 Good day, everyone. I am Dr. Pallavi Bhatt. I am a former D.N.B. resident in the Department of Radio Diagnosis for the Spirit Hospital in Mumbai. And today, I will be presenting an interesting case under the guidance of our HOD, Dr. Shampa Brahmachari. It is about a usual complication, but in an unusual organ. So, we had a 73-year-old female presenting with complaints of lower abdominal pain and fouls milling vaginal discharge for just two days. She was initially sedested and abdominal ultrasound. We have a few ultrasound images here, what we could see were hypericolpochi with shadowing filling the endometric cavity. It could be air. And there was air in the endometric cavity as well as the upper vagina. And we could also see a suspicious streak of hypericolpochi which could be air in the posterior uterine wall as well. So, we're thinking about what could cause this. There was no opposite uterine mass. There was no endometrial thickening or any collection around the uterus or inside. There was no recent history of instrumentation which could explain the, which could introduce the air in the endometrial cavity or even cause uterine injury. The patient also did not have any fever which could explain an infective pathology. She also did not have any bowel related complaints, but the possibility of an enteroyuterine fistula was raised. An infective pathology which could result in gas formation was deemed to be less likely. She was suggested a computed tomography or CT for further clarification of the pathology. She also later underwent an MRI as part of preoperative assessment. We have a few CT images here. We have the axial and coronal images which show irregular circumferential thickening of the cell moite colon. There is surrounding fat stranding and loss of fat plane with the posterior aspect of uterus. We can see air within the endometrial cavity. In the sagittal reformatted images, we can see that the air in the endometrial cavity is actually communicating with the lumen of the bowel specifically at the rectosythmoid junction. There is a clear defect in the posterior uterine wall which measured about 0.5 to a maximum of 1 centimeter. This was a colloid uterine fistula and it was again read to a malignancy. And with majority of the sign centering around the colon, we could say that it was a colonic malignancy rather than a uterine malignancy. In the MRI, we have sagittal T2 images which confirmed our findings showing circumferential transmutal thickening of the rectosythmoid junction. It measured about 19 mm and was seen about 12 centimeter from the anal canal. There was a lateral exophytic component towards the left side which continuously invades the uterine wall. At the time of MRI examination, there were multiple small air pockets as well. We also have actual ansidietal T2 stir images which showed diffuse stir, hyper intense soft tissue edema in para rectal and para material regions. And there was nodularity as well which later turned out to be enlarged lymph nodes. Initially, the patient underwent a colonoscopy with biopsy of visible growth at the rectosythmoid junction which revealed moderately differentiated adenocarcinoma which was not surprising. She underwent a radical sigmoidectomy and hysterectomy with bilaterum sagringoborectomy. Histopathology confirmed moderately differentiated adenocarcinoma of sigmoid colon and rectum infiltrating the serosa as well as the myometrium which was a pathological T4B. So what do we know about colorectal saranoma? It's a relatively common cancer in India. The annual incidence rates for colon cancer are 4.4 and 3.9 per 1 lakh men and women respectively. Five years of viral rate of colorectal cancer in India is one of the lowest in the world at less than 40 percent. Accurate staging is essential for determining the optimal treatment strategies and planning appropriate surgical procedures. Alder son is commonly the initial screening modality based on the presentation. CT is used to evaluate distant metastasis while MRI is used to evaluate local regional extension to assess circumferential rejection margin available. The risk of recurrence and optimal therapeutic strategy also depend on MRI. Complications of colorectal cancer include obstruction, perforation, absence of formation, ischemic colitis and a deception as we see here fistula formation. What we see here is a colune uterine fistula which is very rare. Mostly secondary to colonic diverticulitis but other causes can include malignancy or radiotherapy or even iotrogenate mostly due to insertion of intra uterine devices or endometrial curatage causing uterine and bowel cooperation. Obstetrical injuries can also cause a fistula. It should always be suspected when patient presents with malodorous discharge from the vagina. It can be diagnosed by air and fluid within the uterus on ultrasound or CT scan. However, a CT scan is essential after an ultrasound for an accurate preoperative assessment. Surgical treatment is indicated in almost all patients except in very high cases. So these fistulas which are associated with colon most commonly involve the urinary bladder or vagina which are conveniently located adjacent to it. But the uterus being governed thick and muscular organ it provides a protective barrier of thought against invasion of either benign or even malignant disease. An interesting fact is that the thickness of uterus makes it the last organ to putrify postmortem in the female body. Uterine layers can be identified separately up to 144 hours postmortem. So what do we have in literature? There are very few other similar cases of colorectal fistula mostly secondary to divert colitis or as a complication in known case of colorectal cancer. But in our case it was the initial presentation. A colorectal fistula was first reported by the gentle in 1909. Fistula formation by colonic cancer occurs when a tumor extends or ruptures into an adjacent organ such as bladder, small bowel or vagina. Diagnosis is easily made with clinical history and abdominal pelvic CT scan which reveal the presence of gas collection within the uterine cavity. So we saw an interesting case but what did we learn from it? Malignant invasion and fistulation usually take the path of least resistance but malignancy does not spare even a resistant organ like uterus. Vehicle vaginal discharge may be due to colorectal or colovaginal fistula. They can also present as passage of gas or pus per vaginal. The patient may not be able to differentiate of passage of gas or pus per vaginal or per rectal. It should be suspected in any patient with persistent vaginal discharge as well. Screening of colorectal as well as endometrial cancers should be encouraged to facilitate early diagnosis and treatment. I would like to highlight the importance of screening programs. In a developing country like India it is more so important to have good screening programs for the common cancers like breast, prostate, cervical cancers or even oral cancers as we know early detection can better the cure rates and reduce the morbidity as well also reducing the burden on the health system. We have the availability of screening modalities be it radiological or biochemical, serological and we know that effective screening programs are running in other parts of the world. What we need to do is educate and raise awareness make these screening programs more accessible and affordable include them in our health programs and actually implement them and as we know we radiologists form a big part of these implementation. Together I hope we can and we should meet cancer. Thank you.