Praneeth Bandaru, MD1, Manan Jhaveri, MD2, Srilaxmi Gujjula, MD2, Madhavi Reddy, MD, FACG1, Aam Baqui, MD2; 1The Brooklyn Hospital Center, Brooklyn, NY; 2Brooklyn Hospital Center, Brooklyn, NY
Introduction: Colorectal cancer (CRC) is the fourth most common cause for cancer death worldwide. Colonoscopy is the most widely accepted and effective screening tool for CRC. However, effectiveness of colonoscopy as a screening tool depends on multiple quality measures among which adenoma detection rate and Cecal intubation rate are the most important and should be maintained above the recommended quality threshold. Here we take our case as an opportunity to emphasize the importance of Cecal intubation in screening colonoscopy especially in detecting right colon lesions and how suspicious finding of excessive mucus (Cecal mucus sign) lead to the diagnosis of CRC.
Methods: 60-year-old female with no significant past medical history, presented for screening colonoscopy for first time. No family history of cancers. Colonoscopy showed good prep (BBPS-9) and Cecal intubation was achieved. Colonoscopy finding is significant for excessive mucus (Cecal mucus sign) noted at appendiceal orifice and 5mm ascending colon hyperplastic polyp [figure 1]. Patient was sent to CT imaging for suspected appendiceal mucocele. It showed dilated appendix filled with mucinous material and contains an irregular mass, measuring at least 3.9 x 1.9 cm, most compatible with neoplasm with no extension beyond serosa [figure 2]. Labs were normal except for elevated CEA. Patient was sent for surgical evaluation and subsequently underwent right hemicolectomy with ileocolic anastomosis. Gross surgical specimen showed 7 cm irregular mass extending at ileocecal valve, cecum, base of appendix and ascending colon. Pathology is reported as moderately differentiated adenocarcinoma with areas of mucinous carcinoma features (30%). Patient had uneventful post-surgical course and was discharged with regular follow-ups [figure 3]. Discussion: Interval CRCs or post colonoscopy CRCs account for 3.4% to 9% of all CRCs and primarily involve the right colon. Patients who undergo colonoscopy by endoscopists with Cecal intubation rate of 95% or higher were less likely to have interval CRC. Cecal mucus sign can be a sign of underlying appendiceal mucinous lesion or mucocele which range from a spectrum of simple retention cyst to mucinous adenocarcinoma and warrants further imaging and surgical evaluation. Regardless of the initial modality of detection, surgical resection of all appendiceal mucinous lesions is recommended for both diagnostic and therapeutic purposes.
Figure 1: Colonoscopy picture in cecum showing excessive mucus seen extruding from the appendiceal orifice (Cecal mucus sign)
Figure 2: CT scan of the abdomen in frontal view showing dilated appendix (arrow) filled with mucinous material and contains an irregular mass, measuring at least 3.9 x 1.9 cm, most compatible with neoplasm with no extension beyond serosa.
Figure 3: Haematoxylin and Eosin stained slide (x10) from the resected colon with moderately to poorly differentiated adenocarcinoma with mucin
Disclosures: Praneeth Bandaru indicated no relevant financial relationships. Manan Jhaveri indicated no relevant financial relationships. Srilaxmi Gujjula indicated no relevant financial relationships. Madhavi Reddy indicated no relevant financial relationships. Aam Baqui indicated no relevant financial relationships.