crohn's disease are reported. Seventy-five other cases have been reported to date. Analysis of these cases in comparison with de novo adenocarcinoma of the small bowel shows that they: (1) occur at a younger age; (2) occur in distal small bowel; (3) show a male predilection; and (4) have a worse prognosis. The increasing number of these cases suggests that small intestinal regional enteritis predisposes to adenocarcinoma. Improved prognosis can only be achieved with earlier diagnosis.

Intramucosal carcinoma of the small intestine arising in regional enteritis (Crohn's disease). Report of a case studied for carcinoembryonic antigen and review of the literature

A case of carcinoma of the small intestine arising in a patient with regional enteritis (Crohn's disease) of the ileum is reported. The patient, a 54-year-old woman, had a 21-year history of regional enteritis which was treated intermittently with sulfasalazine and prednisone. Segmental resections of the ileum had been performed on two previous occasions. Because of recurrent low-grade intestinal obstruction, another segment of ileum was resected. The bowel demonstrated the typical gross and histologic appearance of regional enteritis. Histologic examination also disclosed a carcinoma that was confined to the ileal mucosa. This case is the first reported in which a small bowel carcinoma arising in regional enteritis has been found only in the mucosa. Adjacent to the carcinoma, the mucosa showed varying degrees of dysplasia consistent with the "precancerous" changes that have been described in inflammatory bowel disease. Using a peroxidase-antiperoxidase immunoperoxidase technique, carcinoembryonic antigen was identified in normal, hyperplastic, dysplastic, and carcinomatous mucosa, but the most intense staining was seen in hyperplastic and dysplastic cells. Carcinoembryonic staining, however, did not aid in differentiating between hyperplasia, dysplasia, and carcinoma because of an overlap in staining frequency and intensity.

Dysplasia in inflammatory bowel disease: standardized classification with provisional clinical applications

Assessment of epithelial dysplasia in ulcerative colitis has been hindered by inconsistencies in and disagreements about nomenclature and interpretation. To resolve these issues, pathologists from ten institutions participated in three exchanges of multiple slides and, following each exchange, in discussions of the results. A classification system for the epithelial changes that occur in ulcerative colitis was developed, which should be applicable to other forms of inflammatory bowel disease as well. The classification makes use of standardized terminology, addresses specific problem areas, and offers practical solutions. The reproducibility of the system was studied by means of examinations of both inter- and intra-observer variations. The clinical implications of the findings were incorporated into suggestions for patient management. The basis of the classification is that the term "dysplasia" is reserved for epithelial changes that are unequivocally neoplastic and may therefore give rise directly to invasive carcinoma. Specimens are categorized as negative, indefinite, or positive for dysplasia. The negative category includes all inflammatory and regenerative lesions and indicates that only continued regular surveillance is required. The indefinite category is applied to epithelial changes that appear to exceed the limits of ordinary regeneration but are insufficient for an unequivocal diagnosis of dysplasia or are associated with other features that prevent such unequivocal diagnosis. Clinically, it indicates that early repeat biopsy is often required to assess the changes more accurately. The positive category is divided into two subcategories: 1) high-grade dysplasia, for which colectomy should be strongly considered after confirmation of the diagnosis, and 2) low-grade dysplasia, which also requires confirmation and early repeat biopsy or colectomy, depending on other findings.

Cancer in Crohn's disease--an 'occult' malignancy

The purpose of this case report of cancer complicating Crohn's disease is to highlight the occult nature of these tumours. From the literature it is apparent that the majority are only discovered by the pathologist. As many are inconspicuous even on macroscopic examination an improved method of dissection is suggested.

Electron microscopic study of adenocarcinoma of the small bowel associated with Crohn's disease

"Crohn's Carcinoma" of a 34-year-old patient is presented in this paper. The fine structure of the tumour is discussed in detail, because there have been no previous reports of electron microscopic studies of this tumour. The adenocarcinoma cells were electron microscopically less differentiated than expected on the basis of light microscopic examinations. In the tumor cells, several round dense granules were observed. Similar granules were also described in the cells of intestinal type gastric and colon cancers, being considered a sign of pathologic mucus secretion. In a part of the tumour cells, intracisternal parallel tubular inclusions were seen like those described in malignant melanoma and osteosarcoma. In the dysplastic small-bowel mucosa adjacent to the tumour, the maturation disorder of the epithelial cells was similar to changes described in the precancerous states of the colon.

Inflammatory bowel disease in Auckland, New Zealand

Four-hundred-and-fifty-six patients with ulcerative colitis (UC) and 137 patients with Crohn's disease (CD) attended public hospitals within Auckland between 1969 and 1978. Polynesians comprised 15% of the population at risk but accounted for only 0.4% of UC cases and no CD cases. Annual incidence rates were 5.4/100,000 Caucasians for UC and 1.75 for CD. CD was significantly less common in Auckland than in European and North American centres. For patients presenting for the first time between 1969 and 1978, the cumulative probability of surviving 10 years was 93.9% for UC and 89.1% for CD. An excess of observed over expected mortality was limited to the first year of observation in UC and did not occur in CD. Clinical features and local complications of UC and CD have been correlated with the anatomic location of disease. In this first clinical study of inflammatory bowel disease of New Zealand, 61% of CD and 23% of UC patients required at least one surgical resection.

Adenocarcinoma of the small intestine complicating Crohn's disease

Adenocarcinoma of the small intestine is an uncommon complication of Crohn's disease. We report the clinical and pathological details of three cases diagnosed between 1968 and 1980 with a review of 58 cases from the literature. Of the 61 cases, 41 tumours occurred in the ileum, 18 in the jejunum, one in the duodenum and ileum, and one in the ileum and colon. Eighteen occurred in bypassed intestinal loops. The prognosis was poor: 44 patients (72%) had died with a mean interval of only 7.9 months from the diagnosis of cancer.

Adenocarcinoma in perineal fistulas of Crohn's disease

Until recently, Crohn's disease has not been regarded as a premalignant lesion, but the increasing number of patients with Crohn's disease in whom adenocarcinoma of the gastrointestinal tract develops strongly suggests that these patients are indeed at a higher risk for carcinoma. These patients are usually young and tend to develop a malignancy in the bypassed ileum or right colon. Patients with such lesions usually have a poor prognosis. Adenocarcinoma arising in perineal fistulas secondary to Crohn's disease has not been reported in English medical literature except for one case published in 1975. In this article, the authors report a second, similar case of Crohn's disease with recurrent perineal fistulas. An infiltrating adenocarcinoma developed in these fistulas, in the anorectal region, and in the left labia. The risk of malignancy should be seriously considered in the management of Crohn's disease, especially in young patients. Because of the risk of adenocarcinoma in these patients, resection rather than bypass is recommended in the surgical management.

Crohn's disease and adenocarcinoma of the bowel

We present six cases of cancer associated with Crohn's disease and stress the importance of the earlier age of onset than spontaneously arising small-bowel carcinoma, the long period of latency from the time of diagnosis of Crohn's disease to that of carcinoma, and the generally poor prognosis. We emphasize, furthermore, the frequent association with fistulas and the predisposition of bypassed or excluded segments of bowel to undergo malignant transformation. The occurrence of carcinoma in an excluded rectal stump has not previously been reported and stresses the necessity of resecting, rather than excluding, segments of bowel involved with Crohn's disease. These tumors are often not readily apparent by radiographic or endoscopic examination and in fact, may be discovered only after microscopic examination of resected or biopsied tissue.

Malignancy in Crohn's disease

Cancer morbidity has been evaluated in a series of 513 patients with Crohn's disease under long-term review between 1944-76. In comparison with morbidity rates for cancer in the West Midlands Region (the geographical area from which these patients were drawn) the 31 tumours that occurred represented a relative risk of 1.7 (P less than 0.01) of cancer at all sites. For tumours at sites within the digestive system the relative risk was 3.3 (P less than 0.001). A significant excess of tumours was found in both the upper (P less than 0.01) and lower (P less than 0.001) gastrointestinal tract. There was no excess of tumours at any site outside the digestive system.

Adenocarcinoma arising in Crohn's disease: report of two cases

Crohn's disease of the colon and small bowel is associated with a greater-than-chance increased incidence of adenocarcinoma, which also differs from the norm in age and anatomic distribution. The cancer risk appears to rise with earlier age of onset and long duration of the granulomatous disease, and the prognosis is relatively poor, probably due to difficulty in diagnosis because of the overlapping Crohn's disease. Two additional cases of adenocarcinoma arising in Crohn's disease are described.

Adenocarcinoma in Crohn's colitis

A case of Crohn's disease with carcinoma of the rectum is reported, bringing the number of reported cases to 44. Although the exact incidence of carcinoma arising in a segment of Crohn's disease is not known, a review of the literature emphasizes that there does seem to be a definite increased risk.

Multiple adenocarcinomas and premalignant changes in "backwash" ileitis

In a patient with long-staning ulcerative colitis and "backwash" ileitis, multiple carcinomas developed in the colon and ileum. In both locations premalignant mucosal changes of the basal cell proliferation type were seen adjacent to and remote from sites of carcinoma. Although the frequency of such premalignant and malignant changes in "backwash" ileitis is unknown, their concurrence in this case suggests that ulcerative colitis involving the terminal ileum increases the risk of small bowel carcinoma.

Survival rate in Crohn's disease and ulcerative colitis

The survival rate in 709 patients with chronic inflammatory bowel disease (CIBD) was calculated by the log rank test. There were 297 patients with Crohn's disease (CD) and 412 patients with ulcerative colitis (UC). In both diseases there was a survival rate of about 94% in the first year of observation against an expected rate of 99.5% in a general population matched for sex and age. This was because a large number of patients were severely ill at their first admission and required immediate or early surgery. During the subsequent 11 years the death rate in CIBD was higher (two to three times) than in the general population. After 12 years the survival rate was about 77% in both CD and UC. The difference was statistically insignificant. There was no significant difference in the sex ratio. The cancer rate was low. No gastrointestinal cancer occurred among patients with CD. Colorectal cancer was found in four patients with UC, three of whom presented with cancer on their first admission. It is concluded that recurrence and reoperation for recurrence in Crohn's disease have not impaired the prognosis compared to ulcerative colitis in this series.

Lymphosarcoma in Crohn's disease: report of a case

In a patient who had a family history of ulcerative colitis and colonic carcinoma, a jejunal lymphosarcoma developed four years after resection for Crohn's disease of the small intestine. It is suggested that the association of lymphosarcoma with Crohn's disease is more than a chance association.

Ulcerative colitis or Crohn's colitis. Is differentiation necessary?

Three types of colitis are now recognized. In the late 1950's and early 1960's, 51 per cent of our patients having colectomy had classic chronic ulcerative colitis. Of our patients operated on at that time, 39 per cent had Crohn's colitis and 10 per cent had colitis of indeterminate type. These three types of colitis should be differentiated because of the high risk of cancer of the colon in patients with long-standing chronic ulcerative colitis. We have not seen an increased risk of carcinoma associated with Crohn's colitis. We performed resection with anastomosis in approximately one third of patients with Crohn's colitis, but recurrent disease developed in two thirds. In contrast, recurrent Crohn's disease developed in only 5.7 per cent of patients having colectomy with ileostomy. Toxic megacolon associated with Crohn's colitis has been seen only in the early clinical stage of the disease. From the standpoint of management and prognosis, attempts to differentiate between the two major types of colitis are appropriate. We have outlined some of the basic clinical and pathologic differences between these two types of colitis.