Carcinoma in the retained rectum after colectomy for ulcerative colitis

Risk factors for rectal stump cancer in inflammatory bowel disease

BACKGROUND

Patients with long-standing colitis carry an increased risk of colorectal cancer and are therefore enrolled in colonoscopic surveillance programs. It is presently not known if endoscopic surveillance of patients with colitis with a closed rectal stump after a subtotal colectomy is justified. Neither is it clear which of these patients might be at increased risk for rectal stump cancer.

OBJECTIVE

The aim of this study is to identify the risk factors for rectal stump cancer.

DESIGN

This investigation is a retrospective descriptive case-control study.

SETTINGS

This study was conducted at tertiary referral centers in the Netherlands.

PATIENTS

Colorectal cancer cases associated with inflammatory bowel disease diagnosed between 1990 and 2006 were selected in a nationwide pathology archive. Patients with rectal stump cancer were selected from this group. The pathology archive was also used to identify inflammatory bowel disease controls matched for referral center with a closed rectal stump after subtotal colectomy, but without neoplasia. Follow-up started at the date of subtotal colectomy with the formation of a rectal stump. Demographic and disease characteristics were collected at baseline.

MAIN OUTCOME MEASUREMENTS

Hazard ratios with 95% confidence intervals were calculated for factors associated with the development of rectal stump cancer with the use of univariate Cox regression analysis. End points were rectal stump cancer, end of follow-up, or death.

RESULTS

A total of 12 patients with rectal stump cancer and 18 matching controls without neoplasia were identified. Univariate analysis showed an association between rectal stump cancer and primary sclerosing cholangitis, and disease duration until subtotal colectomy.

LIMITATIONS

This study is limited by its retrospective design, and, despite being the largest series to date, it still has a limited number of cases.

CONCLUSIONS

Risk factors for rectal stump cancer in a closed rectal stump after subtotal colectomy were primary sclerosing cholangitis and disease duration until subtotal colectomy.

Colorectal carcinoma in patients with ulcerative colitis

Analysis of a 30 year (1950 to 1979) series of colorectal carcinoma disclosed 29 patients with ulcerative colitis, who were compared in this retrospective study with 1,032 noncolitic patients. Colitic tumors were often multiple and had a predilection for the transverse colon. Nineteen patients were resected with the intention of cure, for a curability rate of 66 percent, which is comparable to the 69 percent rate in noncolitic patients. The 5 year survival rate was 31 percent overall and 47 percent in curable cases, rates similar to those in noncolitic patients (34 and 47 percent). All patients with Dukes' A lesions survived 5 years. A high incidence of Dukes' C lesions was observed; one third of these patients survived 5 years . Apart from the advanced stage, no signs of "aggressiveness" or particular virulence were demonstrated in colitic cancer. Results of procedures less than proctocolectomy in 13 patients were dismal: 4 died from cancer within 3 years, and 6 developed late carcinoma in the retained part of the bowel, with a fatal outcome in all.