Carcinoma of Pelvic Pouch following Restorative Proctocolectomy: Report of a Case and Review of the Literature

Abstract

One of the possible long-term complications following an ileoanal pouch procedure is the development of malignancy in the mucosa of the rectal stump. Only 10 such cases have been reported so far. We report the case of a 23-year-old male who had ulcerative colitis with high-grade dysplasia and underwent an ileoanal pouch procedure. He was found to have a malignancy in the rectal stump 5 years after surgery. The malignancy presented with symptoms of refractory pouchitis. Pouch excision was performed. The risk of developing malignancy in the rectal mucosa after an ileoanal pouch procedure mandates regular follow-up in these patients, with a high index of suspicion especially in patients with delayed onset pouchitis.

Clinical Features of Ileal Pouch Polyps in Patients with Underlying Ulcerative Colitis

“…35,41 These patients with dysplasia or cancer of the ATZ typically had a precolectomy diagnosis of dysplasia or cancer. [34][35][36] In patients with persistent dysplasia, mucosectomy, perianal pouch advancement, neoileal pouch-anal anastomosis, or pouch excision have been recommended. 36,45 There is scanty data on clinical features and management of polyps of the pouch.…”

Low detoxification capacity in the ileal pouch mucosa of patients with ulcerative colitis

“…This colonic metaplasia is presumably an adaptation to the new environmental condition because the ileal pouch may in part substitute for the functions of the large intestine 7. Furthermore, Gullberg et al has reported on the development of severe mucosal atrophy in the pouch with risk of neoplastic transformation8; in addition, there have also been case reports of adenocarcinoma in the ileal mucosa of the pouch 8‐11…”

Pelvic Cancer Ten Years after Restorative Proctocolectomy in Indeterminate Colitis: Report of a Case

“…Eighteen reported cases have surfaced during the past 25 years, all but two in association with CUC. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] This is the first report of this complication occurring in the setting of IC. Although most cases have been diagnosed within a few years of RPC, pouch-related adenocarcinomas have been reported at 12, 6 14, 7 and 18 11 years after index surgery.…”

“…Of 14 cases [5][6][7][9][10][11][12][13]16,[19][20][21] in which pathologic data are available, all but one 8 contained cancer, dysplasia or both in the colorectum. In the present case, as in others reported, the tumor probably originated outside the pouch and grew inward.…”

“…This risk seems to extend over many years. The lag time between operation and the discovery of malignancy can extend from 22 months to 25 years in patients who had mucosectomies [7][8][9][11][12][13]16,18,20 and 16 months to 12 years in patients with anal transition zone-sparing procedures. 6,7,10,17,19 When the indication for surgery in long-standing IBD is cancer or dysplasia, especially involving the rectum, arguments can be made for and against mucosectomy, stapled IPAA, and even the wisdom of any pelvic pouch procedure.…”