Ileostomy Adenocarcinoma in Crohn’s Disease

Abstract

Crohn's disease typically affects the small bowel and colon, and it predisposes to an increased risk of various cancers, including small bowel, colorectal, and lymphoma. Ileostomy adenocarcinoma, although technically a cancer of the small bowel despite any skin involvement, is often thought of as a distinct and separate entity from small bowel adenocarcinoma given its different disease course and prognosis. Furthermore, in Crohn's disease, it is an uncommon complication; to date, there are only five reported cases in the literature.Here, we present a 73-year-old female who was diagnosed with adenocarcinoma of her ileostomy approximately 44 years after her last ostomy revision. Her medical history included Crohn's disease, which was in remission at the time of presentation, diabetes, anemia, asthma, and chronic kidney disease stage 3. She was initially diagnosed with Crohn's disease in 1969. She subsequently underwent proctocolectomy with end ileostomy for acute Crohn's colitis. Afterward she underwent approximately 30 additional surgical procedures due to subsequent infection, wound dehiscence, and hernias. Her ileostomy required two revisions, with the most recent performed for stoma necrosis in 1977.She first started to notice peristomal changes in 2008. These persisted despite topical therapies. In 2020, she noted that she was having difficulty pouching her ostomy, initially thought to be due to a skin fold. In 2021, she presented for evaluation after developing purulent drainage from a peristomal skin lesion, followed by development of multiple nodules (Figure 1). An incisional biopsy was performed in the office, which demonstrated moderately differentiated adenocarcinoma, gastrointestinal in origin. Staging workup revealed no evidence of metastatic disease. She underwent en bloc resection of the ileostomy with relocation of the ostomy. Final pathology demonstrated moderately to poorly differentiated adenocarcinoma with extensive invasion of the surrounding soft tissue and the skin at the stoma site. Margins were negative, but no lymph nodes were identified in the specimen. She was discussed in a multidisciplinary group and referred for chemotherapy.