Image of the MonthAdenocarcinoma Revealing Ileal Crohns Disease
MARIAM SEIRAFI,* DOMINIQUE CAZALSHATEM, and YORAM BOUHNIK**Department of Gastroenterology, IBD, and Nutritive Support, PMAD, and Department of Pathology, Beaujon University Hospital, Clichy, France
See related article, Jovanovic I et al, on page xxviiiin CGH.
A39-year-old woman with no relevant medical history pre-sented with occasional episodes of rectal bleeding. Theatient denied abdominal pain or any bowel movement disor-er. No familial history of colorectal cancer or inflammatoryowel disease was noted. Physical examination was unremark-ble, and laboratory findings were normal except a discrete ironeficiency without anemia. An ileocolonoscopy showed normalolorectal mucosa but ulcerations in the distal ileum suggestingrohns disease. After transfer into a referral center, an endo-
copic videocapsule examination confirmed multiple ileal ulcer-tions (Figure A) and was then completed by an enteromag-etic resonance imaging showing 2 ileal inflammatory lesionsbowel thickness 10 mm) in the terminal ileum. A lowernteroscopy with chromoendoscopy showed small elevated le-ions in the ileum at 15 and 7 cm (Figure B) from the ileocecalalve. Serial and targeted ileal biopsies were consistent withrohns disease ileitis, associated with multiple high-grade dys-lastic lesions on plane and elevated mucosa. A 20-cm ileocecalesection was performed, and the histologic examination high-ighted multiple foci of high-grade dysplasia (Figure C) ex-ended over the last 15 cm of ileum; some of them behaving asell-differentiated adenocarcinoma infiltrating the submucosa
Conflicts of interestThe authors disclose no conflicts.
2011 by the AGA Institute1542-3565/$36.00doi:10.1016/j.cgh.2010.10.029
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:e21e22
e22 IMAGE OF THE MONTH CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 9, No. 3Small bowel adenocarcinoma is rare and represents 2% of alldigestive cancers. It is well-established that Crohns disease isassociated with an increased risk of small bowel dysplasia andadenocarcinoma, with a relative risk estimated to be 28.4 com-pared to the general population.1 The cumulative risk has been
escribed as 0.2% over 10 years and 2.2% over 25 years.2 Onehundred seventy-eight cases have been described in the litera-ture. The duration of the disease is undoubtedly the mostimportant risk factor for adenocarcinoma, with a median timeof 11 years between diagnosis of Crohns disease and adenocar-cinoma.3 However, in some situations as presented here, find-ings of adenocarcinoma can be concurrent to the diagnosis ofCrohns disease. It is important to note that all cases ofadenocarcinoma occur on ill segments. In fact, the recentdevelopment of new therapeutics such as the tumor necrosisfactor- blockers and their proven efficacy has led during thepast few years to a more exclusively medical approach. Thisconservative attitude has subsequently led to leave in placeinflammatory lesions that are potentially at risk of progres-sion toward dysplasia. As opposed to the colon, the restrictedendoscopic accessibility to the small bowel has not allowedenough studies to establish any prevention guideline ondysplasia or early-stage cancer screening. Nevertheless, thegrowing performance of enteroscopy techniques should en-able us to ascertain a systematic small bowel dysplasiascreening program in high-risk Crohns disease patients,namely those with longstanding small bowel inflammatorylesions.
References1. Von Roon A, Reese G, Teare J, et al. The risk of cancer in patients
with Crohns disease. Dis Colon Rectum 2007;50:839855.2. Palascak-Juif V, Bouvier AM, Cosnes J, et al. Small bowel adeno-
carcinoma in patients with Crohns disease compared with smallbowel adenocarcinoma de novo. Inflamm Bowel Dis 2005;11:828832.
3. Piton G, Cosnes J, Monet E, et al. Risk factors associated withsmall bowel adenocarcinoma in Crohns disease: a case-controlstudy. Am J Gastroenterol 2008;103:17301736.
Adenocarcinoma Revealing Ileal Crohns DiseaseReferences