A Japanese male suffered severe appendicitis and received an ileosigmoidostomy without appendectomy in 1966. A prostatectomy was performed for benign prostate hypertrophy at the age of 67. He also received medical treatment for hypertension. A regular check-up in August 2006, when the patient was 72 years of age, revealed a positive fecal occult blood test. A colonoscopy was conducted by his family practitioner and an irregular mucosal lesion with an unclear margin was detected at the ileum mucosa adjacent to the anastomosis. Histological examination of a mucosal biopsy revealed a well differentiated adenocarcinoma. He was then referred to our hospital in October 2006.
He showed no abdominal complaints upon admission. Physical examination showed no abnormal findings other than the operation scar from the bypass operation. Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) were within the normal range. We conducted another colonoscopy and identified an ileo-colonic anastomosis 28 cm from the anal verge. It showed an irregular mucosal surface with a diameter of 4 cm at the ileum (Fig. ). Histological analysis of the mucosal biopsy showed a well differentiated adenocarcinoma of the ileum. A small bowel series and a large bowel series revealed an ileosigmoidostomy in the right lower abdomen. Abdominal computed tomography showed an area with mild thickening in the intestine below the right lower abdominal wall. There was no finding of lymph node swelling or liver metastases.
Colonoscopic findings from the colon side, showing a wide irregular mucosal lesion with white mucus at the ileum.
Surgical exploration was undertaken with the tentative diagnosis of carcinoma of the ileum. The ileosigmoidostomy was identified at the oral side of the ileum, 100 cm from the ileocecal valve. No definite tumor was detected at that anastomotic site. The anastomosis with 7 cm of ileum and 20 cm of sigmoid colon were resected collectively. The ileum was reconstructed by functional-end-to-end anastomosis and the sigmoid colon was reconstructed by the double stapling technique.
The resected specimen showed a flat mucosal lesion with a slight depression at the ileum adjacent to the anastomosis (Fig. ). Histological examination of the specimen revealed intramucosal adenocarcinoma (Tis). It was detected in the ileum mucosa and not at the sigmoid colon side (Fig. ). Immunohistological staining of p53 protein was performed for the resected specimen with carcinoma using D0-7 (Dako Cytomation, Inc. Carpinteria, CA, USA) as the first antibody and iVIEW DAB Detection kit (Ventana Medical Systems, Inc. Tucson, AZ, USA). Over-expression of p53 protein was observed at the dysplastic gland of the ileum (Fig. ).
Figure 2 The resected specimen showing the small bowel and sigmoid colon, including the anastomosis (black arrow). The flat lesion was widely spread around the ileum side of the anastomosis, but not infiltrating into the sigmoid colon. Adenocarcinoma was observed (more ...)
Well differentiated adenocarcinoma in the mucosal layer (A: hematoxylin and eosin, ×10, B: hematoxylin and eosin, ×100).
Over-expression of p53 protein was observed in the adenocarcinoma immunohistochemically.
We got an informed consent from the patient to use the patient's data for a case report.