bluuebunny/crossref_metadata_2025 huggingface dataset:
1629 A Rare Case of Large Cell Neuroendocrine Carcinoma of the Colon
Authors: Chiu Yiu-Ting T. , Michael Sherif , Morgan Kelli , Mokhtari Navid , Kavanaugh Mindie , Morris James D. , Manas Kenneth J.
Published: October 2019

INTRODUCTION:

Colorectal cancers are some of the most common cancers worldwide. Histologically, the vast majority of these cancers are adenocarcinomas. Neuroendocrine tumors of the colon are much less common, and large cell neuroendocrine carcinomas (LCNEC) are even rarer, accounting for less than 1% of all colorectal cancers. Furthermore, LCNEC is a very aggressive tumor with a tendency towards early metastasis. We present a case of LCNEC in a female who initially presented with symptomatic anemia.

CASE DESCRIPTION/METHODS:

A 69-year-old female with a PMH of HTN presented to the hospital complaining of fatigue for 2 weeks. The patient also admitted to abdominal pain and weight loss for 5 months, but denied any frank blood loss. The patient’s family history was significant for colon cancer in her mother and grandson. Despite this, the patient had never had a colonoscopy. Initial labs showed a Hgb of 6. After the patient was resuscitated, endoscopy was performed. EGD showed antral gastritis, while colonoscopy showed a large ulcerated and oozing cecal mass. A staging CT showed hepatic metastasis. The patient’s preliminary pathology report stated the cecal mass was an invasive, poorly differentiated adenocarcinoma. Surgery was consulted, but due to metastasis, they recommended palliative chemotherapy. Oncology was consulted and planned for FOLFOX chemotherapy. The patient’s final pathology report differed from the initial diagnosis, stating the colon mass was a LCNEC, which was supported by the fact that the tumor cells were immunoreactive for chromogranin, synaptophysin and CD56 and immunonegative for CDX-2 and CK20. On outpatient follow-up 2 weeks later, patient was noted to be dehydrated with worsening appetite and pain, so she was admitted. The patient’s condition continued to deteriorate however, and after a thorough discussion, the patient elected for home hospice.

DISCUSSION:

With improved screening helping to detect colonic lesions earlier, death rates from most colorectal cancers have been dropping. However, a diagnosis of LCNEC portends a poor prognosis as these tumors are very aggressive with a median overall survival of 10 months. Surgery is often the primary means of treatment, however that poses a problem with LCNECs, as most have already metastasized by the time of diagnosis. In our patient, her metastatic disease precluded surgery and her rapid decline made chemotherapy less tenable. This case helps highlight the importance of screening awareness, especially in patients with a family history.
1632 Rectal Endometriosis: An Atypical Presentation
Authors: Torralba Ericson J. , Suraweera Duminda B. , Park Sunhee
Published: October 2019

INTRODUCTION:

Endometriosis is a condition in which endometrial tissue is implanted outside of the uterus. Patients with gastrointestinal involvement experience pelvic pain, rectal bleeding and abdominal pain which may be associated with menstruation. Often patients are misdiagnosed or have significant delays in diagnosis, especially in the setting of negative imaging. While endometrial lesions that penetrate the bowel mucosa are rare, endoscopy can play a vital role in the correct clinical setting. We present a rare case of rectal endometriosis that was diagnosed primarily through colonoscopy.

CASE DESCRIPTION/METHODS:

A 46-year-old woman with a history of uterine fibroids was referred to our center for evaluation of severe intermittent rectal pressure for the previous four months. Patient reported that her pain was associated with bowel movements and improved after evacuation. She denied blood in her stool. She had undergone a transvaginal ultrasound and magnetic resonance imaging (MRI) of her pelvis that demonstrated a decrease in size of her uterine fibroids from prior imaging. The bowel was noted to be unremarkable on MRI. She was referred to our clinic for further management of possible irritable bowel syndrome. The patient had a benign abdominal exam and rectal exam revealed internal hemorrhoids. Colonoscopy was subsequently scheduled and showed unremarkable ileum and colon, however approaching the anal verge, a nodularity was found in the rectum with a somewhat hard consistency. Several biopsies were collected. Ink was injected proximal to the nodularity for reference. Pathology review of the biopsies were consistent with endometriosis with no evidence of dysplasia or malignancy. Immunohistochemical stains were positive for estrogen receptor (ER), paired-box gene 8 (PAX 8) and pankeratin, markers for endometriosis. The patient was referred for rectal endoscopic ultrasonography (EUS) to determine the depth of invasion. She follows with gynecology where further treatment options are being discussed.

DISCUSSION:

Gastrointestinal endometriosis serves as the most common site for extra-gynecologic localization and affects 3-38% of women presenting with the endometriosis. Endometriosis is commonly misdiagnosed and often mistaken for other pathologies, resulting in delays in diagnosis, unnecessary testing and mismanagement. For women of childbearing age who present with persistent pelvic pain and associated symptoms of endometriosis, colonoscopy may serve as a primary method for diagnosis.
1634 Extracolonic Neoplasm From Colonic Polyps: A Case of Metastatic Prostate Cancer Diagnosed From a Colonic Polyp
Authors: Haque Zohaib , Almoghrabi Anas , Attar Bashar M. , Elkhouly Mohamed A. , Nwaichi Chineme , Vohra Ishaan , Majeed Muhammad
Published: October 2019

INTRODUCTION:

Prostate Cancer is the 2nd most common cancer among men in the US. Prostate Cancer frequently metastasizes to the bones, lymph nodes, lungs, liver, and brain. Very rarely, patients can develop metastases to the GI tract. We are presenting a patient that was diagnosed with metastatic prostate cancer after a colon biopsy.

CASE DESCRIPTION/METHODS:

A 61-year-old gentleman with no significant past medical history, presented with constipation, weak urinary stream, in addition to remote fall followed by lower back pain, trouble ambulating, and an unintentional 40 lb weight loss. He did not have any history of melena, hematochezia, abdominal pain or family history of cancers Examination was only evident of tenderness overlying lumbar vertebrae. He underwent CT Abdomen/Pelvis which showed sclerotic vertebral bone lesions in addition to abnormal thickening of the mid to lower rectal wall with adjacent perirectal soft tissue masses suspicious for rectal cancer with adjacent conglomerate lymphadenopathy/tumor. Colonoscopy revealed diminutive sigmoid sessile polyps which was removed by cold snare and cold biopsy in addition to an area of ulceration in the proximal rectum. Surprisingly the pathology of the polyps and rectal ulceration was consistent with metastatic prostate adenocarcinoma. He is planned to be started on chemotherapy with Docetaxel.

DISCUSSION:

Prostate cancer may invade the rectum however it remains rare to have metastatic colonic polyps from a prostate cancer. It has been reported to discover metastatic colonic polyps from breast, lung, skin (melanoma) cancer, however the finding of metastatic colonic polyps from a prostate cancer is rare and portends a sinister prognosis. In the light of this infrequent finding it becomes imperative to consider an extracolonic cause as the source of a colonic polyp especially in patients with known or in suspicion for a primary cancer. The mechanism of metastasis to the colonic is thought to be by hematogenous or lymphatic spread, however, rectal involvement often occurs by local tissue invasion. The clinical scenario in our patient is peculiar since there were no prior diagnoses of primary cancer. An extracolonic metastatic polyp may sometimes be the earliest sign of recurrent prostate cancer.
1635 Adenomas Masquerading as Filiform Polyps
Authors: Voaklander Rebecca , Seibert Donald G.
Published: October 2019

INTRODUCTION:

We present a case of adenomatous filiform-like polyps, raising concern for an unrecognized neoplastic potential in these polyps which typically are of an inflammatory origin.

CASE DESCRIPTION/METHODS:

A healthy 64-year-old man with a history of tubular adenomas presented for a routine surveillance colonoscopy. He reported feeling well and denied any recent illness including abdominal pain, diarrhea or blood in his stool. He did not have a history of inflammatory bowel disease, infectious colitis, tuberculosis or histiocytosis X. On colonoscopy, a cluster of worm-like mucosal projections was found in his distal transverse colon. The shape was typical of filiform polyps. Under white light and narrow band imaging (NBI), the pit and vascular pattern of each polyp and stalk had a stacked hoop appearance (as opposed to the typical radial array pattern characteristic of an adenoma). The surrounding mucosa appeared normal with a clear demarcation at the base of the stalk. These polyps were completely removed at the base by cold snare polypectomy, including a small margin of normal appearing mucosa. Histopathalogic examination of the resected specimens consisted of primarily adenomatous tissue with a few small fragments of normal mucosa. There were no inflammatory nor serrated polyp features. Three other typical diminutive tubular adenomas were resected elsewhere in the colon.

DISCUSSION:

Filiform polyps are described as non-neoplastic inflammatory polyps. This is a case of adenomatous filiform-like polyps in a healthy adult without risk factors for inflammatory polyps. They were found in a cluster, which is more typical of filiform polyps rather than adenomas. The polyps appeared to have a stalk but were found to be comprised entirely of adenomatous tissue, necessitating resection at the base rather than transection through the pseudostalk. This unusual finding raises concern that endoscopists should be more cautious of these polyps and complete in their resections as they may have previously unrecognized potential for malignant transformation. A thorough examination of the entire polyp (including the stalk/pseudostalk) for atypical pit and vascular patterns with white light and NBI may aid in differentiating between benign and premalignant growths.
1639 Chronic Diarrhea Due to Pancolitis Caused by Trichuris trichiura
Authors: Adiwinata Sheila , Adiwinata Randy , Uwan Willy brodus , Gunawan Budiman
Published: October 2019

INTRODUCTION:

Indonesia as one of the largest tropical countries in the world, shared the particularly high burden cases of parasitic colitis especially due to worm infections; Therefore patient with chronic diarrhea in tropical country should be evaluated for parasitic infections such as Trichiasis.

CASE DESCRIPTION/METHODS:

22-year-old woman presented with prolonged diarrhea with mucus and no blood since one month ago. She had two to four times bowel movements once a day. She also complained for having recurrent diffuse periumbilical pain and nausea every day. She also reported for having weight loss of 3 kg. She had no remarkable past medical history. She admitted for having poor hygiene lifestyle and using non purified ground water as drinking water. She previously had visited nearest hospital for consultation, the blood test showed hemoglobin of 12.8 g/dl, white blood cell of 28,000/mL; stool analysis showed positive microscopic erythrocyte and leukocyte without worm eggs or other parasites. Other laboratory value was normal. She was admitted and treated with Levofloxacin, attaplugite, and probiotic. After five days of hospitalization, no improvement was seen, therefore she was referred to our hospital endoscopy unit for colonoscopy. Colonoscopy examination showed inflammation of the entire colon with erosion and ulceration, also multiple Trichuris trichiura were found. She was treated with mebendazole. She had clinical improvement and re-colonoscopy was done after two weeks. Re-colonoscopy examination showed no inflammation and no worms were found.

DISCUSSION:

Patients with Chronic diarrhea in tropical countries should always be evaluated for parasitic infections. Stool examination and colonoscopy may be helpful to establish the diagnosis. Trichuris trichiura infections may manifest as asymptomatic infection or chronic diarrhea or dysentery which may mimic inflammatory bowel disease.
1644 Isolated Metastatic Colorectal Cancer Involving the Kidney and Adrenal Gland: A Rare Occurrence
Authors: Saha Aditi , Saha Biplab , Mabourakh Davita , Laharwal Mehak , Bajaj Nikki , Sapru Sunil
Published: October 2019

INTRODUCTION:

Distant metastases in colorectal cancer (CRC) commonly involve liver, lung, brain and bone. Adrenal gland involvement is not uncommon on autopsy in the setting of diffuse metastatic disease. In most reported cases, it is seen as metachronous disease and is diagnosed during extensive work up or on follow up. Isolated synchronous disease involving the kidney and adrenal gland is extremely rare. We present a case where the diagnosis was established intraoperatively during a laparotomy performed for suspected primary adrenocortical malignancy.

CASE DESCRIPTION/METHODS:

A 66-year-old man presented with sudden worsening lower abdominal pain for 6 hours. The pain had started 4 weeks ago and was persistent, non-radiating. He reported a 50 pounds weight loss over the last 3 months. Physical exam was significant for tenderness over the right lower quadrant. Laboratory data showed anemia with hemoglobin of 8.3 g/dl. CT of abdomen and pelvis revealed a mass that was possibly originating from the right adrenal gland. MRI revealed a large heterogeneous, multilobulated, adrenal mass measuring 10 × 7.4 × 13.2 cm. A primary adrenocortical malignancy was suspected. Endocrine and metastatic work up was negative and a laparotomy was planned for adrenalectomy and possible nephrectomy. Intraoperatively, he was found to have an ulcerative tumor involving the terminal ileum and appendix penetrating through the serosa. Right hemicolectomy and nephrectomy with adrenalectomy were performed. Histopathology was consistent with poorly differentiated adenocarcinoma of colon with metastasis to right adrenal gland and kidney.

DISCUSSION:

Common primary tumors that metastasize to the adrenal gland include breast, lung and kidney. In most cases of CRC, adrenal or kidney metastases usually indicate distant hematogenous spread and are associated with poor prognosis. The mean survival is 7 to 8 months. However, CRC with isolated metastasis to adrenal gland and kidney is extremely rare. Retrospectively, an interesting feature in this case was the presumption of the metastatic lesion as the primary tumor as there was no radiologic abnormality involving the gastrointestinal tract. Surgical resection followed by chemotherapy has been shown to promote long term survival in several studies, but there is no prospective data due to the rarity of this condition. In patients with incidental finding of an isolated adrenal/renal mass, an evaluation for occult GI malignancy should be considered.
1645 A Case of Proctocolitis Secondary to the Use of Coffee Enema
Authors: Lee Anna , Kabashneh Sohaip , Rahim Usman , Khan Mir , Anees Mohammad , Levine Diane
Published: October 2019

INTRODUCTION:

Proponents of coffee enemas advocate for its role in cancer treatment, where it is believed to detoxify via vasodilation and toxin excretion. However, there is no science-based evidence to verify these claims, and its use is associated with harmful effects, including electrolyte imbalances and death. We present a case of coffee-enema induced proctocolitis (PC).

CASE DESCRIPTION/METHODS:

A 40-year-old woman presented with acute abdominal pain, bloody diarrhea, and tenesmus. She denied recent travel or sick contacts. She had mixed-type IBS, but denied ever experiencing symptoms this severe. Her brother had ulcerative colitis (UC) and aunts had Crohn’s Disease. CT showed severe PC from rectum to descending colon. WBC 21.8, CRP 23, FLA was positive; however, C. Diff, shiga toxin, stool culture, lipase, LFTs were unremarkable. On day 2, she admitted to using 500mL of room temperature coffee enema to treat gallstones, hours prior to symptom onset, which “never came back out.” Flexible sigmoidoscopy displayed severe rectal inflammation, extending to 60cm depth. She was empirically started on Solu-Medrol. Biopsy revealed necrotic mucosa and purulent exudate, suggesting ischemic colitis (IC), but no crypt abscesses. Repeat sigmoidoscopy on day 10 showed improvement of damage, extending to 30cm depth. Clinical improvement was slow, and she was finally discharged on day 13.

DISCUSSION:

A few South Korean reports of coffee enema induced PC exist in literature. Our patient presented similarly to those cases, suggesting a consistent process through which it achieves its damage. PC occurs in UC, but our patient’s biopsy was more suggestive of IC. IC usually spares rectum due to rich blood supply; our patient’s rectum was not spared. Caffeine may decrease blood flow through a variety of mechanisms (e.g., blocking cGMP formation) and could lead to ischemia. Additionally, it blocks adenosine A2 receptors (AA2Rs). In animal models, AA2R activation attenuates intestinal inflammation, so inhibition may lead to inflammation. Our patient’s PC was likely due to direct contact injury, as well as damage from activation of inflammation and blood flow alteration. Our patient planned to follow up with her naturopathic doctor who recommended the enema. She blamed herself for using too much coffee and could not be persuaded that coffee enemas pose more risk than benefit. It is imperative we educate on risks of “natural” remedies and work to develop trusting relationships with patients so they accept evidence-based practice.
1647 To Flex or Not to Flex? A Case of Immune Checkpoint Inhibitor-Induced Colitis
Authors: Cerne Carlie , Ordway Sarah , Bhushan Anita
Published: October 2019

INTRODUCTION:

Diarrhea is a frequent and well-recognized adverse effect of checkpoint inhibitor therapy, occurring in up to 30% of patients. Management depends on the severity of the symptoms and endoscopic investigation should not delay treatment. We report a case of a patient with metastatic melanoma who developed severe checkpoint inhibitor-induced colitis responsive to one dose of infliximab, and did not require flexible sigmoidoscopy.

CASE DESCRIPTION/METHODS:

A 46-year-old male with metastatic melanoma on Ipilumumab and Pembrolizumab developed diarrhea after his third infusion. He presented to the emergency room with two weeks of 6-7 watery bowel movements daily, nocturnal stools, cramping abdominal pain and nausea. He denied melena, hematochezia or tenesmus. He denied other medical conditions, recent travel, frequent NSAID or recent antibiotic use. His vital signs were normal; physical exam was notable for generalized abdominal tenderness without peritoneal signs. Labs were notable for WBC 9.4 × 109/L, hemoglobin 13.8 g/dL, CRP 1.39 mg/L, and negative HIV-1/2 Ag/Ab screen, C. difficile PCR, stool culture, ova and parasites, Entamoeba histolytica Ag, CMV IgM, and Quantiferon Gold. CT of the abdomen and pelvis with IV contrast showed increased attenuation of the colonic mucosa from the transverse colon to the rectum, compatible with colitis. He received IV methylprednisolone and maximum dose loperamide with no improvement after 3 days. He was diagnosed with presumed checkpoint inhibitor-induced grade 3 toxicity colitis for which he received one dose of infliximab IV 5mg/kg. His symptoms rapidly improved within 24 hours and he was discharged on a steroid taper. Due to his rapid improvement, a previously planned flexible sigmoidoscopy was not performed.

DISCUSSION:

Gastroenterologists are becoming increasingly familiar with colitis as an adverse effect of checkpoint inhibitors. About 1% of patients with severe disease require treatment with immunosuppressive medications such as infliximab. Endoscopic evaluation is recommended for severe or persistent disease to confirm the diagnosis. Our patient suffered from severe colitis which resolved with one dose of infliximab and steroid taper. We propose that when clinical presentation is consistent with severe checkpoint inhibitor-induced colitis and thorough infectious work up is negative, flexible sigmoidoscopy should not delay treatment and may not be necessary prior to treatment with infliximab.
1649 Bone Metastasis in Appendicular Skeleton: Rare Occurrence in Colorectal Cancer
Authors: Vekaria Pratikkumar , Raiyani Chandrika , Patel Ravish , Vaishnani Devin , Raiyani Tejas
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is considered as preventable cancer if diagnosed in the early stage. It is also second leading cause of death from cancer in US. Bone metastases (BM) is uncommon presentation with CRC and if it occurs, it involves axial skeletal more than extremities. Many case studies also reports that survival after BM is considerably poor than without BM. Cancer type and genetic mutations also play an important role in such metastasis.

CASE DESCRIPTION/METHODS:

62-year-old female with pertinent Past Medical History of adenocarcinoma of colon with 5.4 cm Cecal lesion s/p right hemicolectomy with 0/14 positive lymph nodes. She received Capecitabine post-operatively. Approximately one and a half year later, patient developed progressive left knee pain. MRI knee showed left medial femoral condyle mass with associated soft tissue and bone scan showed increased uptake in the same area. She ultimately underwent biopsy which revealed adenocarcinoma consistent with colon primary. Subsequent PET CT showed parotid gland nodule and lung nodule. There was also a central mesentery node and a soft tissue density in T9-T10 anterior vertebrae. She was referred for palliative Radiation and chemotherapy- FOLFOX-Bevacizumab and bisphosphonate. Relevant labs: Adenocarcinoma type CRC - positive for CK-20 and CDX-2. K-RUS mutation in codon 12 and 13 No NRAS, BRAF V600E or V600K mutation CEA- Within Normal Limit.

DISCUSSION:

CRC is considered as a curable cancer if diagnosed in the early stage, but it can be deadly if it gets metastasize to other organ system. Some studies show that prognosis dependents on the site of metastasis. If metastases to liver or lung present and if they are resectable then it can have good prognosis. Nonetheless, bony metastasis is characterize as poor prognosis. Cancer type also matters in BM. Vatandoust & coworker suggested that with signet ring cell cancer, chances of getting BM is higher than other types of CRC (up to 23.7%). In our case, patient had adenocarcinoma type CRC and it is not commonly associated with BM. Our patient also had unusual type of BM that involves appendicular skeleton. To add, patient had K-RUS mutation and that is also not much common mutation type associated with BM. Thus, more molecular studies related to K-RUS and other mutations, and their association with BM need to be done. It can also help deciding appropriate treatment option at the early stage.
1650 A Case of Rectal Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma Presenting as Telangiectasia: A Case Report
Authors: Shafi Amaan , Aziz Hamza , Maklad Muthena , Ohning Gordon
Published: October 2019

INTRODUCTION:

The World Health Organization classification of lymphoid neoplasms consists of several marginal zone lymphoma subtypes, the most common of which is extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT lymphoma). Extranodal marginal zone lymphomas can stem from a number of epithelial tissues, including the lungs, thyroid, skin, and GI tract. Of all tissues with possible extranodal lymphoma involvement, the GI tract is the most common. However of these GI sites, colorectal lymphoma is rare, accounting for approximately 3 percent of the GI lymphomas and only 0.3 percent of all large intestinal malignancies. Symptoms including abdominal pain, occult bleeding, bowel obstruction and diarrhea are possible findings in patients with colorectal lymphoma. Findings on colonoscopy can include mucosal nodularity, ulceration and or even a mass.

CASE DESCRIPTION/METHODS:

This is a 68-year-old male with a past medical history of hemorrhoids who initially presented to clinic with complaints of hematochezia for 15 days. Patient denied any associated symptoms including fever, chills, nausea or vomiting. Physical exam revealed bright red blood per rectum. A colonoscopy was scheduled, during which the patient was found to have inflamed proximal rectal mucosa of which a biopsy was taken and sent for pathology report. Biopsy revealed diffuse infiltration of the mucosa by small lymphoid cells focally involving the epithelium which were positive for b-cell immunoperoxidase markers. These findings were consistent with malignant lymphoma (B-cell phenotype) of the extranodal marginal zone mucosa associated type. Following postoperative recovery, the patient opted for conservative management with repeat colonoscopy scheduled 6 months later.

DISCUSSION:

Extranodal marginal zone lymphomas can arise from numerous tissues. While these neoplasms often remain localized to the tissue from which the originate, diagnosis is critical because not only does recurrence frequently occur locally, but they also have the potential to transform into aggressive B cell lymphoma variants with eventual systemic spread. Although MALT lymphoma of the GI tract can present in different forms such as nodularity, ulceration or mass, this is a case of MALToma presenting in the form of telangiectasia. In this patient, correctly taking a biopsy of a telangiectatic region of mucosa resulted in diagnosis of a rare yet treatable pathology.
1651 Colon, Urothelial and Sebaceous Malignancy All in One: A Rare Presentation of Muir-Torre Syndrome
Authors: Kailas Shilpa D. , Mony Shruti , Duffoo Carla
Published: October 2019

INTRODUCTION:

Muir-Torre syndrome (MTS) is a rare autosomal-dominant condition and phenotypic variant of Lynch syndrome caused by mutations in DNA mismatch repair genes MSH2, MSH6, and MLH1. Clinical diagnostic criteria include the presence of at least one sebaceous gland neoplasm and one visceral malignancy, often colonic or genitourinary. Compared to Lynch syndrome, the prevalence of MTS is likely underreported. We present a unique case of a patient with incidental findings of multiple visceral malignancies associated with skin cancer.

CASE DESCRIPTION/METHODS:

A 57-year-old Caucasian man presented for surveillance colonoscopy. His family history was significant for father with colon cancer at age 50, lung, and renal cancer. The patient was diagnosed with sebaceous adenocarcinoma, invasive squamous cell, and basal cell carcinomas requiring excisional surgery at age 46. Screening colonoscopy at that time was normal, with repeat after 7 years noting diminutive sigmoid tubular adenomas that were resected. Current colonoscopy revealed 14 colon polyps, multiple with high grade dysplasia, and an invasive sigmoid adenocarcinoma. Staging CT A/P was negative for metastatic disease. CEA was normal. The patient opted for left hemicolectomy instead of total proctocolectomy. Tumor pathology revealed moderately differentiated adenocarcinoma with negative margins (pT4N0M0). Colon cancer genetic testing showed lack of expression of MSH2/MSH6 and germline MSH2 mutation, confirming the diagnosis of MTS. A month later he developed hematuria and acute kidney injury that culminated in a new diagnosis of invasive high-grade urothelial carcinoma. Neoadjuvant chemotherapy was started with plan for cystectomy.

DISCUSSION:

MTS is a rare condition that warrants early recognition, regular follow-up and observation for new malignancies. Our case highlights the importance of awareness and the need for early, universal screening in high-risk individuals. MTS patients should undergo screening colonoscopy at ages 20–25 with surveillance every year thereafter to offer mortality benefit. If colon cancer is diagnosed, total rather than partial colectomy is preferred due to a high metachronous cancer rate of 25%. Patients and relatives should be counseled on increased risk of future malignancies. Reconstruction of family history may allow for the identification and selection of patients in whom to proceed with clinical, molecular, and immunohistochemical analysis. Clinicians must therefore be cognizant of this disease and its enduring effects.
1653 Large Cell Neuroendocrine Carcinoma of the Colon
Authors: Thomas Mathew J. , Chand Gaurav , Mohammed Suneel
Published: October 2019

INTRODUCTION:

Neuroendocrine carcinomas heterogeneous group of tumors with variable clinical presentation and prognosis. Gastrointestinal neuroendocrine carcinomas are further divided into two types; small cell or large cell based on mitotic rate and or Ki-67 labeling by WHO or European Neuroendocrine Tumor Society guidelines. Large cell neuroendocrine carcinomas (LNEC) of primary colorectal origin are extremely rare and represent 0.25% of all colorectal cancers. LNEC are malignant and aggressive tumors which present in an advanced stage and median overall survival time is 4–16 months. LNEC can occur within the entire gastrointestinal tract and or biliary tract but are typically found within the colon, stomach and or rectum. Here, we report LNEC to highlight its clinical course and to expand clinician knowledge regarding this rare cancer.

CASE DESCRIPTION/METHODS:

82-year-old male who initially presented to his primary care doctors office with 4-month history of 20-pound unintentional weight loss with associated vague left lower quadrant abdominal pain. Computed Tomography of the abdomen/pelvis revealed mass-like mucosal thickening measuring approximately 5.9 cm × 6.5 cm involving the distal transverse/proximal descending colon and with innumerable hypodense lesions throughout the liver consistent with diffuse metastatic disease. Colonoscopy revealed circumferential fungating partially obstructing large mass in the within the mid-transverse colon. Histopathologic report from the endoscopic biopsy showed positive staining for pancytokeratin and synaptophysin, which was consistent with a large cell neuroendocrine carcinoma. Patient was evaluated by oncology and has started receiving carboplatin and etoposide chemotherapy for palliative purposes.

DISCUSSION:

LNEC rare subtype of neuroendocrine carcinomas, which are aggressive and often present in an advanced stage. Early detection and identification is essential as this malignancy has different treatment implications when compared to adenocarcinoma. Interestingly, extrapulmonary neuroendocrine tumors resemble small cell lung cancer where carboplatin and etoposide have established utility due to high mitotic rate. This is the treatment option chosen for our patient. Further studies will need to be done to determine optimal treatment regimens for this rare disease.
1659 Double Scope Colorectal ESD Using a Gel-Based TAMIS Access Platform
Authors: Samarasena Jason , Hashimoto Rintaro , El Hage Chehade Nabil , Sowa Piotr , Lee David , Leevan Elyse
Published: October 2019

INTRODUCTION:

Endoscopic submucosal dissection (ESD) is a promising endoscopic procedure that is increasingly being used for endoscopic resection of large colorectal lesions that may be difficult to remove en-bloc by snare polypectomy. The greatest challenge for ESD remains technical difficulty in achieving optimal traction. In the following report, we discuss the use of Gel-based Transanal Access Platform, typically used for Transanal Minimally Invasive Surgery (TAMIS), being used to facilitate ESD of colorectal lesions by facilitating use of two separate endoscopes simultaneously.

CASE DESCRIPTION/METHODS:

The procedure was first performed on a patient presenting for resection of a 3 cm × 3 cm rectal lesion. Endoscopic ultrasound was performed and the lesion was classified as T1. A decision was made to perform ESD. A 4 × 4 cm Gel based-TAMIS access device was inserted into the anal canal prior to the start of the procedure. Two access holes were made in the gel cover 2 cm apart with the pre-supplied trocars to allow for the passage of a 1T therapeutic gastroscope and an ultraslim gastroscope. After submucosal injection and circumferential incision, the pediatric forceps were passed through the working channel of the ultraslim scope, and the edge of the lesion was grasped and then manipulated to allow for traction of the lesion. ESD was done using a needle type ESD-knife and resection en-bloc was achieved. There were no complications from the procedure and the patient has no anal pain. Histologic examination demonstrated R0 resection Two additional procedures were carried out on two patients with rectal lesions >2 cm and en-bloc resection was achieved in both cases. Histologic examination in each showed tubulovillous adenoma with high grade dysplasia with clear margins.

DISCUSSION:

By using a commercially available Transanal Access Platform for the first time in an endoscopic procedure, the endoscopist noted more ease performing ESD. This device allowed the insertion of an additional scope which provided more traction and assisted in resecting each lesion without any reported friction between the two scopes. The set-up of this device is simple and this device appears suitable not only for laparoscopic surgical procedures but also for endoscopic interventions. Further studies are underway to determine the technical success, easy of use, and safety of this dual scope with TAMIS platform technique for colorectal ESD.
1662 Colonic Obstruction Leading to a Diagnosis of Polyarteritis Nodosa
Authors: Larson Brian , Shiralkar Malan , Flynn Ann
Published: October 2019

INTRODUCTION:

Polyarteritis Nodosa (PAN) is a rare systemic necrotizing vasculitis that preferentially affects medium-sized arteries. Patients may present with systemic symptoms or with isolated organ involvement. PAN may involve the gastrointestinal (GI), renal, cardiac, musculoskeletal, skin and central nervous systems. When the GI tract is involved, abdominal pain is the most common presentation, thought secondary to transmural necrotizing inflammation of the mesenteric vessels leading to bowel ischemia. The small bowel is the most common site of involvement. Ischemic mucosal ulceration, bowel infarction and perforation can result. Case reports in the pediatric literature and a retrospective case series have described PAN causing severe GI strictures leading to intestinal obstruction. We report a rare case of PAN leading to a colonic obstruction.

CASE DESCRIPTION/METHODS:

A 36-year-old-male was admitted to the hospital with nausea, vomiting, abdominal pain and reduction in the passage of stool and gas for the previous 5 months. Computerized topography of the abdomen and pelvis demonstrated colonic dilatation and obstruction at the level of the sigmoid colon. A flexible sigmoidoscopy was performed and identified severe stenosis at the recto-sigmoid junction, 25 cm from the anal verge. This area could not be traversed with an upper endoscope or an ultrathin endoscope. Given the near complete obstruction of the sigmoid colon, exploratory laparotomy was performed, which revealed a sigmoid stricture with densely adherent loops of small bowel. Sigmoidectomy with en bloc small bowel resection was performed. Pathology demonstrated mucosal ulceration with transmural inflammation and injury of the medium-sized vessels. Some of the medium-sized vessels in the mesentery had evidence of acute injury, while others appeared to be in the healing state with obliteration and recanalization of the lumen. This admixture of early and late lesions was felt consistent with PAN. The patient was discharged with GI, surgery and rheumatology follow up.

DISCUSSION:

PAN is a rare systemic vasculitis that can present with a wide range of symptoms including abdominal pain, nausea, vomiting, GI bleeding, diarrhea and weight loss. Intestinal stricture due to bowel ischemia can occur with resultant obstruction. The small intestine is the most common site of ischemia in the GI tract. As such the differential diagnosis of intestinal strictures should include chronic ischemia from systemic vasculitis.
1666 A Rare Case of Colonic Malakoplakia in an Immunocompetent Man With Prior Chronic Hepatitis C Virus Infection
Authors: Palmer Quinton D. , Broadfoot Brannon , Perisetti Abhilash , Johnson Kemmian D. , Garcia-Saenz-de-Sicilia Mauricio
Published: October 2019

INTRODUCTION:

Malakoplakia is a rare chronic granulomatous condition related to a defect in macrophage phagolysosomal response in which engulfed bacteria are not destroyed. The urinary bladder is the most common site for malakoplakia to present and the gastrointestinal tract is a distant secondly reported site. Malakoplakia is often associated with conditions that cause immunodeficiency. We report a rare case of colonic malakoplakia (CM) in an asymptomatic, immunocompetent man with history of successfully treated hepatitis C virus (HCV) infection.

CASE DESCRIPTION/METHODS:

A 70-year-old African American man with a past medical history of treated HCV due to prior intravenous drug use, was referred by his primary care provider for screening colonoscopy. He was asymptomatic and clinical history was negative for inflammatory or other infectious diseases. He denied use of immunosuppressant medications. HCV RNA was undetectable. HIV serology was negative. No remarkable findings on physical examination. During colonoscopy, a single 5 mm sessile polyp was noted in the transverse colon and was removed (Figure 1). Histopathological analysis of polyp identified targetoid calcospherites on Von Kossa calcium stain consistent with Michaels-Gutman bodies, diagnostic of malakoplakia (Figures 2 and 3). On repeat colonoscopy four months later, a single 14 mm sessile polyp was found in the proximal descending colon with histopathology consistent with tubular adenoma. No findings suggestive of malakoplakia was noted, however, exam may have been limited due to poor bowel prep.

DISCUSSION:

In summary, malakoplakia has been reported to involve the urinary tract in approximately 75% of cases while the gastrointestinal tract is involved less than 10% of reported cases. CM is often associated with neoplasms such as adenocarcinoma, adenoma, and lymphoma and other non-neoplastic conditions such as infections, sarcoidosis, diabetes mellitus, alcoholic liver disease, immunosuppressive therapy, or other conditions of immunodeficiency. Though not previously reported, HCV could have played a role in development of CM. HCV as been reported to be associated with the development of cutaneous malakoplakia; therefore, we cannot exclude association of other extrahepatic manifestations. In conclusion, CM is a rare chronic granulomatous condition that can be incidentally found in immunocompetent individuals, more studies warranted to evaluate any association with HCV.
1670 Simultaneous Diagnosis of Colorectal Adenocarcinoma and Non-Hodgkin Lymphoma
Authors: Ginsberg Terrie , Powell Leonard , Shienbaum Alan , Truscello David , Shah Maulik
Published: October 2019

INTRODUCTION:

This is a case of an 84-year-old female who presented to the hospital complaining of constipation secondary to a new rectosigmoid mass. Histopathologic examination revealed an invasive adenocarcinoma of the colon along with a previously undiagnosed small lymphocytic lymphoma (SLL) in the regional lymph nodes. It is highly unusual to make a simultaneous new diagnosis of two separate malignancies found from the same specimen. We aim here to enlighten readers to the likelihood of finding this presentation in affected patients.

CASE DESCRIPTION/METHODS:

An 84-year-old female was admitted for a 12-day hospital stay following a 2 week history of constipation. She was found to have a new rectosigmoid mass. Abdominal CT revealed new stranding of the perirectal fat with thickening of the adjacent segment of the rectosigmoid colon. Also seen was a small tissue lesion in the adjacent fat abutting the serosal surface of the rectosigmoid colon. Colonoscopy showed a near-obstructing mass lesion located within the rectosigmoid region at approximately 18 cm from the anal verge. The obstructing lesion was encompassing approximately 90% of the colonic lumen. She underwent exploratory laparotomy with lower anterior resection with end colostomy and appendectomy. Histopathologic examination demonstrated an invasive adenocarcinoma of the rectosigmoid measuring 6.5 cm in greatest dimension. The surrounding regional lymph nodes identified in the specimen were involved by a mature B-cell lymphoma most consistent with small lymphocytic lymphoma (SLL).

DISCUSSION:

Detailed histopathologic examination was undertaken to establish the diagnosis, prognosis, and treatment modalities. Dual diagnoses occur uncommonly and warrant a further and more detailed investigation. Histopathologic evaluation of the regional lymph nodes within the rectosigmoid resection utilizing immunohistochemical staining, showed that the lymphocytes of the lymph nodes stained positively with CD20, CD79a, CD5 (DIM), CD23, and BCL-2. This staining pattern supports the diagnosis of a mature B-cell lymphoma most consistent with small lymphocytic lymphoma. Simultaneous diagnosis of SLL and colorectal adenocarcinoma is largely coincidental. This simultaneous development may be the result of long-term immunosuppresion secondary to the previously undiagnosed small lymphocytic lymphoma (SLL). Such a finding warrants further investigation of potential mechanisms which may lead to the development of these two separate malignancies presenting simultaneously.
1677 Few Bumps in the Road Led to Surgical Prophylaxis: Cowden’s Syndrome
Authors: Fernandez Wilfor Diaz , Buse Paul E.
Published: October 2019

INTRODUCTION:

PTEN syndrome is caused by a germline mutation in phosphatase and tensin homolog (PTEN) gene. As a syndrome, it has different clinical manifestations, Cowden syndrome being one of them. We present the case of a 41-year-old female found to have multiple polyps throughout the large and small bowel. Biopsy showed hamartomous type polyps and ganglioneuromas. Genetic testing revealed de novo PTEN mutation.

CASE DESCRIPTION/METHODS:

41-year-old female presented with acute diarrhea to the emergency department. Medical history was relevant for hypothyroidism secondary to thyroidectomy for goiter and multiple skin tags. Colonoscopy showed the small and large bowel carpeted with polyps and biopsies were taken. Pathology showed hamartomatous-type polyps and ganglioneuromas. Genetic testing was positive for PTEN de novo mutation. A multidisciplinary team was involved in the case for cancer surveillance. Estrogen/progesterone receptor positive and HER2-negative invasive lobular carcinoma was found after bilateral prophylactic mastectomy. Follow up endoscopy showed small esophageal nodules and multiple gastroduodenal polyps found to be hyperplastic on pathology. Hysterectomy is planned with subsequent Arimidex as adjuvant therapy.

DISCUSSION:

First reported in 1963, Cowden syndrome has a prevalence of 1 in 200,000–250,000 with 20–34% of individuals having germline PTEN mutation. PTEN acts as a tumor suppressor. A mutation of this gene leads to an increased prevelance of a variety of malignancies (colorectal, breast, thyroid, renal, endometrial skin, and brain) and non-neoplastic growths (trichilemmoma, papules, acral keratosis). The purpose of bringing attention to this very rare polyposis syndrome is increase awareness about the multidisciplinary approach needed for cancer surveillance. Annual physical exam should be performed starting at age 18; baseline screening colonoscopy at age 35 with follow up screening earlier than 5 years. Annual urinalysis and cytology to screen for renal cancer is recommended to start at age 35. Surveillance for thyroid cancer includes baseline thyroid ultrasound starting at age 18, and then annual thyroid exams thereafter. Women with PTEN mutations should have annual breast cancer screening starting at age 25. Our patient was advised to undergo appropriate cancer surveillance according to the National Cancer Center Network guidelines.
1678 When Crime Does Pay: How a Stolen Colon Went Viral and Raised Global Screening Awareness
Authors: Peterson Erin , DeBord Sarah
Published: October 2019

INTRODUCTION:

On the night of October 19, 2018, a shipping container containing a 10' × 12' inflatable colon was stolen out of the back of a truck in suburban Kansas City, MO. The night of the caper, the colon was loaded and prepared to attend a breast cancer awareness walk on Saturday morning, ready to educate the people in attendance about colorectal cancer and the importance of screening. What would unfold over the next 10 days can only be described as the most unintentional global colorectal cancer awareness campaign ever. The message of the importance of screening would reach more than the 100s of people in attendance at that one event, it would reach 100s of millions of people.

CASE DESCRIPTION/METHODS:

Using traditional, online, and social media tracking tools the staff at the Colon Cancer Coalition, the owners of this now famous colon, were able to track the number of stories and the number of people who were exposed to this important health message. Throughout the 10 days that this visual and attention-grabbing educational tool was missing and in the immediate aftermath of its recovery on October 29, online media stories featuring the “stolen colon” totaled 962, reaching a potential 955,302,697 people. The #stolencolon hashtag on social media was shared over 6,500 times, resulting in over 36,050,000 impressions.

DISCUSSION:

This type of coverage of this unexpected crime is unprecedented. The stolen colon caught the attention of People Magazine, Forbes, The New York Times, and more. The lifesaving messages of colorectal cancer prevention and the importance of screening were found on the “Late Show with Stephen Colbert” to the Kansas City Police Department's Twitter feed. Commentaries took a light-hearted view of the incident, with an underpinning of the serious message of screening. The goal of using an educational tool such as an inflatable colon is to educate the public about the colon and preventative cancer screening. The surprising benefit to this unsolved crime is the conversations and engagement across the globe. An additional benefit of this petty thievery is the money donated to purchase an additional two inflatable colons. One person's wrongdoing resulted in an unprecedented conversation about colorectal cancer and the importance of screening for this largely preventable cancer.