Surveillance Colonoscopy (Cases of Small Intestinal Cancers in Crohn’s Disease, Cases of Anal Cancers in Crohn’s Disease)

Fig. 22.1

Preoperative small intestinal examination with contrast material via a long tube. Multiple strictures with intestinal dilation as shell signs are found at the ileum

Fig. 22.2

Findings of preoperative enhanced-abdominal CT scan. The white arrow indicates the wall thickening of the ileum with lymph node swelling at the mesentery. Ascites, an abscess, or a fistula is not detected. No evidence of suspected malignancy is seen

Fig. 22.3

Preoperative endoscopic findings at the ileum distal from the obstruction via total colonoscopy. A severe stricture through which the colonoscope cannot pass is found at the ileum. Colonoscopy could not reach the proximal CD lesions. The white arrow shows the orifice of the small intestinal lumen

Fig. 22.4

Resected specimen of small-bowel cancer in a patient with CD. Thickened wall and ulceration with scar formation are found at the ileum. There are no findings causing suspicion of cancer. Cancer cells could be detected in most of this stricture lesion on histological examination, although that was invisible grossly, and no distinct border was evident. The white bracket with arrows shows the cancer lesion

22.4 Case Presentation-2

22.4.1 Peri-Anal Cancer in Crohn’s Disease

A male developed diarrhea at the age of 22 years and was diagnosed with stricturing CD with ileo-colic behavior. He was surgically treated once at the age of 22 years during his history of CD, which included ileo-cecal resection. He had an anal stricture without a fistula from the initial onset of CD. He had been treated with an elemental diet and oral 5-ASA administration. During outpatient observation, carcinoembryonic antigen (CEA) levels increased gradually above the normal limit (CEA 7.8 ng/ml, normal range <5 ng/ml) at the age of 55 years. Surveillance colonoscopy could not detect any lesions that were malignant or suspicious of malignancy. Subsequently, repeated examinations with colonoscopy were performed in every quarter, because CEA values continued to increase continuously. The initial findings on colonoscopy of the anal canal are shown in Fig. 22.5 (CEA 9.3 ng/ml). Findings of repeated colonoscopies after 6 months are shown in Fig. 22.6 (CEA 12.2 ng/ml). Adenocarcinoma was detected by histological examinations in biopsy specimens only at the last examination. During these follow-up periods, neither pelvic magnetic resonance imaging (MRI) nor positron emission tomography (PET) could detect this PAC. He was surgically treated with abdominoperineal resection and was diagnosed with well-differentiated adenocarcinoma with a mucinous component invading the muscularis propria. He needed additional chemoradiotherapy for local recurrence over 25 months after surgery.

Fig. 22.5

Findings of colonoscopy at the anal canal stricture 6 months prior to the diagnosis of cancer. Although there is slightly irregularity at the transitional zone, no findings causing suspicion of cancer or ulceration of Crohn’s disease are seen

Fig. 22.6

Findings of colonoscopy at the anal canal stricture at the time of diagnosis of cancer. A white elevated cancer lesion with a distinct vascular pattern and irregularity is seen (arrow)

22.5 Recent Advances in Diagnostic Examinations

Unfortunately, there is no useful tool that diagnoses or predicts cancer in CD patients at present. Therefore, diagnosis can only be done with a combination of imaging modalities. The presence of a complex fistula, an associated stricture, and perineal pain prevent a thorough examination of the anus and perineal areas, thus making diagnosis of a concomitant carcinoma difficult. Devon et al. reported that 14 patients with cancer of the anus all had multiple imaging studies, including MRI, CT, and endorectal ultrasound, but none of these studies was diagnostic of carcinoma [12]. The diagnosis of cancer was made preoperatively in ten of 14 patients, usually after multiple biopsies. In four patients, despite multiple tissue biopsies, the diagnosis was made intra-operatively (n = 2) or postoperatively (n = 2) [12].

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