Ileal adenocarcinoma in Crohn's disease: magnetic resonance enterography features

doi:10.1016/j.clinimag.2011.03.006

Clinical Imaging

Volume 36, Issue 1, January–February 2012, Pages 24-28

https://doi.org/10.1016/j.clinimag.2011.03.006 Get rights and content

Abstract

Patients with Crohn's disease are at increased risk for small bowel adenocarcinoma. We report herein two cases of Crohn's disease-related ileal adenocarcinoma, which were investigated by means of magnetic resonance (MR)-enterography. Two different patterns were observed. In one case, the tumor presented as long circumferential, asymmetric and heterogeneous thickening of the ileum with visible nodule on free induction echo stimulated acquisition images. In the other case, the malignant lesion presented as a tumor mass of the terminal ileum, extending onto the cecum, and showed restricted diffusion on diffusion-weighted MR imaging. In both cases, the tumors were diagnosed preoperatively. Histopathological analysis after surgical resection confirmed T4N1 poorly differentiated mucinous adenocarcinoma of the ileum in association with findings consistent with active in one case and inactive Crohn's disease in the other case. Our observations suggest that MR-enterography may be a useful imaging test for the detection of small bowel adenocarcinoma in patients with Crohn's disease.

Introduction

Crohn's disease is a chronic inflammatory bowel disease, which can involve virtually any portion of the gastrointestinal tract [1]. Patients with Crohn's disease are at increased risk for both colon and small bowel adenocarcinoma [2], [3]. Identification of increased colorectal cancer risks in individual patients with Crohn's disease has led to well-established surveillance guidelines [3]. Conversely, although the increased risk for small bowel adenocarcinoma has been identified, no specific screening recommendations exist. As a consequence, imaging may play a critical role for the detection and the characterization of this rare but severe complication.

The multiple patterns of presentation of Crohn's disease have been described extensively, and the imaging features of this disease as observed on magnetic resonance (MR) imaging are well known [4], [5], [6]. Conversely, little attention has been given to the imaging appearance of Crohn's disease-related small bowel adenocarcinoma. In addition, reported studies described findings obtained with barium studies [7], [8] or computed tomography (CT) [9], [10]. To our knowledge, the imaging appearance of Crohn's disease-related small bowel adenocarcinomas using MR imaging have never been reported.

We report herein two cases of small bowel adenocarcinomas that occurred in patients with Crohn's disease, which were investigated by means of MR-enterography.

Section snippets

MR imaging protocol

MR-enterography examinations were obtained at 1.5 T with two different MR units [Magnetom Avanto (Siemens Healthcare, Erlangen, Germany) or Signa Excite HDX (General Electric Healthcare, Milwaukee, WI)] equipped with a high-performance gradient system (gradient strength, 33–45 mT/m; slew rate, 120–200 mT m⁻¹ ms⁻¹). A circular polarized phase-array surface coil was used for signal detection. MR-enterography studies were obtained after ingestion of 1.5 L of a 2.5% water mannitol solution.

Case 1

The patient was a 64-year-old Caucasian male with a 15-year history of ileal Crohn's disease. He had no prior bowel resection or endoscopic procedure and was receiving steroids and mesalazine. He was referred to our hospital for persistent hematochezia, abdominal cramping and weight loss. Clinically, an abdominal mass was palpable in the right iliac fossa. Blood tests showed moderate anemia (hemoglobin, 10.8 g/dl) and elevated C-reactive protein. The serum carcinoembryonic antigen was elevated

Discussion

We have reported the MR-enterography imaging findings in two patients with Crohn's disease-related adenocarcinoma of the small bowel. The two tumors displayed different features at MR imaging. In one case, the tumor presented as long circumferential, asymmetric and heterogeneous thickening of the ileum with visible nodule, whereas in the other case, the malignant lesion presented as a tumor mass of the terminal ileum, extending onto the cecum.

Most cancers in patients with Crohn's disease are

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Patients with Crohn's disease (CD) are at higher risk of small bowel adenocarcinoma (SBA). We aimed to identify radiological predictors of SBA in CD.
We conducted a retrospective case-control study at two tertiary inflammatory bowel disease centers and identified CD patients diagnosed with SBA between 2003 and 2019. Patients were matched with up to four controls. Pre-operative imaging (magnetic resonance imaging (MRI) or computed tomography (CT)) were reviewed by three gastrointestinal radiologists.
Nineteen patients with CD-associated SBA with a mean age of 54.9 and 32 matched controls were included. Mean length of small bowel involvement was 216 (± 188) mm in the SBA group versus 156 (± 167) mm in the control group (p = 0.76). Only 11.8 % of cases had a diagnosis of SBA made preoperatively. In univariate analysis, focal loss of mural stratification (odds ratio [OR], 11; 95%CI, 2.43–49.5, p = 0.002), and wall thickening (OR, 1.32; 95%CI, 1.05–1.66, p = 0.02) were significantly associated with SBA. After adjustment, focal loss of mural stratification was the only independent risk factor (OR, 11; 95 % CI, 2.43-49.5, p = 0.002).
Focal loss of mural stratification was identified as a predictor of CD-associated SBA, which should be described in imaging reports and further validated.
Gastrointestinal cancers in inflammatory bowel disease: An update with emphasis on imaging findings
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Hepatic metastases are present on CT in 14% of patients (Weber et al., 2015). On MR imaging, small bowel adenocarcinoma in CD patients may present as a long circumferential, asymmetric and heterogeneous ileal thickening with visible nodule on T2-weighted images or as a tumor mass of the terminal ileum, extending onto the cecum (Placé et al., 2012). This presentation on MR imaging differs from that of sporadic small bowel adenocarcinoma, which has predominantly an intraluminal growth (Van Weyenberg et al., 2010; Amzallag-Bellenger et al., 2013).
Inflammatory bowel diseases (IBD) are associated with an increased risk of gastrointestinal cancers depending on the specific type of IBD, the extent of the disease and its location. Patients with IBD and extensive colonic involvement are at increased risk of colorectal cancer whereas patients with Crohn disease have an increased risk for small-bowel and anal carcinoma. These cancers preferentially develop on sites of longstanding inflammation. In regards to colon cancer, several key pathogenic events are involved, including chromosomal instability, microsatellite instability and hypermethylation. The risk for colon cancer in IBD patients correlates with longer disease duration, presence of sclerosing cholangitis, pancolitis, family history of colorectal cancer, early onset of the disease and severity of bowel inflammation. Identification of increased colorectal cancer risk in individual IBD patients has led to formal surveillance guidelines. Conversely, although an increased risk for other types of cancer has been well identified, no specific formal screening recommendations exist. Consequently, the role of the radiologist is crucial to alert the referring gastroenterologist when a patient with IBD presents with unusual imaging findings at either computed tomography (CT) or magnetic resonance (MR) imaging. This review provides an update on demographics, molecular, clinical and histopathological features of gastrointestinal cancers in IBD patients including colorectal carcinoma, small bowel adenocarcinoma, neuroendocrine tumors and anal carcinoma, along with a special emphasis on the current role of CT and MR imaging.
Extra-intestinal malignancies in inflammatory bowel diseases: An update with emphasis on MDCT and MR imaging features
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Inflammatory bowel diseases (IBD) are associated with an increased risk of gastrointestinal cancers and more specifically in sites affected by chronic inflammation. However, patients with IBD have also an increased risk for developing a variety of extra-intestinal cancers. In this regard, hepatobiliary cancers, such as cholangiocarcinoma, are more frequently observed in IBD patients because of a high prevalence of primary sclerosing cholangitis, which is considered as a favoring condition. Extra-intestinal lymphomas, mostly non-Hodgkin lymphomas, and skin cancers are also observed with an increased incidence in IBD patients by comparison with that in patients without IBD. This review provides an update on demographics, risk factors and clinical features of extra-intestinal malignancies, including cholangiocarcinoma, hepatocellular carcinoma and lymphoma, that occur in patients with IBD along with a special emphasis on the multidetector row computed tomography and magnetic resonance imaging features of these uncommon conditions.
Adenocarcinoma in Crohn's disease: The pathologist's experience in a tertiary referral centre of inflammatory bowel disease
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The aim of the present study is to describe the histological and mutational characteristics of a series of both large and small bowel adenocarcinomas in patients with Crohn’s disease from a tertiary referral centre of inflammatory bowel disease. Bowel adenocarcinoma was diagnosed in 11 (1.7%) of 660 consecutive patients submitted to surgery for histologically proven Crohn’s disease in 5 years. The following data were collected: tumour site, stage and grade, intracellular/extra-cellular mucin, lymphovascular invasion, immunohistochem-istry for keratin 7, keratin 20 and CDX-2, mutation analyses of KRAS, B-RAF, PI3K and microsatellite instability. A strong predominance of male gender was observed (10/11). Four (36.4%) adenocarcinomas arose in the small bowel, five (45.4%) in the anus/rectum, and two (18.2%) in anastomosis. Furthermore, all cases of anorectal adenocarcinoma showed >50% of extracellular mucin, with associated KRAS mutations in three of five. No influence in cancer incidence by infliximab therapy was observed. Our series, one of the largest on the topic with immunomorphological and molecular deepening, showed that bowel adenocarcinomas in Crohn’s disease have an aggressive behaviour and a strong predominance of extracellular mucin. In surgical specimens from Crohn’s disease patients, mucinous-looking anal fistulas and ileal areas of adhesion/retraction should always be extensively sampled.
Computed tomography enterography and 18F-FDG PET/CT features of primary signet ring cell carcinoma of the small bowel in a patient with Crohn's disease
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A few cases of small-bowel carcinoma containing signet ring cells have been reported in patients with Crohn's disease (CD) [5,6]. In a recent work [6], Placé et al. described the magnetic resonance enterography features of an ileal mucinous adenocarcinoma containing signet ring cells in a patient with a 15-year history of CD. Histologically, inflammatory bowel disease (IBD)-related colorectal cancers contain signet ring cells in a higher proportion of cases than that observed in sporadic colorectal cancers.
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Original articleIleal adenocarcinoma in Crohn's disease: magnetic resonance enterography features

Abstract

Introduction

Section snippets

MR imaging protocol

Case 1

Discussion

Eur J Radiol

Clin Imaging

Clin Imaging

Acad Radiol

Inflammatory bowel disease

N Engl J Med

Small bowel adenocarcinoma complicating Crohn's disease: case series and review of the literature

Am Surg

Small bowel adenocarcinoma in Crohn's disease

Inflamm Bowel Dis

MR enterography with polyethylene glycol as oral contrast medium in the follow-up of patients with Crohn disease: comparison with CT enterography

Abdom Imaging

Assessment of Crohn's disease activity in the small bowel with MR-enteroclysis: clinico-radiological correlations

Abdom Imaging

Carcinoma of the small intestine and colon as a complication of Crohn disease: radiologic manifestations

Radiology

Adenocarcinoma of the ileum in Crohn disease

Abdom Imaging

A case of small bowel adenocarcinoma in a patient with Crohn's disease detected by PET/CT and double-balloon enteroscopy

World J Gastroenterol

Original article
Ileal adenocarcinoma in Crohn's disease: magnetic resonance enterography features