Verrucous carcinoma at ileostomy site

Abstract

We describe of a case, a 50 year old male who was operated for carcinoma of the descending colon and diverting loop ileostomy, developed a fungating lesion in mucocutaneous junction of ileostomy after one year which on histology revealed to be a Verrucous carcinoma. Resumo: Descrevemos um caso, homem, 50 anos, que foi operado para carcinoma de cólon descendente e ileostomia em alça para desvio. Transcorrido um ano, o paciente desenvolveu uma lesão vegetante na junção mucocutânea da ileostomia; a histologia revelou ser um carcinoma verrucoso. Keywords: Ileostomy, Verrucous carcinoma, Mucocutaneous junction, Palavras-chave: Ileostomia, Carcinoma verrucoso, Junção mucocutânea

Full text

JCOL
228
1–3
Please
cite
this
article
in
press
as:
Dhakre
V,
Nagral
S.
Verrucous
carcinoma
at
ileostomy
site.
J
Coloproctol
(Rio
J).
2017.
http://dx.doi.org/10.1016/j.jcol.2017.05.002
ARTICLE IN PRESS
JCOL
228
1–3
j
coloproctol
(rio
j).
2
0
1
7;x
x
x(x
x):xxx–xxx
www.jcol.org.br
Journal
of
Coloproctology
Case
Report
Verrucous
carcinoma
at
ileostomy
site
Vijay
Dhakre∗,
Sanjay
Nagral
Q1
Jaslok
Hospital
and
Research
Centre,
Mumbai,
India
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
12
January
2017
Accepted
1
May
2017
Available
online
xxx
Keywords:
Q3
Ileostomy
Verrucous
carcinoma
a
b
s
t
r
a
c
t
We
describe
of
a
case,
a
50
year
old
male
who
was
operated
for
carcinoma
of
the
descending
colon
and
diverting
loop
ileostomy,
developed
a
fungating
lesion
in
mucocutaneous
junction
of
ileostomy
after
one
year
which
on
histology
revealed
to
be
a
Verrucous
carcinoma
(VC).
Q2
©
2017
Sociedade
Brasileira
de
Coloproctologia.
Published
by
Elsevier
Editora
Ltda.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Carcinoma
verrucoso
em
local
de
ileostomia
Palavras-chave:
Ileostomia
Carcinoma
verrucoso
r
e
s
u
m
o
Descrevemos
um
caso,
homem,
50
anos,
que
foi
operado
para
carcinoma
de
cólon
descen-
dente
e
ileostomia
em
alc¸a
para
desvio.
Transcorrido
um
ano,
o
paciente
desenvolveu
uma
lesão
vegetante
na
junc¸ão
mucocutânea
da
ileostomia;
a
histologia
revelou
ser
um
carci-
noma
verrucoso
(CV).
©
2017
Sociedade
Brasileira
de
Coloproctologia.
Publicado
por
Elsevier
Editora
Ltda.
Este
´
e
um
artigo
Open
Access
sob
uma
licenc¸a
CC
BY-NC-ND
(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Introduction
Complications
of
stomal
site
are
often
encountered
by
clinicians1but
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
carcinoma.
∗Corresponding
author.
E-mail:
vddrvijayd@gmail.com
(V.
Dhakre).
Case
report
A
50
year
old
male
seropositive
for
human
immunodeficiency
virus
(HIV)
was
planned
for
a
loop
ileostomy
closure
after
one
year
of
anterior
resection
for
adenocarcinoma
of
descending
colon.
Patient
had
received
adjuvant
chemotherapy.
Patient
was
also
on
HAART
(highly
active
anti-retroviral
therapy)
for
HIV
infection.
http://dx.doi.org/10.1016/j.jcol.2017.05.002
2237-9363/©
2017
Sociedade
Brasileira
de
Coloproctologia.
Published
by
Elsevier
Editora
Ltda.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

JCOL
228
1–3
Please
cite
this
article
in
press
as:
Dhakre
V,
Nagral
S.
Verrucous
carcinoma
at
ileostomy
site.
J
Coloproctol
(Rio
J).
2017.
http://dx.doi.org/10.1016/j.jcol.2017.05.002
ARTICLE IN PRESS
JCOL
228
1–3
2
j
coloproctol
(rio
j).
2
0
1
7;x
x
x(x
x):xxx–xxx
Fig.
1
–
Intraoperative
ileostomy
site
with
the
lesion
(black
arrow)
in
the
superomedial
mucocutaneous
junction
which
is
dissected
and
mobilized.
Fig.
2
–
Marked
acanthosis
with
broad
bulbous
process
(black
arrow
head).
The
bulbous
rete
processes
“push”
deep
into
the
lamina
propria
so
that
the
base
of
the
lesion
is
below
the
adjacent
basement
membrane.
Before
stoma
closure
CT
scan
had
shown
normal
distal
bowel
and
no
evidence
of
recurrence.
Three
months
prior
to
the
closure;
patient
had
reported
oozing
of
blood
from
the
stomal
site.
A
local
examination
revealed
an
area
of
hyper-
granulation
which
was
attributed
to
chronic
irritation
and
was
left
alone.
During
the
surgery
we
noticed
a
small
fungating
mass
on
the
right
lateral
edge
of
the
mucocutaneous
site
(Fig.
1).
In
view
of
suspicion
of
malignancy
a
wide
local
resection
of
the
loop
ileostomy
was
performed,
keeping
a
margin
of
2
cm
over
the
skin
and
abdominal
wall
layers
(Fig.
2).
Patient
is
well
after
six
months
after
surgery
without
evi-
dence
of
recurrence.
Discussion
Complications
of
stoma
are
well
described
and
include
stomal
herniation,
prolapse
of
stoma,
retraction,
skin
excoriation,
intestinal
obstruction,
stenosis,
abscess,
fistula,
diarrhoea,
urinary
calculus,
ileitis,
and
inflammatory
polyps.1Develop-
ment
of
malignancy
at
ileostomy
in
is
rare2Suarez
et
al.
estimated
the
incidence
of
ileostomy
carcinomas
in
patients
with
ileostomy
for
various
indications
in
the
UK
to
be
2
to
4
per
1000
ileostomies.
Squamous
cell
carcinoma
(SSC)
have
been
described
commonly
in
HIV
positive
patients
at
muco-
cutaneous
junctions
specially
anorectal
junction.3However
to
our
knowledge
VC
has
not
being
described
at
the
ileostomy
site,
although
there
are
reports
of
SCC.
Till
date
only
a
few
cases
of
SCC
at
ileostomy
have
been
described.4Ulcerative
colitis
was
the
most
common
under-
lying
condition;
Farshid
in
their
review
described
timing
of
lesion
from
ileostomy
fashioning
was
in
the
range
of
26
years
to
54
years.
In
our
case
this
time
was
very
short
(12
months).
Maw
et
al.5had
mentioned
in
their
case
series
of
44
stomal
neoplasms;
described
40
adenocarcinomas
and
four
squa-
mous
cell
carcinoma,
but
no
VC
variant
was
described.
They
described
of
ileostomy
neoplasm
associated
with
Crohn’s
dis-
ease,
familial
adenomatous
polyposis
and
ulcerative
colitis.
They
postulated
that
chronic
irritation
predisposed
the
stoma
to
malignant
changes.
They
discussed
a
strong
association
in
patient
with
chronic
diseases
like
ulcerative
colitis
or
primary
sclerosing
cholangitis
making
it
a
high
risk
group
for
ileostomy
neoplasms.
The
chronic
irritation
theory
is
supported
by
the
fact
that
majority
of
stomal
carcinoma
have
been
described
only
in
long
standing
permanent
stomas.6In
the
setting
of
HIV,
human
papilloma
virus
(HPV)
infection
is
well
known
to
predispose
to
carcinomas.
Viral
interactions
in
HPV
can
pre-
dispose
to
VC.6In
our
case
though
the
immunohitochemical
analysis
for
HPV
was
negative.
The
E6/E7
viral
oncoproteins
of
HPV
are
proved
to
inactivate
the
tumour
suppressor
gene
like
p53
and
pRb
which
in
turn
lead
to
the
cell
proliferation
and
eventually
turning
them
in
to
malignant
cells.
Highly
active
anti-retroviral
therapy
(HAART)
modulating
the
immune
is
also
taken
into
account
while
considering
interactions
of
these
viruses.7
Overall
risk
of
carcinomas
in
HIV
patients
is
more
than
in
general
population.7Moreover
associations
of
HIV
–
non-
Hodgkin’s
lymphoma
(NHL)
at
ileostomy
site
specifically
because
of
microtraumatisms
and
locally
present
antigen
stimulation
and
activation
has
been
discussed
in
their
work
by
Levecq
et
al.3
Also
it
is
pertinent
to
mention
activation
of
signalling
path-
ways
like
Akt/mTOR
which
can
get
activated
and
is
also
known
to
cause
VC
in
oral
malignancy.8
Conclusion
Peristomal
carcinoma
is
a
rare
entity.
VC
(a
rare
form
of
SCC)
may
arise
as
a
lesion
from
an
ileostomy.
A
clinician
must
sus-
pect
malignancy
when
there
is
a
hypergranulation
or
mass
like
lesion
at
ileostomy
site.
Immunodeficiency
conditions
like
HIV
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94

JCOL
228
1–3
Please
cite
this
article
in
press
as:
Dhakre
V,
Nagral
S.
Verrucous
carcinoma
at
ileostomy
site.
J
Coloproctol
(Rio
J).
2017.
http://dx.doi.org/10.1016/j.jcol.2017.05.002
ARTICLE IN PRESS
JCOL
228
1–3
j
coloproctol
(rio
j).
2
0
1
7;x
x
x(x
x):xxx–xxx
3
should
be
considered
a
high
risk
group
for
such
rare
forms
of
malignancy.
Conflicts
of
interest
The
authors
declare
no
conflicts
of
interest.
Acknowledgements
Dr
Vijay
Dhakre
designed
and
wrote
up
the
article
with
review
of
literature
and
procuring
the
data,
Dr
Sanjay
Nagral
finalized
the
article
and
literature
review.
r
e
f
e
r
e
n
c
e
s
1.
Attanoos
R,
Billings
P,
Hughes
L,
Williams
G.
Ileostomy
polyps,
adenomas,
and
adenocarcinomas.
Gut.
1995;37:840–4.
2.
Suarez
V,
Alexander-Williams
J,
O’Connor
J,
Campos
A,
Fuggle
J,
Thompson
H,
et
al.
Carcinoma
developing
in
ileostomies
after
25
or
more
years.
Gastroenterology.
1988;95:205–8.
3.
Levecq
H,
Hautefeuille
M,
Hoang
C,
Galian
A,
Hautefeuille
P,
Rambaud
JC.
Primary
stomal
lymphoma.
An
unusual
complication
of
ileostomy
in
a
patient
with
transfusion-related
acquired
immune
deficiency
syndrome.
Cancer.
2006;65:1028–32.
4.
Farshid
E,
Metin
N,
Rangasamy
S.
Squamous
cell
carcinoma
at
an
ileostomy
site
–
Fiftyfour
years
following
colectomy
for
ulcerative
colitis:
a
case
report
and
literature
review.
Int
J
Surg
Case
Rep.
2013;4:678–80.
5.
Quah
HM,
Samad
A,
Maw
A.
Ileostomy
carcinomas
a
review:
the
latent
risk
after
colectomy
for
ulcerative
colitis
and
familial
adenomatous
polyposis.
Colorectal
Dis.
2005;7:
538–44.
6.
Tonna
J,
Palefsky
JM,
Rabban
J,
Campos
GM,
Theodore
P,
Ladabaum
U.
Esophageal
verrucous
carcinoma
arising
from
hyperkeratotic
plaques
associated
with
human
papilloma
virus
type
51.
Dis
Esophagus.
2010;23:E17–20.
7.
Righetti
E,
Ballon
G,
Ometto
L,
Cattelan
AM,
Menin
C,
Zanchetta
M,
et
al.
Dynamics
of
Epstein–Barr
virus
in
HIV-1-infected
subjects
on
highly
active
antiretroviral
therapy.
AIDS.
2002;16:63–73.
8.
Chaisuparat
R,
Limpiwatana
S,
Kongpanitkul
S,
Yodsanga
S,
Jham
BC.
The
Akt/mTOR
pathway
is
activated
in
verrucous
carcinoma
of
the
oral
cavity.
J
Oral
Pathol
Med.
2016;45:581–5.
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130