CASE 13353 Published on 12.02.2016

Spontaneous cutaneous fistulisation of colon carcinoma

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Tonolini Massimo, MD.

"Luigi Sacco" University Hospital,Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org

Patient

92 years, male

Categories

Area of Interest Colon ; Imaging Technique CT

Procedure Staging ; Special Focus Fistula ;

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Clinical History

An elderly male presented with hypertension, a cardiac pacemaker, ischemic heart disease (previous coronary stenting years earlier), and remote history of removed colonic polyps. The patient complained of worsening right-sided abdominal pain, but had normal bowel movements.
Physical examinations revealed absent peritonism, palpation tenderness at the right iliac fossa and draining cutaneous orifice at the anterior abdominal wall.

Imaging Findings

Multiplanar images from contrast-enhanced multidetector CT (Fig.1) revealed a segmental (6-cm long) solid, non-stratified circumferential thickening of the ascending colon, strongly suspicious of primary tumour. The lesion infiltrated the peritoneum ventrally, and was indissociable from the thickened oedematous musculature of the right abdominal wall. The latter contained an abscess cavity with mixed fluid and air content, which communicated to the skin through a cutaneous fistula. Additionally, bilateral pleural effusions and multiple small-sized hypovascular liver metastases with consistent with "target" appearance were present. Ascites and abnormal lymphadenopathies were absent.
Abnormal laboratory data included elevated anaemia, elevated lactate-dehydrogenase (251 U/l) and C-reactive protein (53 mg/l), and chronic kidney impairment.
Colonoscopy and biopsies confirmed ascending colon adenocarcinoma. Surgery and chemotherapy were deemed unfeasible due to the patients' age. The patient was treated supportively with transfusions and positioning of a colostomy-type bag at the cutaneous fistula.

Discussion

Due to improved standards of medical care, nowadays spontaneous enterocutaneous fistulisation (SECF) is exceptionally encountered. Clinically, SECF manifests with foul-smelling purulent or fecal discharge, pain and fever. Physical findings include draining orifices and tender firm masses of the abdominal wall with overlying cellulitis. Currently, most cases occur as complications of known long-standing or undiagnosed active ileal Crohn’s disease [1].
Alternatively, although most colorectal carcinomas (CRC) are currently detected early or in a preclinical phase, SECF from underlying malignancy is occasionally encountered, particularly in elderly patients with multiple comorbidities [2]. Very uncommon compared to bowel obstruction, CRC perforation may be further complicated by intra-abdominal abscess formation, free peritonitis, fistulisation with the urinary bladder or female genital organs, and psoas muscles in descending order of frequency. According to sparse case reports, advanced tumours may perforate the serosa, invade the abdominal wall muscles, fistulise through the subcutaneous fat, and finally reach the skin at either the anterior or lateral abdominal wall. This exceptional occurrence is strongly associated (more than half of cases) with advanced, metastatic disease [3-8].
As this case exemplifies, multidetector CT with multiplanar reformations allows comprehensive diagnosis of malignant SECF including identification of marked, irregular or asymmetric mural colonic thickening. Short segmental involvement, abrupt transition, loss of stratified mural enhancement, and presence of lymphadenopathy support a diagnosis of underlying CRC. Furthermore, cross-sectional imaging allows depicting tumour penetration through the peritoneal serosa, invasion of the abdominal wall muscles, presence of fluid-filled abscess cavities or fistulous tracks coursing through the abdominal wall and subcutaneous fat [4, 9-11]. The key differential diagnosis is represented by mass-forming CRC extending to the skin through direct invasion through the muscles and subcutaneous planes [12].
Therefore, the presence of an underlying perforated CRC should be suspected when faced with a SECF in adults or elderly patients. Neoplastic SECFs represent difficult situations associated with malnutrition, sepsis, severely impaired quality of life, and high 30-day mortality. The limited therapeutic options mostly include en bloc resection with derivative colostomy or ileostomy, and stoma alone in unresectable tumours or moribund patients [2, 8].

Differential Diagnosis List

Spontaneous cutaneous fistulisation of ascending colon carcinoma with liver metastases.

Colorectal carcinoma with direct abdominal wall and cutaneous invasion

Abdominal wall abscess e.g. in sepsis

Colonic lymphoma

Colonic actinomycosis

Colonic tuberculosis

Fistulising Crohn’s disease

Postoperative enterocutaneous fistula

Final Diagnosis

Spontaneous cutaneous fistulisation of ascending colon carcinoma with liver metastases.

References

[1] Cellini C, Safar B, Fleshman J (2010) Surgical management of pyogenic complications of Crohn's disease. Inflamm Bowel Dis 16:512-517. (PMID: 20049952)

[2] Chamberlain RS, Kaufman HL, Danforth DN (1998) Enterocutaneous fistula in cancer patients: etiology, management, outcome, and impact on further treatment. Am Surg 64:1204-1211 (PMID: 9843347)

[3] Kumar A, Pahwa H, Srivastava R, et al. (2012) Multiple spontaneous enterocutaneous fistulae on back: a rare presentation of colonic malignancy. BMJ Case Rep doi: 10.1136/bcr-2012-007119 (PMID: 23144346)

[4] Bogdanic B, Augustin G, Kekez T, et al. (2012) Perforated ascending colon cancer presenting as colocutaneous fistula with abscess to the anterior abdominal wall at the site of a cholecystectomy scar treated with biologic mesh. Coll Antropol 36:335-338 (PMID: 22816243)

[5] Al-Hendal A, Al-Masri W, Al-Mishaan M, et al. (2009) Abscess of the abdominal wall resulting from perforated ascending colon cancer. Gulf J Oncolog: Jan;(5):60-3. (PMID: 20084789)

[6] ElGendy K, Al Duhileb M, Salem A (2014) Transverse colon cancer presenting as acute abdominal wall abscess. BMJ Case Rep doi: 10.1136/bcr-2014-204105. (PMID: 24798363)

[7] Ahnen DJ, Macrae F, Bendell JC (2015) Clinical presentation, diagnosis and staging of colorectal cancer. UptoDate Topic 2496 Version 46.0: :Available at: http://www.uptodate.com/contents/clinical-presentation-diagnosis-and-staging-of-colorectal cancer

[8] Osian G (2012) Emergency Surgery for Colorectal Cancer Complications: Obstruction, Perforation, Bleeding. Contemporary Issues in Colorectal Surgical Practice, Dr Yik- Hong Ho (Ed) InTech, Available from: http://www.intechopen.com/books/contemporary-issues-in-colorectal-surgicalpractice/emergency-surgery-for-colorectal-cancer-complications.

[9] Kim SW, Shin HC, Kim IY, et al. (2010) CT findings of colonic complications associated with colon cancer. Korean J Radiol 11:211-221 (PMID: 20191069)

[10] Catalano O (1997) Perforated carcinoma of the colorectum. Computerized tomography findings. Radiol Med 93:83-86. (PMID: 9380875)

[11] Yeo ES, Ng KH, Eu KW (2011) Perforated colorectal cancer: an important differential diagnosis in all presumed diverticular abscesses. Ann Acad Med Singapore 40:375-37 (PMID: 22065004)

[12] Achanta CR, Dahiya D, Garg M, et al. (2013) Education and Imaging. Gastrointestinal: colon cancer with cutaneous infiltration. J Gastroenterol Hepatol 28:762 (PMID: 23614342)

Case information

URL:	https://www.eurorad.org/case/13353
DOI:	10.1594/EURORAD/CASE.13353
ISSN:	1563-4086

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This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Multiplanar images from contrast-enhanced multidetector CT

Axial images showed bilateral pleural effusion, and multiple hypovascular lesions (short arrows) with "target" appearance consistent with metastases, up to 3 cm in size.

Coronal reconstruction showed a 6-cm long, non-stratified solid segmental thickening (arrows) of the ascending colon suggesting primary tumour. Note hypovascular liver metastasis (short arrow).

Axial (d) and sagittal (e) images confirmed solid neoplastic thickening of the ascending colon (arrows), infiltrating the peritoneum (arrowhead) and indissociable from the thickened oedematous (*) abdominal wall musculature containing an abscess cavity (+).

The circumferential neoplastic thickening of the ascending colon (arrows) infiltrated the peritoneum (arrowhead) and was indissociable from the thickened abdominal wall musculature, which contained an abscess (+) communicating with a cutaneous fistula (thin arrow).

Additional focused oblique reconstructions showed the thickened oedematous (*) right abdominal wall musculature containing an abscess cavity (+).

Additional focused oblique reconstructions showed the thickened oedematous (*) right abdominal wall musculature containing an abscess cavity (+), communicating to the skin through a cutaneous fistula (thin arrow).