Synchronic signet ring carcinoma and adenocarcinoma complicating extensive and long-standing ulcerative colitis

We report the case of a 38 year-old woman with extensive ulcerative colitis (UC) for 9 years that had consistently been under close endoscopic surveillance. She had had two previous severe attacks requiring hospital admission, with good response to intravenous steroids. In the last relapse, a total colonoscopy demonstrated extensive lesions of UC throughout the entire colon. Multiple biopsies taken every 3 cm revealed only low-grade dysplasia and lesions characteristic of UC. Due to medical therapy failure, the patient was submitted for proctocolectomy. Pathological examination of the resected specimen showed a signet ring carcinoma and a synchronic adenocarcinoma in the sigmoid colon, both undetected by colonoscopy and biopsies. The issue of surveillance in patients with extensive and long-standing UC is discussed.