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American Board of Abdominal Surgery


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ABDOMINAL SURGERY

Official Journal of the American Society of Abdominal Surgeons, Inc.

This article originally appeared in the Winter 2013 / Spring 2014 issue of the Journal.

Parastomal Squamous Cell Carcinoma

Bashir Attuwaybi, M.D.
Deepa Taggarshe, M.D.
Joseph Leberer, M.D.
Jeffrey Visco, M.D.

Colon and Rectal Surgery
University at Buffalo, Buffalo, NY, USA

Address for correspondence:
Bashir Attuwaybi, M.D., F.A.C.S., F.I.C.S.
Department of Colon & Rectal Surgery
University at Buffalo, New York
Buffalo Medical Group
4955 N. Baily Avenue, Suite 201
University at Buffalo, Buffalo, NY, USA
Amherst, New York 14226
Tel: 716-630-1086
Fax: 716-250-5949
E-mail: attuwaybibashir@gmail.com


Figure 1
A fungating growth visible at the stoma

click to enlarge

ABSTRACT

Squamous cell carcinoma of the ileostomy is an extremely rare occurrence. These cases we report are among many cases reported of a primary squamous cell carcinoma originating from the ileostomy site. The first case occurred in 1966 in a 76-year-old woman 53 years after a total proctocolectomy for ulcerative colitis.1 Philips and colleague published in the Journal of Diseases of Colon and Rectum reviewed cases since 1966 until 2005 and they found 36 cases reported.4

Since 2005 four more cases reported in the English literature and in this paper we add three more cases from our practice with end ileostomy adenocarcinoma.

CASE REPORT

This patient was a 78 year old female with a history of chronic obstructive pulmonary disease who presented with an exophytic mass lateral to her ileostomy site (Figure 1). She had a history of ulcerative colitis for which she had a total proctocolectomy with end ileostomy at age 16. Physical exam was significant for an ileostomy in the right lower quadrant as well as an 8 x 8 centimeter exophytic friable lesion about half a centimeter lateral to the stoma (Figure 1). There was no inguinal lymphadenopathy. A biopsy done in the office showed a well differentiated squamous cell carcinoma. A preoperative workup showed localized disease with absence of metastatic disease.

PATHOLOGY SLIDE
OF FIGURE 2.

A picture of the pathology of the mass at the ileostomy.

click to enlarge
PATHOLOGY SLIDE
OF FIGURE 2 B.

A picture of the pathology of the mass at the ileostomy.

click to enlarge
FIGURE 3.
Mucinous adenocarcinoma at the ileostomy.

click to enlarge

The patient was taken to the OR for an exploratory laparotomy, takedown of the existing ileostomy, and resiting of the stoma to the left lower quadrant. A wide local excision of the malignant abdominal wall lesion was done with a 1.5 to 2 centimeter margin of normal tissue which included en bloc removal of the remnants of the ileostomy itself.

Her hospital course was complicated by renal insufficiency and a wound infection at the old ileostomy site. She was transferred to a rehabilitation facility two weeks postoperatively.

The final pathology showed invasive, moderately differentiated squamous cell carcinoma (Figure 2). The lesion measured 6.8 x 5.5 x 3.5 cm. Squamous cell carcinoma in situ involved small bowel mucosa at the stoma. The distal small bowel margin was negative for tumor.

As of two and half years postoperatively the patient was doing well. The wound was granulating and there was no evidence of local recurrence.

In our practice we had two more cases with end ileostomy with primary tumor the first one is 86 years old male (Figure 3) with multiple medical problem underwent right hemicolectomy for carcinoid tumor in 2001 did well and in 2005 patient developed left side colon cancer and underwent left colon resection with end ileostomy early 2013 patient presented with ileostomy issues like bleeding and skin irritation biopsy showed mucinous adenocarcinoma patient underwent resection and relocation. The other patient is 64 year old female with history of low rectal cancer and right side cancer underwent total proctocolectomy and end ileostomy 16 months ago presented with ileostomy irritation biopsy showed adenocarcinoma. Patient recent PET scan was negative.

DISCUSSION

The development of squamous cell cancer around an ileostomy site is very rare. As a matter of fact, from reviewing all the literature since 1966 up to now 2013 with inclusion of our cases 30 cases of ilesotomy adenocarcinoma developed from patients who underwent proctocolectomy for ulcerative colitis, 9 patients underwent proctocolectomy for familial adenomatous polyposis, two patients with history of Crohn's disease and the lastly two patients with history of colon cancer, ileostomy squamous cell carcinoma. All of these cases occurred in patients decades after total proctocolectomy except couple of cases with colon cancer where there ileostomy cancer developed in couple of years.

Most patients probably developed squamous cell carcinoma as a result of years of chronic irritation of the skin around the ileostomy site. Chronic irritation leading to the development of squamous cell carcinoma is well documented in the literature.5-7 Patients who present with chronic non-healing parastomal ulcers should have them biopsied to facilitate the diagnosis of this rare complication. Appropriate treatment of this condition is by wide excision and relocation of the stoma in the setting of localized disease.

CONCLUSION

Paraileostomy squamous cell cancer is a rare occurrence. These cases demonstrate the importance of close followup of patients with stomas. Patients with non healing ulcers or lesions around the stoma should have biopsies performed. The proper treatment is wide local excision with resiting of the stoma.

REFERENCES

1. O'Connell PR, Dozois RR, Irons GB, Scheithauer BW. Squamous Cell Carcinoma Occurring in a Skin-Grafted Ileostomy Stoma: report of a case. Dis Colon Rectum. 1987; 30:475-478.

2. Wu JS, Schlek BA, Fazio VW. Parastomal Squamous Cell Carcinoma in an Ileostomy 44 Years after Proctocolectomy. J Am Coll Surg. 2000; 191:107.

3. Carne PW, Farmer KC. Squamous-Cell Carcinoma Developing in an Ileostomy Stoma: report of a case. Dis Colon Rectum. 2001; 44:594.

4. Ramanujam P, Venkatesh KS. An Unusual Case of Squamous Cell Carcinoma Arising at the Stomal Site: Case Report and Review of the Literature. J Gastrointest Surg. 2002; 6:630-631.

5. Barr LH, Menard JW. Marjolin's ulcer: The LSU experience. Cancer. 1983; 52:173-175.

6. Arons MS, Lynch JR, Lewis SR, Blocker TG Jr. Scar tissue carcinoma. Part I. A clinical study with special reference to burn scar carcinoma. Ann Surg. 1965; 161:170-188.

7. Gordon SW. Epidermoid carcinoma arising in hidradenitis suppurativa: Case report. Plast Reconstr Surg. 1977; 60: 800-802.

8. Metzger PP. Slappy AL. Chua HK. Menke DM. Adenocarcinoma developing at an ileostomy: report of a case and review of the literature. Diseases of the Colon & Rectum. 51(5):604-9, 2008 May



Journal CoverOFFICIAL PUBLICATION OF:
The American Board of Abdominal Surgery
The American Society of Abdominal Surgeons, Inc.
Foundation for Abdominal Surgery

Louis F. Alfano, Jr., M.D., Editor-in-Chief
Diane M. Pothier, Executive Editor and
Director of Continuing Medical Education


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Figure 1
A fungating growth visible at the stoma

PATHOLOGY SLIDE OF FIGURE 2.
A picture of the pathology of the mass at the ileostomy.

PATHOLOGY SLIDE OF FIGURE 2 B
A picture of the pathology of the mass at the ileostomy.

FIGURE 3.
Mucinous adenocarcinoma at the ileostomy.