Asymptomatic ileal adenocarcinoma in the setting of undiagnosed Crohn’s disease

A patient with colitis-associated cancer who developed clinically manifest Crohn's disease only after surgery

Background

Patients with prolonged inflammatory bowel disease have a greater risk of colorectal cancer, known as colitis-associated cancer. Here we describe an unusual case of colitis-associated cancer.

Case presentation

The subject is a 41-year-old male who has not presented digestive symptoms and has an appreciable medical history. He consulted a nearby doctor with left flank pain. A colonoscopy revealed a lateral spreading tumor (granular-type) in his descending colon. With a clinical diagnosis of cancer, D3 left hemicolectomy was performed and a small intestine stoma was constructed. The pathological diagnosis of the tumor was mucinous adenocarcinoma, pT4a(SE), pN2a, which was associated with dysplasia in the surface area. Post-operative ileus was prolonged and the endoscopic examination revealed longitudinal ulcers in the ileum. These ulcers responded quite well to the administration of infliximab, confirming the final diagnosis of Crohn’s disease. Pathological re-examination revealed that the tumor was dysplasia-associated type, and another dysplasia was confirmed near the tumor. Furthermore, mural scars and sporadic lymphoid aggregates were noted in the colon tissues, which suggested pre-existing Crohn’s disease. The patient died of peritoneal dissemination of cancer on day 207 after surgery.

Conclusion

The present case was diagnosed as colitis-associated cancer with clinically latent Crohn’s disease, who developed clinically manifest Crohn’s disease only after surgery. Our review of literature revealed no cases comparable to ours.

Eighteen Month Interval Growth of Terminal Ileal Primary Adenocarcinoma: A Consideration for Current Screening Guidelines

Primary adenocarcinoma of the small intestine comprises one of the rarest gastrointestinal malignancies. Further, the terminal ileum is very seldom implicated. This entity occurs sporadically and evades traditional colonoscopic evaluation in which the terminal ileum is not visualized. Herein, a case of interval development of primary terminal ileal adenocarcinoma over a 2-year period is reported as followed by direct endoscopic and colonoscopic visualization. This case demonstrates cecal involvement not found on initial evaluation without the provision of terminal ileum intubation. Relevant guidelines regarding the evaluation of the terminal ileum in routine colonoscopy are reviewed.

Silent ulcerative colitis adjacent to a regular sigmoid adenocarcinoma

There have been studies trying to elucidate the large spectrum and the variety of inflammatory bowel disease (IBD)-related colorectal cancer manifestations and natural history. A 57-year-old male patient underwent a regular screening colonoscopy in our department, which revealed a flat ulcerated mass in the sigmoid whereas the remaining bowel was normal on endoscopic appearance. Biopsies from the mass were compatible with sigmoid adenocarcinoma and the patient underwent left hemicolectomy. Pathology examination of the resected specimen also diagnosed ulcerative colitis adjacent to cancer. The otherwise healthy patient denied any history that could be related to IBD symptoms. Patient was started on 1.6 g of mesalazine and was advised to adhere to an endoscopic surveillance program. This case points toward a need for a more thorough understanding of the natural history of colorectal cancer in IBD to set clinically meaningful guidelines.