S2765 Rapid Development of Cervical Adenocarcinoma in a Young Woman With Crohn’s Disease

Abstract

Introduction: Inflammatory bowel disease (IBD), further characterized into Crohn's disease or ulcerative colitis, is a chronic condition that involves immune-mediated inflammation and subsequent damage to the gastrointestinal tract. Treatment involves immunosuppression, increasing risk for infections and malignancies. Elevated cervical cancer rates are seen in these patients, and thus guidelines recommend annual cervical cancer screening in women receiving immunosuppressive therapy. Case Description/Methods: A 46-year-old female with Crohn's disease (diagnosed at 18) presented with left lower quadrant pain and bloating. Her disease was steroid-refractory and did not respond to mesalamine, azathioprine, or adalimumab. She was in remission for four years on infliximab, however, it was discontinued after a spontaneous mediastinal abscess. She was later treated with vedolizumab and eventually ustekinumab. She had a history of recurrent infections with a negative primary immunodeficiency workup. Computed tomography (CT) abdomen/pelvis revealed two large pelvic masses. Surgical pathology confirmed stage IVA cervical adenocarcinoma, human papillomavirus (HPV) independent, with involvement of the bilateral ovaries and fallopian tubes. CT abdomen/pelvis and Papanicolau smear with HPV co-testing performed less than a year prior to her cancer diagnosis were negative for evidence of malignancy. Discussion: Human papillomavirus (HPV) is the most common cause of cervical cancer. It has been hypothesized that HPV underlies the elevated cervical cancer risk in immunosuppressed patients. This case is notable as it involves an HPV-independent cervical cancer, found at an advanced stage, in a relatively young patient on immunosuppression. To the best of our knowledge, no similar reports have been described in the literature. Liquid based cytology pap smear and high risk HPV cotesting have demonstrated high sensitivity for cervical cancer screening. HPV-negative cervical cancers comprise only a small proportion of cervical neoplasms and are almost entirely adenocarcinomas. These cancers are often diagnosed at an advanced stage. ACG guidelines currently recommend annual screening for patients on immunosuppressive therapy. As in the case we have described, immunosuppressed patients can still develop advanced cancers between screening intervals. When caring for immunosuppressed IBD patients, there should be a low threshold for additional evaluation if patients develop signs or symptoms concerning for underlying malignancy.