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Journal of Digestive Cancer Reports 2021; 9(1): 40-41

Published online June 1, 2021

© Korean Society of Gastrointestinal Cancer Research

Focus on Rectal Mass


Seon-Young Park, Hyun-Soo Kim



Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea

Received: May 14, 2021; Revised: May 26, 2021; Accepted: May 26, 2021

Correspondence to :
Seon-Young Park
E-mail: drpsy@naver.com
https://orcid.org/0000-0002-0962-5977

Received: May 14, 2021; Revised: May 26, 2021; Accepted: May 26, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0). which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

QUESTION: A 47-year-old man was admitted to a hospital for evaluation of rectal mass. He had been diagnosed with ulcerative colitis (UC) 10 years ago (Fig. 1), treated with intravenous steroid and remained in remission with oral mesalazine. He had a history of endoscopic mucosal resection (EMR) for rectal polyp of 2 cm in diameter 5 years ago, which pathologic finding suggested hyperplastic polyp with inflammatory change (Fig. 2). Follow-up colonoscopy showed an about 3 cm sized recurred rectal mass around the previous EMR site (Fig. 3). What is the diagnosis of rectal mass?

Fig. 1.Colonoscopic findings at the diagnosis of ulcerative colitis.

Fig. 2.Rectal polyp. (A) Rectal polyp at the symptomatic remission with intravenous steroid. (B, C) Follow-up colonoscopy showed a rectal polyp around fibrotic mucosa, which was removed by endoscopic mucosal resection.

Fig. 3.Follow-up colonoscopy 10 years after initial diagnosis.

ANSWER: Rectal cancer in patients with long-standing ulcerative colitis.

REVIEW: Long-standing UC is associated with an increased risk of dysplasia or cancer, which develop through a different pathways compared to those in sporadic cancer [1]. In this patient with UC of duration longer than 10 years, rectal cancer (pT3N2Mx) was diagnosed. The pathomechanism is secondary to long-standing inflammation and associated with the duration and extent of diseases. Current guidelines describe starting surveillance colonoscopy 6 to 10 years after the diagnosis of UC [1-3]. The rate of missed malignancy in patients with UC is not insignificant and underestimates the importance of an effective surveillance program [4], which depends on many factors; patient compliance, adequate bowel preparation, adequate mucosal sampling or use of advanced endoscopic imaging for appropriate recognition of abnormal lesions. Debates still exists regarding the optimal strategy for determining which patients with early dysplasia can be managed endoscopically and which require radical surgery. While the optimal management of low grade dysplasia continues to be debated, the finding of high grade dysplasia or colorectal cancer usually warrants surgical resection [5].


No potential conflict of interest relevant to this article was reported.


Conceptualization: Hyun-Soo Kim. Wiritng draft and supervision: Seon-Young Park.

  1. Gaidos JK, Bickston SJ. How to optimize colon cancer surveillance in inflammatory bowel disease patients. Inflamm Bowel Dis 2016;22:1219-1230.
    Pubmed CrossRef
  2. Lamb CA, Kennedy NA, Raine T, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019;68(Suppl 3):s1-s106.
    Pubmed KoreaMed CrossRef
  3. Shergill AK, Lightdale JR, Bruining DH, et al; American Society for Gastrointestinal Endoscopy Standards of Practice Committee. The role of endoscopy in inflammatory bowel disease. Gastrointest Endosc 2015;81:1101-1121.e1-e13.
    Pubmed CrossRef
  4. Wang YR, Cangemi JR, Loftus EV Jr, Picco MF. Rate of early/missed colorectal cancers after colonoscopy in older patients with or without inflammatory bowel disease in the United States. Am J Gastroenterol 2013;108:444-449.
    Pubmed CrossRef
  5. Huang LC, Merchea A. Dysplasia and cancer in inflammatory bowel disease. Surg Clin North Am 2017;97:627-639.
    Pubmed CrossRef

Article

Education Series

Journal of Digestive Cancer Reports 2021; 9(1): 40-41

Published online June 1, 2021 https://doi.org/10.52927/jdcr.2021.9.1.40

Copyright © Korean Society of Gastrointestinal Cancer Research.

Focus on Rectal Mass

Seon-Young Park , Hyun-Soo Kim

Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea

Correspondence to:Seon-Young Park
E-mail: drpsy@naver.com
https://orcid.org/0000-0002-0962-5977

Received: May 14, 2021; Revised: May 26, 2021; Accepted: May 26, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0). which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

QUESTION: A 47-year-old man was admitted to a hospital for evaluation of rectal mass. He had been diagnosed with ulcerative colitis (UC) 10 years ago (Fig. 1), treated with intravenous steroid and remained in remission with oral mesalazine. He had a history of endoscopic mucosal resection (EMR) for rectal polyp of 2 cm in diameter 5 years ago, which pathologic finding suggested hyperplastic polyp with inflammatory change (Fig. 2). Follow-up colonoscopy showed an about 3 cm sized recurred rectal mass around the previous EMR site (Fig. 3). What is the diagnosis of rectal mass?

Figure 1. Colonoscopic findings at the diagnosis of ulcerative colitis.

Figure 2. Rectal polyp. (A) Rectal polyp at the symptomatic remission with intravenous steroid. (B, C) Follow-up colonoscopy showed a rectal polyp around fibrotic mucosa, which was removed by endoscopic mucosal resection.

Figure 3. Follow-up colonoscopy 10 years after initial diagnosis.

ANSWER: Rectal cancer in patients with long-standing ulcerative colitis.

REVIEW: Long-standing UC is associated with an increased risk of dysplasia or cancer, which develop through a different pathways compared to those in sporadic cancer [1]. In this patient with UC of duration longer than 10 years, rectal cancer (pT3N2Mx) was diagnosed. The pathomechanism is secondary to long-standing inflammation and associated with the duration and extent of diseases. Current guidelines describe starting surveillance colonoscopy 6 to 10 years after the diagnosis of UC [1-3]. The rate of missed malignancy in patients with UC is not insignificant and underestimates the importance of an effective surveillance program [4], which depends on many factors; patient compliance, adequate bowel preparation, adequate mucosal sampling or use of advanced endoscopic imaging for appropriate recognition of abnormal lesions. Debates still exists regarding the optimal strategy for determining which patients with early dysplasia can be managed endoscopically and which require radical surgery. While the optimal management of low grade dysplasia continues to be debated, the finding of high grade dysplasia or colorectal cancer usually warrants surgical resection [5].

CONFLICTS OF INTEREST


No potential conflict of interest relevant to this article was reported.

AUTHOR’S CONTRIBUTIONS


Conceptualization: Hyun-Soo Kim. Wiritng draft and supervision: Seon-Young Park.

Fig 1.

Figure 1.Colonoscopic findings at the diagnosis of ulcerative colitis.
Journal of Digestive Cancer Reports 2021; 9: 40-41https://doi.org/10.52927/jdcr.2021.9.1.40

Fig 2.

Figure 2.Rectal polyp. (A) Rectal polyp at the symptomatic remission with intravenous steroid. (B, C) Follow-up colonoscopy showed a rectal polyp around fibrotic mucosa, which was removed by endoscopic mucosal resection.
Journal of Digestive Cancer Reports 2021; 9: 40-41https://doi.org/10.52927/jdcr.2021.9.1.40

Fig 3.

Figure 3.Follow-up colonoscopy 10 years after initial diagnosis.
Journal of Digestive Cancer Reports 2021; 9: 40-41https://doi.org/10.52927/jdcr.2021.9.1.40

References

  1. Gaidos JK, Bickston SJ. How to optimize colon cancer surveillance in inflammatory bowel disease patients. Inflamm Bowel Dis 2016;22:1219-1230.
    Pubmed CrossRef
  2. Lamb CA, Kennedy NA, Raine T, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019;68(Suppl 3):s1-s106.
    Pubmed KoreaMed CrossRef
  3. Shergill AK, Lightdale JR, Bruining DH, et al; American Society for Gastrointestinal Endoscopy Standards of Practice Committee. The role of endoscopy in inflammatory bowel disease. Gastrointest Endosc 2015;81:1101-1121.e1-e13.
    Pubmed CrossRef
  4. Wang YR, Cangemi JR, Loftus EV Jr, Picco MF. Rate of early/missed colorectal cancers after colonoscopy in older patients with or without inflammatory bowel disease in the United States. Am J Gastroenterol 2013;108:444-449.
    Pubmed CrossRef
  5. Huang LC, Merchea A. Dysplasia and cancer in inflammatory bowel disease. Surg Clin North Am 2017;97:627-639.
    Pubmed CrossRef

Journal Info

JDCR
Vol.9 No.1
June 1, 2021
eISSN : 2765-6713
pISSN : 2288-1581
Frequency: Quarterly

open access

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Journal of Digestive Cancer Reports

eISSN 2765-6713
pISSN 2288-1581