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LETTER TO THE EDITOR
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 273-274

Small intestinal adenocarcinoma in crohn's disease: Report of a case


1 Department of Pathology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
2 Department of GastroSurgery, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
3 Department of Surgical Oncology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India

Date of Web Publication26-Dec-2017

Correspondence Address:
Dr. Rashmi Patnayak
Department of Pathology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_16_17

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How to cite this article:
Patnayak R, Singh S, Parida S, Jena A. Small intestinal adenocarcinoma in crohn's disease: Report of a case. J NTR Univ Health Sci 2017;6:273-4

How to cite this URL:
Patnayak R, Singh S, Parida S, Jena A. Small intestinal adenocarcinoma in crohn's disease: Report of a case. J NTR Univ Health Sci [serial online] 2017 [cited 2020 May 26];6:273-4. Available from: http://www.jdrntruhs.org/text.asp?2017/6/4/273/221524



Sir,

In Crohn's disease (CD), mostly cancer of the large intestine has been described, whereas cases of small intestine cancers combined with Crohn's disease are very rare.[1] The presenting symptoms are nonspecific and mimic active or obstructive CD, thereby delaying the diagnosis.[2] Here, we present one such case of small intestinal adenocarcinoma.

A 73-year-old male presented with periumbilical and lower abdominal pain associated with vomiting for the last 15 days. Symptoms increased progressively. He was a known diabetic under medication. He did not provide any suggestive past history. On general physical examination, he was malnourished. Local examination showed distended abdomen with mild tenderness. Computed tomography of the abdomen showed multiple strictures in the terminal ileum with mesenteric lymph nodes [Figure 1]a and [Figure 1]b. On gross examination, multiple strictures with intervening normal looking intestinal mucosa were noted. The presence of creeping fat was noted on the external aspect [Figure 2]a and [Figure 2]b. Histopathological examination showed presence of lymphoid aggregates in all the layers in all the layers [Figure 3]a,[Figure 3]b,[Figure 3]c. No epithelioid granulomas were noted. The clinical. imageological, gross, and histopathological examination suggested CD. One of the stricture (8 cm from the proximal resected margin) showed intestinal mucosa in transition to moderately differentiated adenocarcinoma infiltrating all the layers of intestine. The resected margins were free and one, out of the six isolated, lymph node had metastatic adenocarcinomatous deposits.[Figure 4]a,[Figure 4]b,[Figure 4]c,[Figure 4]d. The pathological stage was pT3N1Mx. The patient had an uneventful postoperative period.
Figure 1: (a and b) Computed tomography images showing long segment of ileal stricture involving mid ileum with dilated proximal small bowel loops till mid jejunum

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Figure 2: (a and b) Gross segment of small bowel with multiple strictures and creeping fat

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Figure 3: (a-c) Diffuse inflammatory infiltrate of lymphocytes and plasma cells in lamina propria, submucosa, muscularis propria, and serosa (Hematoxylin and eosin ×40)

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Figure 4: (a-d) Neoplastic glands in mucosa and muscle layer (Hematoxylin and eosin ×400); (e and f) Metastatic adenocarcinomatous deposits in the lymph node (Hematoxylin and eosin ×100 and ×400)

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Small intestinal adenocarcinoma combined with CD is very rare.[3],[4] Apart from small bowel adenocarcinoma, other malignancies such as sarcomas, lymphomas, and carcinoids have been reported in CD.[2] The data regarding small bowel adenocarcinoma in CD are from case reports and small retrospective series.[3]

Small bowel adenocarcinoma in CD differs from that of de novo small bowel adenocarcinoma as it originates from longstanding ileal inflammation and is difficult to diagnose preoperatively.[2],[4] Majority of the small bowel adenocarcinoma in CD cases are diagnosed at the time of operation or in the postoperative period. In fact, more than 50% of the cases are detected incidentally by histopathological examination.[2],[5] The present case is one such example of incidentally detected small bowel adenocarcinoma. Small bowel adenocarcinoma in CD presents at a younger age and are located more diffusely and distally than de novo carcinomas; thus, it is difficult to diagnose at an early stage.[2] The cumulative risk of small bowel adenocarcinoma increases after 10 years of CD.[3] In a meta-analysis of CD patients, the authors opined that CD is a risk factor for colorectal cancer, small bowel cancer, and fistula cancer. The risk of cancer is moderate compared to ulcerative colitis.[6] Highest occurrence of small bowel carcinomas (30%) has been reported in CD patients who had bypassed loops.[2] Small bowel carcinomas associated with CD are usually poorly differentiated and are associated with a poor prognosis.[2] The present case is an addition to the existing literature.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Higashi D, Futami K, Kojima D, Futatsuki R, Ishibashi Y, Maekawa T, et al. Cancer of the small intestine in patients with Crohn's disease. Anticancer Res 2013;33:2977-80.  Back to cited text no. 1
[PUBMED]    
2.
Cahill C, Gordon PH, Petrucci A, Boutros M. Small bowel adenocarcinoma and Crohn's disease: Any further ahead than 50 years ago? World J Gastroenterol 2014;20:11486-95.  Back to cited text no. 2
[PUBMED]    
3.
Feldstein RC, Sood S, Katz S. Small bowel adenocarcinoma in Crohn's disease. Inflamm Bowel Dis 2008;14:1154-7.  Back to cited text no. 3
[PUBMED]    
4.
Palascak-Juif V, Bouvier AM, Cosnes J, Flourié B, Bouché O, Cadiot G, et al. Small bowel adenocarcinoma in patients with Crohn's disease compared with small bowel adenocarcinoma de novo. Inflamm Bowel Dis 2005;11:828-32.  Back to cited text no. 4
    
5.
Collier PE, Turowski P, Diamond DL. Small intestinal adenocarcinoma complicating regional enteritis. Cancer 1985;55:516-21.  Back to cited text no. 5
[PUBMED]    
6.
Laukoetter MG, Mennigen R, Hannig CM, Osada N, Rijcken E, Vowinkel T, et al. Intestinal cancer risk in Crohn's disease: A meta-analysis. J Gastrointest Surg 2011;15:576-83.  Back to cited text no. 6
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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