Skip to main content

Advertisement

SpringerLink
Log in

Small bowel adenocarcinoma in Crohn’s disease: a rare but devastating complication

  • Original Article
  • Published:
Techniques in Coloproctology Aims and scope Submit manuscript

Abstract

Background

Small bowel adenocarcinoma (SBA) remains a rare entity but occurs at increased frequency in the setting of chronic Crohn’s disease (CD). Our aim was to study the presentation, diagnosis and prognosis of SBA in patients undergoing surgery for CD at a single institution.

Methods

We reviewed the medical records of all patients with CD complicated by adenocarcinoma of the small bowel from 2000 to 2017. Descriptive statistics and Kaplan–Meier overall survival estimates were calculated.

Results

In total, 22 patients (14 males) with CD (median duration of Crohn’s diagnosis 32 years) were diagnosed with SBA and underwent surgical resection (8 isolated small bowel resections, 12 ileocolic resections, and 2 total proctocolectomies). The median patient age at the time of diagnosis was 54 years (range 22–82 years). A total of 17 patients (77%) underwent cross-sectional CT imaging within 3 months of surgery, a cancer diagnosis was suggested in only one patient. In one other patient, SBA was diagnosed preoperatively on endoscopic biopsy of the terminal ileum. The remaining patients were operated on for obstruction (n = 17), abscess or fistulizing disease (n = 2), and sigmoid cancer (n = 1). For these 20 (90%) patients not suspected to have SBA on preoperative assessment, 5 (25%) were diagnosed intraoperatively on frozen section and 15 (75%) were unexpectedly diagnosed postoperatively on final pathology. T staging was characterized by more advanced tumors (T4: 59%, T3: 27%, T2: 9%, and T1: 5%). Nine patients (41%) had nodal involvement and five patients (23%) had hepatic and/or peritoneal carcinomatosis. The 1-, 3-, and 5-year survival estimates for our cohort were 84%, 30%, and 10%, respectively. Median survival was 30.5 months with median follow-up of 23 months (range 6–84 months).

Conclusions

SBA in the setting of CD is most commonly found incidentally after surgical resection for benign indications. As such, any suspicious finding at the time of surgery in a patient with chronic CD should warrant careful investigation with frozen section and/or resection. Prognosis for CD complicated by SBA remains poor even in the modern era.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Ammann R, Bivetti J, Kobler E, Peter P (1977) Gastroenterologisches Röntgenquiz [Gastroenterologic roentgen quiz]. Leber Magen Darm 7(2):91–130

    CAS  PubMed  Google Scholar 

  2. Jess T, Winther KV, Munkholm P, Langholz E, Binder V (2004) Intestinal and extraintestinal cancer in Crohn’s disease: follow-up of a population-based cohort in Copenhagen County, Denmark. Aliment Pharmacol Ther 19:287–293

    Article  CAS  Google Scholar 

  3. Ginzburg L, Schneider KM, Dreizin DH et al (1956) Carcinoma of the jejunum occurring in a case of regional enteritis. Surgery 39:347–351

    CAS  PubMed  Google Scholar 

  4. Svrcek M, Piton G, Cosnes J, Beaugerie L, Vermeire S, Geboes K, Lemoine A, Cervera P, El-Murr N, Dumont S, Scriva A, Lascols O, Ardizzone S, Fociani P, Savoye G, Le Pessot F, Novacek G, Wrba F, Colombel JF, Leteurtre E, Bouhnik Y, Cazals-Hatem D, Cadiot G, Diebold MD, Rahier JF, Delos M, Flejou JF, Carbonnel F (2014) Small bowel adenocarcinomas complicating Crohn's disease are associated with dysplasia: a pathological and molecular study. Inflamm Bowel Dis 20:1584–1592

    Article  Google Scholar 

  5. Liao X, Li G, McBride R, Houldsworth J, Harpaz N, Polydorides AD (2019) Clinicopathological and molecular characterization of Crohn's disease-associated small bowel adenocarcinomas. J Crohns Colitis 14:287

    Article  Google Scholar 

  6. Shaukat A, Virnig DJ, Howard D, Sitaraman SV, Liff JM, Lederle FA (2011) Crohn’s disease and small bowel adenocarcinoma: a population-based case-control study. Cancer Epidemiol Biomark Prev 20:1120–1123

    Article  CAS  Google Scholar 

  7. Hutchins RR, Hani AB, Kojodjojo P et al (2001) Adenocarcinoma of the small bowel. ANZ J Surg 71:428–437

    Article  CAS  Google Scholar 

  8. Bilimoria KY, Bentrem DJ, Wayne JD et al (2009) Small bowel cancer in the United States: changes in epidemiology, treatment, and survival over the last 20 years. Ann Surg 249:63–71

    Article  Google Scholar 

  9. Greenstein AJ (2000) Cancer in inflammatory bowel disease. Mt Sinai J Med 67:227–240

    CAS  PubMed  Google Scholar 

  10. Weber NK, Fletcher JG, Fidler JL et al (2015) Clinical characteristics and imaging features of small bowel adenocarcinomas in Crohn's disease. Abdom Imaging 40(5):1060–1067

    Article  Google Scholar 

  11. Buckley JA, Siegelman SS, Jones B, Fishman EK (1997) The accuracy of CT staging of small bowel adenocarcinoma: CT/pathologic correlation. J Comput Assist Tomogr 17(21):986–991

    Article  Google Scholar 

  12. Engin G (2008) Computed tomography enteroclysis in the diagnosis of intestinal diseases. J Comput Assist Tomogr 32:9–16

    Article  Google Scholar 

  13. Ikeuchi H, Nakano H, Uchino M, Nakamura M, Matsuoka H, Fukuda Y, Matsumoto T, Takesue Y, Tomita N (2008) Intestinal cancer in Crohn’s disease. Hepatogastroenterology 55:2121–2124

    PubMed  Google Scholar 

  14. Kodaira C, Osawa S, Mochizuki C, Sato Y, Nishino M, Yamada T, Takayanagi Y, Takagaki K, Sugimoto K, Kanaoka S, Furuta T, Ikuma M (2009) A case of small bowel adenocarcinoma in a patient with Crohn’s disease detected by PET/CT and double-balloon enteroscopy. World J Gastroenterol 15:1774–1778

    Article  Google Scholar 

  15. Van Weyenberg SJ, Bouman K, Jacobs MA, Halloran BP, Cahill C et al (2014) Small bowel adenocarcinoma in Crohn’s disease. WJG 20(33):11494. https://www.wjgnet.com. Accessed 07 Sept 2014

  16. Kerber GW, Frank PH (1984) Carcinoma of the small intestine and colon as a complication of Crohn disease: radiologic manifestations. Radiology 150:639–645

    Article  CAS  Google Scholar 

  17. Palascak-Juif V, Bouvier AM, Cosnes J et al (2005) Small bowel adenocarcinoma inpatients with Crohn’s disease compared with small bowel adenocarcinoma de novo. Inflamm Bowel Dis 11:828–832

    Article  Google Scholar 

  18. Michelassi F, Testa G, Pomidor WJ et al (1993) Adenocarcinoma complicating Crohn’s disease. Dis Colon Rectum 36:654–661

    Article  CAS  Google Scholar 

  19. Lashner BA (1992) Risk factors for small bowel cancer in Crohn’s disease. Dig Dis Sci 37:1179–1184

    Article  CAS  Google Scholar 

  20. Canavan C, Abrams KR, Mayberry J (2006) Meta-analysis: colorectal and small bowel cancer risk in patients with Crohn’s disease. Aliment Pharmacol Ther 23:1097–1104

    Article  CAS  Google Scholar 

  21. Solem CA, Harmsen WS, Zinsmeister AR et al (2004) Small intestinal adenocarcinoma in Crohn’s disease: a case-control study. Inflamm Bowel Dis 10(32–35):18

    Google Scholar 

  22. Singh K, Singh A, Philpott J, Liska D, Lai K (2019) Occult Adenocarcinoma Arising in Crohn’s-related 18 strictures: a case series. Crohn's Colitis 360(1):3

    Google Scholar 

  23. Scott KW, Grace RH (1989) Detection of lymph node metastases in colorectal carcinoma before and after fat clearance. Br J Surg 76(11):1165–1167

    Article  CAS  Google Scholar 

  24. Cianchi F, Palomba A, Boddi V et al (2002) Lymph node recovery from colorectal tumor specimens: recommendation for a minimum number of lymph nodes to be examined. World J Surg 26(3):384–389

    Article  Google Scholar 

  25. Benson AB 3rd, Schrag D, Somerfield MR et al (2004) American Society of Clinical Oncology recommendations on adjuvant chemotherapy for stage II colon cancer. J Clin Oncol 22(16):3408–3419

    Article  Google Scholar 

  26. Coffey CJ, Kiernan MG, Sahebally SM et al (2018) Inclusion of the mesentery in ileocolic resection for Crohn's disease is associated with reduced surgical recurrence. J Crohns Colitis 12(10):1139–1150

    Article  Google Scholar 

  27. Kelsey CR, Nelson JW, Willett CG et al (2007) Duodenal adenocarcinoma: patterns of failure after resection and the role of chemoradiotherapy. Int J Radiat Oncol Biol Phys 69:1436–1441

    Article  Google Scholar 

  28. Swartz MJ, Hughes MA, Frassica DA et al (2007) Adjuvant concurrent chemoradiation for node-positive adenocarcinoma of the duodenum. Arch Surg 142:285–288

    Article  Google Scholar 

  29. Widmar M, Greenstein AJ, Sachar DB, Harpaz N, Bauer JJ, Greenstein AJ (2011) Small bowel adenocarcinoma in Crohn’s disease. J Gastrointest Surg 15:797–802

    Article  Google Scholar 

  30. de van Buck OA, Wolthuis A, D’Hoore A (2012) Surgery for Crohn’s disease in the era of biologicals: a reduced need or delayed verdict? World J Gastroenterol 18:3828–3832

    Article  Google Scholar 

  31. Greenstein A (1995) Malignancy in Crohn’s disease. Perspect Colon Rectal Surg 8:137–159

    Google Scholar 

  32. Dossett LA, White LM, Welch DC, Herline AJ, Muldoon RL, Schwartz DA, Wise PE (2007) Small bowel adenocarcinoma complicating Crohn’s disease: case series and review of the literature. Am Surg 73:1181–1187

    Article  Google Scholar 

  33. Richards ME, Rickert RR, Nance FC (1989) Crohn’s disease-associated carcinoma. A poorly recognized complication of inflammatory bowel disease. Ann Surg 209:764–773

    Article  CAS  Google Scholar 

  34. Michelassi F, Testa G, Pomidor WJ, Lashner BA, Block GE (1993) Adenocarcinoma complicating Crohn’s disease. Dis Colon Rectum 36:654–661

    Article  CAS  Google Scholar 

  35. Fishman PN, Pond GR, Moore MJ, Oza A, Burkes RL, Siu LL, Feld R, Gallinger S, Greig P, Knox JJ (2006) Natural history and chemotherapy effectiveness for advanced adenocarcinoma of the small bowel: a retrospective review of 113 cases. Am J Clin Oncol 29:225–231

    Article  CAS  Google Scholar 

  36. Collier PE, Turowski P, Diamond DL (1985) Small intestinal adenocarcinoma complicating regional enteritis. Cancer 55:516–521

    Article  CAS  Google Scholar 

  37. Meryn S, Lochs H (1983) Diagnostic usefulness of plasma carcinoembryonic antigen (CEA) levels in Crohn’s disease. Dig Dis Sci 28:478–479

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Main Campus, 9500 Euclid Ave, A31, Cleveland, OH, 44122, USA

    T. Hussain, N. A Jeganathan, G. Karagkounis, L. Stocchi, S. Shawki, S. D. Holubar, T. Hull & D. Liska

  2. Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA

    I. Gordon

Authors
  1. T. Hussain
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. N. A Jeganathan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. G. Karagkounis
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. L. Stocchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. S. Shawki
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. S. D. Holubar
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. I. Gordon
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. T. Hull
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. D. Liska
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

We acknowledge that the following authors have contributed to the study in data collection, writing of manuscript, reference searching and proof-reading the paper. This is an original study and author TH: was involved in writing the manuscript; AJ and KG: did the data collection; LS; TH; SS; DL: were involved in helping with study and contributed to the patients in the study, study design and proof-reading the manuscript. All authors belong to the department of Digestive Diseases Institute, Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, United States.

Corresponding author

Correspondence to T. Hussain.

Ethics declarations

Conflict of interest

We declare no conflict of interest.

Ethical approval

The study was approved by the Instutional Review Board (IRB) at the Cleveland Clinic Foundation, Ohio, USA.

Informed consent

Informed consent for this type of study was not required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hussain, T., Jeganathan, N.A., Karagkounis, G. et al. Small bowel adenocarcinoma in Crohn’s disease: a rare but devastating complication. Tech Coloproctol 24, 1055–1062 (2020). https://doi.org/10.1007/s10151-020-02269-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10151-020-02269-8

Keywords

Search

Navigation