jcoloproctol(rioj).2017;37(4):320–322
w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Case
Report
Verrucous
carcinoma
at
ileostomy
site
Vijay
Dhakre
∗,
Sanjay
Nagral
JaslokHospitalandResearchCentre,Mumbai,India
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Articlehistory:
Received12January2017 Accepted1May2017 Availableonline25May2017
Keywords: Ileostomy
Verrucouscarcinoma Mucocutaneousjunction
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Wedescribeofacase,a50yearoldmalewhowasoperatedforcarcinomaofthedescending colonanddivertingloopileostomy,developedafungatinglesioninmucocutaneousjunction ofileostomyafteroneyearwhichonhistologyrevealedtobeaVerrucouscarcinoma.
©2017SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Carcinoma
verrucoso
em
local
de
ileostomia
Palavras-chave: Ileostomia
Carcinomaverrucoso Junc¸ãomucocutânea
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Descrevemosumcaso,homem,50anos,quefoioperadoparacarcinomadecólon descen-denteeileostomiaemalc¸aparadesvio.Transcorridoumano,opacientedesenvolveuuma lesãovegetantenajunc¸ãomucocutâneadaileostomia;ahistologiarevelouserum carci-nomaverrucoso.
©2017SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
Complications of stomal site are often encountered by clinicians1 but neoplasms of stomal sites are very rare.2 It can be confused or get obscured by granulation, tis-sue excoriation or ignorance by health care provider. We share our experience of a rare case of verrucous carci-noma.
∗ Correspondingauthor.
E-mail:[email protected](V.Dhakre).
Case
report
A50yearoldmaleseropositiveforhumanimmunodeficiency virus(HIV)wasplannedforaloopileostomyclosureafterone yearofanteriorresectionforadenocarcinomaofdescending colon. Patienthad receivedadjuvantchemotherapy.Patient wasalsoonHAART(highlyactiveanti-retroviraltherapy)for HIVinfection.
http://dx.doi.org/10.1016/j.jcol.2017.05.002
jcoloproctol(rioj).2017;37(4):320–322
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Fig.1–Intraoperativeileostomysitewiththelesion(black arrow)inthesuperomedialmucocutaneousjunctionwhich isdissectedandmobilized.
Before stomaclosure CTscan had shown normaldistal bowelandnoevidenceofrecurrence.Threemonthspriorto theclosure;patient had reportedoozing ofblood from the stomalsite.Alocalexaminationrevealedanareaof hyper-granulationwhichwasattributedtochronicirritationandwas leftalone.
Duringthesurgerywenoticedasmallfungatingmasson therightlateraledgeofthemucocutaneoussite(Fig.1).Inview ofsuspicionofmalignancyawidelocalresectionoftheloop ileostomywasperformed,keepingamarginof2cmoverthe skinandabdominalwalllayers(Fig.2).
Patientiswellaftersixmonthsaftersurgerywithout evi-denceofrecurrence.
Fig.2–Markedacanthosiswithbroadbulbousprocess (blackarrowhead).Thebulbousreteprocesses“push” deepintothelaminapropriasothatthebaseofthelesion isbelowtheadjacentbasementmembrane.
Discussion
Complicationsofstomaarewelldescribedandincludestomal herniation, prolapse of stoma,retraction, skinexcoriation, intestinal obstruction, stenosis, abscess, fistula, diarrhoea, urinarycalculus,ileitis,andinflammatorypolyps.1 Develop-ment of malignancyat ileostomy in is rare2 Suarez et al. estimatedtheincidenceofileostomycarcinomasinpatients withileostomyforvariousindicationsintheUK tobe2to 4per1000ileostomies.Squamouscellcarcinoma(SSC)have beendescribedcommonlyinHIVpositivepatientsat muco-cutaneousjunctionsspeciallyanorectaljunction.3Howeverto ourknowledgeVChasnotbeingdescribedattheileostomy site,althoughtherearereportsofSCC.
TilldateonlyafewcasesofSCCatileostomyhavebeen described.4 Ulcerativecolitiswasthe mostcommon under-lyingcondition; Farshid intheirreviewdescribedtimingof lesion from ileostomy fashioning was in the range of 26 years to 54 years. In our case this time was very short (12months).
Mawetal.5hadmentionedintheircaseseriesof44stomal neoplasms; described 40 adenocarcinomas and four squa-mouscellcarcinoma,butnoVCvariantwasdescribed.They describedofileostomyneoplasmassociatedwithCrohn’s dis-ease,familial adenomatouspolyposisand ulcerativecolitis. Theypostulatedthatchronicirritationpredisposedthestoma tomalignantchanges.Theydiscussedastrongassociationin patientwithchronicdiseaseslikeulcerativecolitisorprimary sclerosingcholangitismakingitahighriskgroupforileostomy neoplasms.Thechronicirritationtheoryissupportedbythe factthatmajorityofstomalcarcinomahavebeendescribed onlyinlong standingpermanentstomas.6 Inthesettingof HIV,humanpapillomavirus(HPV)infectioniswellknownto predisposetocarcinomas.ViralinteractionsinHPVcan pre-disposetoVC.6Inourcasethoughtheimmunohitochemical analysisforHPVwasnegative.TheE6/E7viraloncoproteinsof HPVareprovedtoinactivatethetumoursuppressorgenelike p53andpRbwhichinturnleadtothecellproliferationand eventuallyturningthemintomalignantcells.Highlyactive anti-retroviral therapy (HAART) modulatingthe immuneis alsotakenintoaccountwhileconsideringinteractionsofthese viruses.7
Overallrisk ofcarcinomas inHIVpatientsismorethan ingeneralpopulation.7MoreoverassociationsofHIV– non-Hodgkin’s lymphoma (NHL) at ileostomy site specifically because of microtraumatisms and locally present antigen stimulationandactivationhasbeendiscussedintheirwork byLevecqetal.3
Alsoitispertinenttomentionactivationofsignalling path-wayslikeAkt/mTORwhichcangetactivatedandisalsoknown tocauseVCinoralmalignancy.8
Conclusion
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jcoloproctol(rioj).2017;37(4):320–322shouldbeconsideredahighriskgroupforsuchrareformsof malignancy.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgements
DrVijayDhakredesignedandwroteupthearticlewithreview ofliteratureandprocuringthedata,DrSanjayNagralfinalized thearticleandliteraturereview.
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J,ThompsonH,etal.Carcinomadevelopinginileostomies after25ormoreyears.Gastroenterology.1988;95:205–8.
3.LevecqH,HautefeuilleM,HoangC,GalianA,HautefeuilleP, RambaudJC.Primarystomallymphoma.Anunusual complicationofileostomyinapatientwith
transfusion-relatedacquiredimmunedeficiencysyndrome. Cancer.2006;65:1028–32.
4.FarshidE,MetinN,RangasamyS.Squamouscellcarcinomaat anileostomysite–Fiftyfouryearsfollowingcolectomyfor ulcerativecolitis:acasereportandliteraturereview.IntJSurg CaseRep.2013;4:678–80.
5.QuahHM,SamadA,MawA.Ileostomycarcinomasareview: thelatentriskaftercolectomyforulcerativecolitisand familialadenomatouspolyposis.ColorectalDis.2005;7: 538–44.
6.TonnaJ,PalefskyJM,RabbanJ,CamposGM,TheodoreP, LadabaumU.Esophagealverrucouscarcinomaarisingfrom hyperkeratoticplaquesassociatedwithhumanpapilloma virustype51.DisEsophagus.2010;23:E17–20.
7.RighettiE,BallonG,OmettoL,CattelanAM,MeninC, ZanchettaM,etal.DynamicsofEpstein–Barrvirusin HIV-1-infectedsubjectsonhighlyactiveantiretroviraltherapy. AIDS.2002;16:63–73.
