Case Report

Invasive Cancer in a Diminutive Rectal Polyp Amidst Internal Hemorrhoids Detected by Rectal Retroflexion

Authors: Mitchell S. Cappell, MD, PhD, Mihaela Batke, MD

Abstract

A diminutive rectal polyp amidst internal hemorrhoids, detected by rectal retroflexion during colonoscopy, was shown to harbor invasive rectal adenocarcinoma by colonoscopic biopsy. Initially this lesion had appeared to be a relatively innocuous prominent anorectal mucosal fold and was recognized as a diminutive polyp only after careful rectal retroflexion during colonoscopy. This report emphasizes that lesions just above the anorectal junction with atypical endoscopic features for internal hemorrhoids should be carefully examined at rectal retroflexion and that polyps or suspicious lesions amidst internal hemorrhoids identified during colonoscopy should be snared or at least biopsied, even if small. This case report also illustrates how easily an early cancer in a diminutive colonic polyp can be missed when in difficult areas of colonoscopic inspection, such as behind a colonic fold or immediately above the anus.

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References

1. Cappell MS. Reducing the incidence and mortality of colon cancer: mass screening and colonoscopic polypectomy. Gastroenterol Clin North Am 2008;37:129–160.
 
2. Ristvedt SL, Birnbaum EH, Dietz DW, et al. Delayed treatment for rectal cancer. Dis Colon Rectum 2005;48:1736–1741.
 
3. Timaran CH, Sangwan YP, Solla JA. Adenocarcinoma in a hemorrhoidectomy specimen: case report and review of the literature. Am Surg 2000;66:789–792.
 
4. Firoozmand E, Binder S, Thompson A, et al. A gastrointestinal stromal tumor discovered in a resected hemorrhoidal donut after stapled hemorrhoidopexy: report of a case. Am Surg 2005;71:155–158.
 
5. Winburn GB. Anal carcinoma or “just hemorrhoids?” Am Surg 2001;67:1048–1058.
 
6. Hanson JM, Atkin WS, Cunliffe WJ, et al. Rectal retroflexion: an essential part of lower gastrointestinal endoscopic examination. Dis Colon Rectum 2001;44:1706–1708.
 
7. Varadarajulu S, Ramsey WH. Utility of retroflexion in lower gastrointestinal endoscopy. J Clin Gastroenterol 2001;32:235–237.
 
8. Bat L, Pines A, Rabau M, et al. Colonoscopic findings in patients with hemorrhoids, rectal bleeding and normal rectoscopy. Isr J Med Sci 1985;21:139–141.
 
9. Butterly LF, Chase MP, Pohl H, et al. Prevalence of clinically important histology in small adenomas. Clin Gastroenterol Hepatol 2006;4:343–348.
 
10. Church JM. Clinical significance of small colorectal polyps. Dis Colon Rectum 2004;47:481–485.
 
11. Unal H, Selcuk H, Gokcan H, et al. Malignancy risk of small polyps and related factors. Dig Dis Sci 2007;52:2796–2799.
 
12. Colvin M, Delis A, Bracamonte E, et al. Infiltrating adenocarcinoma arising in a villous adenoma of the anal canal. World J Gastroenterol 2009;15:3560–3564.
 
13. Gujral DM, Bhattacharyya S, Hargreaves P, et al. Metastatic rectal ade-nocarcinoma within haemorrhoids: a case report. J Med Case Reports 2008;2:128.
 
14. Cappell MS, Goldberg ES. The relationship between the clinical presentation and spread of colon cancer in 315 consecutive patients: a significant trend of earlier cancer detection from 1982 through 1988 at a university hospital. J Clin Gastroenterol 1992;14:227–235.
 
15. Cappell MS, Friedel D. The role of sigmoidoscopy and colonoscopy in the diagnosis and management of lower gastrointestinal disorders: endoscopic findings, therapy, and complications. Med Clin North Am 2002;86:1253–1288.
 
16. Cappell MS. Gastrointestinal Vascular Malformations or Neoplasms: Arterial, Venous, Arteriovenous, and Capillary, in Yamada T, Alpers DH, Kalloo AN, et al (eds): Textbook of Gastroenterology. Chichester, Wiley-Blackwell, 2009, ed 4, pp 2785–2810.
 
17. Gojnic M, Dugalic V, Papic M, et al. The significance of detailed examination of hemorrhoids during pregnancy. Clin Exp Obstet Gynecol 2005;32:183–184.
 
18. Cappell MS. Colon cancer during pregnancy. Gastroenterol Clin North Am 2003;32:341–383.
 
19. Jaspersen D. Doppler sonographic diagnostics and treatment control of symptomatic first-degree hemorrhoids. Preliminary report and results. Dig Dis Sci 1993;38:1329–1332.