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Video Endoscopic Sequence 1 of 2.
Adenoma of the Recto-Sigmoid junction with chicken skin mucosa
Colonic chicken skin mucosa: an endoscopic and histological abnormality adjacent to colonic neoplasms.
is an endoscopic entity that occurs as a result of fat accumulation in macrophages in the lamina propria of the mucosa adjacent to colonic neoplasms. Small intestine-like microvilli were present in CSM and the pathophysiological implications remain to be elucidated.
CSMrelated adenoma was mainly found in the distal colon, and was associated with advanced pathology and multiple adenomas. CSM could be a potential predictive marker of the carcinogenetic progression of distally located colorectal adenomas.
For more endoscopic features download the video clip by clicking on the endoscopic image if you would like to appreciate in full screen, wait to be downloaded the video complete then press Alt and Enter. All endoscopic images shown in this Atlas contains video clips.
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Video Endoscopic Sequence 2 of 2.
Colonic chicken skin mucosa
White spots are arrangements of foamy cells at the periphery of a tumor. Most frequently found in association with cancers and large adenomas.
Mucosal abnormalities and molecular changes associated with colorectal adenomas have been reported since colonos-copy began to be widely used for the screening of colorectal cancer. However, the clinical significance of colonic mucosal abnormalities on endoscopy is still unknown. Among the endoscopic mucosal abnormalities in the colon, chicken
skin mucosa (CSM) was first identified in 1998 and was described with specific morphologic changes surrounding a colorectal adenoma. CSM is a pale yellow-speckled pattern of colonic mucosa on endoscopy; lipid-filled macrophages in the lamina propria are noted on histopathology.
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Video Endoscopic Sequence 1 of 6.
Large Tubulo-Villous Adenoma.
This 56-year-old lady, since four months has occasional rectal bleeding, also have congestioned internal hemorrhoids a colonoscopy was performed finding this large mass.
The concept of a polyp-cancer sequence is assuming increasing credibility as a factor in the development of colorectal cancer. Colonoscopy permits most colonic polyps to be endoscopically removed and studied pathologically. Of various polyp types encountered in the colon only neoplastic polyps are regarded as having malignant potential. Neoplastic polyps include tubular adenomas (formerly, adenomatous polyps), villous adenomas and villotubular adenomas (formerly, mixed or tuboglandular polyps). Cancerous changes must penetrate the muscularis mucosae for a polyp to be regarded as clinically malignant.
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Video Endoscopic Sequence 2 of 6.
Endoscopic View of Large Colonic Polyp
The pedicle is large and wide.
Most colon cancers arise from conventional adenomatous
polyps (conventional adenoma-to-carcinoma sequence).
COLON POLYP CAUSES
Polyps are very common in men and women of all races who live in industrialized countries, suggesting that dietary and environmental factors play a role in their development.
Lifestyle — Although the exact causes are not completely understood, lifestyle risk factors include the following:
●A high fat diet
●A diet high in red meat
●A low fiber diet
●Cigarette smoking
●Obesity
On the other hand, use of aspirin and other NSAIDs and a high calcium diet may protect against the development of colon cancer.
Aging — Colorectal cancer is uncommon before age 40. Ninety percent of cases occur after age 50, with men somewhat more likely to develop polyps than women; therefore, colon cancer screening is usually recommended starting at age 50 for both sexes. It takes approximately 10 years for a small polyp to develop into cancer.
Family history and genetics — Polyps and colon cancer tend to run in families, suggesting that genetic factors are also important in their development.
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Video Endoscopic Sequence 3 of 6.
Endoscopic View of Large Colonic Polyp
Large colonic polyps present a particular challenge to
endoscopists because of the risks of significant
hemorrhage, perforation, inadequate polypectomy, or trying to snare an
unrecognized cancer. The alternative to endoscopictherapy
of large polyps is surgical resection and although minimally
invasive techniques are available, risks are significant.
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Video Endoscopic Sequence 4 of 6.
Endoscopic View of Enormous Polyp of the Colon
Colon cancer mostly arises from adenomas, recognized as
colonic polyps, but may occasionally arise from the sessile
serrated adenoma. Adenomatous polyposis coli (APC) gene
mutation is the key molecular step in adenoma formation.
Mismatch repair gene mutation is a less common
alternative pathway. Progression from adenomas to colon
cancer is a multistep process, involving mutations of the
DCC, k-ras, and p53 genes; loss of heterozygosity in which
cells loose one allele of some genes from chromosomal
loss; and DNA methylation which can silence DNA
expression.
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Video Endoscopic Sequence 5 of 6.
Endoscopic Image of Colonic Polyp
Numerous environmental factors can increase the risk of
colon cancer, presumably by modulating these molecular
pathways. While colon cancer in an advanced andincurable
stage often produces clinical findings, premalignant
adenomatous polyps and early, highly curable, colo cancer
are often asymptomatic. This phenomenon renders
adenomas or early cancers difficult to detect by clinical
presentation and provides the rationale for mass screening
of asymptomatic adults over 50 years old for early
detection and prevention of colon cancer.
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Video Endoscopic Sequence 6 of 6.
Endoscopy Video of Polyps of the Colon
Colonoscopy is the primary screening test. All polyps
identified at colonoscopy are removed by colonoscopic
polypectomy. Endoscopic mucosal resection is required for
deeply penetrating noncancerous polyps. Colonoscopy is
repeated every ten years if the index colonoscopy revealed
no lesions, but is repeated more frequently if adenomatous
polyps were identified at this colonoscopy due to an
increased risk of subsequent polyps or colon cancer.
Flexible sigmoidoscopy every few years with annual fecal
occult blood testing is a significantly less sensitive
screening protocol.
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Video Endoscopic Sequence 1 of 7.
Endoscopic Appearance of Pedicled Polyp of the Descending Colon.
This is the case of a 54 year-old male with rectal bleeding.
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Video Endoscopic Sequence 2 of 7.
Endoscopic Appearance of Tubular Adenoma on a Long Stalk.
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Video Endoscopic Sequence 3 of 7.
Endoscopic Image of Tubular Adenoma on a Long Stalk.
Adenomatous polyps are precursors of most colorectal
cancers, and their prevalence increases with age.
The chance of detecting adenomatous polyps at
colonoscopy is generally independent of the indication for
the procedure.
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Video Endoscopic Sequence 4 of 7.
Endoscopic snare excision of large pediculated polyp.
Most pedunculated polyps are removed by transection of
the stalk with a polypectomy snare. The major risk with this
approach is postpolypectomy bleeding. As a result, many
endoscopists use one or more methods to reduce the risk of
bleeding, particularly in polyps with wide stalks (pedicles
larger than 1 to 1.5 cm in diameter).
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Video Endoscopic Sequence 5 of 7.
The practice of removing polyps at colonoscopy is based on
the assumption that their removal prevents progression to
cancer. This concept, often called the adenoma-carcinoma
sequence.
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Video Endoscopic Sequence 6 of 7.
Large pedunculated polyps (> 2-3 cm) are often easily
removed with standard snare cautery techniques. The
difficulty most commonly encountered is when a large
polyp has a particularly long stalk, and the head of the
polyp prolapses in both directions when snaring is
attempted.
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Video Endoscopic Sequence 7 of 7.
Final Status of the Polypectomy.
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Video Endoscopic Sequence 1 of 13.
Flat adenoma of ileocecal valve
A 59 year-old female that underwent a colonoscopy due to
medical control of routine, the image displays a sessile
tubulovillous adenoma that emerging from the ileocecal
valve.
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Video Endoscopic Sequence 2 of 13.
An adenoma was located at the level of the digestive
mucosa. It is a benign tumor, always dysplastic and
considered as a pre-cancerous lesion.
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Video Endoscopic Sequence 3 of 13.
The image and the video display the catheter spraying the
methylene blue.
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Video Endoscopic Sequence 4 of 13.
Chromoendoscopy
For more endoscopic features download the video clip by
clicking on the image.
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Video Endoscopic Sequence 5 of 13.
Using high-magnification chromoscopic colonoscopy.
Tubulovillous adenoma, Video-endoscopy with
chromoscopy.
Magnifying endoscopy with methylene blue demonstrates
sulciform pattern.
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Video Endoscopic Sequence 6 of 13.
Chromoendoscopy and magnifying endoscopy are useful for
detection and recognition of small non polypoid lesions, for
differential diagnosis between hyperplastic and
adenomatous lesions and for determining not only the
lateral extent but also the depth of a lesion. Pit analysis
would especially be useful in the differential diagnosis
between depressed-type early cancers (type IIIS) and flat
adenomas with pseudodepression (type IIIL).
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Video Endoscopic Sequence 7 of 13.
Endoscopic Image of Sessile Tubulovillous Adenoma
Another view using magnifying chromo-endoscopy.
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Video Endoscopic Sequence 8 of 13.
In order to establish the magnitude of the size of the polyp
and to plan its extraction, we used forceps of biopsy,
moving forwarding and pushing the adenoma.
The adenoma was excised using a snare wire and
electrocautery.
See the video clip.
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Video Endoscopic Sequence 9 of 13.
A polypectomy is being performed, the polypectomy snare
is displayed.
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Video Endoscopic Sequence 10 of 13.
Note the traction which the lesion is being removed.
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Video Endoscopic Sequence 11 of 13.
The fragment of the polyps have been falled out.
Shown here after removal of the polyp.
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Video Endoscopic Sequence 12 of 13.
Benign tubulo villous neoplasia of the ileocecal valve with
mild dysplasia.
Mild dysplasia is characterized by uniform loss of mucin
and hyperchromatic and elongated cells. Glands appear
branched and budding.
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Video Endoscopic Sequence 13 of 13.
Another Histopatologic view.
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Video Endoscopic Sequence 1 of 3.
Enormous Sessile Villous Adenoma.
An 80 year-old female have a sessile mass between the
first and second rectal valves.
Morphologically, villous adenomas of the colon are
generally sessile and papilliferous.
Lesions that tend to secrete mucus.
The epithelial element of these adenomas is more
dysplastic than that seen in tubular adenomas and
consequently these have, in general, greater potential for
malignant change.
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Video Endoscopic Sequence 2 of 3.
The immediate risks of adenomas include hemorrhage,
obstruction with intussusception, and, possibly, torsion.
However, the main concern is malignant progression of the
villous adenoma. Studies have defined the risk of
progression of adenomas to adenocarcinoma.
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Video Endoscopic Sequence 3 of 3.
Villous Adenoma, after spraying methilene blue.
Adenomas are believed to have an abnormal process ofcell
proliferation and apoptosis. The proliferative component is
not confined to the crypt base and accumulates onto the
surface and infolds downward. In villous adenomas,
mesenchymal proliferation results in longer projections and
larger polyps.
Epidemiological studies provide evidence of
adenoma-to-carcinoma progression. The mean age of
adenoma diagnosis is 10 years earlier than with carcinoma,
and progression to carcinoma takes a minimum of 4 years.
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Video Endoscopic Sequence 1 of 7.
Cap polyposis that resemble a adenocarcinoma of the rectum.
This 22 year-old lady, has been presented with rectal
bleeding and mucus discharge, also has been suffering of
Bulimia Nervosa.
Digital rectal examinations revealed polypoidal masses in the rectum.
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Video Endoscopic Sequence 2 of 7.
Cap polyposis is characterized by the presence of
inflammatory polyps with a "cap" of granulation tissue. It
may represent one end of a spectrum of conditions caused
by chronic straining.
Polyps have an erythematous and inflamed appearance
and are capped with a purulent fibrin exudate.
The pathogenesis is not well known although many
affected individuals have long standing colonic dysmotility
manifested by chronic constipation. It is hypothesized that
recurrent mucosal trauma due to chronic straining can
result in the clinical spectrum of mucosal prolapse
syndrome which includes solitary rectal ulcer syndrome
and the more dramatic finding of cap polyposis.
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Video Endoscopic Sequence 3 of 7.
The findings here are of cap polyposis, a rare condition
thought to be related to chronic constipation and straining
causing prolapse of mucosa in the rectum and sigmoid.
Often mistaken for pseudopolyps, the polyps seen can
range from sessile to pedunculated in morphology and can
be found anywhere from the rectum to the cecum although
the vast majority are found in the rectosigmoid region as in
this example.
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Video Endoscopic Sequence 4 of 7.
Chromoendoscopy with indigo carmin.
Cap polyposis is characterized by rectosigmoid polyps that
have tortuous elongated crypts and are covered by a cap
of fibropurulent exudate. The pathogenesis is unknown,
but the histology suggests that mucosal prolapse may play
a role. The current therapy often used for inflammatory
bowel diseases has frequently been ineffective. Overall,
infliximab lead to symptomatic improvement and histologic
resolution of the polyps.
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Video Endoscopic Sequence 5 of 7.
Argon Plasma Coagulation was used as ablative therapy.
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Video Endoscopic Sequence 6 of 7.
Recently, there was a case report published, on a patient
with cap polyposis who was treated with a single infusion of
infliximab 5 mg/kg and who demonstrated dramatic
symptomatic improvement.
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Video Endoscopic Sequence 7 of 7.
Status after the polyps were considered successfully
ablated with argon plasma coagulation.
Three different session of argon plasma coagulator were used.
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Cap Polyposis.
Another Case.
This 47 year-old female, who has been suffering of rectal discharge with mucoid secretion.
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Video Endoscopic Sequence 1 of 3.
Flat Adenoma of the third rectal valve, with irregular
surface is appreciated.
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Video Endoscopic Sequence 2 of 3.
High magnification with Cresyl violet.
Dye spray technique may result in a higher detection rate
of flat colonic lesions.
Clinical usefulness of high-resolution chromoendoscopy, i.e.
colonoscopy with topically applied agents, in an attempt to
discriminate neoplastic from non-neoplastic colorectal
polyps. Using both specially designed videocolonoscopes
that produce high-resolution images at great magnification
and dye spray, a contrast stain which accentuates epithelial
topography, thus allowing recognition of otherwise
unnoticeable epithelial changes, it seems possible
to distinguish adenomatous from nonadenomatous
colorectal polyps measuring <10 mm3. The clinical utility of
standard videocolonoscopy and staining with a dye
especially in the diagnosis of very small colorectal polyps.
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Video Endoscopic Sequence 3 of 3.
High-resolution video colonoscopy and chromoscopy.
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Tubular Adenoma.
Of the third rectal valve some diverticulae are observed
nearby.
Most colonic polyps are asymptomatics.
Adenomoatous Polyps result of epithelial and dysplasia.
Tree types: tubular, villous and mixed.
Risk of malignancy related to size, histologic type and
severity of dysplasia.
Since they are considered premalignant all should be
removed.
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Video Endoscopic Sequence 1 of 2.
Large and long stalk villous adenoma inserting in therectal dentate line, appearing as a multi lobular mass.
Polyps are classified based on the type of tissue they contain:
Tubular adenomas are the most common type. About 80%to 86% of adenomatous polyps are this type. Tubular adenomasare the polyps that are least likely to develop into colon cancer.
Villous adenomas are the least common type. About 3% to16% of adenomatous polyps are this type. Villous adenomas aremost likely to become cancerous.
Tubulovillous adenomas are a combination of the othertwo tissue types. About 8% to 16% of adenomatous polyps arethis type and are more likely than tubular but less likely thanvillous adenomas to develop into cancer.
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Video Endoscopic Sequence 2 of 2.
Prolapsing tumor through the anus.
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Pediculated tubular adenoma.
Colonoscopic picture of a pediculated tubular adenoma.
Note the stalk and raspberry-like appearance of the
polyp. Most adenomas are encountered incidentally
during colorectal cancer surveillance.
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Large Villous Adenoma of the Sigmoid.
The cancer risk of a tubular adenoma is controversial, butstrong evidence suggests that it can become malignant. Risk ofmalignancy is related to size; a 1.5-cm tubular adenoma has a 2%risk. As its size increases, its glands become villous. When > 50%of its glands are villous, it is called a villoglandular polyp; itsmalignancy potential is still that of a tubular adenoma. When > 80% of the glands are villous, the polyp is called a villous adenoma, which becomes malignant in about 35% of cases. A villousadenoma has a greater risk of malignancy than a tubular adenomaof the same size.
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Video Endoscopic Sequence 1 of 2.
Cecum stalk polyp inside of the appendiceal orifice.
Benign polyps of the vermiform appendix are rare and usually discovered incidentally during surgery or at autopsy. A gross abnormality of the appendix is recognized in 5% of these cases . The reported incidence of benign appendiceal polyps from various autopsy series ranges from 0.004% to 0.08% . Lack of careful inspection of the appendiceal lumens by pathologists may be one of the reasons of such wide fluctuation in the reported incidences. Polyps might be discovered more frequently if the appendix could be cut along its entire length before fixation rather than by the usual multiple transverse cuts . Appendiceal polyps are usually located in the proximal appendix and may be solitary or multiple. Synchronous polyps in the colon have been described in up to 25% of the cases. Multiple appendiceal polyps are well described in familial polyposis syndromes . A case have been described where adeno-carcinoma of the appendix was the initial presentation of a patient with adenomatous polyposis. Hamartomatous polyps of the appendix have also been described in Puetz-Jeghers syndrome . Histologically mutinous cystadenomas are the most common benign polyps followed by villous adenomas and adenomatous polyps.
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Video Endoscopic Sequence 2 of 2.
Cecum stalk polyp inside of the appendiceal orifice.
After the biopsies of
the polyp. The appendiceal orifice is displayed.
The diameter of the orifice is enlarged and almost
permitted introduction of the tip of the colonoscope.
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Flat ulcerated tubular adenoma.
Flat ulcerated tubular adenoma in the ascending colon
that caused severe hemorrhage and hypovolemic shock.
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Serrated large Mass.
A 32 year-old physician, who had rectal bleeding.
A large mass between the second and third rectal
valve is appreciated.
The histopathologic study reveled tubular adenoma.
The "hyperplastic polyp" is considered a benign lesion with
no malignant potential, whereas "serrated adenoma" is a
precursor of adenocarcinoma. The morphologic complexity
of the serrated adenoma varies from being clearly
adenomatous to being difficult to distinguish from
hyperplastic polyp, which creates a need for more detailed
morphologic analysis of all serrated polyps.
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Large ulcerated polyp at the splecnic flexure.
A 71 year-old male that had severe rectal bleeding and
shock due to this tumor.
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Video Endoscopic Sequence 1 of 2.
Bilobulated, Pediculated Villotubular Adenoma.
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Video Endoscopic Sequence 2 of 2.
A large stalk is seen.
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Lymphoid hyperplasia.
Seen at hepatic angle, multiple tiny 1 to 2 mm in size
usually incidental.
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Video Endoscopic Sequence 1 of 2.
Endoscopic Image of Enormous Tubulovillous Tumor
Enormous tubulovillous tumor of the sigmoid with wide
pediculated stalk.
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Video Endoscopic Sequence 2 of 2.
Endoscopic View of Enormous Tubulovillous Tumor
Another view of the wide stalk with the mass.
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Video Endoscopic Sequence 1 of 2.
Juvenile polyps in a 15 year-old girl. She presented rectal
hemorrhage for a week.
The image displays a bleeding juvenile polyp.
The video displays two rectal polyps.
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Pediculated Polyp of the descendent colon.
Causes of adenomatous polyps:
Genetic factors: From the NPS data, relatives of patients with polyps have an increased risk of carcinoma. This includes siblings of patients with adenomas detected prior to age 60 years or siblings of patients with adenomas detected at any age if either parent has colorectal cancer. Offer these patients screening colonoscopy every 5 years after age 40 years.
Acromegaly: Patients with acromegaly have an increased risk of adenomas and colon cancer. Prevalence rates of 14-35% for adenomas are reported. The mechanism for increased risk is not known.
Uterosigmoidostomy sites: Patients who undergo urinary diversion procedures are at increased risk of developing polyps or carcinomas at uterosigmoidostomy sites as many as 38 years later. Prevalence rates of 29% are reported.
Inflammatory bowel disease (IBD): In patients with IBD who develop carcinomas, 50% of the lesions are found to be juxtaposing serrated or villous adenomas. These possibly are the lesions from which the carcinomas originate. However, a dysplasia-associated lesion or mass is reported to be the premalignant lesion of adenocarcinoma in ulcerative colitis, in which the adenoma-carcinoma sequence is not preserved.
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Video Endoscopic Sequence 1 of 8.
This 80 year-old lady with a polyp of the rectosigmoid junction proved it to be with the biopsies that is a malign polyp.
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Video Endoscopic Sequence 2 of 8.
There was no invasion of the stalk, and polypectomy was
therefore curative cautery is applied to the wire loop which
has been tightened around the stalk of the polyp.
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Video Endoscopic Sequence 3 of 8.
The gross feature of the polyp.
Follow-up colonoscopies were negative to recurrence
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Video Endoscopic Sequence 4 of 8.
Microscopic view of the glandular distortion.
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Video Endoscopic Sequence 5 of 8.
Nuclear and pleomorfic celular characteristic are shown.
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Video Endoscopic Sequence 6 of 8.
Nuclear and pleomorfic celular characteristic are shown.
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Video Endoscopic Sequence 7 of 8.
P 53 expression is diffuse.
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Video Endoscopic Sequence 8 of 8.
A high power view of p53 positivity.
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Video Endoscopic Sequence 1 of 2.
Colonoscopy of large hiperplasic polyp
Hyperplastic polyps are usually small, located in the end-portion of the colon (the rectum and sigmoid colon), have no potential to become malignant, and are not worrisome It is not always possible to distinguish a hyperplastic polyp from an adenomatous polyp based upon appearance during colonoscopy, which means that hyperplastic polyps are often removed or biopsied to allow microscopic examination.
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Video Endoscopic Sequence 2 of 2.
Image and video clip of a large hiperplasic polyp
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Video Endoscopic Sequence 1 of 4.
Carpet villous adenoma of the cecum
This is a 88 yera-old, lady that in a computer axial tomography displays a mass of the cecum
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Video Endoscopic Sequence 2 of 4.
Carpet villous adenoma of the cecum
No malignancy was demonstrated in the histopathology, in these cases to obtain the final result the surgical specimen is needed but the family chose not to do anything because of the age of the patient.
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Video Endoscopic Sequence 3 of 4.
Carpet villous adenoma of the cecum |
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Video Endoscopic Sequence 4 of 4.
Carpet villous adenoma of the cecum |
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Video Endoscopic Sequence 1 of 10.
Carpet tubulovillous adenoma of the rectum with foci of severe dysplasia.
A 59 year-old female, who has presented recurrent rectal bleeding, sometimes with mucus of a year of evolution as well as tenesmus. The digital examination palpates soft and extensive mass.
A colonoscopy is performed, finding an extensive multilobular mass that starts just above the dentate line, line and infiltrates the rectum. One small polyp was found in the cecum and four more in the ascending colon. |
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Video Endoscopic Sequence 2 of 10.
Retroflection image observing the multilobular mass
Malignant potential dramatically increases with size.
Carpet lesions of the colon were first described using double-contrast barium enema by Rubesin et al. and were defined as flat, lobulated lesions causing an alteration in surface texture. They often involve a large surface area of the colon with little or no protrusion into the lumen. Carpet lesions have been recognized as a separate entity from flat adenomas, flat depressed adenomas, and plaque like carcinomas. Carpet lesions have been grouped with villous tumours, given their propensity to contain villous components. Carpet lesions occur predominantly in the caecum, ascending colon, and rectum for reasons that are not well understood. These lesions may also be seemingly indistinguishable from the normal surrounding colonic mucosa on colonoscopy. |
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Video Endoscopic Sequence 3 of 10.
Retroflection image observing the multi-lobed mass
The prevalence of carpet lesions is uncertain, has not been reported;
Carpeted villous adenomas of rectum may be extensive
While they may present with lower GI symptoms, hypersecretory diarrhoea and electrolyte abnormalities (Mckittrick- Wheelock syndrome) have been reported.
Carpet lesions of the colon are defined as flat, lobulated lesions causing an alteration in surface texture. They may involve a large surface area of the colon, but they show little or no protrusion into the lumen. Occasionally, carpet lesions may be recognized as a contour defect in the barium filled colon.They are easier to detect en face, however, as a nodular or reticular mucosal surface pattern with the double contrast enema Fourteen cases of carpet lesions in which the lesion was resected were collected at the Hospital of the UniversUy of Pennsylvania. Invasive carcinoma was found in only one case despite the large size of many of the
lesions.
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Video Endoscopic Sequence 4 of 10.
A dilated blood vessel which connects infiltrative type tissue.
Given the large size of carpet lesions, it is somewhat difficult to completely examine the entire lesion for malignant foci with biopsies alone. Although their malignant degenerative potential is unclear, small series report malignancy rates of 7-40%. |
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Video Endoscopic Sequence 5 of 10.
Rectum seen at retroflexed image
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Video Endoscopic Sequence 6 of 10.
Another image and video observing multilobes
Carpet lesions are flat lesions that spread along the surface of the colon,but show little protrusion into the lumen.
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Video Endoscopic Sequence 7 of 10.
A sessile infiltration is displayed
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Video Endoscopic Sequence 8 of 10.
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Video Endoscopic Sequence 9 of 10.
Another image and video of the tumor |
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Video Endoscopic Sequence 10 of 10.
A close up to the tumor
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