Squamous cell carcinoma arising from longstanding colocutaneous fistula: a case report.

Abstract

A 60-year-old female patient suffered unhealed wounds over left flank for around 30 years after surgical removal of left renal stones. Fecal material spilled from the two small openings of the scar, bothered her all day long. During the course of the 30 years, she suffered from intermittent fever, diarrhea and wound pain and presented with malnourished condition. After serial examinations, tumor associated with iatrogenic colo-cutaneous fistula was impressed and she received en bloc resection. Pathology revealed squamous cell carcinoma arising from the fistula with colon and spleen invasion. To the best of our knowledge, no such case has been reported, as yet.

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• CASE REPORT •
Squamous cell carcinoma arising from longstanding colocutaneous
fistula: A case report
Yueh-Tsung Lee, Sheng-Der Hsu, Chien-Long Kuo, Dev-Aur Chou, Mao-Sheng Lin, Min-Ho Huang, Hurng-Sheng Wu
ELSEVIER
PO Box 2345, Beijing 100023, China World J Gastroenterol 2005;11(33):5251-5253
www.wjgnet.com World Journal of Gastroenterology ISSN 1007-9327
wjg@wjgnet.com © 2005 The WJG Press and Elsevier Inc. All rights reserved.
Yueh-Tsung Lee, Dev-Aur Chou, Min-Ho Huang, Hurng-Sheng
Wu, Division of General Surgery, Department of Surgery, Show-
Chwan Memorial Hospital, Changhua, Taiwan, China
Chien-Long Kuo, Department of Pathology, Show-Chwan Memorial
Hospital, Changhua, Taiwan, China
Sheng-Der Hsu, Division of General Surgery, Department of Surgery,
Tri-Service General Hospital, Taipei, Taiwan, China
Mao-Sheng Lin, Division of Urology, Department of Surgery, Show-
Chwan Memorial Hospital, Changhua, Taiwan, China
Supported by the National Natural Science Foundation of China,
No. 30224801
Correspondence to: Dr. Hurng-Sheng Wu, No 542 Sec.1, Chung-
Shang Rd, Changhua 500, Taiwan, China. m0931m@yahoo.com.tw
Telephone: +886-4-7256166 Fax: +886-4-7227116
Received: 2005-01-05 Accepted: 2005-03-21
AbstractAbstract
Abstract Abstract
Abstract
A 60-year-old female patient suffered unhealed wounds
over left flank for around 30 years after surgical removal
of left renal stones. Fecal material spilled from the two
small openings of the scar, bothered her all day long. During
the course of the 30 years, she suffered from intermittent
fever, diarrhea and wound pain and presented with
malnourished condition. After serial examinations, tumor
associated with iatrogenic colo-cutaneous fistula was
impressed and she received en bloc resection. Pathology
revealed squamous cell carcinoma arising from the fistula
with colon and spleen invasion. To the best of our knowledge,
no such case has been reported, as yet.
© 2005 The WJG Press and Elsevier Inc. All rights reserved.
Key words: Squamous cell carcinoma; Colo-cutaneous fistula
Lee YT, Hsu SD, Kuo CL, Chou DA, Lin MS, Huang MH, Wu HS.
Squamous cell carcinoma arising from longstanding
colocutaneous fistula: A case report. World J Gastroenterol
2005; 11(33): 5251-5253
http://www.wjgnet.com/1007-9327/11/5251.asp
INTRODUCTIONINTRODUCTION
INTRODUCTIONINTRODUCTION
INTRODUCTION
Malignant tumors arising from previously existing fistulas
are rare. Squamous cell carcinoma arising from colocutaneous
fistula has never been reported. Herein, we report a case
of squamous cell carcinoma arising from previously existing
longstanding colocutaneous fistula. The diagnosis made
has been based on high suspicion, history, imaging and
pathology.
CASE REPORT CASE REPORT
CASE REPORTCASE REPORT
CASE REPORT
A 60-year-old female patient was admitted due to general
weakness, anorexia accompanied with fever and chills for
2 wk. She denied any other systemic disease. The patient
originally was diagnosed with left renal stones and had left
nephrectomy, at some other hospital three decades ago.
She got stool spillage from surgical wound on left flank
after that surgery. Despite wound treatment, two fistulous
openings were left with intermittent fecal discharge. During
this period, she received supportive treatment while infective
symptoms such as fever, chills, diarrhea and local cellulites
were present.
We noted that she was a cachectic, frail female with pale
conjunctivae. The abdomen was palpated without tenderness
and the bowels were normally peristaltic on auscultation.
Two chronic unhealing wounds involving the left flank with
fecal discharge were noted (Figure 1A). Local erythematous,
swollen and tender to palpated were noted. No enlarged
lymph nodes were palpated. Anemia (Hb 4.4 g/dL) and
chronic renal insufficiency (Cr 2.3 mg/dL) were noted.
Abdominal computed tomography discovered splenomegaly
with soft tissue density adjacent to it and the splenic flexure
of T-colon with air bubbles (Figure 1B). After infection
had subsided, fistulograms revealed communication between
skin and bowel tract (Figures 1C and D). Under a period of
nutritional support, surgical intervention was performed.
At laparotomy, the low pole of the spleen adhered to the
splenic flexure of T-colon densely with irregular soft tissue
beside the region (Figure 1E). Partial wall of the jejunum, 10
cm distal to Treitz’s ligament, adhered to the distal T-colon
was noted (Figure 1F). En bloc resection with splenectomy,
segmental resection of colon with primary anastomosis and
wedge resection of jejunum were performed (Figure 1G).
Postoperative course was grossly smooth. She is being
followed up at the outpatient department.
The pathologist reported moderately differentiated squamous
cell carcinoma in virtually all specimens (Figure 2A).
However, the microscopic photographs revealed the tumor
cells arising from the fistulas (Figure 2B) with spleen (Figure 2C)
and colon invasion (Figure 2D).
DISCUSSIONDISCUSSION
DISCUSSION DISCUSSION
DISCUSSION
It is well-known that surgery is still the most common
cause of entero-cutaneous fistula. The causes of persistent
entero-cutaneous fistula include foreign body, radiation,
infection, inflammation, epithelization, neoplasm and distal
obstruction[1]. Squamous cell carcinoma can develop from
chronic ulcers, scars, wounds, sinuses, and fistulas[2]. The
latent periods are long and take around 37 years for patients

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5252 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol September 7, 2005 Volume 11 Number 33
Figure 1 A: Surgical scar over left flank with two fistulous openings; B:
Abdom inal CT scan revealed irregular m ass between the pancreatic tail, spleen
and left lateral abdominal wall with air bubbles; C: The fistulogram revealed
communication between the skin and sinus tract; D: The fistulogram revealed
communication between the skin and intestinal tract; E: At laparotomy,
splenomegaly and dense adhesion to the splenic flexure of colon (arrow) and
the left abdom inal wall were noted; F: The drawing revealed the relation between
the fragile soft mass, the fistulas, the spleen and the bowels; G: The specimen
was shown and these two openings in the colon communicating with skin were
indexed with the instruments.
Figure 2 Microscopic photograph. A: The squamous cancer cells and keratin
pearls (arrow) were shown on the m icroscopic photograph; B: The pathological
photograph revealed fistulous tract (arrow) and the tumor cells arose from its
epithelium; C: The microscopic photograph revealed the tumor cells (arrow)
invading the spleen (triangular arrow); D: The m icroscopic photograph revealed
the tumor cells (arrow) invading the colon (triangular arrow).
with burn scars except 1-7 years for immunocompromised
patients[2,3]. The most significant factor reported in predicting
the outcome for the squamous cell carcinoma from the
pre-existing scar or sinus was the grade of the tumor[4].
Squamous cell carcinoma associated with prior renal stones
have always been reported[5] and the median survival time
was 3.6 mo[6]. It was dismal and was not compatible with
the long-term history of the patients. We might consider
A
CD
E
B
F
G
ACDB

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Lee YT et al. SCC arising from colocutaneous fistula 5253
the development of squamous cell carcinoma as the result
of chronic irritation and infection due to unhealed wounds[7].
The strong evidence was that the microscopic photographs
revealed the origination of tumor cells from the epithelium of
the fistulous tract. However, there are no prior reported articles
available as this case. Because of its insidious course, the long-
standing colo-cutaneous fistula should be examined carefully
for tumor development. The early nutritional intervention
is important for patients with entero-cutaneous fistula[8] and
surgery is inevitable for long-term unhealed fistula.
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