pdbadcCsan(

Image of the Month

Adenocarcinoma Revealing Ileal Crohn’s Disease

MARIAM SEIRAFI,* DOMINIQUE CAZALS–HATEM,‡ and YORAM BOUHNIK*

*Department of Gastroenterology, IBD, and Nutritive Support, PMAD, and ‡Department of Pathology, Beaujon University Hospital, Clichy, France

esvCprltw(

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. The

atient 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 suggestingrohn’s 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 entero–mag-etic resonance imaging showing 2 ileal inflammatory lesions

bowel thickness �10 mm) in the terminal ileum. A lower

nteroscopy 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 withrohn’s 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

pT1(sm1)).

Conflicts of interestThe authors disclose no conflicts.

© 2011 by the AGA Institute1542-3565/$36.00

doi:10.1016/j.cgh.2010.10.029

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:e21–e22

d

e22 IMAGE OF THE MONTH CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 9, No. 3

Small bowel adenocarcinoma is rare and represents 2% of alldigestive cancers. It is well-established that Crohn’s 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 Crohn’s disease and adenocar-cinoma.3 However, in some situations as presented here, find-ings of adenocarcinoma can be concurrent to the diagnosis ofCrohn’s 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 Crohn’s 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 Crohn’s disease. Dis Colon Rectum 2007;50:839–855.2. Palascak-Juif V, Bouvier AM, Cosnes J, et al. Small bowel adeno-

carcinoma in patients with Crohn’s disease compared with smallbowel adenocarcinoma de novo. Inflamm Bowel Dis 2005;11:828–832.

3. Piton G, Cosnes J, Monet E, et al. Risk factors associated withsmall bowel adenocarcinoma in Crohn’s disease: a case-controlstudy. Am J Gastroenterol 2008;103:1730–1736.