Rectal mucosal dysplasia in Crohn's disease

Colon Cancer in Patients with Crohn’s Disease and Diabetes Mellitus

Introduction: Diabetes mellitus and colorectal cancer are diseases with an increasing impact on the population. Colorectal cancer is a well-recognized complication of inflammatory bowel diseases, such as ulcerative colitis and Crohn’s colitis. Here we describe an unusual case of diabetes mellitus, Crohn`s colitis-associated cancer.

Case report: We report the case of a 49-year-old woman, known with Crohn's disease and diabetes, who developed a transverse colon adenocarcinoma associated with multiple outbreaks of high-grade or low-grade intraepithelial dysplasia/neoplasia, for which a subtotal proctocolectomy with ileorecto-anastomosis with “J” pouch it was made.

Conclusions: The risk of colonic carcinoma in Crohn's disease is increasing. An association of colorectal cancer with diabet mellitus and inflammatory bowel disease has been established. From diagnosis to treatment the management of these cases can be difficult and challenging.

Clinicopathological and prognostic evaluations of anorectal cancer after fecal diversion for patients with Crohn's disease

PURPOSE

Colorectum diversion with a proximal stoma is often the preferred surgical approach in patients with Crohn's disease-related anorectal lesions or refractory colitis. To date, few studies have assessed the incidence and prognosis of cancer in the diverted anorectal segments. This study aimed to evaluate the clinical characteristics and prognosis of anorectal cancer associated with Crohn's disease following fecal diversion.

METHODS

This was a retrospective study based on medical records of patients diagnosed with Crohn's disease between 1999 and 2020. It was conducted at Yokohama Municipal Citizen's Hospital. Patients diagnosed with anorectal cancer following fecal diversion were identified, and their prognosis was the primary outcome measure.

RESULTS

Among 1615 patients, 232 patients (14%) underwent colorectum diversion. Of those 232 patients, 11 were diagnosed with anorectal cancer following fecal diversion, ten were diagnosed with advanced cancer, 10 underwent abdominoperineal resection, and eight died. 1 could not undergo resection due to multiple lung metastasis and died. The overall five-year survival rate in patients diagnosed with anorectal cancer following fecal diversion was 20%.

CONCLUSION

Crohn's disease-associated anorectal cancer following fecal diversion was challenging to diagnose early, and patients had a poor prognosis even after curative resection. Early abdominoperineal resection may be considered for patients with Crohn's disease who cannot benefit from cancer screening and surveillance due to difficulty accessing the anorectal stricture via endoscopy.

Challenges in Crohn's Disease Management after Gastrointestinal Cancer Diagnosis

Simple Summary

Crohn’s disease (CD) is a chronic inflammatory bowel disease affecting both young and elderly patients, involving the entire gastrointestinal tract from the mouth to anus. The chronic transmural inflammation can lead to several complications, among which gastrointestinal cancers represent one of the most life-threatening, with a higher risk of onset as compared to the general population. Moreover, diagnostic and therapeutic strategies in this subset of patients still represent a significant challenge for physicians. Thus, the aim of this review is to provide a comprehensive overview of the current evidence for an adequate diagnostic pathway and medical and surgical management of CD patients after gastrointestinal cancer onset.

Abstract

Crohn’s disease (CD) is a chronic inflammatory bowel disease with a progressive course, potentially affecting the entire gastrointestinal tract from mouth to anus. Several studies have shown an increased risk of both intestinal and extra-intestinal cancer in patients with CD, due to long-standing transmural inflammation and damage accumulation. The similarity of symptoms among CD, its related complications and the de novo onset of gastrointestinal cancer raises difficulties in the differential diagnosis. In addition, once a cancer diagnosis in CD patients is made, selecting the appropriate treatment can be particularly challenging. Indeed, both surgical and oncological treatments are not always the same as that of the general population, due to the inflammatory context of the gastrointestinal tract and the potential exacerbation of gastrointestinal symptoms of patients with CD; moreover, the overlap of the neoplastic disease could lead to adjustments in the pharmacological treatment of the underlying CD, especially with regard to immunosuppressive drugs. For these reasons, a case-by-case analysis in a multidisciplinary approach is often appropriate for the best diagnostic and therapeutic evaluation of patients with CD after gastrointestinal cancer onset.

Dysplasia associated with Crohn's colitis: segmental colectomy or more extended resection?

BACKGROUND AND OBJECTIVE

There is limited data on the appropriate management of dysplasia in Crohn's colitis. An evidence-based surgical strategy is provided.

METHODS

Patients with a pathologic diagnosis of dysplasia in Crohn's colitis from 1987 to 2009 were identified. Patients were classified by dysplasia grade (low grade or LGD, high grade or HGD). Clinical, endoscopic, operative, and pathologic data were retrieved. Factors associated with a final cancer diagnosis were analyzed. Survival data on patients undergoing limited versus radical resection for cancer and HGD was compared.

RESULTS

From 1987 to 2009, 50 patients underwent a colectomy for Crohn's colitis-associated dysplasia. The predictive value of HGD for a final HGD or cancer diagnosis was 73%. The predictive value of LGD on biopsy for HGD in the colectomy was 36%. Sixteen patients (44%) who underwent a total proctocolectomy (TPC) or subtotal colectomy (STC) had multifocal dysplasia. Four of 10 (40%) cancer patients had evidence of dysplasia remote from cancer site on pathologic examination. During follow-up, there were 3 cancer-related deaths. One patient died of metachronous cancer after STC.

CONCLUSIONS

The findings confirm the risk of cancer in patients with CD dysplasia. Because of the multifocal nature of dysplasia in Crohn's colitis, TPC is recommended in good-risk patients. In specific circumstances, such as poor-risk patients especially in the setting of LGD, close endoscopic surveillance or alternatively segmental or STC with close postoperative endoscopic surveillance, depending upon the individual circumstance, may be discussed.

Colorectal carcinoma and preceding fistula in Crohn's disease

BACKGROUND

An increased risk for intestinal carcinoma is known in Crohn's disease, but there are also several reports on patients with perianal fistula and later carcinoma at this location - so to call fistula associated carcinoma.

METHODS

We retrospectively investigated 591 patients with CD who underwent abdominal surgery during the last 10 years (1997-2006) and found seven patients (5 male, 2 female, median age: 53 years (range 37-74)) with colorectal cancer (Dukes A-C), four of them (57%) with fistula associated CRC. These seven patients with CRC were matched 1:3 to randomly selected Crohn's patients based on age. The medical records of these 21 patients (11 with perianal fistula (52%)) were evaluated with respect to duration and pattern of intestinal involvement of CD, fistula history, intestinal surgery, perianal surgery, prior immunosuppressive and 5-ASA derivative intake.

RESULTS

Colorectal cancer was significantly (p=0.048) associated with longstanding anorectal fistula (median=11 years (range 0-28 years)) in the CRC group compared to the matched Crohn's patients (median=1 year (range 0-6 years)). Earlier colonic surgery seemed to protect from later malignancy (p=0.036). No significant symptoms preceded rectal carcinoma, except for new blood drainage from fistula in 2 patients. Two patients underwent ileocolonoscopy within 1 year before the diagnosis of malignancy and 2 patients underwent MRI of the pelvic region within 4 months.

CONCLUSION

Colorectal carcinoma is frequently associated with the presence of longstanding anorectal fistula.

Colonic adenocarcinoma revealing Crohn's disease: a case report

INTRODUCTION

There is growing evidence from epidemiological studies and clinicopathological data obtained from case reports that Crohn's disease is associated with an increased risk of carcinoma of the large bowel.

CASE PRESENTATION

A 70-year-old Arabic African man with undiagnosed Crohn's disease presented with acute abdominal obstruction due to an occlusive carcinoma of the sigmoid. At laparotomy, the colonic tumor was excised with continuity restored by end-to-end anastomosis.

CONCLUSION

The risk of colonic carcinoma in Crohn's disease is increasing. Several case reports actually support the possibility that a genuine association between these two conditions exists.

Anal and rectal cancer in Crohn's disease

Several epidemiological studies have been published regarding the risk of Crohn's disease- associated colorectal cancer. The findings are, however, contradictory and it has been particularly difficult to obtain indisputable information on the incidence of cancer limited to the rectum and the anus. During 1987-2000 rectal or anal cancer was diagnosed in 335 patients in Sweden (153 males, 182 females). In other words, approximately 3 Crohn patients per million inhabitants were diagnosed with rectal or anal cancer every year during that time period which is 1% of the total number of cases. At diagnosis of cancer 36% were aged below 50 years and 58% below 60 years. Corresponding figures for all cases of anal and rectal cancer were 5% and 18%, respectively. Present knowledge from the literature implies that there is an increased risk of rectal and anal cancer only in Crohn's disease patients with severe proctitis or severe chronic perianal disease. However, the rectal remnant must also be considered a risk factor. Multimodal treatment is similar to that in sporadic cancer but proctectomy and total or partial colectomy is added depending on the extent of the Crohn's disease. The outcome is the same as in sporadic cancer at a corresponding stage but the prognosis is often poor due to the advanced stage of cancer at diagnosis. We suggest that six high-risk groups should be recommended annual surveillance after a duration of Crohn's disease of 15 years including extensive colitis, chronic severe anorectal disease, rectal remnant, strictures, bypassed segments and sclerosing cholangitis.

Adenocarcinoma of the rectum with various grades of atypia in association with Crohn's disease: a case report and immunohistochemistry of p53 and Ki-67

A case of adenocarcinoma of the rectum in a 41-year-old woman, in association with Crohn's disease is presented. The patient had suffered diarrhea and constipation, and Crohn's disease was suspected. Although the endoscopy did not reveal the presence of any tumors, biopsy specimens demonstrated adenocarcinoma. A Miles' operation was performed. The adenocarcinoma was composed of various grades of atypia and had invaded the non-peritonealized perirectal tissues. The infiltration of lymphocytes and plasma cells was moderate at the perimeter of the carcinoma and mild in the distant regions. Epithelioid cell granulomas were found. The p53 labeling index (LI) increased with the grade of atypia over the entire length of the carcinomatous gland. In carcinomas with high grade atypia, the p53 LI was high in both the upper and the lower halves of the gland. In carcinomas with low or moderate grade atypia however, the p53 LI was high in the lower half and low in the upper half of the gland. The Ki-67 LI over the entire gland was higher in carcinomas with high grade atypia than in carcinomas with low or moderate grade atypia.

Intestinal adenocarcinoma in Crohn's disease: a report of 30 cases with a focus on coexisting dysplasia

There are relatively few reports that detail the types of intestinal adenocarcinoma complicating Crohn's disease and examine associated epithelial dysplasia. We determined the prevalence, grade, and type of dysplasia found adjacent to and distant from Crohn's-related adenocarcinomas. Thirty cases of resected Crohn's-related adenocarcinoma were reviewed, and histologic type, degree of differentiation, TNM stage, and the presence or absence, grade, and location of dysplasia were recorded. Most of the patients were male (70%). The median ages at diagnosis of Crohn's disease and adenocarcinoma were 34 and 49 years, respectively. The extent of Crohn's disease included ileocolitis in 21 patients, only colonic disease in six, and only small bowel disease in three. In most cases (67%), carcinoma was found incidentally at surgery. All carcinomas arose in areas involved by Crohn's disease. Eight (27%) adenocarcinomas arose in the small bowel, and 22 (73%) arose in the colon, including two in out-of-circuit rectums. Most carcinomas (63%) were poorly differentiated. Dysplasia was found adjacent to the carcinoma in 26 (87%) cases. Of the colorectal carcinomas, 19 (86%) had adjacent dysplasia, and nine (41%) had distant dysplasia. In conclusion, most cases of Crohn's-related intestinal adenocarcinoma have dysplasia in adjacent mucosa, and 41% of those arising in the colorectum have distant dysplasia, supporting a dysplasia-carcinoma sequence in Crohn's disease.

Colorectal adenocarcinoma in Crohn's disease: a retrospective histologic study

PURPOSE

The aim of this study was to review all histopathologic sections from surgical specimens with inflammatory bowel disease and colorectal carcinoma filed at this hospital between 1951 and 1996.

METHOD

A total of 40 surgical (n = 39) or autopsy (n = 1) colon or colorectal specimens were reviewed. Internationally accepted histologic criteria were strictly applied to differentiate Crohn's disease (CD), ulcerative colitis (UC), and indeterminate colitis (IC).

RESULTS

Of the 40 specimens with inflammatory bowel disease and carcinoma, 22 (55 percent) had CD, 16 (40 percent) had UC, and the remaining 2 (5 percent) had IC. Males accounted for 72.7 percent or 16 of the 22 patients with colorectal carcinoma in CD and for 68.7 percent or 11 of the 16 patients with carcinoma in UC. Both patients with IC and carcinoma were males. The median age of patients at diagnosis was as follows: CD, 20 (range, 7-68) years; UC, 23 (range, 5-21) years. In IC, the age was 61 and 81 years, respectively. The median disease duration (before detection of colorectal cancer) was as follows: CD, 18.5 (range, 1-45) years; UC, 19 (range, 6-38) years. For cases with IC, it was 13 and 19 years, respectively. Median age of patients at cancer diagnosis was as follows: CD, 48 (range, 21-78) years; UC, 49 (range, 21-81) years. Ages at cancer diagnosis in IC were 68 and 81 years. Colorectal carcinoma tend to develop among relatively young patients with CD and UC. Mucinous adenocarcinomas accounted for approximately one-third of the carcinomas affecting CD. Thirty percent of old specimens (before the end of 1982) had in fact carcinoma complicating CD and not UC (the latter being the diagnosis appearing in old pathologic reports). During a time lapse of 38 years (i.e., between 1951 and 1989), only 11 cases of colorectal CD with carcinoma (i.e., 0.2 cases/year) were found, but as many as 11 during the past 6.5 years (i.e., 1.7 cases/year) have been diagnosed. Only 42.3 percent (11/26) of cases with colorectal inflammatory bowel disease and carcinoma operated on between 1951 and the end of 1989 had Crohn's colitis but as many as 78.6 percent (11/14) of those operated on between 1990 and May 1996 had Crohn's colitis. Review of the literature indicated that 64.8 percent or 191 of the 295 cases of colorectal carcinomas in CD so far reported occurred in the past 6.5 years. It would seem as if the risk of colorectal carcinoma in Crohn's colitis has increased in later years.

CONCLUSIONS

1) Reports on cancer frequency in UC based on old histopathologic records should be subjected to critical histologic re-evaluation; 2) carcinoma in Crohn's colitis has increased at this hospital, particularly since 1990; 3) the surveillance program strategy used in patients with long-standing UC at this hospital should also embrace patients with Crohn's colitis.

Development of mucinous adenocarcinoma in chronic Crohn's disease fistulae without luminal involvement

A patient with Crohn's disease who developed mucinous adenocarcinoma in chronic fistulae is reported. Malignancy may complicate chronic nonhealing Crohn's sinus tracts and fistulae, even with no mucosal involvement by carcinoma. Persistent non-remitting perianal induration and pain should alert the physician to the possibility of underlying malignancy. Prompt examination under anesthesia and biopsy or fine-needle aspiration may facilitate diagnosis and therapy of the carcinoma at an early stage.

Dysplasia and early carcinoma in inflammatory bowel disease and colorectal adenomas

The control of colorectal cancer is currently dependent on early detection, and its prevention requires the recognition and treatment of its precursor lesions. The adenoma has been established as the precursor of colorectal carcinoma in the general population. Among patients with inflammatory bowel disease (IBD), dysplasia is associated with, and precedes, invasive carcinoma. In this section criteria are described for the histological detection of preinvasive and early invasive neoplasia in the large intestine of patients with and without IBD. The therapeutic implications of these diagnoses are stressed. A brief review of subcellular changes, including genetic alterations, in colorectal neoplasia is included.

Similarity of colorectal cancer in Crohn's disease and ulcerative colitis: implications for carcinogenesis and prevention

Colorectal cancer is the most frequent malignant complication in patients with inflammatory bowel disease. Eighty patients with colorectal cancer complicating Crohn's disease (CD) or ulcerative colitis (UC) with median ages at diagnosis of colorectal cancer of 54.5 years and 43.0 years respectively were studied. The median duration of disease to the diagnosis of cancer was long (CD 15 years; UC 18 years). Most cancers developed after more than eight years of disease (CD 75%; UC 90%). Patients with multiple carcinomas at diagnosis were equally common (CD 11%; UC 12%). Carcinoma occurred in the area of macroscopic disease in most patients (CD 85%; UC 100%). Mucinous and signet ring histological features were equally common (CD 29%; UC 21%). Dysplasia was present with similar frequency in both diseases (CD 73%; UC 79%). The overall five year survival rates were also similar (CD 46%; UC 50%). These findings show that carcinomas complicating CD and UC have strikingly similar clinicopathological features and suggest that a common underlying process, such as chronic inflammation, maybe important in the pathogenesis of colorectal carcinoma.

Lower gastrointestinal malignancy in Crohn's disease

An increased incidence of carcinoma of the small bowel and colon has been described in patients with Crohn's disease. Tumours arising in the rectum and anus are reported less often. Between 1940 and 1992, of some 2500 patients with Crohn's disease seen at this hospital, 15 are known to have developed carcinoma of the lower gastrointestinal tract. Malignancy occurred in the colon in two patients, in the upper two thirds of rectum in one, in the lower third of rectum in seven, and in the anus in five. The 12 patients with carcinoma arising in the anus or lower rectum had longstanding severe anorectal Crohn's disease, which included a stricture in four, fistula in four, proctitis in one, abscess in two, and enlarged anal skin tags in one. The development of malignancy in patients with Crohn's disease may apply particularly to those with chronic complicated anorectal disease.

Crohn's disease of the colon, rectum, and anus

The varied presentations and complexities of Crohn's disease involving the colon, rectum, and anus mandate decisions that can challenge even the most experienced surgeon. Symptomatic large-bowel disease, with its number of operative indications, is often amenable to resection that maintains intestinal continuity with acceptable rates of recurrence. Disease of the anus, occurring with or without proximal disease, typically is treated in a conservative manner, although occasional definitive treatment may yield improved results. As Crohn's disease is recognized as incurable, the treatment options discussed focus on the amelioration of symptoms while optimizing function without risking excessive morbidity.

Rabbit gut permeability in response to histamine chloramines and chemotactic peptide

Granulocyte-derived chlorinated amines and bacterial formyl peptides are thought to enhance epithelial permeability. In the current study, gut permeability to [51Cr]ethylenediaminetetraacetic acid (EDTA) was monitored in response to luminal formyl-methionyl-leucyl-phenylalanine (fMLP) and histamine monochloramine and dichloramine. Responses were determined in rabbits during states of basal and elevated permeability. Luminal fMLP had minimal effects of gut permeability in control and injured states. Histamine monochloramine or dichloramine enhanced epithelial permeability under basal conditions; this effect was exaggerated by a pre-existing injury. Both histamine monochloramine and dichloramine retained full histamine agonist properties, and a combination of antioxidant and antihistamine therapy was required to block this increase in gut permeability. Whereas histamine chloramines caused a dose-dependent cytotoxicity in rat-cultured enterocytes, marked histological changes to the mucosa were not evident, nor were mucosal glutathione levels depleted. As histamine chloramines retain the histaminergic and oxidizing potential of their precursors, they represent a unique form of inflammatory mediator, although their highly reactive nature precludes in vivo confirmation of their formation.

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.

DNA aneuploidy in Crohn's disease and ulcerative colitis: results of a comparative flow cytometric study

DNA ploidy and S-phase fractions were assessed by flow cytometry in colonic biopsy specimens from 28 patients with ulcerative colitis and 51 with Crohn's disease. Whereas only diploid DNA histograms were found in Crohn's disease and control subjects, three patients with ulcerative colitis exhibited DNA aneuploidy. In one case, aneuploidy was associated with low grade dysplasia. S-phase fractions were higher in ulcerative colitis (mean (SD) 17.8 (7.7)%) than in Crohn's disease (13.1 (4.6)%) or control subjects (14.2 (4.6)%), but did not correlate with either disease activity or duration in any group. In this study, aneuploidy was associated exclusively with ulcerative colitis, even in the absence of dysplasia. In view of the epidemiological differences in malignant colonic transformation between ulcerative colitis and Crohn's disease, this study suggests that flow cytometry may help to identify individuals with an increased cancer risk in ulcerative colitis.

Potential role of histamine monochloramine in a rabbit model of ileitis

Histamine chloramines, derived from the chlorination of histamine by granulocyte-derived oxidants, are potential mediators of intestinal injury and dysfunction in states of atopy or inflammation. We assessed the ability of histamine monochloramine to increase epithelial permeability in rabbit distal small intestine and determined whether the conditions for histamine chloramine formation are favorable in a rabbit model of ileitis. Epithelial permeability, quantified by the blood-to-lumen clearance of 51Cr-labeled ethylenediaminetetraacetic acid, was enhanced by luminal perfusion with either histamine or histamine monochloramine (10 microM), although the latter was twice as effective (p less than 0.05). In a rabbit model of ileitis induced by a luminal solution of acetic acid (200 mM) and casein (10 mg/ml) there was a marked increase in epithelial permeability and in the release into the lumen of histamine, myeloperoxidase, 6-keto-prostaglandin F1 alpha and protein. These results suggest that the conditions are favorable for histamine chloramine formation and that histamine and histamine chloramine may impair the integrity of the epithelial barrier.