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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_713_Библиотеки_им_академика_М_И_Перельмана.pdf
14 Intestinal Cancer inCrohn’s Disease
291
14.2 Granulomatous Colitis withCancer
Clinical Presentation A 21-year-old woman with a 13-year history of colitis. This
patient is moderately symptomatic requiring 30mg of prednisone daily to control
her symptoms. Recent colonoscopy showed an area of dysplasia in the sigmoid colon.
Diagnostic Studies Colonoscopy revealed universal colitis with sigmoid lesion
(see Fig.14.2b).
Surgical Treatment At surgery, the patient had universal colitis with Crohn’s dis-
ease of the terminal ileum and an indurated area in the sigmoid colon. She underwent a subtotal colectomy and ileostomy (see Fig.14.2a).
Pathology Active Crohn’s ileocolitis with well-differentiated adenocarcinoma of
the sigmoid colon invading the serosa. The surrounding mucosa shows severe dysplasia. Forty-eight lymph nodes are negative for tumor.
Follow-Up She did well after surgery. She completed a course of chemotherapy
and 1year later underwent completion proctectomy with abdominoperineal resection of the rectum.
Comment This patient was young at the age of diagnosis of colon cancer but
already had a 13-year history of colitis. Biopsies of the area with a polypoid lesion
in the sigmoid colon showed severe dysplasia. The malignant lesion was not seen
until the time of surgery when a small area of induration in the sigmoid colon was
palpated and biopsy conrmed the presence of a small deeply invasive carcinoma.
The area with severe dysplasia in this patient was a marker of high cancer risk and
was adjacent to an area of invasive cancer, which was not visible on surveillance
colonoscopy (Fig.14.2).
Sigmoid colo
Cancer
s
Ileitis
292
T. M. Heimann and R. J. Kurtz
a
n
Dysplasia
b
Fig. 14.2 Granulomatous colitis with cancer
Crohn’s coliti
Cancer
14 Intestinal Cancer inCrohn’s Disease
293
14.3 Recurrent Ileocolitis withCancer
Clinical Presentation A 59-year-old woman with a 40-year history of Crohn’s
colitis. She had a previous ileocolic resection for ileocolitis at age 17 and now
comes in with a recent onset of anemia and left lower quadrant pain.
Diagnostic Studies Colonoscopy showed an adenocarcinoma in the descending
colon. No evidence of metastatic disease on the CT scan (see Fig.14.3c).
Surgical Treatment This patient underwent a proctocolectomy with Brooke ileos-
tomy (see Fig.14.3a, b).
Pathology Inactive Crohn’s ileocolitis with adenocarcinoma of the descending
colon invading the perirectal fat. Lymph nodes are negative for tumor.
Follow-Up This patient received adjuvant chemotherapy following surgery and is
well 3years later.
Comment This patient presented with anemia probably secondary to chronic
blood loss from this ulcerated tumor. She also had pain caused by the narrowing of
the colonic lumen. The tumor was deeply invasive but free of metastasis. This case
underscores the need for yearly surveillance colonoscopy in Crohn’s colitis. When
symptoms develop, the tumor is usually advanced, and the cure rate is much lower
than when asymptomatic tumors are found on yearly endoscopy. This patient did
well after proctocolectomy and ileostomy, and there is no evidence of recurrence at
this time (Fig.14.3).
294
Ascending
d
Transverse
T. M. Heimann and R. J. Kurtz
colon
a
Cancer
Fig. 14.3
colon
b
Recurrent ileocolitis with cancer
Sigmoi
colon
Cancer
ancer
Mild
14 Intestinal Cancer inCrohn’s Disease
Crohn’s colitis
c
295
C
Fig. 14.3 (continued)
14.4 Ileocolitis withCancer
Clinical Presentation A 59-year-old woman with a 33-year history of Crohn’s
colitis. She has been known to have a sigmoid stricture for 6years. Found to have a
colonic adenocarcinoma of the splenic exure on surveillance colonoscopy
(see Fig.14.4b). Previous colonoscopy was 2years before and did not show this
lesion. Physical exam showed no abdominal masses, liver was normal in size, and
rigid sigmoidoscopy showed minimal rectal inammation.
Diagnostic Studies CT scan of the abdomen showed no evidence of metastatic
disease.
Surgical Treatment This patient underwent a total proctocolectomy with Brooke
ileostomy (see Fig.14.4a).
Pathology
Crohn’s ileocolitis with mucin-secreting signet ring adenocarcinoma of
the splenic exure, invading the pericolonic fat. Small metastatic nodules are
296
T. M. Heimann and R. J. Kurtz
present in the serosal surfaces. Multiple lymph nodes contain metastatic carcinoma.
Inammatory stricture in the sigmoid colon. The colitis is supercial and quiescent.
Follow-Up This patient had an uneventful postoperative recovery, she received
chemotherapy following surgery and developed recurrent disease in the peritoneal
surfaces 1year later.
Comment Strictures in ulcerative colitis are more likely to be malignant than
colonic strictures in Crohn’s disease. This patient is an example that cancer may be
responsible for the development of a new stricture in Crohn’s disease. This lesion
was not seen at a previous colonoscopy 2years ago, nevertheless, at the time of
resection, the tumor was advanced with nodal and small peritoneal metastasis.
Signet ring cell tumors, such as this one, tend to be more aggressive and more likely
to metastasize. She initially did well following proctocolectomy and ileostomy but
developed recurrent disease 1year later. This case demonstrates that 2years between
colonoscopy is too long an interval to nd these tumors before they become
advanced (Fig.14.4).
Cancer
Tr
Descending
Ileitis
14 Intestinal Cancer inCrohn’s Disease
a
297
ansverse
colon
Crohn’s colitis
Cancer
colon
b
Fig. 14.4 Ileocolitis with cancer
298
T. M. Heimann and R. J. Kurtz
14.5 Granulomatous Colitis withCancer
Clinical Presentation A 48-year-old man with a 30-year history of Crohn’s colitis.
He has had a sigmoid stricture for several years but recently developed increased
abdominal distention and vomiting.
Diagnostic Studies Endoscopy showed an obstructing lesion in the rectosigmoid.
Previous colonoscopies showed pancolitis. CT scan showed colonic dilatation with
a transition point in the distal sigmoid colon. Previous barium studies showed normal small bowel (see Fig.14.5c).
Surgical Treatment Patient was found to have a massively dilated colon at surgery
with an obstructing tumor at the rectosigmoid. Several small peritoneal implants
were present in the pelvis. He underwent a total colectomy with partial proctectomy
and Hartmann’s closure of the remaining rectum and Brooke ileostomy
(see Fig.14.5a, b).
Pathology Extensive Crohn’s colitis with mucinous adenocarcinoma of the sig-
moid colon inltrating the pericolonic fat. Four lymph nodes contain metastatic
carcinoma. Biopsy of pelvic nodule also contains metastatic adenocarcinoma. The
ileum shows minimal nonspecic inammation.
Follow-Up The patient received chemotherapy and did well for 2years following
surgery. He then returned with intestinal obstruction and was found to have multiple
peritoneal metastases.
Comment The stricture in the area of the rectosigmoid was due to an advanced
tumor in this patient. At the time of resection, he had colonic obstruction, and several pelvic peritoneal implants were present. He therefore underwent a palliative
total colectomy with resection of the tumor and Hartmann’s closure of the rectum.
He subsequently did well for 2years until a metastatic deposit obstructed the distal
ileum and he required a proximal ileostomy. The malignant nature of the rectosigmoid stricture was not initially appreciated, and biopsies showed only inammation. As the tumor progressed and the patient became obstructed, preoperative
colonoscopic biopsies were positive for carcinoma (Fig.14.5).
Transverse
Diffuse
d
Ascending
14 Intestinal Cancer inCrohn’s Disease
299
colon
a
b
colon
Rectal cancer
colitis
Sigmoi
colon
Fig. 14.5
Rectal
cancer
Granulomatous colitis with cancer
300
colitis
Cancer
T. M. Heimann and R. J. Kurtz
c
Crohn’s
Fig. 14.5 (continued)
14.6 Ileocolitis withCancer
Clinical Presentation A 28-year-old woman with a 12-year history of colitis. She
was found to have a lesion in the rectum at 8cm from the anal verge, which on
biopsy was an adenocarcinoma.
Diagnostic Studies
the mid-rectum (see Fig.14.6b).
Surgical Findings Diffuse colitis with ileitis of the terminal ileum. This patient
underwent total proctocolectomy with Brooke ileostomy (see Fig.14.6a).
Pathology Ileum with chronic ileitis. The colon showed chronic colitis with four
independent carcinomas. Two cancers are located in the rectum, one in the sigmoid,
and another in the descending colon. All four cancers invade the muscularis propria.
A metastatic subserosal nodule was present in the rectosigmoid. The lymph nodes
were negative for tumor.
Follow-Up She had an uneventful recovery after surgery and is well 6years later.
Colonoscopy showed mild diffuse colitis with a 2cm lesion in