Hammad et al. Journal of Medical Case Reports 2011, 5:556 http://www.jmedicalcasereports.com/content/5/1/556 Page 2 of 4 Figure 1 A fungating growth visible at a stoma. This fungating growth at an end ileostomy was created 31 years ago, after a panproctocolectomy for familial adenomatous polyposis (FAP). An en bloc resection of the stoma showed an invasive and moderately differentiated adenocarcinoma arising in a severely dysplastic tubulovillous adenoma with foci of high-grade dysplasia at the mucocutaneous border. the ileostomy site revealed benign villous adenoma with high-grade epithelial dysplastic changes. The possibility of an invasive focus elsewhere in the lesion could not be excluded. The EGD revealed duodenal polyps, and a biopsy showed tubular adenoma. A computed tomography scan of her chest, abdomen, and pelvis after oral and intravenous contrast showed no evidence of metastatic disease. Carcinoembryonic antigen was within normal range. After a discussion in the colorectal multi-disciplinary team meeting, a deci- sion was made to keep the duodenal polyps under sur- veillance and to carry out a barium meal and follow through study. The results of the contrast study were clear; therefore, our patient underwent a laparotomy with en bloc small bowel resection with the ileostomy and safety margin of the skin around the stoma. About 45 cm of adherent small bowel was removed alone with the ileostomy specimen. The rest of the small bowel was examined and did not show any gross pathology. A new stoma was created in her right iliac fossa. She went home seven days after a smooth recovery from the operation. Pathology showed an invasive, moderately differen- tiated adenocarcinoma arising in a severely dysplastic tubulovillous adenoma with foci of high-grade dysplasia at the mucocutaneous border (Figure 2). The tumor infiltrated the submucosa and was focally present in the ileostomy stump. The remainder of the resected bowel was clear. As discovered at a follow-up one year ago, she had developed a polypoid mass at the ileostomy site (Figure 3). The results of a limited endoscopic examination of the small bowel up to 50 cm through the stoma were clear. She underwent further wide excision of the term- inal ileum and refashioning of the stoma. The specimen was reported as benign tubular adenoma. The follow-up plan was to review our patient every six months in the clinic with an EGD examination every six months. Discussion FAP is an autosomal dominant inherited disease charac- terized by the presence of hundreds of adenomatous polyps in the colon and rectum. The annual reported incidence ranges from one in 5000 to one in 17,000 live births [2]. The incidence of small bowel malignancy is very low in the general population (seven per 1,000,000) [3]. Suarez and colleagues [4] estimated the incidence of the adenocarcinoma in all ileostomies in Britain to be two to four per 1000, indicating that ileostomies are more prone to malignant changes. In addition, many cases of adenoma in the ileal pouch after proctocolect- omy for FAP have been reported and some of them have progressed to adenocarcinoma [5-7]. Figure 2 A picture of the pathology of a polypoid mass at an ileostomy. Sections from the ileostomy show an invasive and moderately differentiated adenocarcinoma arising in a severely dysplastic tubulovillous adenoma with foci of high-grade dysplasia at the mucocutaneous border.