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Objective The aim of the study was to develop a model for predicting cancer risk in colorectal polyps' patients (CPPs), as well as to reveal additional prognosis factors for Stage III colorectal cancer based on differences in subpopulations of tetraspanins, tetraspanin-associated and tetraspanin-non-associated proteases in blood plasma exosomes of CPPs and colorectal cancer patients (CRCPs). Methods The subpopulations of CD151- and Tspan8-positive exosomes, the subpopulations of metalloproteinase at the surface of СD9-positive exosomes and the level of 20S proteasomes in plasma exosomes in 15 CPPs (tubulovillous adenomas) and 60 CRCPs were evaluated using flow cytometry and Western blotting. Logistic regression analysis was performed to predict cancer risk of CPPs. Results The levels of 20S proteasomes in exosomes, MMP9+, MMP9+/MMP2+/EMMPRIN+ in CD9-positive blood plasma exosomes are associated with the risk of malignant transformation of colorectal tubulovillous adenomas. In patients with Stage III CRC, the levels of 20S proteasomes (less than 2 units) and MMP9+ subpopulations (more than 61%) in plasma exosomes are unfavorable prognostic factors for overall survival. The levels of 20S proteasomes and ADAM10+/ADAM17- subpopulations in CD9-positive blood plasma exosomes are the most significant values for predicting relapse-free survival. Conclusion Protease cargo in CD9-positive blood plasma exosomes is prognostic biomarker for colorectal polyps and colorectal cancer.

A healthy 41-year-old female was referred for the endoscopic management of a large rectal laterally spreading lesion (LSL). On index colonoscopy, performed for the evaluation of rectal bleeding, multiple proximal sessile serrated polyps were identified meeting diagnostic criteria for serrated polyposis syndrome. Family history was notable for a sister with a history of sessile serrated polyps. Using an Olympus 190 series high-definition colonoscope (Olympus, Tokyo, Japan), the lesion was evaluated under white-light (figure 1A), narrow-band imaging (NBI) (figure 1B) and near-focus (figure …

This study aimed to assess the reliability of rectal villous tumors staging between rectal MRI and histological examination used as the Gold Standard and to investigate causes for discrepancies. The rectal 1.5 T MR scans of 40 patients followed for a histologically proven rectal villous adenoma were retrospectively included. Two independent experienced radiologists staged each tumor according to the TNM classification and described the occurrence of retraction of the rectal wall or spiculations within the associated mesorectum. A third radiologist collected tumor’s morphological characteristics. Among the 40 villous tumors studied, 25 (63%) were non-invasive and 15 (37%) were invasive. The mean volume of tumors with spiculations and retraction was significantly greater (p

McKittrick-Wheelock syndrome (MWS) is a rare cause of acute kidney injury and electrolyte depletion. It is driven by a secretory tumour or polyp of the distal large colon. Although rare, it is a diagnosis that must be considered in patients presenting with the above conditions. Treatment is with surgical resection of the offending growth. We present the case of a 70-year-old woman who presented multiple times with electrolyte depletion and acute kidney injury. The diagnosis of MWS was established and treatment options discussed. Surgical intervention was declined, and management consisted of patient education, the careful replacement of fluid and electrolytes and close monitoring of electrolytes and kidney function. After a short period as an inpatient, the patient went on to be discharged and, with regular follow-up, has managed to continue a normal life.

Introduction Villous adenomas are dubiously benign lesions, which are difficult to interpret because of their malignant potential. Distal villous adenomas present with bleeding or mucus discharge. Giant adenomas are not amenable for endoscopic or transanal resection. Only few isolated cases have been reported by laparoscopic resection. We present our case of a circumferential giant villous adenoma of the rectum managed successfully by laparoscopic ultra-low anterior resection with colo-anal anastomosis with a review of literature in regard to their malignant potential. Case report A 62-year-old lady presented with complaints of painless bleeding per rectum and a fleshy mass protruding from the anal canal which on digital rectal examination appeared a large soft velvety flat mass with mucus discharge. Colonoscopy showed circumferential irregular, friable, edematous mucosa in rectum extending for 15 cm. Computed tomography showed a large heterogeneously enhancing polypoid mass lesion in the rectal wall involving the entire rectum. The patient underwent laparoscopic low anterior resection with colo-anal anastomosis and protecting loop ileostomy. Histopathological examination of the resected specimen revealed villous adenoma of the rectum with moderate to severe dysplasia. Discussion Villous adenomas are sessile growths lined by dysplastic glandular epithelium, whose risk of malignancy is especially high up to 50% when greater than 2 cm in size. Large size, villous content, and distal location are all associated with severe dysplasia in colorectal adenomas. Large villous rectal tumors, particularly of circumferential type pose a great challenge for endoscopic or transanal removal. Henceforth, open or laparoscopic surgery is required for these cases. Conclusion Giant rectal villous polyps are usually unresectable by endoscopic methods or transanal endoscopic microsurgery and are associated with a high rate of unsuspected cancer which requires a formal radical oncologic resection. As per current data, the combined risk of dysplasia/malignancy is about 83% with 50% risk of dysplasia and frank malignancy in 33% of cases of giant rectal villous adenomas of more than 8 cm in size. Laparoscopic colorectal resection is safe and effective.

Villous adenoma is uncommonly seen in the urogenital tract and is even more rarely seen in the upper urinary tract and renal pelvis. Like colorectal adenomas, these neoplasms can transform into adenocarcinoma. The preoperative diagnosis is challenging due to their frequent association with hydronephrosis. Herein, we present the case of a villous adenoma of the renal pelvis in a 62-year-old man presenting with recurrent urinary tract infection. The computed tomography scan showed marked hydronephrosis but no suspicious mass in the right kidney. A laparoscopic right nephrectomy was performed. Gross examination revealed a dilated renal pelvis with an irregular exophytic lesion in the renal pelvis’s upper surface. The histopathological examination showed slender, elongated villi with thin fibrovascular cores, consistent with villous adenoma morphology. Isolated villous adenomas have a favorable prognosis. However, the pathologist should undertake a search for an invasive component.

A 69-year-old woman is evaluated for 3 days of muscle cramping, weakness, and fatigue. She reports difficulty walking up stairs. She reports no fever, chills, nausea, or vomiting, and no change in bowel movements. In the past 6 months, she was admitted to hospitals elsewhere three times, for

Colorectal cancer being the 4th most common cause of cancer death in which most arise from a preexisting adenomatous polyp. Among the various adenomas Giant villous adenoma (GVA) is less common. We came across a 65 years female with intermittent per rectal mucus discharge for last 10 years and intermittent fresh, painless, scanty per rectal bleeding along with weakness and fatigue for last 5 years. No members of her family had been suffering from colorectal malignancy. DRE revealed irregular gritty feelings of rectal mucosa starting 2cm from anal verge and the examining fingertip was blood tinged mixed with mucus. On proctoscopic examination the accessible rectum was studded with thousands of polyps with granular appearance, with variable sizes and there was mucus mixed blood within the rectum. Colonoscopy reveals- polypoid lesion starting 2cm from anal verge and extends up to 2cm with granular and velvety appearance. Biopsy was done 2 times for suspicious lesion and histopathology reveals tubulovillous adenoma with dysplasia. However as clinical suspicion of an adenocarcinoma was strong but histopathological report of colonoscopic biopsy was contradictory, intersphincteric ultra-low anterior resection with coloanal anastomosis with covering ileostomy was done. Resected specimen was sent for histopathological study and it reveals- villous adenoma with low grade dysplasia. Two months later reversal of ileostomy was done and now the patient is under regular follow up and now she is asymptomatic.

Villous adenomas (VAs) in the female urethra are rare with only seven cases in the English literature to our knowledge. In patients with bladder augmentation cystoplasty, the neoplasia development risk increases and most of these develop in the neobladder or anastomosis line. Only two cases of VA developing from the native bladder mucosa have been reported. Physical examination of a 76-year-old female who had a history of augmentation cystoplasty revealed a caruncula-like structure protruding from the urethral meatus. The urinary USG showed that the lesion had no relation with the bladder. The lesion was excised. Microscopically, it consisted of villous structures covered with pseudostratified intestinal type epithelium. Low-grade dysplasia was present in the epithelium but high-grade dysplasia or in-situ/invasive carcinoma was not observed. Immunohistochemical study showed positivity for CK7, CK20, EMA, CEA and CDX2. The case was reported as VA of the urethra. We presented the first VA case arising in the urethra of a female patient with intestinal bladder augmentation. Excision is curative for pure VAs. Transformation to carcinoma or recurrence has not been reported. However, in one third of the cases, a malignant tumor may accompany the lesion. Therefore, all excision material should be examined carefully. Routine endoscopic follow-up should be performed in cases with bladder augmentation.

Background Considering that the knowledge of adenocarcinoma in villous adenoma of the colorectum is limited to several case reports, we designed a study to investigate independent prognostic factors and developed nomograms for predicting the survival of patients. Methods Univariate and multivariate Cox regression analyses were used to evaluate prognostic factors. A nomogram predicting cancer-specific survival (CSS) was performed; internally and externally validated; evaluated by receiver operating characteristic (ROC) curve, C-index, and decision curve analyses; and compared to the 7th TNM stage. Results Patients with adenocarcinoma in villous adenoma of the colorectum had a 1-year overall survival (OS) rate of 88.3% (95% CI: 87.1–89.5%), a 3-year OS rate of 75.1% (95% CI: 73.3–77%) and a 5-year OS rate of 64.5% (95% CI: 62–67.1%). Nomograms for 1-, 3- and 5-year CSS predictions were constructed and performed better with a higher C-index than the 7th TNM staging (internal: 0.716 vs 0.663; P P Conclusion Age, race, T stage, pathologic grade, N stage, tumor size and M stage were prognostic factors for both OS and CSS. The constructed nomograms were more effective and accurate for predicting the 1-, 3- and 5-year CSS of patients with adenocarcinoma in villous adenoma than 7th TNM staging.

Long-term colorectal cancer incidence and mortality after colorectal polyp removal remains unclear. We aimed to assess colorectal cancer incidence and mortality in individuals with removal of different histological subtypes of polyps relative to the general population.We did a matched cohort study through prospective record linkage in Sweden in patients aged at least 18 years with a first diagnosis of colorectal polyps in the nationwide gastrointestinal ESPRESSO histopathology cohort (1993-2016). For each polyp case, we identified up to five matched reference individuals from the Total Population Register on the basis of birth year, age, sex, calendar year of biopsy, and county of residence. We excluded patients and reference individuals with a diagnosis of colorectal cancer either before or within the first 6 months after diagnosis of the index polyp. Polyps were classified by morphology codes into hyperplastic polyps, sessile serrated polyps, tubular adenomas, tubulovillous adenomas, and villous adenomas. Colorectal cancer cases were identified from the Swedish Cancer Registry, and cause-of-death data were retrieved from the Cause of Death Register. We collected information about the use of endoscopic examination before and after the index biopsy from the Swedish National Patient Registry, and counted the number of endoscopies done before and after the index biopsies. We calculated cumulative risk of colorectal cancer incidence and mortality at 3, 5, 10, and 15 years, and computed hazard ratios (HRs) and 95% CIs for colorectal cancer incidence and mortality using a stratified Cox proportional hazards model within each of the matched pairs.178 377 patients with colorectal polyps and 864 831 matched reference individuals from the general population were included in our study. The mean age of patients at polyp diagnosis was 58·6 (SD 13·9) years for hyperplastic polyps, 59·7 (14·2) years for sessile serrated polyps, 63·9 (12·9) years for tubular adenomas, 67·1 (12·1) years for tubulovillous adenomas, and 68·9 (11·8) years for villous adenomas. During a median of 6·6 years (IQR 3·0-11·6) of follow-up, we documented 4278 incident colorectal cancers and 1269 colorectal cancer-related deaths in patients with a polyp, and 14 350 incident colorectal cancers and 5242 colorectal cancer deaths in general reference individuals. The 10-year cumulative incidence of colorectal cancer was 1·6% (95% CI 1·5-1·7) for hyperplastic polyps, 2·5% (1·9-3·3) for sessile serrated polyps, 2·7% (2·5-2·9) for tubular adenomas, 5·1% (4·8-5·4) for tubulovillous adenomas, and 8·6% (7·4-10·1) for villous adenomas compared with 2·1% (2·0-2·1) in reference individuals. Compared with reference individuals, patients with any polyps had an increased risk of colorectal cancer, with multivariable HR of 1·11 (95% CI 1·02-1·22) for hyperplastic polyps, 1·77 (1·34-2·34) for sessile serrated polyps, 1·41 (1·30-1·52) for tubular adenomas, 2·56 (2·36-2·78) for tubulovillous adenomas, and 3·82 (3·07-4·76) for villous adenomas (p0·05 for all polyp subtypes). There was a higher proportion of incident proximal colon cancer in patients with serrated (hyperplastic and sessile) polyps (52-57%) than in those with conventional (tubular, tubulovillous, and villous) adenomas (30-46%). For colorectal cancer mortality, a positive association was found for sessile serrated polyps (HR 1·74, 95% CI 1·08-2·79), tubulovillous adenomas (1·95, 1·69-2·24), and villous adenomas (3·45, 2·40-4·95), but not for hyperplastic polyps (0·90, 0·76-1·06) or tubular adenomas (0·97, 0·84-1·12).In a largely screening-naive population, compared with individuals from the general population, patients with any polyps had a higher colorectal cancer incidence, and those with sessile serrated polyps, tubulovillous adenomas, and villous adenomas had a higher colorectal cancer mortality.US National Institutes of Health, American Cancer Society, American Gastroenterological Association, Union for International Cancer Control.

Frequency indices of tubulovillous adenoma are higher than the ones of colorectal cancer, and probably, the majority of adenomas are prone to malignancy. It is often impossible to determine which adenoma tends to tumorous neoplasia. However, increase in the adenomas and expressed dysplasia contribute to adenomas malignant transformation. In this regard, the purpose of the study is to evaluate cellular proliferation, apoptosis, beta-catenin in tubulovillous intestinal adenomas with varying degrees of dysplasia. The study used biopsy materials of tubulovillous adenomas obtained from 50 patients who underwent ectomy. After resection the adenomas were cut by the maximum size for the full thickness of tunicae mucosae, muscularis be included into the section. Immunohistochemical reactions used a cellular proliferation marker (Ki-67), that of apoptosis (P-53), of a transcription factor (β-catenin). In tubulovillous adenomas with the low grade dysplasia degree there are low indicators of cellular proliferation and apoptosis, located primarily in basal glandular segments. As dysplasia degree increases, cellular division in the glandular epithelium intensifies and nuclear expression of beta-catenin appears as well. Against the background of a meaningful increase in cellular proliferation, a small number of cells in apoptotic condition are revealed. Thus, increased indicators of Ki-67 and β-catenin in a tubulovillous adenomas in high grade dysplasia contributes to limiting cellular differentiation, violates intercellular contacts.Частота встречаемости тубуловиллезной аденомы превышает показатели колоректального рака. Вероятно, большая часть аденом склонна к малигнизации. Часто невозможно определить, какая аденома склонна к неоплазии. Однако увеличение размеров аденом и выраженная дисплазия способствуют малигнизации. Цель исследования — оценка клеточной пролиферации, апоптоза, β-катенина в тубуловиллезной аденоме толстой кишки с разной степенью дисплазии. Были использованы биоптаты тубуловиллезной аденомы 50 пациентов, подвергшихся эктомии. Аденомы после резекции разрезали по наибольшему размеру, чтобы в срез входила вся толща tunicae mucosae, muscularis. Для иммуногистохимических реакций применяли маркеры клеточной пролиферации (Кi-67), апоптоза (Р-53), транскрипционного фактора (β-катенин). В тубуловиллезной аденоме с low grade dysplasia имеются невысокие показатели уровня клеточной пролиферации и апоптоза, расположенные преимущественно в базальных отделах желез. По мере увеличения степени дисплазии в эпителии желез нарастает клеточное деление и появляется ядерная экспрессия β-катенина. На фоне значимого повышения клеточной пролиферации выявлено небольшое число клеток в состоянии апоптоза. Таким образом, повышение показателей Кi-67 и β-катенина в тубуловиллезной аденоме при high grade dysplasia способствует ограничению дифференцировки клеток, нарушает межклеточные контакты.

Villous lesions are advanced adenomas that manifest most commonly in the colon; however, they can develop throughout the gastrointestinal tract. The duodenum is the most common small-bowel site of these lesions. Although in most cases these are isolated lesions that occur sporadically, patients with certain specific colorectal cancer syndromes, including familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer, may develop multiple advanced adenomas. Villous lesions are important because although they are histologically benign, they may harbor dysplasia and have potential for malignancy. These characteristics make them a primary target for colorectal cancer screening with optical and virtual colonoscopy. However, these lesions can also be symptomatic and detected at diagnostic imaging when patients present for examination. They have characteristic features at a variety of imaging examinations, including barium fluoroscopy, CT, MRI, and endoscopic US. It is important for radiologists to be aware of these lesions, their potential morphologies, and their typical appearances at multimodality imaging. Although villous tumors can be detected at imaging and confirmed with biopsy, owing to limitations in identifying dysplasia and foci of malignancy with the above modalities alone and the potential for malignancy, referral for surgical resection of these lesions ultimately is required. ©RSNA, 2018.

AIM In the UK Bowel Scope Screening Programme (BSSP), patients progress to colonoscopy based on high-risk features on flexible sigmoidoscopy (FS). We aim to assess the practice of colonoscopy conversion and predictors of detection of additional adenomas on colonoscopy. METHOD The Bowel Cancer Screening database was interrogated and collated with endoscopic and histological findings from patients undergoing colonoscopy following FS between August 2013 and August 2016. Multivariate analysis was performed to identify predictors of new adenomas. RESULTS FS was performed on 11 711 patients, with an adenoma detection rate (ADR) of 8.5% and conversion to colonoscopy in 421 (3.6%). The additional ADR at colonoscopy was 35.2%, with one additional malignant diagnosis (0.26%). The adenoma miss rate was 3.6%. On multivariate analysis, a polyp ≥ 10 mm was the only high-risk indication associated with additional ADR at colonoscopy (OR 3.68, 95% CI 1.51-3.65, P

Very few cases of villous adenomas of the bladder or urinary tract have been described. To our knowledge this is the first account of resection of an urachal villous adenoma via robotic laparoscopy, which is a safe and efficacious surgical approach. At this time, there is not enough evidence to suggest that progression of disease to carcinoma is the typical course. Nonetheless, follow-up cystoscopy is recommended after complete removal of the adenoma to monitor for recurrence. This case report reviews the current literature and describes a novel approach to treatment of this exceedingly rare entity.

Background Duodenal carcinoma is very rare. It represents 33–45% of the all tumours of the small bowel. The symptoms are non-specific, and the diagnosis is often accidental. Clinical case A 35-year-old man was admitted to our hospital with post-prandial abdominal pain. Upper gastrointestinal examination revealed a tumour of the third duodenal portion, which was diagnosed, using endoscopic biopsy, as a tubular adenoma with high grade dysplasia. The computed axial tomography scan, the magnetic resonance imaging, and the endoscopic ultrasound showed the neoplasia of the third duodenal portion with no lymph node or peritoneal metastases. Partial resection of the duodenum was performed. The definitive histopathological diagnosis was primary adenocarcinoma of the third duodenal portion. pT2 N0M0, originated in a tubular adenoma. Conclusions Primitive neoplasia of the duodenum is very rare. Duodeno-cephalo-pancreatectomy is recommended in proximally located tumours, while segmental resection of the duodenum is appropriate for distal locations, with the same survival.

Transanal endoscopic microsurgery has become the standard of treatment for rectal villous adenomas. However, the role of preoperative imaging for these lesions is not clear. The aim of this study was to compare the value of preoperative imaging and surgeon clinical staging in the preoperative evaluation of patients with rectal villous adenomas having transanal endoscopic microsurgery resection.We conducted a single-centre comparative retrospective cohort study of patients who underwent transanal endoscopic microsurgery surgery for rectal villous adenomas from 2011 to 2013. The intervention was preoperative imaging versus surgeon clinical staging. The primary outcome was the accuracy of clinical staging by preoperative imaging and surgeon clinical staging according to the histopathologic staging.A total of 146 patients underwent transanal endoscopic microsurgery surgery for rectal villous adenomas. One hundred and twelve (76.7%) of those patients had no preoperative imaging while 34 patients (23.3%) had either endorectal ultrasound (22 patients) or magnetic resonance imaging (12 patients). Surgeon staging was accurate in 89.3% of cases whereas staging by endorectal ultrasound was accurate in 40.9% cases and magnetic resonance imaging was accurate in 0% of cases. In the imaging group, inaccurate staging would have led to unnecessary radical surgery in 44.0% of patients.This study was subject to selection bias because of its retrospective nature and the limited number of patients with imaging. Patients with rectal villous tumours without invasive carcinoma on biopsies and without malignant characteristics on appearance in the judgment of an experienced colorectal surgeon might not benefit from preoperative imaging before undergoing transanal endoscopic microsurgery procedures.La microchirurgie endoscopique transanale est devenue le traitement standard des adénomes villeux rectaux. La valeur de l’imagerie préopératoire pour le traitement de ces lésions n’est toutefois pas bien établie. Cette étude visait à comparer l’exactitude de la stadification par imagerie préopératoire et de la stadification clinique par le chirurgien dans le cadre de l’évaluation préopératoire des patients atteints d’adénomes villeux rectaux qui subissent une résection par microchirurgie endoscopique transanale.Nous avons mené une étude de cohorte rétrospective comparative monocentrique chez des patients ayant subi une microchirurgie endoscopique transanale pour un adénome villeux rectal entre 2011 et 2013. Les interventions comparées étaient la stadification par imagerie préopératoire et la stadification clinique par le chirurgien. L’issue principale était l’exactitude de la stadification clinique par imagerie préopératoire et de la stadification clinique par le chirurgien, confirmée par stadification histopathologique.Au total, 146 patients ont subi une microchirurgie endoscopique transanale pour le traitement d’un adénome villeux rectal. De ces patients, 112 (76,7 %) n’avaient pas subi d’imagerie préopératoire et 34 (23,3 %) avaient subi une échographie endorectale (22 patients) ou une imagerie par résonance magnétique (12 patients). La stadification par le chirurgien était exacte dans 89,3 % des cas, contre 40,9 % des cas pour l’échographie endorectale et 0 % des cas pour l’imagerie par résonnance magnétique. Dans le groupe ayant subi une imagerie, l’inexactitude de la stadification aurait mené à une chirurgie radicale inutile pour 44,0 % des patients.Cette étude comportait un biais de sélection en raison de sa nature rétrospective et du nombre limité de patients ayant subi une imagerie. L’imagerie préopératoire avant une microchirurgie endoscopique transanale pourrait ne présenter aucun avantage pour les patients présentant des tumeurs villeuses rectales dans les cas où aucun carcinome invasif n’a été détecté par biopsie et où un chirurgien colorectal chevronné n’a détecté aucune caractéristique maligne.

A 65-year-old man was previously admitted to our university hospital thrice in the last 2 years because of acute kidney failure. This time he was admitted because of frequent diarrhea, anorexia, exacerbation of renal function, and hyponatremia. Rectal wall thickening was detected on computed tomography. Subsequently, a rectal polyp with mucous secretion was found on colonoscopy, which was further diagnosed as a subcutaneous villous adenoma on biopsy. Thus, electrolyte depletion syndrome associated with the rectal polyp was thought to be the cause of his symptoms. Finally, the patient underwent abdominoperineal resection of the rectum. Histopathologically, the rectal lesion was diagnosed as a villous/tubularadenoma without malignancy, and this is such a rare case to be reported.

Patient: Female, 64 Final Diagnosis: Colon cancer Symptoms: Abdomen distension • abdominal pain • anorexia • constipation • early satiety • general weakness • night sweats • tenesmuss • vomiting Medication: — Clinical Procedure: Laparatomy – Hartmann’s procedure Specialty: Surgery Objective: Rare co-existance of disease or pathology Background: Multiple primary tumors are defined as more than 1 synchronous or metachronous tumor in the same patient. It is important to diagnose each type stage accurately because the treatment is basically directed towards the most advanced and serious primary tumor. Case Report: We report a case of advanced mucinous colon cancer and borderline mucinous ovarian tumor that was also implanted with colonic deposits, which presented with acute obstruction. Conclusions: Multiple primary ovarian and colorectal tumors are commonly encountered. In such cases, accurate diagnoses and staging are important. Immunohistochemistry is the most important investigation to differentiate primary cancers in cases of synchronized tumors and metastases.

Villous adenomas arising in the bladder following augmentation cystoplasty procedures are exceedingly rare. Even rarer is their occurrence in the native bladder mucosa and the upper urinary tract. In this article, we present a unique case of multifocal recurrent villous adenoma involving native bladder mucosa of an augmented bladder, bilateral ureters, and renal pelvis, with coexistent foci of adenocarcinoma and neuroendocrine carcinoma, in a patient with history of augmentation colocystoplasty. We additionally discuss the pathogenesis of development of carcinoma in the setting of augmentation cystoplasty.

Intestinal-type adenocarcinoma is a rare primary vaginal carcinoma and considerably more uncommon than metastatic lesions which represent the most frequent malignancy at this anatomic site. Among all malignant tumors, colorectal, breast and female genital tract carcinomas have the tendency to metastasize to the vagina.As morphologic and immunohistochemical features of intestinal-type adenocarcinoma occurring primarily in the vagina are not specific, clinical and radiologic information is crucial to exclude a metastatic lesion.Herein we present a rare case of intestinal-type adenocarcinoma from a villous adenoma, presenting as a polypoid mass in the posterior wall of vaginal introitus of 51-year-old menopausal woman. To the best of our knowledge, only 19 cases of intestinal-type adenocarcinoma of the vagina have been reported in the English literature so far. Notably the origin from a previous villous adenoma has been well documented only in a few cases.

Very few data are available about the clinical relevance of magnetic resonance (MR) imaging in preoperative evaluation of rectal villous adenoma. The aim is to evaluate the impact of MR imaging for the surgical management of rectal villous adenoma treated by transanal endoscopic microsurgery (TEM). All patients with histologically proven rectal villous tumours operated by TEM who had a preoperative MR imaging between 2009 and 2017 were retrospectively reviewed. All patients underwent TEM because preoperative evaluation suggested systematically usT0 or usT1 tumour. Pathological stage was blindly compared to preoperative MR imaging (location according to the anal verge and the peritoneal reflection, amount of circumferential involvement, tumour size and staging) and preoperative transrectal ultrasonography (TRUS) results. Forty-five patients were included (24 men, mean age 65 ± 8 years) with TRUS data available only in 37. Pathologic results were pT0-pTis in 32, pT1 in 10 and pT2 in 3. TRUS diagnosed correctly 36/37 lesions (97%) and understaged one pT2 tumour. A significant correlation between TRUS and pathologic results was noted (r = 0.99; p = 0.01). MR imaging diagnosed correctly 19/42 pTis-T1 and 1/3 pT2 tumours (46%). Overstaging by MR imaging was noted in 25 cases (54%). No correlation between MR imaging and pathologic results was noted (r = 0.7; p = 0.3). Preoperative evaluation of rectal villous adenoma is overstaged by MRI in more than half of the patients. This study suggests that the indication of local excision by TEM for rectal villous adenoma should be based on TRUS rather than on MRI.

McKittrick-Wheelock syndrome is a rare complication of rectosigmoid villous adenoma leading to secretory diarrhea, prerenal acute kidney injury and severe fluid and electrolyte imbalances. There are about 50 cases reported in literature. We represent a case of 71 year-old patient with persistant chronic diarrhea, prerenal azotemia, severe hypokalemia, and hyponatremia. Initially, the patient's kidney function and serum potassium values were normalized by conservative treatment, and villous adenoma was removed by surgery.

Transanal endoscopic microsurgery (TEM) allows local excision of rectal tumors located 4 to 18 cm above the anal verge. The technique is not yet generally established because of the necessary special instrumentation and tools, the unusual technical aspects of the approach, and the stringent patient selection criteria. The aim of this prospective, descriptive study was to analyze the currently accepted indications for TEM and to evaluate the use of this procedure for treating rectal cancer. Over a 4-year period 50 patients aged 31 to 86 years (mean 64 years) underwent TEM for treatment of rectal tumors located 12 cm above the anal verge (range 4–18 cm). The local complication rate was 4%. Altogether, 76% of lesions were benign, and 24% were T1 and T2 tumors. Of 12 cancer cases, 4 required reoperation by total mesorectal resection; the other 8 are currently under follow-up management. Over the follow-up period of 30.6 months (range 11–54 months) the recurrence rate of T1 tumors was 8.3%. TEM is a minimally invasive surgical technique that may benefit a small, specific population of patients with rectal tumors. Compared with conventional transanal resection, TEM provides superior exposure of tumors higher up in the rectum (i.e., up to 18 cm from the anal verge). The greater precision of resection combined with low morbidity (10%, relative to that of anterior resection) and short duration of hospitalization (5.5 days) make this technique a reliable and in some cases more effective surgical approach than laparotomy and low anterior resection.

One of the minimally invasive methods used in the surgical treatment of large-based polypoid lesions located in the rectum is transanal minimally invasive surgery (TAMIS). This method, which relieves patients from the severe morbidities of invasive surgical procedures, is performed in both malign (T1-T2) and benign lesions. Difficulty of suturation after TAMIS emerges as the most important factor to prolong the procedure. We aimed to analyse the efficacy of TAMIS procedure with partial thickness resection without suturation.This was a retrospective study. The study was conducted in a Turkish Education and Research Hospital in 2016. Data of 10 patients who diagnosed with benign rectal masses were included in the study. Patients who were suspected for muscularis propria invasion and lymph node positivity in magnetic resonance imaging preoperatively excluded from the study. All lesions were resected with TAMIS and the mucosal defects were not closed in any patients. Demographic features, lesion's distances to anal verge, excised lesion's size, histopathological report, operation times, duration of hospital stay and complications were recorded RESULTS: Six male and 4 female patients were treated. The mean distance to the anal werge of the lesions was 8.5 (5-12) cm. The longest diameters of the lesions ranged from 1-4 cm in length. All the patients were discharged the day after the surgery. Operation times were found to be 46.1 ± 5 min (30-70). Histopathological examinations of the removed lesions revealed villous adenomas in 3 patients, villous adenoma and Tis adenocarcinoma in 5 patients, villous adenoma and T1 adenocarcinoma in 1 patient and neuroendocrine tumor in 1 patient. There were no early complications such as bleeding, and late complications such as perforation, anal incontinence or anorectal dysfunction in any patient. No evidence of recurrence was found in any of the patients under control rectosigmoidoscopy and pelvic MRI examinations.Partial thickness resection of rectal benign lesions by TAMIS method is safe. After resection some surgeons suggest to close the defect by suture or stapler. In our study resection without closure of the defect is found safe and feasible with limited patient prejudice.Rectal benign lesions, Transanal partial thickness excision.Uno dei metodi minimamente invasivi utilizzati nel trattamento chirurgico delle lesioni polipoidi di grandi dimensioni situate nel retto è la chirurgia transanale minimamente invasiva (TAMIS). Questo metodo, che allevia i pazienti dalle gravi morbilità conseguenti alle procedure chirurgiche invasive, viene eseguito sia in lesioni maligne (T1-T2) che benigne. La difficoltà di sutura dopo che TAMIS emerge come il motivo più importante di prolungamento dell’intervento. Abbiamo inteso analizzare l’efficacia della procedura TAMIS con resezione parziale dello spessore senza sutura.Lo studio, di tipo retrospettivo, è stato condotto in un ospedale turco di istruzione e ricerca nel 2016, includendo i dati di 10 pazienti con diagnosi di massa benigna rettale, ed escludendo quelli con sospetto di invasione della muscolare propria e di positività linfonodale all’imaging preoperatoria con risonanza magnetica. Tutte le lesioni sono state reseccate con TAMIS e la soluzione di continuo della mucosa non è stata riparata in nessuno di essi. Sono stati registrati le caratteristiche demografiche, le distanze della lesione dal bordo dell’ano, le dimensioni della lesione asportata, il referto istopatologico, la durata dell’interbento, la durata della degenza ospedaliera e le complicanze.La casistica riguarda sei uomini e 4 donne. In media la distanza dal margine anale delle lesioni era di 8,5 (5-12) cm. I diametri longitudinali maggiori delle lesioni variavano da 1-4 cm. Tutti i pazienti sono stati dimessi il giorno successivo al’intervento chirurgico. I tempi operatori sono stati registrati a 46,1 ± 5 min (30- 70). Gli esami istopatologici delle lesioni rimosse hanno rivelato in 3 pazienti un adenoma villoso, adenoma villoso e adenocarcinoma Tis in 5 pazienti, adenoma villoso e adenocarcinoma T1 in 1 paziente e tumore neuroendocrino in 1 paziente. Non ci sono state complicazioni precoci come sanguinamenti nè complicazioni tardive come perforazione della parete, incontinenza anale o la disfunzione anorettale in nessun paziente. Non è stata riscontrata alcuna recidiva in nessuno dei pazienti sottoposti a controllo sigmoidoscopico nè al controllo con risonanza magnetica della pelvi.La resezione parziale dello spessore delle lesioni benigne rettali mediante il metodo TAMIS è sicura. Dopo la resezione alcuni chirurghi suggeriscono di chiudere il difetto mediante sutura o cucitrice. Nello studio, numericamente limitato nella casistica, la resezione senza chiusura del difetto si è dimostrata sicura e fattibile.

Lipomas of the digestive tract are rare benign tumours which, in most cases, are totally asymptomatic. Because of their localization within the intestinal wall, endoscopy may be completely negative so contrast-enhanced computed tomography (CT) is very important for detecting and typing these lesions. The case of a 49-year-old man with abdominal pain is presented. Colonoscopy and biopsy of a polypoid lesion on the right colonic flexure concluded for tubulovillous adenoma. The subsequent CT showed a polylobate lesion of 5 cm in diameter with predominant fat density causing luminal sub-stenosis. Histological examination of the surgical specimen confirmed the presence of a voluminous submucosal lipoma. CT allows to diagnose lipomas of the large bowel thanks to the density measurement (between -40 and -120 Hunsfield Units) with an accurate detection of the site and nature of lumen stenosis.

Introduction: McKittrick Wheelock Syndrome (MKWS) is a rare syndrome characterized by secretory diarrhea, dehydration, prerenal acute kidney injury, and severe electrolyte abnormalities caused by a large hypersecretory villous adenoma located in the rectum or rectosigmoid junction. Transabdominal (laparoscopic) procedures are the most described procedures in the treatment of MKWS. We report an alternative surgical approach, transanal minimally invasive surgery (TAMIS), to solve this syndrome. Materials and Methods: All patients who underwent transanal endoscopic microsurgery or TAMIS were included in a prospectively collected database in our center. Between 1996 and 2015, 3 patients were found to have MKWS and treated by TAMIS. Demographics, characteristics of the adenoma, surgery-related data, and outcome were analyzed. Results: The first patient had a villous adenoma 0-12cm from the anal verge. After TAMIS, she complained of a stenosis that was successfully treated by dilatation. The second patient had an impressive bulky tumor in the rectum. An endoscopic mucosal resection was attempted twice, but incompletely. Pathology analysis showed villous adenoma with high-grade dysplasia and intramucosal carcinoma. One year after TAMIS, a recurrence was detected and treated by an abdominal-perineal resection. A TAMIS was performed in the third patient because of a giant villous circular adenoma, but because of high mucus and fluid production, no proper overview could be obtained. Together with opening of the peritoneum, this prompted us to convert to a laparoscopic Hartmann procedure. Besides this technical difficulty, the patient recovered uneventful. Conclusions: MKWS is a rare syndrome and missed diagnosis could result in life-threatening situations. Different endoscopic and surgical treatments are described to solve this syndrome. TAMIS should be considered as a rectum-preserving surgical treatment option for such extensive adenomas

Most colorectal polyps are classified readily, but a subset of tubulovillous adenomas (TVA) with prominent serrated architecture causes diagnostic confusion. We aimed to (i) identify histological features that separate serrated TVAs from both conventional TVAs and traditional serrated adenomas (TSA) and (ii) perform a clinicopathological and molecular analysis to determine if the serrated TVA has unique features.We collected 48 serrated TVAs, 50 conventional TVAs and 66 BRAF wild-type TSAs for analysis. For each polyp we performed a clinicopathological assessment, BRAF and KRAS mutation profiling, cytosine-phosphate-guanosine (CpG) island methylator phenotype status, MGMT methylation and immunohistochemical assessment of seven markers [MutL homologue 1 (MLH1), p16, p53, β-catenin, Ki67, CK7 and CK20]. We found that serrated TVAs can be diagnosed reliably, and have features distinct from both conventional TVAs and TSAs. Compared to conventional TVAs, serrated TVAs are larger, more often proximal, more histologically advanced, show more CpG island methylation and more frequent KRAS mutation. Compared to TSAs they are more often proximal, show less CpG island methylation, more frequent MGMT methylation and more frequent nuclear staining for β-catenin.The serrated TVA can be diagnosed reliably and has unique features. It represents a precursor of KRAS mutated, microsatellite stable colorectal carcinoma.

Mutations of the human Kirsten rat sarcoma viral oncogene homologue (KRAS) and the highly homologous human neuroblastoma RAS viral oncogene homologue (NRAS) are associated with resistance to antiepidermal growth factor receptor therapies in patients with colorectal cancer. In this report, we describe a caecal adenocarcinoma that contains both KRAS c.35G>T (G12V) and NRAS c.34G>A (G12S) mutations. The adenocarcinoma arises from a contiguous high-grade tubulovillous adenoma, which also carries the identical KRAS and NRAS mutations, supporting their common origin. While KRAS mutations are common in colorectal cancers, NRAS mutations are relatively rare and the coexistence of multiple RAS mutations is not documented, presumably reflecting similar functions of wild-type and mutant forms of RAS. Recent experimental evidence has suggested that KRAS and NRAS may in fact mediate distinct biological processes in the colon, and this unusual case potentially illustrates the hypothesis clinically. Characterisation of the diverse and divergent functions of RAS family members and mutant forms of RAS in the colon form important considerations for the development of RAS-targeting therapeutics.

Purpose Unexpected focal colonic or rectal radiotracer activity is an usual finding in patients subjected to a PET study. The aim of this work has been to evaluate the clinical significance of this finding in the prediction of an existing colorectal malignancy. Material and methods During the last three years, all patients studied with 18 F-FDG PET/CT and PET for oncologic work-up purposes were prospectively surveyed for focal colorectal radiotracer activity. Colonoscopy was performed in all patients with this incidental finding in order to exclude colonic malignancy. CEA level, maximum standardized uptake value (SUVmax), CT findings, colonoscopy findings and histopathological results were prospectively analyzed in all patients. Results A total of 2290 patients were evaluated, 158 of whom were studied with PET and the remainder with a hybrid PET/CT. Focal FDG colorectal activity was incidentally detected in 27 patients with no previous history of colorectal cancer. Colorectal adenocarcinoma was diagnosed in seven (25.9%) patients. A pre-cancerous lesion was found in eleven patients (40.7%). Eight patients (29.6%) had no macroscopic lesions. One patient was diagnosed with a benign lesion. Any focal activity found in the colon by 18 F-FDG PET/CT examination predicts a probability greater than 50% of an underlying malignant or premalignant lesion in the histopathological analysis (logistic regression, p = 0.01), independently of the calculated SUVmax. Conclusion According to the results of the present study, we recommend the performance of a colonoscopy and biopsy of any suspicious lesions, in all patients with unexpected focal FDG activity found in colon or rectum during a 18 F-FDG PET/CT examination.

Transanal Minimally Invasive Surgery (TAMIS) is a one of new platform used to help and achieve better outcome in using transanal approach for the treatment of rectal neoplasm. High definition camera and high tech equipment are used to perform this kind of surgery. The main benefit of using this approach is to provide the best outcome or the patient compared to the traditional transanal approach. This platform can be used for a variety of cases, benign and malignant tumor and for the benign condition. We report the first TAMIS perfo b rmed in the Kuwait and probably in the Middle East with 2 years of follow up. We had no complication and patient returned home and to normal activity in next day. More studies needed to validate this technique.

A high rate of association between neuroendocrine tumors (NETs) and secondary primary malignancy (SPM) has been described in literature and this association can occur either in a synchronous or a metachronous presentation. A wide range of hypothesis has been postulated to explain the high rate of association between NETs and SPM, without definitive conclusions.We report a case of an ileal neuroendocrine tumor found incidentally at the histologic examination of the surgical specimen in a 72 years old male underwent to right hemi colectomy for two colic adenomatous polips with high grade dysplasia.Large multicentric epidemiological studies should be considered to assess the association between NETs and SPM.Neuroendocrine tumors (NETs), Progression-Free Survival (PFS), Secondary primary malignancy (SPM).In letteratura sono stati riportati alcuni casi di associazione tra tumori neuroendocrini (NETs) ed un secondo o più tumori primitivi (SPM). Quest’associazione può presentarsi sia in maniera sincrona che metacrona. Dal punto di vista eziopatogenetico sono state fatte molteplici ipotesi, senza alcuna conclusione definitiva. L’ipotesi più accreditata sostiene l’insorgenza di un secondo tumore in seguito al ruolo carcinogenetico svolto dai peptidi rilasciati dal tumore neuroendocrino Noi riportiamo il caso di un tumore neuroendocrino ileale scoperto incidentalmente all’esame istologico del pezzo operatorio di un uomo di 72 anni sottoposto ad emicolectomia destra per la presenza di due polipi adenomatosi del colon destro con alto grado di displasia. Dovrebbero essere considerati ampi studi epidemiologici multicentrici per caratterizzare meglio e spiegare le cause patogenetiche dell’associazione tra NET ed SPM.