Intestinal and extra-intestinal cancer in Crohn's disease: follow-up of a population-based cohort in Copenhagen County, Denmark

AIM

To determine the long-term risk of intestinal and extra-intestinal malignancies in Crohn's disease patients in Copenhagen County, Denmark.

METHODS

In Copenhagen County, a strictly population-based cohort of 374 patients with Crohn's disease diagnosed between 1962 and 1987 was followed until 1997 in order to determine the long-term risk of intestinal and extra-intestinal malignancies. Information on cancer occurrence was provided by the Danish National Cancer Registry and confirmed by the examination of hospital files. The observed number of cases was compared with the expected number, calculated from individually computed person-years at risk and 1995 cancer incidence rates for the background population.

RESULTS

The risk of small bowel adenocarcinoma was significantly increased, independent of age and gender (standardized morbidity ratio, 66.7; 95% confidence interval, 18.1-170.7). The risk of colorectal cancer was not increased, either in the total group of patients or in patients with colonic Crohn's disease exclusively (standardized morbidity ratio, 1.64; 95% confidence interval, 0.20-5.92). Extra-intestinal cancer did not occur more frequently than expected.

CONCLUSIONS

This population-based study of patients with Crohn's disease revealed no increase in colorectal cancer risk, possibly due to maintenance treatment with 5-aminosalicylic acid preparations and surgery in treatment failure. In contrast, the risk of small bowel cancer was increased more than 60-fold, but the numbers were small. The risk of extra-intestinal cancer was not increased and no lymphomas were observed.

Small intestinal adenocarcinoma in Crohn's disease: a case-control study

BACKGROUND

Small bowel adenocarcinoma is an uncommon complication of Crohn's disease. We sought to describe the clinical features, outcomes, and risk factors of small bowel adenocarcinoma in Crohn's disease.

METHODS

A centralized diagnostic index identified all patients with Crohn's disease with small bowel adenocarcinoma evaluated at our institution between 1976 and 2000, and the medical records were abstracted. Two controls with Crohn's disease were selected for each case, matched by gender and age.

RESULTS

Nine cases (four males) were identified. The patients presented with abdominal pain (89%), obstruction (89%), and weight loss (78%). Cancer was located in the ileum in 8 patients (89%) and the jejunum in 1 patient (11%). All cases but 1 had either lymph node involvement or metastasis. All cases had surgery, with 1 receiving adjuvant chemotherapy. No significant risk factors were found. The mortality rates at 1 and 2 years were 42% and 61%.

CONCLUSIONS

Small bowel adenocarcinoma is a rare complication of Crohn's disease that typically involves the ileum. Affected patients have symptomatic, advanced malignancies upon diagnosis. No significant risk factors were identified.

Gardner's syndrome. Recent developments in research and management

In recent years, a number of comprehensive reviews have been written on inherited intestinal polyposis syndromes (1-7), but none has dealt specifically with Gardner's syndrome and none has focused on basic research being carried out in an attempt to understand this syndrome and to improve the medical management of affected patients. A better understanding of this rare genetic disorder is essential for surgeons, gastroenterologists, cancer researchers, and geneticists alike. To the clinician, it poses difficult challenges in management; to the cancer researcher, it presents a rare opportunity to study very early premalignant transformations; and to the geneticist, it poses exciting questions at the cellular, chromosomal, and molecular levels.

Adenocarcinoma and lymphoma of the small intestine. Distribution and etiologic associations

Malignant small-bowel tumors in 171 patients over 64 years included 68 with adenocarcinomas, 41 with primary lymphomas, 50 with carcinoids, and 12 with sarcomas. The distribution of the carcinomas showed approximately 80% preponderance in the duodenum and proximal jejunum. A similar distribution in the upper small bowel in small-bowel carcinomas induced in Fischer and Sprague-Dawley rats by azoxymethane (90-160 mg/kg) suggests defense mechanisms within ileal mucosa. The clinical series from 1958 to 1976 included two Crohn's carcinomas (jejunum, defunctioned ileum), two jejunal cancers (lymphoma, carcinoma) associated with celiac disease, two duodenal carcinomas arising in villous adenomas, and one jejunal lymphoma following exposure to irradiation. Multiple primary malignancies were found in 20 to 25% of enteric cancers. Hemorrhage was more common with carcinoma than lymphoma, but lymphomas predominated considering perforation or a palpable mass. Both carcinoma and lymphoma had 75 to 80% resectability rates and 14 to 15% five-year postoperative survival rates. The prognosis was least poor for carcinoma of the jejunum, one third of patients with "curative" resections surviving five years.

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.

Risk factors for adenocarcinoma of the small intestine

We have investigated the relation between alcohol, tobacco and dietary habits and risk of adenocarcinoma of the small intestine using data from 2 hospital-based case-control studies on intestinal cancers conducted in 6 Italian centres between 1985 and 1996. Cases were 23 patients below age 75 years with adenocarcinoma of the small intestine. Controls were 230 patients admitted to hospital for a wide spectrum of acute, non-neoplastic, non-digestive tract diseases, matched to cases on sex, age, study and centre. Odds ratios (ORs) were estimated using conditional logistic regression. Alcohol and tobacco consumption did not increase the risk of adenocarcinoma of the small intestine. The risk appeared to be directly related to intake of bread, pasta or rice (OR = 3.8), sugar (OR = 2.9) and red meat (OR = 4.6), and inversely to coffee (OR = 0.4), fish (OR = 0.3), vegetables (OR = 0.3) and fruit (OR = 0.6). Our results suggest that dietary correlates of adenocarcinoma of the small intestine are similar to those of colon cancer and at least of the same magnitude. While the present data are inconsistent with a major effect of tobacco or alcohol, a moderate association between these factors and small bowel cancer may have been obscured by the play of chance.

Non-colorectal intestinal tract carcinomas in inflammatory bowel disease: results of the 3rd ECCO Pathogenesis Scientific Workshop (II)

Patients with inflammatory bowel diseases (IBD) have an excess risk of certain gastrointestinal cancers. Much work has focused on colon cancer in IBD patients, but comparatively less is known about other more rare cancers. The European Crohn's and Colitis Organization established a pathogenesis workshop to review what is known about these cancers and formulate proposals for future studies to address the most important knowledge gaps. This article reviews the current state of knowledge about small bowel adenocarcinoma, ileo-anal pouch and rectal cuff cancer, and anal/perianal fistula cancers in IBD patients.

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.

Intussusception in the adult

Intussusception in the adult is an uncommon cause of intestinal obstruction. Seventeen cases were seen at two teaching hospitals over a twenty-year period. A local causative lesion was present in all cases; a malignant tumour was present in two out of seven intussusceptions arising in the small intestine and in seven out of ten arising in the large intestine. More than half the cases had a protracted clinical course prior to diagnosis.

Associations between small intestine cancer and other primary cancers: an international population-based study

Cancer of the small intestine is a rare neoplasm, and its etiology remains poorly understood. Analysis of other primary cancers in individuals with small intestine cancer may help elucidate the causes of this neoplasm and the underlying mechanisms. We included 10,946 cases of first primary small intestine cancer from 13 cancer registries in a pooled analysis. The observed numbers of 44 types of second primary cancer were compared to the expected numbers derived from the age-, gender- and calendar period-specific cancer incidence rates in each registry. We also calculated the standardized incidence ratios (SIR) for small intestine cancer as a second primary after other cancers. There was a 68% overall increase in the risk of a new primary cancer after small intestine carcinoma (SIR = 1.68, 95% confidence interval [CI] = 1.47-1.71), that remained constant over time. The overall SIR was 1.18 (95% CI = 1.05-1.32) after carcinoid, 1.29 (1.01-1.63) after sarcoma, and 1.27 (0.78-1.94) after lymphoma. Significant (p < 0.05) increases were observed for cancers of the oropharynx, colon, rectum, ampulla of Vater, pancreas, corpus uteri, ovary, prostate, kidney, thyroid gland, skin and soft tissue sarcomas. Small intestine cancer as a second primary was increased significantly after all these cancers, except after oropharyngeal and kidney cancers. Although some of the excess may be attributable to overdiagnosis, it is plausible that most additional cases of second primary cancers were clinically relevant and were due to common genetic (e.g., defects in mismatch or other DNA repair pathways) and environmental (e.g., dietary) factors.

Ulcerative jejunoileitis and enteropathy-associated T-cell lymphoma

Ulcerative jejunoileitis and enteropathy-associated T-cell lymphoma are rare conditions described in patients with refractory coeliac disease. Ulcerations affect the small bowel and are unrelated to drugs, ischaemia, infections or other known causes. We describe a female patient with an unclassified enteropathy who experienced several episodes of jejunoileal ulcerations. Several resections of the small bowel segments were necessary. The repetitive ulcerations were either from cytotoxic T cells, the patient developed a T-cell lymphoma, and malignant cells could be detected at the bottom of the ulcers, or from acid-producing cells in areas of gastric metaplasia. Two mechanisms might thus be responsible for the occurrence of repetitive ulceration, and require different treatment strategies. The patient is currently being treated with proton pump inhibitors, oral steroids and parenteral nutrition.

Carcinoma of the small intestine and colon as a complication of Crohn disease: radiologic manifestations

Barium examinations of the large and small bowel were analyzed in six of seven patients who had adenocarcinoma in areas of the intestine affected with Crohn disease; radiographic changes were correlated with clinical, surgical, and pathologic findings. Radiographic examinations were available in five of these patients at the time of diagnosis of tumor. Two of the five patients demonstrated classic radiographic changes associated with carcinoma. In the other three cases, the radiographic changes were atypical for carcinoma and demonstrated progression of disease over time to include more portions of the bowel and presence of fistulas, strictures, and obstruction. The most frequent clinical presentation of adenocarcinoma in these patients was a recrudescence of symptoms after a long quiescent period. In patients with long-standing Crohn disease plus these clinical features and the above radiographic findings, the diagnosis of a coexisting carcinoma should be considered.

A comparative immunohistochemical study of jejunoileal and appendiceal carcinoids. Implications for histogenesis and pathogenesis

BACKGROUND

The purpose of this study was to determine the histogenesis of jejunoileal and appendiceal carcinoids and to ascertain whether this could be useful in further explaining the pathology of these neoplasms.

METHODS

Eight cases each of multiple jejunoileal carcinoids and appendiceal carcinoids together with their respective age-matched and sex-matched controls were stained with silver stains, chromogranin A, serotonin, and S-100. Histomorphometric evaluations of the endocrine cells in the mucosa adjacent to the carcinoids were carried out and compared with the respective controls using the Student's t test.

RESULTS

All the carcinoids from both groups stained for argyrophilia, argentaffinity, chromogranin A, and serotonin. Histomorphometric evaluations showed intraepithelial endocrine cell hyperplasia (IECH) in the jejunoileal carcinoid group (P = 0.007, chromogranin; P = 0.004, serotonin) but not in the appendiceal carcinoid group. On the other hand, subepithelial endocrine cell aggregates that were separate from the main tumor were seen in two cases of appendiceal carcinoids. With S-100, all appendiceal carcinoids showed intrinsic tumor positivity whereas the jejunoileal carcinoids did not.

CONCLUSIONS

The finding of IECH with multiple jejunoileal carcinoids suggests that these carcinoids arise from a field effect. The absence of IECH with appendiceal carcinoids as well as their association with subepithelial endocrine cell aggregates and their intimate relationship with Schwann cell processes suggests that appendiceal carcinoids arise from a more discrete unit, the subepithelial neuroendocrine complex.

Ampullary somatostatinomas and jejunal gastrointestinal stromal tumor in a patient with Von Recklinghausen’s disease

Von Recklinghausen’s disease is an autosomal dominant hereditary disease associated with a wide number of neoplasms. We report a case of a 47-year-old Caucasian male affected by Von Recklinghausen’s disease who developed a malignant somatostatinoma of the papilla major and minor associated with jejunal gastrointestinal stromal tumour with uncertain behaviour. At laparotomy, multiple hepatic metastases were evident. Whipple pancreaticoduodenectomy, jejunal resection, extensive lymphadenectomy and multiple hepatic wedge resections were performed. The patient was alive without recurrence after 24 mo. This is the fourth case reported in the world literature of a patient with Von Recklinghausen’s disease associated with periampullary somatostatinomas and jejunal stromal tumor. In patients with Von Recklinghausen’s disease who complain of gastrointestinal symptoms, a high suspicion index for periampullary endocrine tumours and/or gastrointestinal stromal tumour is required. An aggressive surgical approach seems to give long term survival also in metastatic patients.

Radioprotective effect of captopril on the mouse jejunal mucosa

PURPOSE

Captopril, an inhibitor of angiotensin I converting enzyme, has been shown to modify radiation damage and prevent radiation injury of normal tissue in rats and pigs. The present study was carried out to determine whether captopril would reduce radiation changes in the proximal small bowel in mice.

METHODS AND MATERIALS

Mice were subjected to whole body irradiation with 9 Gy or 15 Gy. Captopril was administered in drinking water at a regimen of 62.5 mg/kg/day (captopril group I) and 125 mg/kg/day (captopril group II), continuously from 7 days before irradiation to the end of each designed experiment. The jejunal damage was evaluated microscopically by crypt count per circumference and by histologic damage grading.

RESULTS

Crypt number in the sham-irradiated control was 133 +/- 6.8/circumference. In both captopril group I and II, crypt numbers and histologic scores were not significantly different from those in the normal group. The 9 Gy and 15 Gy radiation alone groups showed significantly lower crypt counts and histologic scores compared with the sham-irradiated control group (p < 0.05). The groups exposed to 9 Gy radiation plus captopril I and II showed significantly higher crypt counts and lower histologic damage scores on the third day, and lower histologic damage scores on the fifth day compared with the 9 Gy radiation alone group (p < 0.05). The 15 Gy radiation plus captopril I and II groups had significantly higher crypt counts and lower histologic damage scores on the third day than those of the 15 Gy radiation alone group (p < 0.05). All mice of the 15 Gy radiation group succumbed to intestinal radiation death.

CONCLUSION

Our results suggest that captopril provides protection from acute radiation damage to the jejunal mucosa in mice.

Recurrence in jejunal pouch after proximal gastrectomy for early upper gastric cancer

Recently, jejunal pouch reconstruction after proximal gastrectomy has been a common procedure in Japan. However, according to our investigation, there are no reports of recurrence in the jejunal pouch. We experienced a patient with a recurrence in the jejunal pouch after proximal gastrectomy for early upper gastric cancer. In view of the pathological findings and the recurrence site, we suspected an implantation on the staple-line made for the jejunal pouch.

Massive gastrointestinal hemorrhage from AIDS-related Kaposi's sarcoma confined to the small bowel managed with radiation

A > 50% incidence of Kaposi's sarcoma (KS) of the gastrointestinal tract has been seen in acquired immunodeficiency syndrome (AIDS) patients with cutaneous KS. Although gastrointestinal Kaposi's sarcoma (GIKS) is usually asymptomatic, hemorrhages from the oral cavity, esophagus, stomach, and large bowel have occurred in this disease. We describe a patient with acute, massive gastrointestinal hemorrhage from GIKS confined to the small bowel who was treated with chemotherapy, surgery, and radiation. To the best of our knowledge, this is the first reported case of AIDS-related GIKS limited to the small bowel. Although chemotherapy is generally used successfully to palliate diffuse GIKS, we report that radiation was an effective modality that rapidly resulted in resolution of considerable local bleeding and could be used in such cases as an alternative to surgery. Details of this case history, including radiographs, are presented.

Multifocal adenocarcinoma of the proximal small intestine in a patient with celiac sprue

Adenocarcinoma of the small intestine is a known complication of celiac sprue. We report a 63-year-old man with a history of celiac disease who developed anemia, guaiac-positive stools, and jaundice. Five discrete adenocarcinomas of the proximal small intestine were identified over a 9 year period. Endoscopic retrograde cholangiopancreatographic (ERCP) and radiographic evaluation of the small bowel were helpful in diagnosing adenocarcinoma involving the ampulla of Vater and jejunum. This case demonstrates for the first time the multifocal, malignant potential of sprue. It also illustrates the importance of an aggressive, systematic work-up of patients whose course has changed despite dietary restriction.

Widespread hyperplasia induced by transgenic TGFalpha in ApcMin mice is associated with only regional effects on tumorigenesis

Using a mouse predisposed to neoplasia by a germ line mutation in Apc (Apc(Min)), we tested whether induced hyperplasia is sufficient to increase intestinal tumor multiplicity or size in the intestine. We found that hyperplasia in the jejunum correlated with a significant increase in tumor multiplicity. However, tumor multiplicity was unchanged in the hyperplastic colon. This result indicates that even an intestine predisposed to neoplasia can, in certain regions including the colon, accommodate net increased cell growth without developing more neoplasms. Where hyperplasia correlated with increased tumor multiplicity, it did not increase the size or net growth of established tumors. This result suggests that the event linking hyperplasia and neoplasia in the jejunum is tumor establishment. Two novel observations arose in our study: the multiple intestinal neoplasia (Min) mutation partially suppressed both mitosis and transforming growth factor alpha-induced hyperplasia throughout the intestine; and zinc treatment alone increased tumor multiplicity in the duodenum of Min mice.

Coeliac disease, adenocarcinoma of jejunum and in situ squamous carcinoma of oesophagus

The development of both adenocarcinoma of the jejunum and in situ squamous carcinoma of the oesophagus in an adult coeliac patient is described. Good evidence that adenocarcinoma of jejunum occurs more frequently in patients with coeliac disease has recently become available though this association has been suggested for some time. While oesophageal carcinoma has long been associated with coeliac disease, in situ carcinoma of oesophagus has not been previously described in these circumstances. We feel that the risk of this complication, as calculated from published series, warrants a screening programme for oesophageal malignancy in adult coeliacs.

Autoimmune hemolytic anemia associated with postirradiation malignant stromal tumor (leiomyosarcoma) of the jejunum

We describe a patient who presented with autoimmune hemolytic anemia and small bowel obstruction secondary to a malignant stromal tumor (leiomyosarcoma) of the jejunum, 25 years postchemotherapy and radiation treatment for stage IIA Hodgkin's disease. The patient was treated with corticosteroid therapy and surgical resection of the jejunal tumor. We conclude that autoimmune hemolytic anemia may be an unusual presentation for postirradiation sarcoma.

Mucosa-associated lymphoid tissue (MALT) lymphoma combined with tuberculous enteritis at the same site in the jejunum

Mucosa-associated lymphoid tissue (MALT) lymphoma is derived from the marginal zone B-cell compartment and can be found at a wide variety of extranodal sites, most frequently at the gastrointestinal site. Recent clinicopathologic studies suggest a relationship between MALT lymphoma and chronic inflammatory disorders, such as Helicobacter pylori infection in the stomach or autoimmune disorders, such as Sjögren's syndrome in the salivary glands. Primary gastrointestinal MALT lymphomas most commonly arise in the stomach and less often in the small and large intestine. Recently we experienced a case who had MALT lymphoma combined with tuberculous enteritis at the same site (jejunum) confirmed by exploratory laparotomy. We suspect that there may be some relationship between MALT lymphoma and chronic inflammatory process of mycobacterial tuberculous enteritis.

Chemotherapy in Small Bowel Adenocarcinoma Associated with Celiac Disease: A Report of Three Cases

Tumors of the small intestine are rare and usually occur in association with genetic disease and chronic intestinal inflammation. We report three cases of small bowel adenocarcinoma in patients affected by celiac disease who received a safe chemotherapy regimen (FOLFOX IV or LV5FU2) after tumor resection.

[Gastrointestinal stromal tumours (GIST) of the jejunum in a patient with neurofibromatosis type 1 (von Recklingshausen's disease)]

CASE REPORT

A 72-year-old female patient with known neurofibromatosis type 1 was admitted to the hospital with symptomatic anaemia and a history of melaena. Upper and lower endoscopy did not show any signs of bleeding. Ultrasound and computed tomography revealed an abdominal mass. The histological analysis of a US-guided puncture showed a mesenchymal tumour with spindle-shaped appearance. Laparotomy revealed two jejunal tumours which could be classified as gastrointestinal stromal tumours (GIST) by immunohistochemistry.

CONCLUSION

Patients with neurofibromatosis type 1 have an increased risk of developing gastrointestinal tumours including rare types such as GIST. Because the localisation in the small intestine by conventional endoscopy can be difficult, further diagnostic means such as ultrasound, computed tomography or possibly capsule endoscopy should be considered.