ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI An Irregular-Shaped Stenosis of the Sigmoid Colon Yoshihide Matsumoto,1,2 Hiroshi Seno,2 and Shigeki Ono1 1
Division of Gastroenterology, Ako City Hospital, Hyogo, Japan; 2Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
Question: A 77year-old woman was admitted to our hospital for lower abdominal pain and diarrhea. She had undergone endoscopic mucosal resection to remove a 5-mm diameter rectal neuroendocrine tumor (NET) 10 years earlier. The endoscopic mucosal resection had been successfully performed with a negative surgical margin, and histopathology of the resected specimens suggested no vascular or lymphatic invasion. Blood tests on admission were normal, including tumor markers. Computed tomography showed wall thickening of the sigmoid colon. Colonoscopy revealed an irregular-shaped stenosis with edematous mucosa (Figure A). Multiple biopsies obtained from the stricture showed no significant findings. A gastrograffin enema revealed a stricture, which was approximately 20 cm (Figure B). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2013.09.021
Gastroenterology 2014;146:e5–e6
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 3: Metastasis of NET to the Sigmoid Colon
A sigmoidectomy was performed to treat aggravation in stenosis and symptoms. The resected sigmoid colon revealed no mucosal changes, but the tumor cells had infiltrated the muscular layer of sigmoid colon via the lymph and blood vessels. Pathologic examination revealed small uniform tumor cells in trabecular and rosette-like pattern (Figure C) on synaptophysin and chromogranin immunostaining (chromogranin; Figure D). The Ki-67 proliferative index was approximately 5%, and the tumor was graded an intermediate-grade NET as per the 2010 World Health Organization TNM staging system.1 NETs of the colon are relatively rare, but they are currently diagnosed more frequently because of high prevalence of endoscopic examination techniques. NETs that are 10 mm in diameter occasionally metastasize to the liver, but rarely to the gastrointestinal tract.3 The histopathology of the tumor revealed involvement of the muscular and serous layers, but not the mucosal and submucosal layers. Because the rectal NETs generally originate from the deep mucosal layer,1 we diagnosed that the rectal NET had metastasized to the sigmoid colon after 10 years (initial rectal NET, Figure E).
References 1. 2. 3.
e6
Mandair D, Caplin ME. Colonic and rectal NETs. Best Pract Res Clin Gastroenterol 2012;26:775–789. Chung TP, Hunt SR. Carcinoid and neuroendocrine tumors of the colon and rectum. Clin Colon Rectal Surg 2006; 19:45–48. Bhosale P, Shah A, Wei W, et al. Carcinoid tumours: predicting the location of the primary neoplasm based on the sites of metastases. Eur Radiol 2013;23:400–407.
Division of Gastroenterology, Ako City Hospital, Hyogo, Japan; 2Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
Question: A 77year-old woman was admitted to our hospital for lower abdominal pain and diarrhea. She had undergone endoscopic mucosal resection to remove a 5-mm diameter rectal neuroendocrine tumor (NET) 10 years earlier. The endoscopic mucosal resection had been successfully performed with a negative surgical margin, and histopathology of the resected specimens suggested no vascular or lymphatic invasion. Blood tests on admission were normal, including tumor markers. Computed tomography showed wall thickening of the sigmoid colon. Colonoscopy revealed an irregular-shaped stenosis with edematous mucosa (Figure A). Multiple biopsies obtained from the stricture showed no significant findings. A gastrograffin enema revealed a stricture, which was approximately 20 cm (Figure B). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2013.09.021
Gastroenterology 2014;146:e5–e6
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 3: Metastasis of NET to the Sigmoid Colon
A sigmoidectomy was performed to treat aggravation in stenosis and symptoms. The resected sigmoid colon revealed no mucosal changes, but the tumor cells had infiltrated the muscular layer of sigmoid colon via the lymph and blood vessels. Pathologic examination revealed small uniform tumor cells in trabecular and rosette-like pattern (Figure C) on synaptophysin and chromogranin immunostaining (chromogranin; Figure D). The Ki-67 proliferative index was approximately 5%, and the tumor was graded an intermediate-grade NET as per the 2010 World Health Organization TNM staging system.1 NETs of the colon are relatively rare, but they are currently diagnosed more frequently because of high prevalence of endoscopic examination techniques. NETs that are 10 mm in diameter occasionally metastasize to the liver, but rarely to the gastrointestinal tract.3 The histopathology of the tumor revealed involvement of the muscular and serous layers, but not the mucosal and submucosal layers. Because the rectal NETs generally originate from the deep mucosal layer,1 we diagnosed that the rectal NET had metastasized to the sigmoid colon after 10 years (initial rectal NET, Figure E).
References 1. 2. 3.
e6
Mandair D, Caplin ME. Colonic and rectal NETs. Best Pract Res Clin Gastroenterol 2012;26:775–789. Chung TP, Hunt SR. Carcinoid and neuroendocrine tumors of the colon and rectum. Clin Colon Rectal Surg 2006; 19:45–48. Bhosale P, Shah A, Wei W, et al. Carcinoid tumours: predicting the location of the primary neoplasm based on the sites of metastases. Eur Radiol 2013;23:400–407.
