Mucinous carcinoma in Crohn’s disease originating in a fistulous tract

Perianal Mucinous Adenocarcinoma: A Case Report and a Systematic Review of the Literature

BACKGROUND

Mucinous adenocarcinoma of anus is an uncommon neoplasm of the gastrointestinal tract. In most of the cases, early diagnosis of this disease is difficult since its symptoms frequently mimic benign inflammatory conditions.

METHODS

A systematic PubMed and Scopus search was conducted, a propos of a case report.

RESULTS

One hundred fifty patients from 93 case reports were included. The mean age of the patients was 60.5 years (range: 18-81). The majority of them were males (124 out of 150, 82.7%), while the main known risk factor was the history of chronic fistula (109 out of 150, 72.7%). Recurrent perianal sepsis and perianal pain were the principal symptoms at the time of presentation. No symptoms have been reported only in three patients (3 out of 150, 2%). Regarding the prior surgical history of the patients, multiple abscess drainage and perianal fistula's related interventions were present in 62 (41.3%) and 19 (12.7%) patients, respectively. Neoadjuvant chemoradiotherapy was administered in 53 out of 150 patients (35.3%), while the majority of them have been treated with combined treatment of chemotherapy and radiotherapy. APR and its variations were the most applied surgical treatment (68%). Adjuvant chemoradiotherapy was administered almost up to one-third of the included patients (34%). Recurrence of the disease was reported in 41 out of 150 patients (27.3%). Death was reported in 44 out of 150 patients (29.3%).

CONCLUSION

Review of the available published literature suggests that perianal mucinous adenocarcinoma is an extremely rare neoplasia. Τhere is no consensus as far as the diagnosis and the treatment strategies, due to the rarity of this neoplasm. High degree of clinical suspicion as well as histopathological confirmation is the principal requisites for the diagnosis of mucinous adenocarcinoma, especially in the ground of chronic ulcero-proliferative perianal lesions.

Perianal Fistulizing Crohn's Disease-Associated Anorectal and Fistula Cancers: Systematic Review and Expert Consensus

BACKGROUND & AIMS

Perianal fistulizing Crohn's disease (PFCD)-associated anorectal and fistula cancers are rare but often devastating diagnoses. However, given the low incidence and consequent lack of data and clinical trials in the field, there is little to no guidance on screening and management of these cancers. To inform clinical practice, we developed consensus guidelines on PFCD-associated anorectal and fistula cancers by multidisciplinary experts from the international TOpClass consortium.

METHODS

We conducted a systematic review by standard methodology, using the Newcastle-Ottawa Scale quality assessment tool. We subsequently developed consensus statements using a Delphi consensus approach.

RESULTS

Of 561 articles identified, 110 were eligible, and 76 articles were included. The overall quality of evidence was low. The TOpClass consortium reached consensus on 6 structured statements addressing screening, risk assessment, and management of PFCD-associated anorectal and fistula cancers. Patients with long-standing (>10 years) PFCD should be considered at small but increased risk of developing perianal cancer, including squamous cell carcinoma of the anus and anorectal carcinoma. Risk factors for squamous cell carcinoma of the anus, notably human papilloma virus, should be considered. New, refractory, or progressive perianal symptoms should prompt evaluation for fistula cancer. There was no consensus on timing or frequency of screening in patients with asymptomatic perianal fistula. Multiple modalities may be required for diagnosis, including an examination under anesthesia with biopsy. Multidisciplinary team efforts were deemed central to the management of fistula cancers.

CONCLUSIONS

Inflammatory bowel disease clinicians should be aware of the risk of PFCD-associated anorectal and fistula cancers in all patients with PFCD. The TOpClass consortium consensus statements outlined herein offer guidance in managing this challenging scenario.

Perirectal Mucinous Adenocarcinoma After Subtotal-Colectomy for Crohn's Disease: A Case Report

Colorectal carcinoma (CRC) represents the third most common cancer and the second highest cause of cancer-related death in the United States. CRC is particularly prevalent in patients with underlying inflammatory bowel disease. Adenocarcinoma represents more than 90% of new CRC diagnoses. The mucinous subtype of colorectal adenocarcinoma is found in approximately 10-20% of all colorectal cancer patients and is most frequently located in the proximal colon. We report a case of mucinous adenocarcinoma arising from the rectal stump of a patient who had previously undergone subtotal-colectomy with end ileostomy for Crohn's disease. She initially presented with gradually worsening chronic abdominal pain and gelatinous rectal discharge. She was found to have a complex cystic lesion communicating with her Hartman's pouch. She ultimately underwent a completion proctectomy, radical hysterectomy, and bilateral salpingo-oophorectomy in conjunction with gynecology oncology. To the best of our knowledge, this case represents the first description of a perirectal mucinous adenocarcinoma arising in a patient after subtotal-colectomy for Crohn's disease.

Mucinous adenocarcinoma in perianal fistula in Crohn's disease: Case report and literature review

Introduction and importance

Crohn's disease (CD) is a chronic bowel disease that, due to exacerbated inflammation, can lead to complications such as the development of perianal fistulas. The development of mucinous adenocarcinoma in perianal fistulas in patients with CD is rare and, consequently, few reports exist in the literature.

Case presentation

We report the case of a 71-year-old man diagnosed 22 years ago with CD with perineal involvement, who came with complaints of intense perianal pain, a gluteal mass, and local bleeding. Tomography of his abdomen showed an expansive, heterogeneous, and solid perianal mass on the right, with interspersed necrotic/liquefied areas and possible mucinous content. The patient was referred to the surgery department for an incisional biopsy, which confirmed mucinous adenocarcinoma. The patient underwent extra levator abdominoperineal rectal resection (APR) with partial prostatectomy.

Clinical discussion

Perineal mucinous adenocarcinoma arising in a fistula associated with CD is very rare. Since the symptoms overlap, early diagnosis of malignancy is difficult. Histological analysis is the gold standard for its diagnosis. Surgical resection through APR is well-established and, despite being a complex procedure with potential complications, tends to have good results. However, the locoregional and inguinal lymph node involvement was related to a worse progression in this case.

Conclusion

The diagnostic hypothesis of mucinous adenocarcinoma should be suspected in CD patients who present long-term perineal involvement with fistulas. Biopsies and imaging exams should be performed to aid the diagnosis of the condition and thus contribute to the surgical plan.

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Mucinous adenocarcinoma in perianal fistulas from CD patients is extremely rare.

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Magnetic resonance imaging findings help in Mucinous adenocarcinoma diagnosis.

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Locoregional and inguinal lymph node involvement is related to a worse progression.

Mucinous adenocarcinoma arising from recurrent perianal fistula in patient with Crohn's disease: case report

Introduction Anal carcinoma is a rare variant of epithelial tumors of the anal canal. When associated with chronic and active anal fistulas, usually this is an aggressive cancer that has difficult diagnosis and poor prognosis. Anal fistulas are a common manifestation of Crohn's disease (CD). This study aims to report a case of mucinous adenocarcinoma originating from recurrent perianal fistula in patients with CD.

Case report A man of 43 years, with melanoderma, complaining of perianal tumors, anal pain and mucopurulent secretion, the patient was diagnosed with fistulae. Colonoscopy revealed a chronic inflammatory process associated with villous polypoid lesion in the colonic and rectal mucosa. In a new episode, where it was diagnosed, chronic colitis of rectum and sigmoid was being prescribed sulfasalazine with improvement. There were relapses and the patient underwent repeated fistulectomias. After investigation, CD was diagnosed. Computed tomography (CT) of abdomen and pelvis showed multiple perineal and gluteal collections, and the patient underwent abdominoperineal resection of the rectum. Anatomopathological exam showed invasive mucinous adenocarcinoma. A new CT showed residual growth of the lesion. The patient was referred to the oncology referral service, where chemotherapy and radiotherapy were planned. The patient developed unfavorably, and his death occurred two months after treatment.

Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of inflammatory bowel disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the general principles of surgical treatment of inflammatory bowel disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Mucinous adenocarcinoma arising from chronic perianal fistula mimicking horseshoe abscess

Perianal fistulae are commonly seen clinical entity. Development of malignancy within a perianal fistula is rare. Even rarer is the development of mucinous adenocarcinoma in a chronic fistula-in-ano. Only a handful of such cases have been reported in the past. A case of mucinous adenocarcinoma arising in chronic perianal fistula in a 34-year-old woman is being described. She presented with complaints of perineal fullness, pain and recurrent pus discharge from perianal fistula for 4 years. On radiological workup, a large solid-cystic pelvic mass was seen in relation to the fistula. On MRI, the lesion was mimicking a large horseshoe abscess. Transrectal ultrasound-guided biopsy and subsequent histopathological examination confirmed the presence of mucinous adenocarcinoma with tumour cells immunopositive for CK7 and CK20.

Results of the Fifth Scientific Workshop of the ECCO (II): Pathophysiology of Perianal Fistulizing Disease

The fifth scientific workshop of the European Crohn's and Colitis Organization (ECCO) focused on the relevance of fistulas to the disease course of patients with Crohn's disease (CD). The objectives were to reach a better understanding of the pathophysiological mechanisms underlying the formation of CD fistulas; to identify future topics in fistula research that could provide insights into pathogenesis; to develop novel therapeutic approaches; and to review current therapeutic strategies (with clarification of existing approaches to prevention, diagnosis and treatment). The results of the workshop are presented in two separate manuscripts. This manuscript describes current state-of-the-art knowledge about fistula pathogenesis, including the roles of epithelial-to-mesenchymal transition and cytokine matrix remodelling enzymes, and highlights the common association between fistulas and stenosis in CD. The review also considers the possible roles that genetic predisposition and intestinal microbiota play in fistula development. Finally, it proposes future directions and needs for fistula research that might substantially increase our understanding of this complex condition and help unravel novel therapeutic strategies and specific targets for treatment. Overall, it aims to highlight unanswered questions in fistula research and to provide a framework for future research work.

Adenocarcinoma in an ano-vaginal fistula in Crohn's disease

INTRODUCTION

Fistulas are a relatively common occurrence in Crohn's disease (CD), and often present early in the disease process. Additionally, patients suffering from either CD or ulcerative colitis are shown to have an increased risk of colorectal malignancies compared with the general population.

PRESENTATION OF CASE

We present a case of adenocarcinoma in an ano-vaginal fistula in a patient with longstanding CD.

DISCUSSION

Various pathogenic mechanisms for the development of carcinoma in fistulas have been suggested, but there is no consensus and indeed this risk may be cumulative. In this case report, we also discuss the pathogenesis of mucinous adenocarcinoma in fistulas secondary to CD.

CONCLUSION

Better detection of adenocarcinoma in patients presenting with persistent non-resolving fistulas in the presence of CD should be undertaken with regular biopsies following examinations under anaesthetic of the anorectum.