Intraoperative random biopsies of strictureplasty sites can detect early small-bowel adenocarcinoma in patients with Crohn's disease

Case series of small bowel adenocarcinoma associated with Crohn's disease

Long-standing Crohn's disease (CD) is well known to be associated with gastrointestinal malignancies. Patients with CD have a higher risk of developing small bowel adenocarcinoma (SBA) compared to healthy individuals. However, CD-associated SBA is not as common as colorectal cancer. While patients with CD often present with complicated stricture lesions in the small intestine, it is difficult to confirm all lesions by endoscopy. There is still no consensus on the surgical treatment of small bowel strictures with suspected CD-associated SBA. We report a case of small bowel high-grade dysplasia and two cases with advanced SBA. Case 1 involved a 53-year-old man whose high-grade dysplastic lesion of the small intestine was discovered incidentally postoperatively and successfully resected curatively. Case 2 was that of a 60-year-old man and Case 3 involved a 69-year-old man. Both patients had multiple small bowel stenotic lesions and were diagnosed with advanced small bowel cancer during follow-up. In conclusion, for patients with long-standing Crohn's disease who are refractory to treatment or have stenotic lesions, surgical resection should be considered as a treatment option with CD-associated SBA in consideration.

Focal loss of mural stratification as a radiological predictor for small bowel adenocarcinoma in Crohn's disease

AIM

Patients with Crohn's disease (CD) are at higher risk of small bowel adenocarcinoma (SBA). We aimed to identify radiological predictors of SBA in CD.

METHODS

We conducted a retrospective case-control study at two tertiary inflammatory bowel disease centers and identified CD patients diagnosed with SBA between 2003 and 2019. Patients were matched with up to four controls. Pre-operative imaging (magnetic resonance imaging (MRI) or computed tomography (CT)) were reviewed by three gastrointestinal radiologists.

RESULTS

Nineteen patients with CD-associated SBA with a mean age of 54.9 and 32 matched controls were included. Mean length of small bowel involvement was 216 (± 188) mm in the SBA group versus 156 (± 167) mm in the control group (p = 0.76). Only 11.8 % of cases had a diagnosis of SBA made preoperatively. In univariate analysis, focal loss of mural stratification (odds ratio [OR], 11; 95%CI, 2.43-49.5, p = 0.002), and wall thickening (OR, 1.32; 95%CI, 1.05-1.66, p = 0.02) were significantly associated with SBA. After adjustment, focal loss of mural stratification was the only independent risk factor (OR, 11; 95 % CI, 2.43-49.5, p = 0.002).

CONCLUSIONS

Focal loss of mural stratification was identified as a predictor of CD-associated SBA, which should be described in imaging reports and further validated.

Small bowel adenocarcinoma in Crohn's disease: a systematic review and meta-analysis of the prevalence, manifestation, histopathology, and outcomes

BACKGROUND AND AIMS

Small bowel adenocarcinoma (SBA) is a rare neoplasm that is associated with Crohn's disease (CD). This study aims to quantify the prevalence of CD-SBA, review the current evidence of histopathology and molecular analysis findings, and identify the clinical presentation and outcomes of CD-SBA.

METHODS

Electronic databases Medline and Embase were searched for articles describing SBA in inflammatory bowel disease patients. The histopathology, molecular analysis findings, clinical presentation, prevalence, and outcomes of CD-SBA were extracted, and results were pooled with random effects.

RESULTS

In total, 33 articles were included in the analysis. Prevalence of SBA was 1.15 (CI: 0.31-2.33) per 1000 CD patients. Only 11% (CI: 0.04-0.21) of CD-SBA patients had observable radiological features. CD-SBA was most commonly found in the ileum (84%), diagnosed at stage 2 (36%), with main presenting complaints including obstruction, weight loss, and abdominal pain. Significant histopathological findings included adjacent epithelial dysplasia, and an equal distribution of well-differentiated (49%) and poorly differentiated subtypes (46%). Most prevalent genetic mutation was KRAS mutation (18%), followed by mismatch repair deficiency (9.7%). The 5-year overall survival for CD-SBA patients was 29% (CI: 0.18-0.41), and 33% (CI: 0.26-0.41) for de novo SBA. No statistically significant increase in risk for CD-SBA was noted for treatment with thiopurines, steroids, and 5-ASA.

CONCLUSION

Our meta-analysis found the prevalence of CD-SBA to be 1.15 per 1000 CD patients. The 5-year overall survival for CD-SBA was poor. The presenting symptoms were non-specific, and therefore the diagnosis requires a high index of suspicion.