Peer Reviewed

Review Article

Colorectal Carcinoma: Maintaining a High Index of Suspicion in Patients of All Ages

Nickul N. Shah, MD; Albert Cooper, MD; Roland Purcell, MD; Albert Wright, MD; and David Roman, RPA-C

ABSTRACT: The incidence of colorectal carcinoma is increasing in the United States, and it is a leading cause of US cancer deaths. Occurrence rates progressively increase after age 35 years, peaking at age 70 and older. While colorectal cancer is relatively rare in persons younger than age 50, cases have been reported in this population, including children and adolescents. Moreover, few US cases have been reported in people of African descent compared with the white population. Clinicians should be vigilant for the gastrointestinal tract symptoms of colorectal carcinoma and include it in the differential diagnosis, which might be dismissed in younger people, especially those of African descent, such as the patient in the case presented here. Due to the rarity, misdiagnosis, and advanced symptomology with aggressive histopathologic profile, young patients often are diagnosed late, with a poor prognosis. A high index of suspicion for colorectal carcinoma, utilizing diagnostic modalities such as abdominal ultrasonography, colonoscopy, and histopathologic staging can improve outcomes.

KEYWORDS: Colorectal cancer, colonoscopy, cancer staging, mucinous signet ring cell adenocarcinoma

Increased rates of colorectal cancer have been identified in the United States, Canada, Japan, New Zealand, Israel, Europe, and Australia, largely due to obesity and physical inactivity.1 Colorectal cancer is the fourth leading cause of cancer death among men and women in the United States.2 However, very few US cases have been reported in people of African descent compared with the white population.3-5

Adenocarcinoma of the colon is the most common histopathologic type of colorectal carcinoma.1 Adenocarcinomas compromise the vast majority (98%) of colon and rectal cancers.1 Mucinous adenocarcinoma is a distinct subgroup of adenocarcinoma that compromises approximately 10% to 15% of all colorectal carcinomas.3 In children, it is considered to be rapidly growing, which presents at an advanced stage, with an overall 5-year survival between 7% and 12%.5-7

Other rare cancers include carcinoid (0.4%), lymphoma (1.3%), and sarcoma (0.3%).2 Approximately 20% of colon cancers arise in the cecum, another 20% arise in the rectum, and 10% arise in the rectosigmoid junction.3 Rates of colorectal cancer progressively increase after age 35 and peak at age 70 and older.2 Cases in younger patients are relatively rare: The probability of US persons younger than age 50 years developing colorectal cancer is 0.3%, and their probability of dying from it is 0.1%.2 The mortality and malignancy is much higher in men.8 Left-sided colon carcinomas are more likely to occur in men, whereas right-sided colon carcinomas are more likely to occur in women.9

Cases of colorectal carcinoma recently have been reported in young children and adolescents.2,10-13 This may be related to low-fiber dietary consumption and lack of exercise.10 Associated risk factors may include premalignant conditions such as familial adenomatous polyposis coli syndrome and inflammatory bowel disease.10 Due to its atypical presentation, patients often are misdiagnosed and the condition is often missed, which delays treatment.13,14 When a young patient receives a colorectal carcinoma diagnosis, however, the presentation usually occurs at its later stages, thus providing unfavorable tumor histology, such as mucinous carcinoma, and poor outcome.14-16 It is quite unusual to observe a case of advanced-staged colorectal carcinoma in a patient younger than 40 years, even without any significant history. Therefore, it is imperative to maintain a high index suspicion to diagnose colorectal malignancy, especially in young patients of African descent.

Case Presentation

A 22-year-old African American woman presented to a community hospital emergency department (ED) with diffuse, sharp abdominal pain at the right lower quadrant, associated with nausea and poor appetite. She had had 3 episodes of frothy and bilious emesis, without hematemesis.

The woman was a marijuana smoker but did not smoke tobacco or consume alcohol. Her medical history was significant for controlled bronchial asthma. She reported having been apparently healthy over the past 2 weeks before experiencing intermittent, generalized periumbilical and abdominal pain. At initial onset, the pain had been acute, but it eventually had progressed to last between 20 seconds and 1 minute. She described the pain as sharp and wrenching and radiating to the chest and upper and middle back. As the pain increased in frequency, it became quite severe and was slightly relieved with food. Abdominal bloating and vomiting were associated with the pain.

She reported not having had a normal bowel movement since the symptoms arose. In addition, she mentioned that she had lost some weight over the past month. She denied fever, vaginal bleeding or discharge, dysuria or burning on micturition, headache, changes in vision or hearing, dysphagia, sore throat, chest pain, dyspnea, palpitations, pedal edema, joint pain, or rashes.

She initially had visited a different hospital a week prior with the same symptoms. At that time, a computed tomography (CT) scan demonstrated wall thickening at the cecum and terminal ileum, extending to the ascending colon. The appendix was mildly dilated. The results of a complete blood cell count (CBC) at the time were within normal limits. Upon discharge from that hospital, she had been prescribed metronidazole, 500 mg twice daily, and ciprofloxacin for presumed colitis.

At the current presentation, the patient appeared to be hemodynamically stable, without any signs of distress. On pulmonary examination, the chest was clear to auscultation and percussion and nontender to palpation. Minimal wheezes were heard bilaterally in the lung fields. Cardiac examination revealed a soft heart murmur after S2 and a nondisplaced point of maximal impulse.

Figures 1 and 2. CT of the abdomen and pelvis with contrast on hospital admission day 1 showed moderate wall thickening in the right colon involving the ileocecal valve and extending distally into the proximal right colon. Associated moderate small-bowel dilatation is present, particularly involving the distal ileum. Pneumatosis was not present. These findings are associated with bowel obstruction at the level of the ileocecal valve.

Figure 3. The colonoscope was passed under direct visualization and advanced with ease to the cecum. There was a large, firm tumor of uncertain nature; a cauliflowerlike growth occupied 75% to 99% of the circumference of the cecum and partially obstructed the ileocecal valve. Four cold biopsies were taken. The ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, rectosigmoid junction, and rectum appeared normal. Multiple rectal biopsies were obtained during the colonoscopy.


Physical examination identified normoactive bowel sounds, along with diffuse palpable tenderness at the right lower right quadrant without rebound or guarding. CBC results showed an elevated white blood cell count of 15,000/µL. CT with contrast of the abdomen and pelvis (Figures 1 and 2) showed findings similar to those of the CT performed the other hospital.

She was admitted to the hospital and placed on intravenous (IV) metronidazole, 500 mg; levofloxacin, 500 mg; hydromorphone, 2 mg; and dicyclomine, 20 mg. Colonoscopy followed 2 days later, which identified an edematous, cauliflower-like growth in the cecum near the ileocecal junction (Figure 3). Biopsies were performed at the site, as well as at the rectosigmoid junction.

On hospital day 6, the patient’s vital signs were stable, and she did not have any new episodes of diarrhea, abdominal pain, or fever. She was transferred from the intensive care unit to the medical unit, where metronidazole and levofloxacin were discontinued. Docusate sodium, 100 mg, was initiated because the patient had not had a bowel movement since admission.

Over the following 2 days, she reported feeling better, her abdominal pain had resolved, and she was able to tolerate solid food.

On hospital day 9, the biopsies taken during colonoscopy were reviewed and suggested minute fragments of superficial colonic mucosa with adenocarcinoma and signet ring cell features (Figures 4 and 5). The medical and surgical teams both advised the patient to stay in the hospital for surgical ileocolectomy and oncology evaluation. She was started on a liquid diet and oral polyethylene glycol 3350 with electrolytes for clean-bowel preparation prior to surgery.

Figure 4. Lower-power magnification of the resected specimen demonstrating infiltration of malignant cells.

Figure 5. Higher-power magnification demonstrating signet ring cells infiltrating normal architecture. Signet ring cells have a characteristic displaced nucleus due to intracytoplasmic mucin.


Cancer antigen tests results were as follows: carcinoembryonic antigen (CEA), 1.2 ng/mL; cancer antigen (CA) 19-9, 32 U/mL; and CA 125, 12.5 U/mL.

On hospital day 12, the patient underwent exploratory laparotomy and right hemicolectomy under general anesthesia. A large bulky tumor mass was discovered occupying the entire cecum and ileocecal junction, without the presence of lymphadenopathy. There were no metastatic lesions affecting the liver. Peritoneal seeding was not present. The resected distal terminal ileum and right colon specimens (Figures 6 and 7) were sent for pathologic evaluation, and the midline incision was sutured closed. Although the patient lost 100 mL of blood during the procedure, she tolerated the procedure well, and IV saline bolus fluid was started to promote hemodynamic stability. The patient experienced no intraoperative or postoperative complications.

Figures 6 and 7. Intraoperative resection of the ileocecal mass, which was sent for pathologic evaluation.


On postoperative day 1, the patient was evaluated at bedside and showed no signs of any distress. She denied syncope, dyspnea, diaphoresis, and palpitations. However, she also denied having had a bowel movement or having passed flatus. Vital signs were within normal limits compared with baseline. Cardiac and respiratory examination findings were within normal limits, the chest was nontender to palpation, the lungs were clear to auscultation without wheezes or crackles, and the heart did not have murmurs or gallops. Her abdomen was soft and nondistended, and bowel sounds were hypoactive.

Over the following 2 days, the patient remained hemodynamically stable. She appeared alert, ambulatory, and not in distress. She complained of mild intermittent pain at the surgical site. She denied fever, chills, chest pain, dyspnea, nausea, and vomiting. The incision site with linear laparotomy sutures was clean, dry, and intact. Bowel sounds were hypoactive, and bowel functions had not returned. She was started on a liquid diet, and encouraged to ambulate.

On postoperative days 4 and 5, the patient had started ambulating more, had tolerated liquid and soft foods well, and had had successive bowel movements without color changes or blood. She did not show signs of distress while lying in bed. Her lungs sounded clear, and she had normal heart sounds without adventitious murmurs or a displaced point of maximal impulse. The abdomen was soft, nondistended, and tender to palpation, and bowel sounds were normoactive. There were no signs of edema at the lower extremities.

On postoperative day 6, the patient complained of surgical site pain; however, she did not appear to be in any distress. She tolerated a soft diet, and she experienced regular bowel movements. Vital signs were within normal limits relative to baseline. Physical examination findings revealed no changes since the previous day. A preliminary pathology report from the surgical specimens demonstrated a stage T3N2 tumor and warranted further cytogenetic testing.

Figure 8. Immunohistochemical stain of the biopsied specimen, observed under highpower magnification.


Cytogenetic analysis results revealed positive antibodies for AE1/AE3, CDX2, CAM 5.2, and CK20. CK7 antibody results were negative under immunohistochemical staining (Figure 8; Table). In addition, no KRAS or BRAF mutations were identified. The oncology team scheduled outpatient chemotherapy for her and recommended placement of a portacath. Discharge was planned for the patient the following day, and she was given recommendation to follow up with the oncology team.

A week after discharge, the patient returned to the ED with dull, diffuse abdominal pain that was nonradiating and was associated with nausea and vomiting. She denied fevers, chills, back pain, urinary symptoms, and wound-site complications. The patient appeared to be in moderate distress.

On physical examination, her chest was nontender, and her lungs were clear, without abnormal breath sounds. There was no edema. Peripheral pulses were present, and heart rate and rhythm were within normal limits. The abdomen was moderately distended and soft to palpation; the incision site was healing well, and bowel sounds were present.

Figure 9. On postoperative day 14, readmission day 1, radiography showed dilated small-bowel loops with air-fluid levels, suspicious for partial small-bowel obstruction.

Figure 10. On postoperative day 14, readmission day 1, CT of the abdomen and pelvis with contrast showed multiple fluid-filled, dilated small-bowel loops consistent with small-bowel obstruction. The transition point appeared to be in the right lower quadrant. No free air was seen. No abscess collections were seen. There was no significant adenopathy. There were new mild ascites.


Abdominal radiographs (Figure 9) demonstrated small-bowel obstruction, which warranted nothing-by-mouth status and IV fluids. CT scan of the abdomen and pelvis with contrast (Figure 10) identified multiple fluid-filled, dilated small-bowel loops consistent with small-bowel obstruction.

On readmission day 2, the patient complained of right-lower and left-lower quadrant pain with loss of energy. She was alert but was uncomfortable and in mild distress. Vital signs were within normal limits. Examinations of the chest, heart, and lungs demonstrated no abnormalities. There was mild distention of the abdomen, with hyperactive bowel sounds and palpable tenderness at the left and right lower quadrants. Edema and cyanosis were absent. Nothing-by-mouth status and nasogastric (NG) suction were continued for the patient, along with periodic monitoring of electrolyte levels.

The following day, readmission day 3, the patient started to pass small flatus. She was alert, afebrile, and not in distress. She was hemodynamically stable. Electrolyte levels were within normal limits, and NG suction drainage increased to 400 mL.

On readmission day 4, her pain had decreased, and she passed bowel movements with flatus. The wound was healing without complications. The patient appeared to be alert and not in distress. The abdomen appeared less distended, with normoactive bowel sounds. There was mild tenderness to palpation at the left and right lower quadrants. The NG suction drainage increased from 400 mL to 1100 mL.

Over next 3 days, her bowel function decreased and NG suction volume increased. The plan was to insert a central line for total parenteral nutrition. The following day, a right subclavian triple-lumen catheter was placed under 1% lidocaine anesthesia. The wound appeared clean, and chest radiographs were ordered.

Upon bedside examination on postoperative day 1, the patient stated she had had a bowel movement. She appeared awake and comfortable. Vital signs were stable; examination findings showed the lungs and heart to be within normal limits. Her abdomen appeared distended without tenderness, with a clean, dry, and intact incision.

Figure 11. Abdominal radiographs (flat, left; upright, right) on postoperative day 21 showed persistent, disproportional, dilated proximal small-bowel loops with air-fluid levels, consistent with small-bowel obstruction as noted on previous radiographs. No free air was seen. There was minimal interval change. The NG tube is visible, approximating the duodenum.


The next day, the patient had experienced 10 total bowel movements without nausea or vomiting. She felt more comfortable, and NG output decreased to 300 mL. Abdominal radiographs were ordered the following day (Figure 11), which demonstrated persistent and mildly improving bowel dilation and suspected slowly resolving obstructed pattern. IV hydration was started; the patient was continued on nothing-by-mouth status with NG suction drainage.

On postoperative days 3 and 4, the patient had more bowel movements without nausea or vomiting. NG suction was removed, and a liquid diet was initiated. The patient was awake and alert, and abdominal distention has resolved. The patient continued to improve on the liquid diet and was scheduled for small-bowel series on the following 2 days. The small-bowel series identified no mechanical obstruction or persistent distal small-bowel dilation (Figure 12). There was no radiologic evidence of high-grade mechanical small-bowel obstruction. The patient therefore was encouraged to ambulate and continue on a full liquid diet. She was discharged 3 days later, after her diet had been advanced gradually from clear liquids to soft food. She tolerated the advancement well and experienced regular bowel function soon after.

Figure 12. Small-bowel series with contrast showed mildly dilated small-bowel loops, as well as a mildly dilated colon, likely representing ileus. Hypersecretions were noted within the small bowel. No abnormal displacement of loops was appreciated. There was no evidence of mechanical intestinal obstruction.



Colon cancers generally are classified as well-differentiated, moderately well-differentiated, or poorly differentiated, based on the degree of preservation of normal glandular architecture and cytologic features.17 Progressively poorer differentiations provide a histologic marker for further underlying genetic mutations and are currently under study.17 Poorly differentiated cancers contribute to approximately 20% of cases and have a poor prognosis; 15% of colon cancers are mucinous or colloid due to prominent intracellular accumulation of mucin.18,19 Signet ring cell colorectal carcinoma is a rare subtype of colon cancer that demonstrates abundant intracytoplasmic mucin that displaces the nucleus into the periphery, forming a signet ring appearance.20 More than 96% of signet ring cell carcinomas arise in the stomach, and signet ring cell carcinomas accounts for less than 1% of all colon cancer cases.21

Colon cancer is the second most common cause of mortality compared with other cancers.22 The American Cancer Society estimated that colorectal carcinoma in 2015 would account for 8% of cancer deaths in men and 9% in women.9 However, earlier detection with colonoscopy and screening programs has identified colorectal carcinomas much earlier, accounting for a recent increase in incidence since 1995 and a decrease in mortality rates.23

More than 90% of persons with colorectal cancer are older than 55 years.14 Colorectal carcinomas in young patients more commonly are associated with genetic mutations, which ultimately lead to cellular injury and dysplasia. Most commonly found genetic components include MLH1 with mismatch repair genes; KRAS mutations; DCC deletion mutation; APC mutations; FAP polyposis syndromes; Lynch syndrome; and inflammatory bowel disease.15 Signet ring cell carcinomas, in particular, tend to affect younger individuals and those with hereditary nonpolyposis colorectal cancer.13,24-27 However, one group of authors28 reported finding no relationship between hereditary nonpolyposis colorectal cancer and primary signet ring cell carcinoma of the rectum and colon.

Environmental factors also play a major etiologic role in colon cancer.17,22 In addition, diets containing red meat, high fats, and low fiber, have also been associated with increased colorectal carcinoma risk.29 African Americans have a slightly increased risk of colon cancer compared with white Americans.30 The prevalence of colorectal malignancy, particularly left-sided, is higher in men.31

Our patient’s history was significant for marijuana use; however, the presentation of symptoms did not support cannabinoids as the cause. Cannabinoids may cause antitumor effects through various mechanisms, including induction of cell death, inhibition of cell growth, and inhibition of tumor angiogenesis invasion and metastasis.30 Compounds found in cannabinoids appear to kill tumor cells by inducing apoptosis and to protect normal cells against cell death.32 Numerous studies have demonstrated that cannabinoid use is associated with tumor reduction in animal models, including glioma, breast cancer, prostate cancer, and hepatocellular carcinoma.33-38 In another study, Δ9-tetrahydrocannabinol (THC), Δ8-THC, and cannabinol inhibited the growth of lung adenocarcinoma cells via the inhibition of epithelial growth factor-induced proliferation and migration of non–small-cell cancer cell lines.39 Other tumors were found to be sensitive to cannabinoid-induced growth inhibition through THC-induced apoptosis.40,41

Our patient’s symptoms and initial radiographic imaging findings (Figures 1 and 2) gave rise to the hypothesis of suspected colitis. The most notable symptoms warranting further evaluation for colorectal malignancy include abdominal pain, rectal bleeding, altered bowel habits, and involuntary weight loss, all of which can mimic inflammatory bowel disease. In young patients who develop colorectal carcinoma without predisposing genetic risk factors, late diagnosis may result from clinicians’ failure to consider the possibility of malignant disease in the differential diagnosis.42 Presentation of colonic obstruction also indicates a poor prognosis. Obstruction occurs in the sigmoid colon because of the narrowed lumen and passing of hard stool. Patients will experience abdominal pain, obstipation, abdominal tenderness, distention, and hypoactive bowel disease.43,44 Colon cancer, however, rarely causes ischemic colitis, which complicates the diagnosis and prognosis of colorectal cancer.44

Most concerning in our patient’s case was the palpable abdominal mass noted during the physical examination. A palpable abdominal mass is a rare finding that suggests advanced disease.17 Therefore, to prevent delay, it is important to consider the possibility of malignant disease in a patient who presents such symptoms without predisposing risk factors because of the colonic dilation proximal to the malignant obstruction.43

Various literature reviews10-12 have demonstrated that upon physical examination, a palpable abdominal mass is a rare finding that also suggests an advanced disease stage, which was the case in our patient. The serum CEA level, although elevated in our patient, is moderately sensitive but tends to be elevated in advanced cancers. It also is poorly specific, owing to the fact that patients with advanced malignancies tend to have higher levels, and patients with early and curable cancer tend to have minimally elevated levels, findings that can overlap in patients without cancer.45,46 An elevated serum CEA level prior to resection is a poor prognostic indicator, demonstrating the likelihood that the cancer is extensive and with a possibility of postoperative recurrence.47,48

Colonoscopy is used less frequently in patients younger than 50 years.49,50 In our patient’s case, colonoscopy was necessary in order to observe the size of the lesion and its malignant extension. Colonoscopy also allowed biopsies of polyps for histopathologic evaluation, as well as identification of metastatic lymph node involvement, prior to surgical resection. However, a greater diagnostic yield arose from resecting the colorectal carcinoma and performing microscopic and cytologic examination of its gross pathology (Figures 4-7).51

BRAF, a component of the cytoplasmic RAS-RAF-MAPK transduction pathway, mediates and regulates protein transcription.52 An oncogenic mutation of BRAF at V600E of exon 15, has been described in a variety of cancers,53 including melanoma (70%), thyroid (30%), ovarian (30%), and colorectal carcinoma (15%). In our patient’s resected specimens, the BRAF mutation was not identified, indicating that the specimens were not of hereditary origin.54 Patients with the BRAF mutation would be resistant to anti-epidermal growth factor receptor (EGFR) monoclonal antibody therapeutics such as cetuximab and panitumumab.55

KRAS encodes for a GTP-binding protein for signal transduction downstream of the EGFR to regulate apoptosis, cell proliferation, cell differentiation, and angiogenesis.56 Oncogenic mutations lead to overactivation and are found in many carcinomas, including colorectal carcinomas (30%-50%), non-small-cell-lung adenocarcinomas (15%-30%), and pancreaticobiliary neoplasms.56 KRAS mutation was not identified in resected specimens from our patient; this indicates a favorable prognosis and treatment response to EGFR-tyrosine-kinase inhibitors.56,57

CDX2 and CK20 results were positive (Table), indicating that the resected and biopsied lesions were consistent with lower gastrointestinal anatomy. Cytokeratins represent the epithelial class of intermediate sized filaments of the cytoskeleton.58 CK7 is found in many ductal and glandular epithelia, including breast, lung, ovary, and endometrium.59-61 CK20 is expressed in the gastrointestinal epithelium, urothelium, and Merkel cells.53 The combinational expression patterns of CK7 and CK20 have been studied extensively in various primary and metastatic carcinomas.61-63 CK20 is expressed alone in the majority of intestinal adenocarcinomas and Merkel cell carcinomas, whereas CK7 is present without CK20 in most breast, lung, and ovarian adenocarcinomas and with CK20 in urothelial, pancreatic, and gastric carcinomas.58

CDX2 is a caudal-type homeobox gene encoding a transcription factor for proliferation and differentiation of intestinal epithelial cells.64 CDX2 expression is found in gastric carcinoma and other carcinomas of intestinal-type morphology.65-67 Colonic adenocarcinoma recently has been evaluated in a number of studies using antibodies to CDX2 protein, having a sensitivity and specificity of greater than 90% to CDX2 tumor marker.68-70 Both the CK7-negative/CK20-positive phenotype and the expression of the antibody CDX2 are highly specific and sensitive markers of cancer of colorectal origin.70,71

Carcinoma in situ, or high-grade dysplasia, is histologically classified as cancer confined to the mucosa without penetration into the muscularis mucosa. Using the Dukes criteria, invasive colon cancer stages range from A to D.17 Stage A represents colon cancer penetrating beyond the colonic muscularis mucosa into the submucosa. Stage B1 extends beyond the submucosa into the muscularis propria, and stage B2 extends through the muscularis propria into the serosa. Stage C has regional lymph node metastasis, and stage D has distant metastasis. Patients with poorly differentiated tumors have a poor prognosis.72 In addition, poorly differentiated colorectal cancers have been shown to correlate with bowel penetration, lymph node involvement, and vascular invasion, all of which indicate a high risk for dissemination.73

Young children and very old elderly persons have a poor prognosis, which may be due to the rapid progression of the disease.74,75 Some hereditary colon cancers become more aggressive in younger patients without any symptoms or may show up later in the course.76 Young patients with advanced disease, categorized as Dukes Stage C and D with peritoneal involvement, have a poor prognosis that is similar to that of older patients with the same disease stage.17

Colon cancer staging utilizes the TNM classification based upon the depth of the primary tumor, lymph node metastasis, and distant metastasis.72 The pathologic stage is highly correlated with cancer prognosis.77 Stage 1 corresponds to Dukes stage A or B1 lesions; stage 2 corresponds to Dukes stage B2 lesions; stage 3 corresponds to Dukes stage C lesions; and stage 4 corresponds to Dukes stage D classification.17 In the case described here, the pathologic staging was determined as T3N2M0. Diagnostic delays result in a more advanced pathologic stage.17


Clinicians should be aware of alarming gastrointestinal tract symptoms of colorectal carcinoma and include it in the differential diagnosis, which might be dismissed in younger people, especially of African descent. Due to the rarity, misdiagnosis, and advanced symptomology with aggressive histopathologic profile, patients often are diagnosed late, offering a poor prognosis. A high index of suspicion for colorectal carcinoma, utilizing diagnostic modalities such as abdominal ultrasonography, colonoscopy, and histopathologic staging can improve such outcomes.

Nickul N. Shah, MD, is a 2016 medical graduate of the American University of Antigua College of Medicine.

Albert Cooper, MD, is an attending surgical physician at Interfaith Medical Center in Brooklyn, New York.

Roland Purcell, MD, is an attending surgical physician at Interfaith Medical Center in Brooklyn, New York.

Albert Wright, MD, is an attending surgical physician at Interfaith Medical Center in Brooklyn, New York.

David Roman, RPA-C, is a surgical physician assistant at Interfaith Medical Center in Brooklyn, New York.


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The authors thank Shamah Iqbal, MD, for providing the histopathologic specimens, gross specimens, and cytogenetic analyses; Sam Weissman, MD, for providing the colonoscopy information and photographs; and Robert Limani, MD, for providing the abdominal CT and radiography images.