Presentation
Long history of left lower quadrant pain. Change in bowel habit with increasing constipation. Biopsies are not conclusive of malignancy. Is there a colonic malignancy on imaging?
Patient Data
Short segment circumferential thickening of the sigmoid colon, with diverticula seen within this segment. Narrowing means that the fold pattern is not clearly seen. Relatively shouldered distal edge. Minimal fat stranding but no adjacent peritoneal thickening and no free fluid. Some tissue extends to the superior bladder wall but there is no intraluminal gas to indicate an established fistula. Multiple small nodes in the adjacent fat. No signs of colonic obstruction. No perforation. No suspicious liver lesion. Small right lower lung nodule unchanged over many years, with no suspicious lung nodules seen.
There are mixed signs of both diverticular disease and malignancy here, but on balance due to the preservation of diverticula this was felt to be benign disease. Nonetheless, due to symptoms, the patient underwent surgery.
HISTOLOGY REPORT
Clinical Details: Rectosigmoid mass
Site of tumor - Sigmoid colon
Maximum tumor diameter - 60 mm
Distance to nearest longitudinal resection margin - 50 mm (distal)
Tumor perforation present? - None
Relation to peritoneal reflection - Above
CRM has been inked orange. Tumor appears to invade the muscularis macroscopically and there are diverticula seen
Tumor type - Adenocarcinoma
Differentiation - Moderately differentiated
Extent of spread - Beyond muscularis propria
Distance beyond MP - 1.5 mm
Serosal involvement - None
Lymphovascular invasion - None apparent
Perineural invasion - None apparent
No. of lymph nodes - 25
No. of involved nodes - None
Non-nodal tumor deposits (N1c) - None
Background abnormalities - diverticular disease
Additional description: There is marked inflammation of the surrounding stroma with foci of abscess and extensive fibrosis. Some abscess is seen adjacent to the tumor, but this does not extend to the serosal surface and therefore the staging remains T3. Diverticular disease was seen macroscopically, which is likely to have contributed to fibrosis and inflammation.
Margins
Proximal - Well clear
Distal - Well clear
CRM - Well clear
Conclusion: Sigmoid colon - Moderately differentiated adenocarcinoma TNM 8 - pT3 pN0 (0/25) pMx R0 V0
Case Discussion
On the basis of the imaging findings of numerous diverticula in the region of the sigmoid colon abnormality, this was considered to be a diverticular stricture. The other most predictive feature of malignancy, shouldered edges, was not convincingly seen. This case highlights the overlap in findings between diverticular and malignant strictures of the sigmoid colon, with the pathology analysis here showing that this was in fact a malignant stricture.
Contrast this with this case in which the imaging was suggestive of a malignant stricture but post-operative pathology analysis identified a diverticular stricture.
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