Current strategies for malignant pedunculated colorectal polyps

Despite significant advances in imaging techniques, the incidence of colorectal cancer has been increasing in recent years, with many cases still being diagnosed in advanced stages. Early detection and accurate staging remain the main factors that lead to a decrease in the cost and invasiveness of the curative techniques, significantly improving the outcome. However, the diagnosis of pedunculated early colorectal malignancy remains a current challenge. Data on the management of pedunculated cancer precursors, apart from data on nonpolypoid lesions, are still limited. An adequate technique for complete resection, which provides the best long-term outcome, is mandatory for curative intent. In this context, a discussion regarding the diagnosis of malignancy of pedunculated polyps, separate from nonpedunculated variants, is necessary. The purpose of this review is to provide a critical review of the most recent literature reporting the different features of malignant pedunculated colorectal polyps, including diagnosis and management strategies.

Signet ring cell carcinoma hidden beneath large pedunculated colorectal polyp:A case report

BACKGROUND Large pedunculated colorectal polyps are not frequent among colonic polyps.We present a clinical case of a large pedunculated colorectal polyp with signet ring cell cancer infiltrating the submucosa and lymph node invasion in a patient who ultimately underwent additional surgery.Clinicians should attach importance to pedunculated colorectal polyps and choose the most appropriate therapy.CASE SUMMARY A 52-year-old female farmer underwent routine screening colonoscopy and denied constipation,diarrhea,hematochezia,or other gastrointestinal symptoms.Her past medical history and general biochemical examination results were unremarkable.During the colonoscopy,a 25-mm pedunculated polyp in the sigmoid colon was identified.The superficial epithelium was macroscopically congestive,rough,and granular,showing characteristic features of adenoma.We first ligated the root of the pedunculated polyp using nylon loops as well as a titanium clip.Histopathological examination revealed high-grade intraepithelial neoplasia of the tumor surface and a negative margin with signet ring cell adenocarcinoma infiltrating the submucosal layer.The deepest infiltration was approximately 0.9 cm from the tumor surface and 0.55 cm from the stratum basale.We performed radical resection of the left colon with lymph node dissection after two weeks.The lesion was completely resected,and pathological assessment revealed signet ring cell adenocarcinoma infiltrating the submucosal layer as well as lymph node invasion(stage PT1N1M0 and grade IIIA in pathological grading,NRAS-,BRAF V600E-,KRAS-).CONCLUSION This case highlights the importance of paying attention to the malignancy of large pedunculated polyps.Polyps or adenomas removed via endoscopy must be evaluated histologically.Even if adenomas may be fragile,endoscopy doctors should still remove polyps as completely as possible and choose perpendicular sections through the stalk and base to fix by formaldehyde solution.

Huge Intravaginal Pedunculated Fibroid Embolization and Resectoscopy—A Case Report and Review of Literature

Background: Submucosal fibroids account for approximately 15 - 20 percent of total fibroids. Rarely, they prolapse. Common size is 2 - 6 cm, because larger fibroids are unlikely to fit through the cervix. Larger fibroids are associated with significant bleeding and pose a surgical challenge. Case Presentation: We present a 38-year-old woman nulliparous with an intravaginal pedunculated fibroid, 12 cm in diameter. She presented with metrorrhagia and an intense malodorous vaginal discharge, irresponsive to oral therapy. The patient had a history of resectoscopic fibroid enucleation, 7 months earlier, followed by insertion of an (intra-uterine device) IUD. There was no uterine prolapse. Management involved bilateral uterine artery embolization, followed by hysteroscopic excision with rigid resectoscope. The fibroid was “delivered” transvaginally intact. The uterus was preserved. The IUD was partly buried within the mass. Blood loss was negligible. Patient recovery was quick and uneventful. At 6-months follow up, pelvic anatomy has been restored. Conclusion: Large pedunculated fibroids are very rare. Embolization of uterine arteries has proven a valuable tool in challenging gynecologic operations. In our case, not only it prevented massive bleeding during excision, but also allowed a fertility-sparing minimally invasive management.

Sigmoid Volvulus, Intestinal Obstruction and Bowel Perforation;an Unusual Presentation of Pedunculated Fibroid Torsion. Case Report

Pedunculated fibroid torsion presenting as a case of acute abdomen from sigmoid volvulus and large bowel perforation is rare. Without prompt diagnosis and intervention, this could lead to serious morbidity and mortality. Ms FM was a 52-year-old perimenopusal woman who was admitted to the Intensive Therapy Unit (ITU) with worsening symptoms of confirmed Covid-19 infection. On the 10th day of her admission, she developed abdominal distension and tenderness. A pelvic ultrasound scan showed a large pedunculated fibroid measuring 23 × 15 × 22 cm. The plan was for conservative management to use pain killers. Following deterioration of her clinical state, an abdominal CT scan was done which confirmed a large uterine fibroid, large bowel distention. CT findings also showed sigmoid volvulus and large bowel perforation. Following a multidisciplinary team assessment, she had an emergency exploratory laparotomy with findings of a large, torted, pedunculated fibroid with adherent sigmoid colon which had become twisted and obstructed. The large bowel segment above the Sigmoid volvulus was grossly distended and there was a gangrenous hepatic flexure with perforation. She had a right hemicolectomy, a de-functioning colostomy and subtotal hysterectomy. Postoperatively, she made very good clinical improvement. Fibroid histology report showed tissue infarction and necrosis which confirmed the torsion. She was discharged home after making good recovery.

Unlocking quality in endoscopic mucosal resection

A review of the development of the key performance metrics of endoscopic mucosal resection(EMR),learning from the experience of the establishment of widespread colonoscopy quality measurements.Potential future performance markers for both colonoscopy and EMR are also evaluated to ensure continued high quality performance is maintained with a focus service framework and predictors of patient outcome.

Impact of black cherry on pedunculate oak vitality in mixed forests:Balancing benefits and concerns

The vitality of European forests continues to decline due to new pests and diseases,climate-change related disturbances and high loads of atmospheric nitrogen deposition.Deteriorating soil health is a major factor underpinning the low vitality of West-European forests.Selecting tree species with soil ameliorative traits is proposed as an avenue to counteract soil acidification and improve overall forest vitality.Here we evaluate the impact of black cherry(Prunus serotina Ehrh.),a known rich litter species,on the vitality of neighboring pedunculate oak(Quercus robur L.)in ten mixed forests on sand in Germany,Belgium and the Netherlands.We found that black cherry admixture increases foliar N and P to a surplus whereas it causes deficiencies in foliar Mg,thereby resulting in an overall negative effect on oak foliar nutrient concentrations.Contrary,defoliation of oak leaves by herbivory decreases with the proximity of black cherry.Using structural equation modelling(SEM),we tested the hypothesized‘improved soil health’pathway.Our analyses showed that black cherry admixture leads to lower accumulation in the humus layer,resulting in higher soil base saturation which has a positive effect on foliar Ca yet a negative effect on total chlorophyll.Moreover,the SEM illustrated that herbivory of oak leaves decreases when black cherry is admixed,both via dilution and improved soil health.Indirect effects of black cherry on oak vitality via“improved soil health”in our SEM are however small in comparison to direct relations.Hence,our study showed that the combined positive and negative impacts of black cherry on oak vitality are limited,which tempers the potential benefits of using the rich litter species to counteract oak decline via improved soil health–yet,the concern of black cherry as an invasive alien species negatively affecting the vitality of mature pedunculate oak trees may also be exaggerated.

Surgical removal of a large mobile left ventricular thrombus via left atriotomy

Left ventricular(LV) thrombus is a life-threatening complication of severe LV dysfunction. Ventriculotomy has been a commonly performed procedure for LV thrombus; however, it often further decrease LV function after surgery. We present an alternative approach to thrombectomy in order to minimize the postoperative LV dysfunction. A 37-year-old female with a postpartum cardiomyopathy found to have poor LV function and a large left ventricular apical thrombus(3 cm × 3 cm) attached to the apex by a narrow stalk. Given her severe LV dysfunction, the LV thrombus was approached via left atriotomy under cardiopulmonary bypass. The LV thrombus was easily extracted with gentle traction via the mitral valve. Postoperatively, the patient was discharged home without any embolization event or inotropic support. LV thrombectomy via left atriotomy through the mitral valve could be an alternative option for the patients with poor LV function with a mobile LV thrombus.

Giant Fibrous Epulis: A Case Report of a Benign Mass of the Oral Cavity

The epulis is a relatively frequent benign oral lesion that originates from the gingival and which has no degenerative potential. A 73-year-old-woman came to our attention for a mass, located in the oral cavity and more precisely in the right inferior maxillary alveolar ridge, that the patient firstly noticed 2 years earlier. Its dimensions increased over time and now were relevant. The mass was mobile, and non-ulcerated e did not evoke pain when palpated. It was characterized by a thin pedicle and its resection, under local anesthesia, allowed a complete removal of the mass itself. The histological examination showed a fibrous and plasmacellular epulis with calcific spots and mixoid aspects. We here report this case for the unique dimensions of this epulis and in order to give a useful example that could help in the differential diagnosis of the lesions located in the oral cavity.