Primary Adenocarcinoma of an Ileostomy in Crohn's Disease

Primary adenocarcinoma of an ileostomy in a Crohn patient: a case report

Proctocolectomy with ileostomy is an established surgical treatment in patients with inflammatory bowel disease. Adenocarcinoma of an ileostomy is a rare complication in long-term ileostomies. We present the case of a 69-year-old man who presented with bloody stools and a tumour at the ileostomy site 37 years after ileostomy formation. Biopsies confirmed the presence of an adenocarcinoma. Imaging did not show any metastases or advanced local infiltration. A resection of the ileostomy with a broad safety margin and reimplantation of a new Ileostomy was performed. At 18-month follow-up, there is no sign of recurrence. Ileostomy adenocarcinoma in a Crohn's disease patient is rare with only four cases described in literature. An en-bloc resection and relocation of the ileostomy is the recommended treatment. Education of patients and healthcare professionals on this long-term ileostomy complication is vital for the early diagnosis and treatment.

A systematic review of primary ileostomy site malignancies

BACKGROUND

This paper aimed to elucidate the etiologies of all primary ileostomy site malignancies published in the literature.

METHODS

A review of the literature was conducted following PRISMA guidelines by querying PubMed, Global Health, and Web of Science for articles published before November 2020. Search criteria contained broad terminology for ileostomy site neoplasms without language, date, or publication limitations. A full-text review of the abstracts confirmed primary malignant pathologies and was evaluated for study inclusion.

RESULTS

Literature search discovered 858 publications, with 76 meeting eligibility criteria. The final sample contained 91 patients, with equal males and females. The mean age of patients with ileostomy site malignancy was 62.0 ± 12.2, with an average ileostomy age of 29.4 ± 12.4. The most common indications for ileostomy creation were inflammatory bowel disease (IBD) (73.6%) and familial adenomatous polyposis (FAP) (20.9%). There was a total of eight ileostomy malignant pathologies reported, with adenocarcinoma being the most common (76.9%), followed by squamous cell carcinoma (SCC) (11.0%). Adenocarcinoma was diagnosed at a younger age than SCC (59.7 vs. 72.3) and developed over a shorter time (28.8 vs. 37.0). Patients with FAP almost exclusively developed adenocarcinoma (94.4%) at a younger stoma age (25.8 vs. 31.4) than those with IBD who developed seven diverse pathologies. With a median follow-up of 0.75 years, four patients developed disease recurrence and received oncologic resection of their cancer less often than the 55 negative patients (p = 0.04).

CONCLUSION

Ileostomy site malignancies are late-appearing complications that require curative surgery. Their presentation is associated with ileostomy duration and creation indication, such as FAP or IBD. We recommend screening at a stoma age ≥ 20 or patient age ≥ 50 for patients with FAP, while stoma age ≥ 25 or patient age ≥ 60 for IBD patients.

Ileostomy adenocarcinoma in Crohn's disease

PURPOSE

Adenocarcinoma of an ileostomy is rare with less than 50 reported cases in the literature. Ileostomy adenocarcinoma in Crohn's disease is even more rare, with only 4 reported cases. We present a case of ileostomy adenocarcinoma with lymph node metastasis occurring 51 years after proctocolectomy and Brooke ileostomy in a female with Crohn's disease. This case represents the longest documented interval between Brooke ileostomy and ileostomy adenocarcinoma diagnosis and summarizes clinical signs that warrant biopsy of a peristomal plaque to differentiate adenocarcinoma from clinical mimics such as pyoderma gangrenosum (PG).

METHODS

Clinical, histological, and surgical patient data were reviewed. A literature review of adenocarcinoma arising from ileostomy sites was performed.

RESULTS

We report a case of a 67-year-old woman that presented with a peristomal skin lesion developing over 10 years. After multidisciplinary discussion between gastroenterology, colorectal surgery, and dermatology, ileoscopy revealed moderately differentiated, invasive adenocarcinoma arising from the ileostomy site. Wide surgical excision and en bloc resection of the peristomal lesions were performed, and the final pathology revealed lymph node metastasis. The patient is currently undergoing adjuvant chemotherapy.

CONCLUSIONS

Clinicians should maintain a high level of suspicion when ileostomy patients develop a peristomal lesion.