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

Small Bowel Adenocarcinoma Complicating Crohn's Disease: Case Series and Review of the Literature

Colonic adenocarcinoma frequently complicates inflammatory bowel disease of the colon, but small bowel adenocarcinoma (SBA) is a rare complication of Crohn's disease (CD). We present two patients with SBA in CD and review the literature with regards to CD-related SBA. A 45-year-old male with a 17-year history of ileal CD presented with obstructive symptoms but no radiographic evidence of a mass. After laparoscopic ileocolectomy and repair of incidental ileosigmoid fistula, pathology showed a T3N0 adenocarcinoma within the ileal CD. Two years after his resection he was without evidence of disease. A 59-year-old male with a 15-year history of CD presented with an acute exacerbation. Small bowel follow through demonstrated a long ileal stricture for which he underwent an ileocolic resection. Postoperative pathology confirmed a T3N1 CD-related SBA. He died from metastatic cancer 3 months later. Review of the literature identified 154 cases of SBA complicating CD with several distinguishing features from de novo SBA. Patients with SBA and CD are, as a group, younger and more likely to be male. SBA is rarely diagnosed preoperatively in these patients, and has a poor prognosis due to its advanced stage at diagnosis.

Detection of pyloric metaplasia may improve the biopsy diagnosis of Crohn's ileitis

BACKGROUND

Pyloric metaplasia (PYME) is seen frequently in ileal resections from patients with Crohn's disease (CD). It represents a nonspecific reparative reaction in intestinal ulcers. The presence of PYME in terminal ileum biopsies (TIbxs) of CD has not received much attention and has been considered a rare finding.

STUDY

We reviewed 45 TIbxs from 45 adult patients with indisputable clinicopathologic diagnosis of CD. Endoscopic biopsies were obtained with an Olympus CIF 140 videoscope. The samples were fixed in 10% buffered formalin and were processed routinely.

RESULTS

Pyloric metaplasia was identified in 10 TIbxs from 10 patients. Most of the metaplastic glands formed small aggregates in the mucosal base, and they were frequently noted below regenerating crypts and in the vicinity of granulation tissue and ulceration.

CONCLUSIONS

In our material, 22.2% of the TIbxs revealed PYME. The single previous study with similar data showed an incidence of 2.27%. The difference could reflect the stage of the disease or the thoroughness of the endoscopic and pathologic examinations. Pyloric metaplasia, despite its lack of specificity, remains a sensitive indicator of persistent ulceration with inflammation. Because PYME is not as rare as previously thought, it should be carefully looked for in TIbxs to support the diagnosis of CD in the appropriate clinical setting.

Small bowel adenocarcinoma metastatic to the ovaries in a 12-year-old girl

PURPOSE

Small bowel adenocarcinoma is a rare cancer and usually occurs in elderly males. A 12-year-old girl with metastatic small bowel adenocarcinoma and her clinical course are described. The difficulties in making the pathologic diagnosis and the literature are also reviewed.

PATIENTS AND METHODS

A 12-year-old girl had partial small bowel obstruction and bilateral ovarian enlargement. Exploratory laparotomy revealed a jejunal tumor with bilateral ovarian involvement and extensive peritoneal and pelvic studding. The pathologic diagnosis of small bowel adenocarcinoma was made.

RESULTS

The patient had a moderate response to therapy with 5-fluorouracil, leucovorin, and alpha-interferon before developing progressive disease unresponsive to therapy with topotecan, taxol, or carboplatin. She survived for 23 months after diagnosis.

CONCLUSION

Making an accurate diagnosis of tumors metastatic to the ovary can be difficult and requires attention to histologic detail. Small bowel adenocarcinoma is usually a chemoresistant tumor with extremely poor outcome. This patient had a moderate response to chemotherapy and a prolonged survival compared to that of patients previously reported.

Carcinoma in Crohn's disease of the colon

Two cases of carcinoma in Crohn's disease of the colon are reported. One patient was a 30-year-old man who had asymptomatic Crohn's ileocolitis resulting in an acute presentation due to toxic dilatation of the colon. This was preceded by a short prodromal period of four weeks, characterized by intermittent diarrhea on the basis of a coloileal tumor fistula. A mucus-secreting adenocarcinoma was present in the sigmoid colon associated with both adjacent and one nearby focus of high-grade mucosal dysplasia. Pelvic wall and abdominal metastases were present, and the patient died two months later. The other patient was a 60-year-old woman who had a nine-year history of biopsy-proven Crohn's proctocolitis. A stricture of the sigmoid colon due to Crohn's disease also harbored an invasive adenocarcinoma. The carcinoma was not evident preoperatively or on initial gross pathologic examination. The presentation and pathology of large intestinal carcinoma in Crohn's colitis are discussed and illustrated.