Synchronous multifocal colorectal carcinoma in a patient with delayed diagnosis of ulcerative pancolitis

Patients with ulcerative colitis face an increased lifetime risk of developing colorectal cancer. Relatively often, the patients present with multiple synchronous or metachronous tumors. Here, we report a case of ulcerative colitis-associated synchronous multifocal colorectal carcinomas. A 36-year-old male presented with symptoms of persisting abdominal pain that had lasted for several months. Histology of the colonic biopsies showed active ulcerative pancolitis with extensive multifocal low- and high-grade dysplasia. Regardless of the diagnosis and medical advice, the patient initially refused therapy, and proctocolectomy was delayed for 12 months. In the resection specimen, four clinically unsuspected, partly mucinous adenocarcinomas accompanied by several foci of low- and high-grade dysplasia were found in the left colon and rectum. At the time of colectomy, advanced tumor stage was diagnosed and classified as pT3c(4) pN1(2/120) M0 V1 R0, UICC stage IIIB, G2. Furthermore, a mucinous cystadenoma was found in the appendix in the setting of ulcerative colitis. We discuss the neoplastic transformation, current surveillance guidelines, and the therapeutic management in ulcerative colitis.