Malignant Gastrocolic Fistula as a Late Complication of Radiation Therapy

• DOI: 10.1007/s12029-012-9399-9
• Publication Date: 2012-06-20T15:48:25Z
• Authors: Joan Costelloe; Clare O’Connell; Orla Mc Cormack; Finbar MacCarthy; Darragh F. Halpenny; Ramadan Shatwan; Cian Muldoon; Narayanasamy Ravi; John V. Reynolds
• Keywords: Gastric Fistula; Male; Radiotherapy; Middle Aged; Prognosis; 3. Good health; Colonic Diseases; 03 medical and health sciences; 0302 clinical medicine; Testicular Neoplasms; Intestinal Fistula; Humans; Tomography, X-Ray Computed

Malignant gastrocolic fistula is a rare mode of presentation of gastric or colonic carcinoma [1–3]. A benign aetiology is more common, including peptic ulcer disease, particularly benign gastric ulcers which may relate to non-steroidal antiinflammatory use. Other benign causes include inflammatory bowel disease, post-PEG insertion, post-gastroenterostomy, pancreatitis, abdominal tuberculosis, trauma, perforated diverticular disease and infections including CMV, histoplasmosis, actinomycosis, amoebiasis, echinococcosis and lymphogranuloma venereum [2, 4–7]. A malignant gastrocolic fistula is most commonly found between the greater curvature of the stomach and the distal half of the transverse colon [8]. They are usually seen in the setting of large infiltrative tumours with a surrounding inflammatory reaction, and lymph node involvement is uncommon [8]. The colon rather than the stomach is the more usual site of origin. In a review of 1,500 cases of stomach cancer and 3,200 cases of colon cancer at the Lahey Clinic, 11 cases of gastrocolic fistula were reported, with 10 being of colonic origin [9]. Radiation therapy is associated with an increased risk of second cancers. Abdominal radiation therapy has been most frequently administered in the context of testicular cancer, where the overall cure rate is greater than 90 % [10]. The average age of presentation of testicular cancer is 35, and second neoplasms are uncommon but well-recognised complications where radiation therapy has been given [11–14]. Exposure to radiation may induce a broad variety of DNA damage including singleand double-stranded DNA breaks, cross-linking and damage to nucleotide bases [15]. Radiation-related genomic instability enhances the rate at which mutations and epigenetic changes are acquired in the descendants of that cell line after many generations of replication. In a cohort study of 40, 576 survivors of testicular cancer, Travis et al. reported on 2,285 second solid tumours observed where 1,619 new cancers were expected, demonstrating an elevated relative risk (ERR) as well as an excess absolute risk of developing a second neoplasm in comparison with the general population [16]. A further report of 5,142 patients treated with radiation therapy describes a 3.4fold increased risk of stomach cancer in survivors of testicular cancer and Hodgkin’s lymphoma [17]. This study found that the risk of second cancer begins approximately 10– 15 years after the original cancer diagnosis. We report herein a case of an adenocarcinoma presenting acutely as a J. Costelloe : C. O’Connell :O. Mc Cormack :N. Ravi : J. V. Reynolds Department of Surgery, St. James’s Hospital, Dublin, Ireland