Colon and Rectal Cancer.  El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
Synchronous Cancers, Familial Polyposis.   Prolapsed Adenocarcinoma of the rectum and  adenocarcinoma of the transverse colon.   This is the case of a 48, year-old female, referred to us to evaluate a rectal prolapsed mass, one brother died due to a colon cancer and two brothers died due to rectal hemorrhage at 11 ands 12 years.

Video Endoscopic Sequence 1 of 36.

Synchronous Cancers, Familial Adenomatous Polyposis

 Prolapsed Adenocarcinoma of the rectum and
 adenocarcinoma of the transverse colon.

 This is the case of a 48, year-old female, referred to us to
 evaluate a rectal prolapsed mass, one brother died due to a
 colon cancer and two brothers died due to rectal
 hemorrhage at 11 and 12 years.

 For more endoscopic details download the video clips by
 clicking on the endoscopic images, wait to be downloaded
 complete then press Alt and Enter; thus you can observe
 the video in full screen.

 All endoscopic images shown in this Atlas contain
 video clips.

The image as well as display a large and irregular mass that was proven by histopathology to be an adenocarcinoma. Synchronous carcinomas of the colon and rectum are of considerable clinical significance because of their frequency, the number of extra tumours missed and the difficulty of preoperative diagnosis.

Video Endoscopic Sequence 2 of 36.

 The image as well as display a large and irregular mass
 in the transverse colon that was proven by histopathology
 to be an adenocarcinoma.

 Synchronous carcinomas of the colon and rectum are of
 considerable clinical significance because of their
 frequency, the number of extra tumours missed and the
 difficulty of preoperative diagnosis.

 

The genetic defect in FAP is a germline mutation in the adenomatous polyposis coli (APC) gene. Syndromes once thought to be distinct from FAP are now recognized to be, in reality, part of the phenotypic spectrum of FAP.

Video Endoscopic Sequence 3 of 36.

The patient has several flat adenomas in the rectum.

 The genetic defect in FAP is a germline mutation in the
 adenomatous polyposis coli (APC) gene. Syndromes once
 thought to be distinct from FAP are now recognized to be,
 in reality, part of the phenotypic spectrum of FAP.

 

The principal cause of mortality is colorectal cancer, which develops in all patients unless they are treated. The mean age at which colorectal cancer develops in patients with classic FAP is 39 years. Patients with adenomatous polyposis itself often are asymptomatic.

Video Endoscopic Sequence 4 of 36.

Multiple Adenomas in the Sigmoid are displayed. Colonoscopy revealed hundreds of polyps throughout the colon.

  • The principal cause of mortality is colorectal cancer, which develops in all patients unless they are treated. The mean age at which colorectal cancer develops in patients with classic FAP is 39 years. Patients with adenomatous polyposis itself often are asymptomatic.
"	The second reported lethal complication of FAP is diffuse mesenteric fibromatosis and is referred to as a desmoid tumor. It involves intra-abdominal organs and vessels, causing gastrointestinal obstruction and constriction of veins, arteries, and ureters. Desmoid tumors are reported in 4-32% of patients. Even after the appropriate surgical treatment of FAP, 20% of patients may develop desmoid tumors after colectomy. Studies have not found a correlation between specific APC mutation sites and desmoid tumor development.

Video Endoscopic Sequence 5 of 36.

More Adenomas in the Descending Colon

 The second reported lethal complication of FAP is diffuse
 mesenteric fibromatosis and is referred to as a desmoid
 tumor. It involves intra-abdominal organs and vessels,
 causing gastrointestinal obstruction and constriction of
 veins, arteries, and ureters. Desmoid tumors are reported
 in 4-32% of patients. Even after the appropriate surgical
 treatment of FAP, 20% of patients may develop desmoid
 tumors after colectomy. Studies have not found a
 correlation between specific APC mutation sites and
 desmoid tumor development.

 

The two most common inherited forms of colorectal cancer are familial adenomatous polyposis and hereditary non-polyposis colorectal cancer. The second most common malignancy in patients with FAP is adenocarcinoma of the duodenum and the papilla of Vater. It affects as many as 12% of patients.

Video Endoscopic Sequence 6 of 36.

 The two most common inherited forms of colorectal cancer
 are familial adenomatous polyposis and hereditary
 non -polyposis colorectal cancer.

  • The second most common malignancy in patients with FAP is adenocarcinoma of the duodenum and the papilla of Vater. It affects as many as 12% of patients

Video Endoscopic Sequence 7 of 36.

 A large Ulcerated Adenoma is seen at the Splenic Flexure
 The ulcer displayed it may be due to the biopsies taken 19
 days in a previous colonoscopy.

Video Endoscopic Sequence 8 of 36.

This unusual finding is an artery that feed two polyps.

 

  • Rarer cancers associated with FAP include medulloblastomas (Turcot syndrome),
    hepatoblastoma, thyroid cancer, gastric cancer, pancreatic cancer, and adrenal cancer.

Video Endoscopic Sequence 9 of 36.

Again more images and video clips of the Adenocarcinoma of the transverse colon.

Video Endoscopic Sequence 10 of 36.

The hole of the apendix is surrounded by adenomatous tissue.

 

Video Endoscopic Sequence 11 of 36.

Cecum, the terminal Ileum was unremarkable.

Video Endoscopic Sequence 12 of 36.

A large pediculated mass is displayed at ascending colon.

Video Endoscopic Sequence 13 of 36.

Florid polyposis, usually with over 100 polyps in the colon and often several thousand.

This image and the video clip shown multiple polyps and the adenocarcinoma of the transverse colon.

Video Endoscopic Sequence 14 of 36.

 The video clip displays the biopsy of the cancer of the transverse colon.

Video Endoscopic Sequence 15 of 36.

Splenic Flexure.

Video Endoscopic Sequence 16 of 36.

In FAP the male-to-female ratio is 1:1.

 

"	The average age of onset of polyposis in FAP is 16 years.

Video Endoscopic Sequence 17 of 36.

 

  • The average age of onset of polyposis in FAP is 16 years.
  • The average age of onset for colorectal cancer is 39 years.
  • The average age of onset for polyps in AAPC is 36 years, and the average age of onset for cancer in AAPC is 54 years. These patients have fewer polyps (approximately 30 polyps) compared to patients with FAP.
  • Most patients with FAP are asymptomatic until they develop cancer. As a result, diagnosing presymptomatic patients is essential.
  • Of patients with FAP, 75-80% have a family history of polyps and/or colorectal cancer at age 40 years or younger.

Video Endoscopic Sequence 18 of 36.

The adenocarcinoma of the rectum.

Video Endoscopic Sequence 19 of 36.

The image and the video clip display, some biopsies are taken of an irregular flat adenoma of the rectum.

Video Endoscopic Sequence 20 of 36.

 

  • Nonspecific symptoms, such as unexplained rectal bleeding (hematochezia), diarrhea, or abdominal pain, in young patients may be suggestive of FAP.
  • Congenital hypertrophy of the retinal pigment epithelium is highly specific for FAP and is best seen by slit-lamp examination.

Video Endoscopic Sequence 21 of 36.

The rectum has several flat polyps.

Video Endoscopic Sequence 22 of 36.

Again a flat polyp of the rectum.

Video Endoscopic Sequence 23 of 36.

Retroflexed image of the rectal adenocarcinoma.

Video Endoscopic Sequence 24 of 36.

Again, retroflexed image.

Video Endoscopic Sequence 25 of 36.

Prolapsed adenocarcinoma.

Video Endoscopic Sequence 26 of 36.

More images and video clip.

Surgical specimen of the colon  after total colectomy with ileostomy. Note the carpetlike appearance of the mucosa covered with polyps.

Video Endoscopic Sequence 27 of 36.

 Surgical Specimen

 Surgical specimen of the colon after total colectomy with
 ileostomy. Note the carpetlike appearance of the mucosa
 covered with polyps.

 The surgical specimen showed besides of multiple colon
 carcinoma a large number of adenomas of which many
 contained areas with high grade dysplasia.

Macroscopic Specimen of Familial adenomatous polyposis (FAP)

Video Endoscopic Sequence 28 of 36.

 Macroscopic Specimen of Familial adenomatous polyposis (FAP), Familial polyposis coli: the entire colonic mucosa is carpeted with a close crop of polyps.

 

Video Endoscopic Sequence 29 of 36.

Macroscopic Specimen of Familial adenomatous polyposis (FAP).

Video Endoscopic Sequence 30 of 36.

Macroscopic Specimen of Familial adenomatous polyposis (FAP).

Video Endoscopic Sequence 31 of 36.

Macroscopic Specimen of Familial adenomatous polyposis (FAP).

Video Endoscopic Sequence 32 of 36.

Macroscopic Specimen of Familial adenomatous polyposis (FAP).

Video Endoscopic Sequence 33 of 36.

Macroscopic Specimen of Familial adenomatous polyposis (FAP).

Video Endoscopic Sequence 34 of 36.

Macroscopic Specimen of Familial adenomatous polyposis (FAP).

Video Endoscopic Sequence 35 of 36.

Macroscopic Specimen of Familial adenomatous polyposis (FAP).

Video Endoscopic Sequence 36 of 36.

Macroscopic Specimen of Familial adenomatous polyposis (FAP).

CacECUMDF1

Video Endoscopic Sequence 1 of 3.

Adenocarcinoma of the Cecum

 This 42 year-old male presented with severe abdominal pain in the right iliac fossa and weight lost of 20 lbs.

 Carcinoma of the cecum and ascending colon is commonly
 believed to produce symptoms of anemia, diarrhea, and
 alternating diarrhea and constipation obstruction and pain.
 Symptoms of obstruction and pain are supposedly not
 common symptoms of malignancy in this region of
 the colon.

 

CacECUMDF2

Video Endoscopic Sequence 2 of 3.

 Video Endoscopy of Adenocarcinoma of the Colon

 Cecal carcinoma has been associated with a poorer
 prognosis than other colon carcinomas because of the
 presumed longstanding obscure symptoms.

 Epidemiology

  Colorectal carcinoma is a disease of the older population
 except for people with hereditary non-polyposis and
 polyposis syndromes or chronic inflammatory bowel
 disease
  The male/female ratio for rectal carcinoma is 2/1 while the
 male/female ratio of right sided lesions is 1/1
  The remarkably higher incidence in more affluent
 countries and the change in incidence in migrants to the
 area of migration suggests a strong environmental affect
 which most studies relate to high dietary fat, low fiber and
 high refined carbohydrates.

CacECUMDF3

Video Endoscopic Sequence 3 of 3.

 Colorectal carcinoma develops over a long period of time
 with an estimated doubling time of almost two years
  Presenting symptoms are related to chronic blood loss
 with the signs and symptoms of iron deficiency anemia,
 increasing luminal obstruction with change in bowel habits,
 diameter of stool, variable constipation, diarrhea, and
 vague abdominal discomfort or pain. A palpable mass
 lesion is a late finding
  Right sided tumors are most associated with blood loss
 and rarely with obstruction while left sided lesions present
 with signs of obstruction.
  Treatment is surgical and prognosis is related to stage at
 presentation.
  About 25% of patients will present with metastatic
 disease, primarily lymph nodes and liver. The overall
 survival is 50%.

Adenocarcinoma of the cecum,This 69 year-old female was referred to our endoscopic unit for evaluation of anemic syndrome, fecal occult blood in 3 times was negative.

Video Endoscopic Sequence 1 of 4.

Adenocarcinoma of the Cecum

 This 69 year-old female was referred to our endoscopic
 unit for evaluation of anemic syndrome, fecal occult blood
 test for 3 times was negative. 

Colorectal cancer (CRC) is the second leading cause of cancer-related death in the Western world and the incidence in El Salvador is also rising.

Video Endoscopic Sequence 2 of 4.

 Endoscopic Image of Cancer of the Colon

 Colorectal cancer (CRC) is the second leading cause of
 cancer-related death in the Western world and the
 incidence in El Salvador is also rising.

The incidence of colorectal cancer has been rising dramatically following economic development and industrialization. Currently, colorectal cancer is the third leading cause of cancer deaths in both males and females in the United States.

Video Endoscopic Sequence 3 of 4.

 Colon and rectal cancer incidence was negligible before
 1900.

 The incidence of colorectal cancer has been rising
 dramatically following economic development and
 industrialization. Currently, colorectal cancer is the third
 leading cause of cancer deaths in both males and females
 in the United States.

 

Approximately 20% of colon cancers develop in the cecum, another 20% in the rectum, and an additional 10% in the rectosigmoid junction. Approximately 25% of colon cancers develop in the sigmoid colon.

Video Endoscopic Sequence 4 of 4.

 Approximately 20% of colon cancers develop in the cecum,
 another 20% in the rectum, and an additional 10% in the
 rectosigmoid junction. Approximately 25% of colon cancers
 develop in the sigmoid colon.

Rectum Adenocarcinoma. This 72 year-old female presented with rectal bleeding since one year previously with weigh loss of 20 libs.

Video Endoscopic Sequence 1 of 4.

Rectum Adenocarcinoma

 This 72 year-old female presented with rectal bleeding
 since one year previously with weigh loss of 20 libs.

The significant portions of colorectal carcinomas are adenocarcinomas. The adenoma-carcinoma sequence is well described in the medical literature.  Colonic adenomas precede adenocarcinomas. Approximately 10% of adenomas will eventually develop into adenocarcinomas. This process may take up to 10 years

Video Endoscopic Sequence 2 of 4.

 The significant portions of colorectal carcinomas are
 adenocarcinomas. The adenoma-carcinoma sequence is
 well described in the medical literature. Colonic adenomas
 precede adenocarcinomas. Approximately 10% of
 adenomas will eventually develop into adenocarcinomas.
 This process may take up to 10 years.

Bleeding is the most common symptom of rectal cancer, occurring in 60% of patients. Bleeding often is attributed to other causes (eg, hemorrhoids), especially if the patient has a history of other rectal problems. Profuse bleeding and anemia are rare. Bleeding may be accompanied by the passage of mucus, which warrants further investigation.

Video Endoscopic Sequence 3 of 4.

 Bleeding is the most common symptom of rectal cancer,
 occurring in 60% of patients. Bleeding often is attributed
 to other causes (eg, hemorrhoids), especially if the patient
 has a history of other rectal problems. Profuse bleeding
 and anemia are rare. Bleeding may be accompanied by the
 passage of mucus, which warrants further investigation.

Change in bowel habits is present in 43% of patients; change is not evident in some cases because the capacity of a rectal reservoir can mask the presence of small lesions. When change does occur it is often in the form of diarrhea, particularly if the tumor has a large villous component. These patients may have hypokalemia, as shown in laboratory studies. Some patients experience a change in the caliber of the stool.  Large tumors can cause obstructive symptoms. Tumors located low in the rectum can cause a feeling of incomplete evacuation and tenesmus.

Video Endoscopic Sequence 4 of 4.

 Change in bowel habits is present in 43% of patients;
 change is not evident in some cases because the capacity
 of a rectal reservoir can mask the presence of small
 lesions. When change does occur it is often in the form of
 diarrhea, particularly if the tumor has a large villous
 component. These patients may have hypokalemia, as
 shown in laboratory studies. Some patients experience a
 change in the caliber of the stool. Large tumors can cause
 obstructive symptoms. Tumors located low in the rectum
 can cause a feeling of incomplete evacuation and tenesmus.

Ulcerated Adenocarcinoma of the ascending colon that was removed laparoscopicaly found intraoperatory causing colonic intussusception..

Photography Sequence 1 of 6.

Ascending Colon Intussusception due to a Adenocarcinoma

 Ulcerated Adenocarcinoma of the ascending colon that was
 removed laparoscopicaly found intraoperatory causing
 colonic intussusception.

 The vast majority of intussusceptions occur in children
 under the age of 2 years. Intussusception in adults is
 usually caused by a tumor; when the intussusception is
 colonic, the underlying tumor is most often malignant. The
 most common cause is a polypoid cecal carcinoma,
 although other lesions such as a lipoma, lymphomatous
 mass, or even a cecal endometrioma may be responsible.

 

Click on the images to enlarge in a new windows

The appearance of this tumor is that of a enormous polyp that degenerated in a neoplasia. Adult intussusceptions are rare entities that are almost always associated with a demonstrable lead point.

Photography Sequence 2 of 6.

The appearance of this tumor is that of a enormous polyp that degenerated in a neoplasia.

 Adult intussusceptions are rare entities that are almost
 always associated with a demonstrable lead point.

 General Gross Description

The gross appearance is dependent on the stage of the
 tumor.
Early invasive carcinoma may maintain the appearance of
 the original adenoma either polypoid or sessile.
More commonly, the tumor has obliterated evidence of the
 underlying adenoma and when first seen is a firm, white,
 flat, well demarcated mucosal lesion with raised rolled
 margins, often with central ulceration.
Over time, the lesion spreads circumferentially through
 circular lymphatics to produce a constricting napkin-ring
 lesion in the mucosa.
  As mucosal spread occurs, tumor also invades the full
 thickness of the muscular wall, and only at this stage is
 tumor seen grossly involving the perirectal fat, or
 mesentery.
  Cecal lesions often have a different appearance because
 of the large volume of space in which they can grow before
 producing symptoms. Cecal carcinomas often cover large
 areas of the cecum with fungating sessile or bulky lesions
 which can be extensively necrotic.
Because of their long growth time before discovery cecal
 lesions often are seen as large deeply invasive tumors with
 attachment to the adjacent peritoneal wall.

The symptoms of adult intussusception of the colon vary considerably. The signs and symptoms are often associated with the chronic process of obstruction, and not with acute abdomen. As a result, it is difficult to diagnose adult intussusception of the colon, and most cases are diagnosed when patients undergo laparotomy. When ultrasonography shows the typical concentric hyperechoic double ring coupled with thickening of the intestinal walls, a diagnosis of colonic intussusception should be considered. CT permits an even more detailed view of suspected intussusception, and thus plays an important role in determining the most appropriate therapeutic strategy.

Photography Sequence 3 of 6.

A close up of the Ascending Colonic Adenocarcinoma

 The symptoms of adult intussusception of the colon vary
 considerably. The signs and symptoms are often associated
 with the chronic process of obstruction, and not with acute
 abdomen. As a result, it is difficult to diagnose adult
 intussusception of the colon, and most cases are diagnosed
 when patients undergo laparotomy. When ultrasonography
 shows the typical concentric hyperechoic double ring
 coupled with thickening of the intestinal walls, a diagnosis
 of colonic intussusception should be considered.
 CT permits an even more detailed view of suspected
 intussusception, and thus plays an important role in
 determining the most appropriate therapeutic strategy.

Radical surgical resection is the definitive treatment for tumor-induced intussusception. Reduction of an intussusception with suspected malignancy should be avoided, since it can cause bowel perforation and tumor cell dissemination. While resection has been assumed to be the most appropriate treatment for intussusception of the colon in adults, it is sometimes possible to reduce intussusceptions by simple manipulation or by compression. With total inversion, partial resection may be necessary; however, when carcinoma is considered peroperatively, an extended resection with lymph node dissection should be performed .

Photography Sequence 4 of 6.

Adenocarcinoma of the Ascending Colon

 Radical surgical resection is the definitive treatment for
 tumor-induced intussusception. Reduction of an
 intussusception with suspected malignancy should be
 avoided, since it can cause bowel perforation and tumor
 cell dissemination. While resection has been assumed to
 be the most appropriate treatment for intussusception of
 the colon in adults, it is sometimes possible to reduce
 intussusceptions by simple manipulation or by
 compression. With total inversion, partial resection may
 be necessary; however, when carcinoma is considered
 peroperatively, an extended resection with lymph node
 dissection should be performed.

In emergency cases, the surgeon has to evaluate the need for a resection with immediate or delayed anastomosis, versus a colostomy with deferred resective treatment. The choice of the type of operation may depend on the clinical status of the patient, the condition of the bowel (e.g., whether it is ischemic or not), the site of intussusception and of the tumor, the diagnostic certainty of malignancy, and the experience of the surgeon.

Photography Sequence 5 of 6.

 In emergency cases, the surgeon has to evaluate the need
 for a resection with immediate or delayed anastomosis,
 versus a colostomy with deferred resective treatment.
 The choice of the type of operation may depend on the
 clinical status of the patient, the condition of the bowel
 (e.g., whether it is ischemic or not), the site of
 intussusception and of the tumor, the diagnostic certainty
 of malignancy, and the experience of the surgeon.

 

Laparoscopic treatment of ascending colon intussusception by large malignant tumor.  The combination of clinical findings and diagnostic techniques can elucidate the diagnosis of adult colonic intussusception, and the most decisive diagnostic modality appears to be computerized tomography. Surgical resection is the definitive treatment for intussuscepting tumors. However, the choice and timing of the operation depend on the clinical condition of the patient and the status of the intussuscepted bowel.

Photography Sequence 6 of 6.

 Laparoscopic treatment of ascending colon intussusception
 by large malignant tumor.

 The combination of clinical findings and diagnostic
 techniques can elucidate the diagnosis of adult colonic
 intussusception, and the most decisive diagnostic modality
 appears to be computerized tomography. Surgical resection
 is the definitive treatment for intussuscepting tumors.
 However, the choice and timing of the operation depend
 on the clinical condition of the patient and the status of the
 intussuscepted bowel.

CaCiegoXCnelzxc1

Video Endoscopic Sequence 1 of 3.

Adenocarcinoma of the Cecum

A 85 year-old male, Retired Colonel, with weigh loss of 20 libs has this large mass in the cecum.

CaCiegoXCnelzxc2

Video Endoscopic Sequence 2 of 3.

More images and video clips

CaCiegoXCnelzxc3

Video Endoscopic Sequence 3 of 3.

More images and video clips

CaColonCarias1

Video Endoscopic Sequence 1 of 3..

This 76 year-old male, had 20 pounds weight loss and also had defecation disorders.

CaColonCarias2

Video Endoscopic Sequence 2 of 3.

Endoscopic Image of Colon Cancer

CaColonCarias3

Video Endoscopic Sequence 3 of 3.

Video Endoscopic Image of Colon Cancer