AT THE FOCAL POINT Massimo Raimondo, MD, Associate Editor for Focal Points
Endoscopic appearance of Blumer’s shelf
A 60-year-old woman with a cT3, Nþ, M0 gastric cancer underwent total gastrectomy with D2 lymphadenectomy. Pathology evaluation demonstrated a T4, N3, moderate to poorly differentiated adenocarcinoma, stage IIIC by the American Joint Committee on Cancer classification. Eight months later, the patient began complaining of diffuse abdominal pain and decreased bowel movements. On rectal examination, a palpable hard mass was detected in the middle rectum. CT evaluation was consistent with a lobulated increase in bowel thickness at the rectosigmoid level and marked dilation of the proximal colon (A). Colonoscopy revealed a polypoid, lobulated, congestive, friable process circumferentially involving the middle and proximal rectum (B, C). The lesion was causing luminal narrowing and noticeable distension proximally. Biopsy specimens did not show any neoplastic cells. A laparotomy was conducted, and multiple metastatic nodules were seen at the level of the cul-de-sac. One of these was excised and a derivative colostomy performed. The histologic examination, with hematoxylin and eosin and CAM 5.2 immunohistochemical
www.giejournal.org
staining, identified a poorly differentiated carcinoma, compatible with metastatic involvement from the gastric cancer, establishing the diagnosis of Blumer’s shelf (D, H&E, orig. mag. x10; CAM 5.2, orig. mag. x10; H&E, orig. mag. x10). Currently, the patient is undergoing chemotherapy with optimal clinical, analytical, and imaging responses. DISCLOSURE All authors disclosed no financial relationships relevant to this article. Ricardo Küttner-Magalhães, MD, Department of Gastroenterology, Isabel Mesquita, MD, Pedro N. Brandão, MD, Department of Surgery, Carlos Peixoto, MD, Department of Pathology, Pedro Varzim, MD, Department of Radiology, Ângela Rodrigues, MD, Isabel Pedroto, MD, PhD, Department of Gastroenterology, Hospital Santo António, Centro Hospitalar Porto, Porto, Portugal http://dx.doi.org/10.1016/j.gie.2015.02.011
Volume
-,
No.
-
: 2015 GASTROINTESTINAL ENDOSCOPY 1
At the Focal Point
Commentary Dr George Blumer (1872-1962) was born in Darlington, England. He moved to California at age 17 to train as a surgeon at San Francisco County Hospital, before serving as a house officer under Sir William Osler in Baltimore, Maryland. While serving as Professor of Medicine at Yale in 1909, he described what would come to be known as Blumer’s shelf, “a neglected rectal sign of value in the diagnosis and prognosis of obscure malignant and inflammatory disease within the abdomen.” Blumer’s shelf presents as metastatic infiltration of the pouch of Douglas, a space named after Scottish anatomist Dr James Douglas (1675-1742). The pouch of Douglas is the deepest point of the peritoneal cavity, located between the rectum and the posterior wall of the uterus in women (the similar space in men is known as the retrovesicular excavation). As the most dependent peritoneal segment, physiologic fluid commonly occupies the region. However, it can also harbor metastases. Multiple malignancies have been reported to present with Blumer’s shelf, including lung, pancreas, gastric, and ovarian cancers. As noted by the authors, although classic endoscopic appearance can be striking, many cases require EUS-guided FNA or surgical biopsy if EUS is not available. Clinical suspicion based on classic physical examination and endoscopic signs should prompt a complete evaluation for etiology, along with investigation of common culprit primary malignancies. William C. Palmer, MD Fellow in Gastroenterology and Hepatology Mayo Clinic Florida Massimo Raimondo, MD Associate Editor for Focal Points
2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2015
www.giejournal.org
Endoscopic appearance of Blumer’s shelf
A 60-year-old woman with a cT3, Nþ, M0 gastric cancer underwent total gastrectomy with D2 lymphadenectomy. Pathology evaluation demonstrated a T4, N3, moderate to poorly differentiated adenocarcinoma, stage IIIC by the American Joint Committee on Cancer classification. Eight months later, the patient began complaining of diffuse abdominal pain and decreased bowel movements. On rectal examination, a palpable hard mass was detected in the middle rectum. CT evaluation was consistent with a lobulated increase in bowel thickness at the rectosigmoid level and marked dilation of the proximal colon (A). Colonoscopy revealed a polypoid, lobulated, congestive, friable process circumferentially involving the middle and proximal rectum (B, C). The lesion was causing luminal narrowing and noticeable distension proximally. Biopsy specimens did not show any neoplastic cells. A laparotomy was conducted, and multiple metastatic nodules were seen at the level of the cul-de-sac. One of these was excised and a derivative colostomy performed. The histologic examination, with hematoxylin and eosin and CAM 5.2 immunohistochemical
www.giejournal.org
staining, identified a poorly differentiated carcinoma, compatible with metastatic involvement from the gastric cancer, establishing the diagnosis of Blumer’s shelf (D, H&E, orig. mag. x10; CAM 5.2, orig. mag. x10; H&E, orig. mag. x10). Currently, the patient is undergoing chemotherapy with optimal clinical, analytical, and imaging responses. DISCLOSURE All authors disclosed no financial relationships relevant to this article. Ricardo Küttner-Magalhães, MD, Department of Gastroenterology, Isabel Mesquita, MD, Pedro N. Brandão, MD, Department of Surgery, Carlos Peixoto, MD, Department of Pathology, Pedro Varzim, MD, Department of Radiology, Ângela Rodrigues, MD, Isabel Pedroto, MD, PhD, Department of Gastroenterology, Hospital Santo António, Centro Hospitalar Porto, Porto, Portugal http://dx.doi.org/10.1016/j.gie.2015.02.011
Volume
-,
No.
-
: 2015 GASTROINTESTINAL ENDOSCOPY 1
At the Focal Point
Commentary Dr George Blumer (1872-1962) was born in Darlington, England. He moved to California at age 17 to train as a surgeon at San Francisco County Hospital, before serving as a house officer under Sir William Osler in Baltimore, Maryland. While serving as Professor of Medicine at Yale in 1909, he described what would come to be known as Blumer’s shelf, “a neglected rectal sign of value in the diagnosis and prognosis of obscure malignant and inflammatory disease within the abdomen.” Blumer’s shelf presents as metastatic infiltration of the pouch of Douglas, a space named after Scottish anatomist Dr James Douglas (1675-1742). The pouch of Douglas is the deepest point of the peritoneal cavity, located between the rectum and the posterior wall of the uterus in women (the similar space in men is known as the retrovesicular excavation). As the most dependent peritoneal segment, physiologic fluid commonly occupies the region. However, it can also harbor metastases. Multiple malignancies have been reported to present with Blumer’s shelf, including lung, pancreas, gastric, and ovarian cancers. As noted by the authors, although classic endoscopic appearance can be striking, many cases require EUS-guided FNA or surgical biopsy if EUS is not available. Clinical suspicion based on classic physical examination and endoscopic signs should prompt a complete evaluation for etiology, along with investigation of common culprit primary malignancies. William C. Palmer, MD Fellow in Gastroenterology and Hepatology Mayo Clinic Florida Massimo Raimondo, MD Associate Editor for Focal Points
2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2015
www.giejournal.org
