0:01

So for this case, this is a, a very special case for me

0:03

because it's a case of myself.

0:06

I don't think many radiologists can say

0:08

that they get a chance to show their, their, their own bum

0:11

to, uh, the entire world.

0:13

But, uh, this is my chance.

0:15

This is my own CT colonography

0:16

that I performed when I turned 45.

0:19

And I guess the first teaching point is that, uh,

0:21

45 is the new 50.

0:23

So, uh, just, um, remember that the, the screening age

0:28

for the United States now starts at the age 45,

0:31

and that's solely because

0:33

of the increasing risk in the increasing incidence

0:35

of colorectal cancer in younger and younger patients.

0:38

There's certainly a, a trend over the last, um, couple

0:42

or decades that, um, colorectal cancer is starting

0:47

to appear in younger and younger patients.

0:49

And I'm seeing many patients that are even under the age

0:51

of 50 as well as 40.

0:53

I mean, I'm seeing patients in their thirties

0:55

and even a few in their twenties presenting

0:57

with colorectal cancer,

0:59

especially rectal cancer in particular.

1:01

So, you know, there are many researchers trying

1:03

to figure out what the reasons for the, um,

1:05

increasing incidences in younger patients is.

1:07

And it could be multifactorial environment, diet, uh,

1:11

the gut microbiome.

1:12

There's a whole bunch of different theories out

1:13

there as to why.

1:15

But, um, the bottom line is that, uh, now it's recommended

1:19

to start screening at an even earlier age,

1:21

and even earlier than 45 if you have a family history

1:24

of colon cancers at, uh, younger than the age of 45.

1:28

So certainly 10 years younger than the, uh,

1:30

first index case in a close family member.

1:34

So this was a finding

1:35

that I saw while I was on the table getting this

1:39

CT colonography on myself.

1:41

And, um, I saw this on the scout images while I was lying on

1:45

the, on the scanner table.

1:47

Uh, so I knew something was gonna be up with this case,

1:50

and I had zero symptoms other than, uh,

1:53

I do have a family history of colon cancer.

1:55

So that was another reason for why I was very, um,

1:58

conscientious in getting screened at the age of 45.

2:02

I wasn't expecting to have a positive finding.

2:04

And in this case, here you can see on the two D images,

2:07

on the axial images, there's a mass in the right colon,

2:10

and this is a pretty sizable mass.

2:13

I, I'm getting close to, uh, to four

2:15

or five centimeters in size,

2:16

at least four centimeters in size.

2:18

And this is just on the axial images.

2:20

So if you look on the three D images,

2:22

you could probably get a, a number even closer

2:24

to five centimeters if you measure along the two long axis.

2:27

And this is an example, another example of why, um,

2:30

measuring of just the cardinal axis, um,

2:34

may underestimate significantly the size of the mass.

2:37

And you've gotta rotate around to,

2:40

to really make sure you've got the long axis of this mass,

2:44

as you can see here,

2:46

getting a couple different measurements.

2:48

But the important thing is that, you know,

2:50

you're getting much larger than one centimeter.

2:52

So this is something I knew I was gonna end up getting a

2:54

colonoscopy for.

2:56

In addition, there's another interesting finding here in

2:59

that just next door to that mass,

3:02

and this is actually wearing the, the terminal ileum.

3:04

On those images there, you could see there's actually a

3:07

stock from inside the terminal ileum.

3:09

So here on the, on the chal image, you might be able

3:12

to tell better that the mass is actually arising from the

3:14

terminal ileum rather than the colon itself.

3:18

So if you can see the ileocecal valve, this is going

3:21

through the ileocecal valve.

3:23

So this is the terminal ileum here.

3:25

And so it's arising from the terminal ileum from a fold in

3:28

the terminal ileum and prolapsing

3:30

through the ileocecal valve

3:32

to show up in the right colon at the region of

3:34

where the ileocecal valve is supposed to be.

3:37

But that other finding I wanted to show you,

3:40

it was a very diminutive polyp right here

3:43

below your typical size, uh, threshold for calling a polyp.

3:47

But I mentioned it

3:48

because I knew that I was going to colonoscopy for this

3:50

and this tiny little polyp here,

3:52

it's maybe like three millimeters, four millimeters in size,

3:55

so below the six millimeter cutoff that we typically use.

3:59

This also ended up being a true polyp as well.

4:02

I got the colonoscopy later that same day.

4:04

So in a perfect scenario,

4:07

we would have gastroenterologists available to do same day

4:11

optical colonoscopies for positive CT colon photographies.

4:15

And as you could imagine, there's, there's a lot

4:18

of complexity to setting up a schedule to allow for that.

4:21

You know, we're we're gracious enough to be able to add on,

4:24

uh, same day CT colonies for incomplete colonoscopies,

4:28

but it's probably a, a heavier lift

4:31

for the gastroenterologists to offer the same

4:34

for screening CT colon photographies

4:36

to go onto an optical colonoscopy

4:38

for a diagnostic polypectomy.

4:40

But if you have gastroenterologists that are willing to, um,

4:44

make room in their schedule for same day add-ons,

4:47

then the perfect world would be a patient that comes

4:50

for CT colonoscopy if they choose that

4:52

as their primary screening option,

4:54

and then g getting the same day add on optical colonoscopy

4:58

without having to re-prep the bowel for a,

5:01

an actual polypectomy.

5:02

But I had arranged with a gastroenterologist friend of mine

5:07

to add me on the same day when I saw this finding first

5:10

thing that same morning.

5:11

So he was gracious enough to clear off his morning schedule

5:15

and add me on for a polypectomy for this finding.

5:18

And in this case, uh, this is what he found.

5:22

So this was the big mass, definitely confirmed at the time

5:25

of the, uh, colonoscopy.

5:27

This took him three hours to resect in piecemeal piece

5:31

by piece by piece until he got down to the base

5:33

of the stock in the terminal ileum itself.

5:36

So he confirmed that this was a,

5:38

a large polyp actually meets the definition of a mass,

5:41

if you think about the sea Rads, uh,

5:42

classification system being greater than

5:44

three centimeters in size.

5:46

Um, and I woke up before the end of the procedure

5:49

because he ran out of the, uh, he ran out of fentanyl

5:52

for the, uh, for the sedation.

5:54

But, um, you know, it's,

5:56

This happens sometimes in, in colonoscopies and,

5:59

and many colonoscopies are actually performed without

6:01

sedation at all in, uh, other parts of the world.

6:03

So, um, I was not surprised.

6:06

Uh, and I got to see the, um, what was left

6:08

after the polypectomy,

6:10

and then the pathology came back as a hamartoma,

6:13

which is a benign polyp.

6:15

Uh, not your typical, uh, adeno bitus, um, or,

6:19

or hyperplastic polyp that you typically see on colonoscopy.

6:23

So, very grateful that it wasn't a malignancy in my

6:26

particular case, but, uh, it did prompt, uh,

6:28

a Puti Eggers workup, which ended up being negative.

6:31

But I'm grateful that I had the option of a CT colonography

6:35

for screening because I don't know if I would've gone on,

6:38

if I would've gotten an optical colonoscopy, um, if

6:42

that was my only choice for, for polyp detection.

6:45

The teaching, uh, point here is, uh, 45 is new 50, so don't,

6:49

uh, forget to get your screening if you reached the, the age

6:52

of 45 or even earlier.

6:54

If you have a family history of, uh, colon cancer.