Apple core sign of colon cancer

Case contributed by Dr Mohamed Mahmoud Elthokapy


Diffuse abdominal pain, repeated vomiting, and chronic constipation

Patient Data

Age: 60 years
Gender: Male

Fair colonic opacification achieved after contrast enema administration showing significant short segmental concentric soft tissue mass/ thickening is seen involving the splenic colonic flexure encroaching upon its lumen, additionally, the CT images clearly illustrate the pericolic smudging as well the enlarged peri-colic lymph nodes

Subsequently, significant proximal bowel loops dilatation with partial intestinal obstruction.

Annotated image

Concentric constriction of splenic flexure with apple core appearance 


Underwent surgical excision (partial colectomy) which was histologically proven to be colonic adenocarcinoma. 

Intraoperative photos are courtesy of Dr Adel Abdelwahed (oncosurgery consultant)

Case Discussion

The apple core sign, also known as a napkin ring sign, is most frequently associated with constriction of the lumen of the colon by a stenosing annular colonic carcinoma due to bowel wall thickening with resultant circumferential constriction of the lumen. 

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