[Mckittrick-Wheelock syndrome as a rare manifestation of villous adenoma of the rectum]

McKittrick-Wheelock syndrome is a rare disease when villous adenoma of the distal colon predisposes to profuse watery diarrhea with subsequent severe electrolyte disturbances and acute renal damage. A differentiated approach to correct diagnosis requires in-depth pathophysiological knowledge of regulation of water-electrolyte metabolism, functional and organic disorders of gastrointestinal tract and clinical manifestations of hypoosmolar dehydration. The peculiarity of the McKittrick-Wheelock syndrome is a 100% probability of death without treatment and complete regression of symptoms under complex correction of homeostasis and total resection of tumor. We demonstrate the main clinical trends of the McKittrick-Wheelock syndrome. This report may be useful for general practitioners, gastroenterologists, oncologists, nephrologists and anesthesiologists.

Mucinous adenocarcinoma derived from villous adenoma of the kidney with muconephrosis

Upper respiratory tract villous adenoma (VA) with muconephrosis is rare and should be included in the differential diagnosis when pelvic dilatation with a solid component is detected. VA may transform into malignant mucinous adenocarcinoma, which should be suspected if contrast enhancement on computed tomography (CT)/magnetic resonance imaging (MRI) and restricted diffusion on MRI are observed.

McKittrick-Wheelock Syndrome: A Case Report

An adenoma is the most typical large bowel tumor found in 30% of all screening colonoscopies. However, it is often asymptomatic but sometimes might lead to abdominal pain or bleeding of the rectum. Critical electrolyte disbalance and acute kidney injury caused by secretory diarrhea is an untypical clinical manifestation of adenoma. It has rarely been reported in the literature and is defined as McKittrick-Wheelock syndrome. A 61-year-old patient was hospitalized for heavy dyselectrolytemia, diarrhea, acute kidney injury, sepsis, and fever. After the renal function was corrected and electrolyte imbalance persisted, visual instrumental diagnostics tests revealed a large tumor in the sigmoid colon. Subsequently, the patient underwent surgical resection, which exhibited evidence of tubulovillous adenoma on pathology. The atypical signs of McKittrick-Wheelock syndrome and comorbidities can make the diagnostics challenging. When severe hyponatremia and hypokalemia are followed by persistent mucous diarrhea, the clinicians should suspect MWS as a possible reason for it.

Villous adenoma of bladder with uncommon location in a super-aged patient without gross hematuria

INTRODUCTION

There have been few reported cases of villous adenoma of the bladder. It commonly occurs in the superior area of the bladder with hematuria as the most common symptom. Here, we have presented a case of villous adenoma of the bladder neck and reviewed the existing literature.

CASE PRESENTATION

A 90-year-old man presented with voiding difficulty. Although urine analysis revealed microscopic hematuria and pyuria, the patient never complained about gross hematuria. Ultrasonography and cystoscopic examination revealed a bladder tumor located at the bladder neck. Transurethral resection was performed and villous adenoma was diagnosed by histopathologic examination.

CONCLUSION

Villous adenoma of the bladder is a rare disease, which is difficult to diagnose when the patient presents with uncommon clinical features. Although villous adenoma is known as a benign tumor, some reports suggest its association with malignancy. Therefore, careful management and follow-up are necessary.

Clinical, endoscopic and histological profile of colorectal cancers seen on colonoscopy in Kano, North-Western Nigeria

Background

Colorectal cancer (CRC) is the most prevalent gastrointestinal (GI) cancer. With 5% risk of developing CRC in life, it became the third leading cause of cancer death in developed nations. In Nigeria, it is the most common GI cancer. However, there are limited data on CRC in the study area (North-Western part of Nigeria). The aim of this study was to identify the clinical, endoscopic and histological profile of CRC seen on colonoscopy.

Methodology

This was a retrospective descriptive study where colonoscopic and histological records of suspected CRC in the study centre between January 2008 to December 2017 were evaluated.

Results

Records of 135 patients were reviewed, and males constituted 63.7%. The mean age was 46.61 ± 16.80 years, with 30-39 years as a modal group. Common presentations were diarrhoea (86.7%) and bleeding per rectum (68.9%). Areas affected were rectosigmoid colon (63%), ascending colon (14.1%), descending colon (8.9%), transverse colon (7.4%) and anal canal (6.7%). Histologically, adenocarcinoma was reported in 57.8%, mucinous adenocarcinoma in 8.1% and signet ring cell adenocarcinoma in 3.7%. Tubular and villous adenomas were 3% each. Others were carcinoid tumours (1.5%), metastatic adenocarcinoma, squamous cell carcinoma, basal cell carcinoma, GI stromal tumour, inflammatory myofibroblastic tumour, angiosarcoma and adenoid cyst carcinoma reported in 0.7% each.

Conclusion

Majority of the patients with CRC were in their young age. The most common presentations were diarrhoea, weight loss and anaemia. The most common site of affectation was in the left colon, while the most common histological finding was adenocarcinoma.

Villous Adenoma Arising in the Urethra of a Female with Bladder Augmentation History: A Case Report and Review of the Literature

Villous adenomas (VAs) in the female urethra are rare with only seven cases in the English literature to our knowledge. In patients with bladder augmentation cystoplasty, the neoplasia development risk increases and most of these develop in the neobladder or anastomosis line. Only two cases of VA developing from the native bladder mucosa have been reported. Physical examination of a 76-year-old female who had a history of augmentation cystoplasty revealed a caruncula-like structure protruding from the urethral meatus. The urinary USG showed that the lesion had no relation with the bladder. The lesion was excised. Microscopically, it consisted of villous structures covered with pseudostratified intestinal type epithelium. Low-grade dysplasia was present in the epithelium but high-grade dysplasia or in-situ/invasive carcinoma was not observed. Immunohistochemical study showed positivity for CK7, CK20, EMA, CEA and CDX2. The case was reported as VA of the urethra. We presented the first VA case arising in the urethra of a female patient with intestinal bladder augmentation. Excision is curative for pure VAs. Transformation to carcinoma or recurrence has not been reported. However, in one third of the cases, a malignant tumor may accompany the lesion. Therefore, all excision material should be examined carefully. Routine endoscopic follow-up should be performed in cases with bladder augmentation.

Lessons of the month 2: McKittrick-Wheelock syndrome: Case report of a patient declining resection of a large villous adenoma

McKittrick-Wheelock syndrome (MWS) is a rare cause of acute kidney injury and electrolyte depletion. It is driven by a secretory tumour or polyp of the distal large colon. Although rare, it is a diagnosis that must be considered in patients presenting with the above conditions. Treatment is with surgical resection of the offending growth. We present the case of a 70-year-old woman who presented multiple times with electrolyte depletion and acute kidney injury. The diagnosis of MWS was established and treatment options discussed. Surgical intervention was declined, and management consisted of patient education, the careful replacement of fluid and electrolytes and close monitoring of electrolytes and kidney function. After a short period as an inpatient, the patient went on to be discharged and, with regular follow-up, has managed to continue a normal life.

Villous Morphology in Urinary Bladder Biopsy: An Approach to Diagnosis

Villous morphology in urinary bladder biopsy is a relatively uncommon finding. Villi are slender, finger-like structures that are commonly seen in the small intestine or in neoplastic lesions of gastrointestinal lineage/differentiation. Importantly, placenta also exhibits villi that are morphologically and functionally different from the intestinal one. Majority of the neoplastic lesions of urinary bladder are urothelial in origin with a minor subset showing glandular differentiation. While the presence of benign villi in urinary bladder biopsy necessitates a search for an occult perforation, provided a sample mismatch is ruled out, cytoarchitecturally abnormal/dysplastic villi indicate a neoplastic lesion of the urinary bladder encompassing villous adenoma and adenocarcinoma and urothelial carcinoma with villoglandular differentiation. The dysplastic villi in urinary bladder also imply a lower gastrointestinal endoscopy to rule out a colorectal primary. The development of the villous lesions in the urinary bladder and the colorectum are embryologically related and pose a major diagnostic challenge to the clinicians and surgical pathologists due to identical histomorphology and immunohistochemistry. We tend to discuss the morphological differentials and diagnostic approach to the villous lesions in the urinary bladder biopsy.

Precursor lesions of the urinary bladder

The classification of neoplastic precursor lesions in the urinary tract has evolved slowly with the gradual accumulation of clinicopathological data. Current nomenclature was codified most recently by the 2016 WHO classification, which is based on primary data with clinical outcome, consensus group statements and considerations of practical utility in routine diagnosis. This review discusses precursor lesions of urothelial, squamous and glandular lineage. For urothelial neoplasia, both flat lesions with atypia and early 'difficult-to-classify' proliferations are considered. Subtypes of squamous metaplasia, florid non-invasive squamous proliferations and frank squamous dysplasia are also addressed. Finally, rare glandular precursors of adenocarcinoma are reviewed, to include intestinal metaplasia, glandular dysplasia and villous adenoma. For each category, morphology (including differential diagnostic considerations), immunohistochemistry and any known molecular correlates are detailed. The goal is to provide a concise, practical up-to-date overview of this complex topic.

Villous Adenoma Arising in the Native Bladder Mucosa and the Upper Urinary Tract With Coexisting Neuroendocrine Carcinoma Following Augmentation Cystoplasty

Villous adenomas arising in the bladder following augmentation cystoplasty procedures are exceedingly rare. Even rarer is their occurrence in the native bladder mucosa and the upper urinary tract. In this article, we present a unique case of multifocal recurrent villous adenoma involving native bladder mucosa of an augmented bladder, bilateral ureters, and renal pelvis, with coexistent foci of adenocarcinoma and neuroendocrine carcinoma, in a patient with history of augmentation colocystoplasty. We additionally discuss the pathogenesis of development of carcinoma in the setting of augmentation cystoplasty.

Clinicopathological features of advanced colorectal serrated lesions: A single-center study in China

OBJECTIVE

A growing body of evidence indicates that patients with colorectal serrated lesions, especially advanced serrated lesions (ASLs), are at risk of subsequent malignancy. This study aimed to analyze the clinicopathological features of ASLs and the association between ASLs and synchronous advanced colorectal neoplasia (sACN) in a single center of China.

METHODS

A retrospective cross-sectional study of consecutive symptomatic patients and healthy individuals who underwent colonoscopy between January 2010 and March 2016 was performed. Clinicopathological characteritics of the patients with ASLs were documented from the colonoscopy database.

RESULTS

Colorectal serrated lesions were pathologically confirmed in 277 (N = 38 981, 0.7%) cases. Among them, 156 (56.3%) were found to have ASLs, with a total of 161 lesions including 71 sessile serrated adenoma/polyps (SSA/P) and 90 traditional serrated adenomas (TSAs). There were no differences in age and gender between the ASL and non-ASL patients. Among the 161 ASLs, 29 (18.0%) were ≥10 mm in diameter. Compared with non-ASLs, ASLs appeared more in the proximal colon (P = 0.007). Flat and subpedunculated lesions were more commonly found in the ASL group compared with the non-ASL group. Nearly all ASLs (160/161) had dysplasia. Moreover, 16 sACN lesions were found in 156 ASL patients, and large diameter (≥10 mm) might be a significant risk factor for sACN (odds ratio 4.35, 95% confidence interval 1.467-12.894, P < 0.05).

CONCLUSIONS

ASLs are more likely to occur in the proximal colon, and mainly present as flat and sub-pedunculated types. Large ASLs are significantly associated with sACN.

Urothelial tumors with villous morphology: Histomorphology and role of immunohistochemistry in diagnosis

Villous adenoma and urothelial carcinoma with villoglandular differentiation (UCVGD) are rare urothelial tumours showing villous morphology, the former being a preneoplastic entity and the latter being a malignant one. The detailed immunohistochemistry of these entities is previously not described in the literature. Moreover, a limited biopsy sample of UCVGD or a villous adenoma with or without adenocarcinoma may be difficult to distinguish on the basis of the histomorphology alone. An immunohistochemical panel comprising of GATA3, p63, β-catenin, CK7 and CK20 was performed on five cases of UCVGD and three cases of villous adenoma with the aim of studying the expression of the proteins thereby aiding in the diagnosis of these entities in a limited surgical pathology specimen. The mean age of UCVGD was 66.8 years and all the patients were male. All the cases of UCVGD were associated with high grade papillary urothelial carcinoma with lamina propria invasion. The immunohistochemical panel showed strong nuclear GATA3 expression in the urothelial component of UCVGD. Interestingly, the high grade and the low grade villoglandular components of UCVGD also expressed GATA3 (nuclear) with a progressive loss of expression from the high grade to the low grade component. The villous adenomas showed negativity or aberrant cytoplasmic positivity for GATA3. The β-catenin showed a gradual loss of membranous expression from villous adenoma to low grade and high grade villoglandular components of UCVGD with a patchy membranous expression in the urothelial component of the UCVGD. p63 showed strong nuclear positivity in the urothelial component and uniform negativity in the villous adenoma and villoglandular component of UCVGD irrespective of its grade, thereby distinguishing the villoglandular component from the urothelial component. The urothelial component of UCVGD showed strong membranous CK7 expression and was higher than the CK20 expression in the urothelial component. In contrast, CK20 expression was higher in villous adenoma as compared to CK7. There was no difference in the expression of CK7 and CK20 in the villoglandular components and low grade and high grade villoglandular areas. The above-mentioned immunohistochemical pattern may help to distinguish the UCVGD from the villous adenoma.

McKittrick Wheelock Syndrome Treated by Transanal Minimally Invasive Surgery: A Single-Center Experience and Review of the Literature

INTRODUCTION

McKittrick Wheelock Syndrome (MKWS) is a rare syndrome characterized by secretory diarrhea, dehydration, prerenal acute kidney injury, and severe electrolyte abnormalities caused by a large hypersecretory villous adenoma located in the rectum or rectosigmoid junction. Transabdominal (laparoscopic) procedures are the most described procedures in the treatment of MKWS. We report an alternative surgical approach, transanal minimally invasive surgery (TAMIS), to solve this syndrome.

MATERIALS AND METHODS

All patients who underwent transanal endoscopic microsurgery or TAMIS were included in a prospectively collected database in our center. Between 1996 and 2015, 3 patients were found to have MKWS and treated by TAMIS. Demographics, characteristics of the adenoma, surgery-related data, and outcome were analyzed.

RESULTS

The first patient had a villous adenoma 0-12 cm from the anal verge. After TAMIS, she complained of a stenosis that was successfully treated by dilatation. The second patient had an impressive bulky tumor in the rectum. An endoscopic mucosal resection was attempted twice, but incompletely. Pathology analysis showed villous adenoma with high-grade dysplasia and intramucosal carcinoma. One year after TAMIS, a recurrence was detected and treated by an abdominal-perineal resection. A TAMIS was performed in the third patient because of a giant villous circular adenoma, but because of high mucus and fluid production, no proper overview could be obtained. Together with opening of the peritoneum, this prompted us to convert to a laparoscopic Hartmann procedure. Besides this technical difficulty, the patient recovered uneventful.

CONCLUSIONS

MKWS is a rare syndrome and missed diagnosis could result in life-threatening situations. Different endoscopic and surgical treatments are described to solve this syndrome. TAMIS should be considered as a rectum-preserving surgical treatment option for such extensive adenomas.

Cytopathological features of villous adenoma of the urinary bladder in urine: A rare case report

Villous adenoma of the urinary bladder is a rare tumor that histologically mimics its enteric counterpart. Patients with an isolated villous adenoma have an excellent prognosis, but associated adenocarcinomas can frequently be identified in them as well. There is no literature that discusses the cytopathologic features of villous adenoma. Here we report a case which was diagnosed as villous adenoma histologically, which has been followed up with urine cytology. In urine cytology, many mucin producing cells are recognized. Few cell clusters show glandular formation or arrangement along the basement membrane. When glandular cells with columnar mucin-filled goblet cells are seen in urine cytology, the presence of a primary glandular lesion of the urinary bladder, such as villous adenoma, should be considered possible. Diagn. Cytopathol. 2016;44:632-635. © 2016 Wiley Periodicals, Inc.

Single incision laparoscopic surgery - trans anal endoscopic microsurgery: A technological innovation

Trans anal endoscopic microsurgery (TEM) first burst upon the scene several decades ago and then underwent a period of immersion. We have herein reported our experience in two cases who underwent TEM using laparoscopic techniques. The advent of single incision laparoscopic surgery (SILS) has made great inroads into various fields of general and gastrointestinal (GI) surgery. We decided to make use of the same technique in TEM for two patients who had large sessile villous adenomas of the rectum. We used this port and fixed it transanally to the edge of the anus. Carbon dioxide used for insufflation in laparoscopic surgery was used through one of the ports, and a telescope was inserted to the larger port. We made sure that the entire polyp was cut out completely until the circular muscle of the internal sphincter was clearly exposed. Next, the cut edges of the rectum were undermined between the mucosa and the circular muscles in order to bring the cut edges closer together. We were able to perform this SILS TEM in two cases. In both the cases, well differentiated villous adenoma (colonoscopically, biopsy proven before surgery) was confirmed after excision. The question has been raised whether TEM is the new laparoscopy for anorectal surgery. Increasingly, several reports are showing promise for treatment for early stage cancers and large rectal adenomas using TEM. Adoption of our technique using the SILS port that has not been previously described in medical literature, seems to be a promising tool for the future.

TEM first burst upon the scene several decades ago and then under went a period of immersion. In recent years, with the onset of laparoscopic surgery, the thoughts and the ideas of using a laparoscopic surgical technique have invaded the area of colorectal cancer as well. We have herein reported our experience in two cases who underwent TEM using laparoscopic techniques.

McKittrick-Wheelock syndrome: a rare cause of acute renal failure and hypokalemia not to be overlooked

McKittrick-Wheelock syndrome is a rare disorder in which a colorectal tumor (usually a villous adenoma) determines secretory mucous diarrhea, which in turn leads to prerenal acute renal failure, hyponatremia, hypokalemia and metabolic acidosis. Even though the outcome is usually favorable with complete recovery after surgery, the diagnosis is often delayed, making the patient susceptible to life-threatening complications, mainly severe acidosis and hypokalemia. We present two paradigmatic cases with extreme electrolytes imbalance and complete recovery following the appropriate treatment. The pathogenesis of this degenerative condition is discussed in detail.

McKittrick-Wheelock syndrome presenting with dermatomyositis and rectal prolapsed

McKittrick–Wheelock syndrome is a rare disease characterized by a large hypersecretory rectosigmoid villous adenoma resulting in persistent large volume diarrhea, electrolyte abnormalities, and renal dysfunction. We report an unusual presentation of this syndrome in a patient who developed persistent diarrhea along with dermatomyositis and rectal prolapse and was later discovered to have a large rectal villous adenoma along with a smaller sigmoid tubulovillous adenoma. In our literature review, we were able to find one case report of a dermatomyositis occurring in conjunction with a tubulovillous adenoma and few case reports of rectal prolapse in the setting of a secretory villous adenoma. However, there were no reports on both occurring in association with McKittrick–Wheelock syndrome. This report highlights the variable manifestations of colorectal adenomas and the importance of searching for an underlying neoplastic entity in patients with new onset dermatomyositis or rectal prolapse or both.

KRAS gene mutations are more common in colorectal villous adenomas and in situ carcinomas than in carcinomas

We have evaluated the frequency of KRAS gene mutations during the critical transition from villous adenoma to colorectal carcinoma to assess whether the adenomas contain a KRAS mutation more frequently than carcinomas. We analyzed sporadic villous and tubulovillous adenomas, in situ carcinomas, and primary colorectal carcinomas from multiple patients. The cancers were further evaluated for mucinous status and microsatellite instability. Standard PCR molecular techniques were used for KRAS and microsatellite analyses. A KRAS mutation was found in 61.9% of 134 adenomas, 67.8% of 84 in situ carcinomas, and just 31.6% of 171 carcinomas. Our study clearly demonstrates that tubulovillous and villous adenomas, as well as both the benign and malignant parts of in situ carcinomas, are statistically more likely to contain a somatic KRAS gene mutation than colorectal carcinomas. This difference is confined to the non-mucinous and the microsatellite stable tumors. Our data support the possibility that non-mucinous and microsatellite stable carcinomas with wild-type KRAS gene may have had a mutation in the KRAS gene during their earlier stages, with the mutation lost during further growth.

Villous adenoma of gallbladder in a patient with systemic lupus erythematosus

Villous adenomas occur most frequently in the rectum and colon. These tumors are rarely seen in the gallbladder. We report a case of gallbladder villous adenomas in a 69-year-old patient who has systemic lupus erythematosus (SLE). The patient was admitted for investigation of a gallbladder mass. Ultrasonography, computed tomography, and magnetic resonance imaging showed two well-circumscribed lobulated masses in the gallbladder. Open cholecystectomy was performed and histological examination revealed typical features of villous adenoma. This report describes the first case of villous adenomas of gallbladder with SLE, and documents its imaging findings comprehensively.

Villous adenoma of the urinary bladder: rare location. Contemp Oncol (Pozn). 2012;16:276-277. [PMID: 23788894 PMCID: PMC3687408 DOI: 10.5114/wo.2012.29300]

Villous adenomas are common lesions of the gastrointestinal tract but they are rarely located in the urinary tract including the urinary bladder. There are a few case reports and series in the literature. Here we report a 43-year-old male patient who had a polypoid lesion located on the left lateral wall of the urinary bladder. Transurethral resection was performed. The diagnosis was ‘villous adenoma of urinary bladder’ with clinical and histopathological findings.

Villous adenomas are mostly seen in elderly males. The coexistence of villous adenoma with adenocarcinoma, squamous cell carcinoma, and urothelial carcinoma was observed but there is not clear evidence about progression to carcinoma, in spite of its colonic counterpart. Generally complete surgical resection is accepted as curative but there are no exact data about follow-up and recurrence. By presenting this case, we aim to emphasize that it is a rare but important lesion because of coexistence with malignancies and uncertain malignant potential.

Villous adenoma of the renal pelvis and ureter

Villous adenoma originating in the urinary tract is a rare condition. Mucus-filled kidney (muconephrosis), one of the manifestations of this condition, occurs due to intestinal type of metaplastic changes occurring in the urothelium. This condition is commonly associated with urolithiasis and/or chronic infection. Concomitant adenocarcinomatous changes in the urothelium may be present along with this and unless a careful search is made to identify this, this serious condition may be overlooked leading to an inappropriate follow-up and dire consequences. We are reporting the third case of muconephrosis due to villous adenomatous changes of the renal pelvis and ureter.

Local management of rectal neoplasia

The treatment of rectal neoplasia, whether benign or malignant, challenges the surgeon. The challenge in treating rectal cancer is selecting the proper approach for the appropriate patient. In a small number of rectal cancer patients local excision may be the best approach. In an attempt to achieve two goals-cure of disease with a low rate of local failure and maintenance of function and quality of life-multiple approaches can be utilized. The key to obtaining a good outcome for any one patient is balancing the competing factors that impact on these goals. Any effective treatment aimed at controlling rectal cancer in the pelvis must take into account the disease in the bowel wall itself and the disease, or potential disease, in the mesorectum. The major downside of local excision techniques is the potential of leaving untreated disease in the mesorectum. Local management techniques avoid the potential morbidity, mortality, and functional consequences of a major abdominal radical resection and are thus quite effective in achieving the maintenance of function and quality of life goal. The issue for the transanal techniques is how they fare in achieving the first goal-cure of the cancer while keeping local recurrence rates to an absolute minimum. Without removing both the rectum and the mesorectum there is no completely accurate way to determine whether a rectal cancer has moved outside the bowel wall, so any decision on local management of a rectal neoplasm is a calculated risk. For benign neoplasia, the challenge is removing the lesion without having to resort to a major abdominal procedure.

Mucinous adenocarcinoma with superficial stromal invasion and villous adenoma of urachal remnants: a case report

This report describes a case of mucinous adenocarcinoma with superficial stromal invasion and villous adenoma originating in the dome of the urinary bladder. Although no urachal remnants were identified, the location suggested urachal derivation. Only two previous cases of urachal adenocarcinoma with features of early stromal invasion associated with a villous tumour have been described.