A Rare Case of Colonic Leiomyosarcoma in Association with Ulcerative Colitis

Leiomyomatous Lesions of the Colon: Two Case Reports with Radiological Features, Pathological Correlations, and Literature Review

Colonic leiomyomatous lesions are smooth muscle tumors including both benign leiomyoma and malignant leiomyosarcoma. They usually occur in elderly and middle-aged groups. They are rare, representing 3% of all gastrointestinal leiomyomas. Descending and sigmoid colon are the most commonly affected segments of colon. Patients are usually asymptomatic but occasionally they may present with abdominal pain, hemorrhage, and intestinal obstruction. Radiological findings for these lesions are variable and overlapping with other diagnoses but usually manifest as large lesions with lobulated margins, extra-colic growth, and heterogeneous enhancement. Final diagnosis is achieved by tissue diagnosis in which immunohistochemistry is used to differentiate them from other types of mesenchymal tumors like gastrointestinal stromal tumor. A complete surgical/endoscopic resection is usually curative with an excellent prognosis in cases of benign leiomyoma. In cases of leiomyosarcoma, post-surgical chemotherapy and radiotherapy are usually needed with a five-year survival of about 50%. We report the radiological findings with pathological correlation and literature review of two cases of colonic leiomyomatous lesions that presented with nonspecific abdominal pain. The lesions were resected surgically and confirmed histopathologically as leiomyoma and leiomyosarcoma of the colon, respectively. To the best of our knowledge, these cases are the first of colonic leiomyomatous lesions to be reported in Oman.

[Rectal leiomyosarcoma, a rare malignant tumor diagnosed in ulcerative colitis]

Patients with chronic inflammatory diseases (IBD) of the digestive tract are known to have an increased risk of colorectal cancer. These are usually adenocarcinomas, and the occurrence of malignant mesenchymal tumours, particularly leiomyosarcomas, is exceptional. We report one case in a 40-year-old woman, followed for 9 years for ulcerative colitis. The tumour measured 2cm in length and infiltrated the entire rectal wall as far as the subserosa. It was composed of fusiform cells, with 5 mitoses for 10 fields at ×400 magnification, and expressing actin, desmin and caldesmone under immunohistochemical study. We review the 2 cases of leiomyosarcomas associated with Crohn's disease and 3 cases developed during ulcerative colitis published in the literature.

Two cases of primary leiomyosarcoma of sigmoid colon treated with laparoscopic surgery: A case report and a review of literature

INTRODUCTION AND IMPORTANCE

Leiomyosarcoma (LMS) of the colon is an extremely rare and highly invasive tumor arising from the muscularis propria of the gastrointestinal tract. After the introduction of oncogenic role of KIT by immunohistochemistry (IHC), the reported cases of gastrointestinal leiomyosarcoma were highly limited. True LMS of the colon is such a rare disorder that there isn't much description of its nature.

CASE PRESENTATION

We reported two very rare cases of primary leiomyosarcoma of sigmoid colon, which referred to our institution with symptoms of abdominal pain, lower GI bleeding and fatigue. After the initial investigations, both patients were diagnosed with primary LMS of sigmoid colon that underwent laparoscopic tumor resection.

CLINICAL DISCUSSION

The classical colonic LMS presents with a vast majority of non-specific symptoms including mild abdominal pain, fresh/obscure rectal bleeding, and weight loss. The most common location for colonic LMS is the sigmoid colon, and ascending colon. The prognostic factors for the disease outcome have not been established properly; however, patient age, tumor size/grade, and local/distant dissemination are of great importance.

CONCLUSION

Herein, we reported two rare cases of primary leiomyosarcoma of sigmoid colon that was treated with laparoscopic surgery.

A pooled analysis of risk factors of surgically treated leiomyosarcoma of the colon in adults

Background

This current systematic review aimed to evaluate the role of surgical management and risk factors by pooled cases from all identified patients with colonic leiomyosarcomas.

Methods

The authors searched the Ovid MEDLINE, Embase, PubMed, and Cochrane databases using the keywords “colonic,” “colon,” and “leiomyosarcoma.” Risk factors of colonic leiomyosarcoma in the pooled cohort were also evaluated.

Results

Between 1923 and 2019, 41 cases of colonic leiomyosarcoma were identified in 22 (53.7%) males and 19 (46.3%) females, with a mean and median age of 58.7 ± 2.2 years and 56.0 years. According to univariate analysis, smaller tumor size < 8 cm was significantly associated with longer progression-free survival (HR = 6.957, 95% CI 1.405–34.442; p = 0.017), and younger age < 60 years was trending toward better overall survival (HR = 2.765, 95% CI 0.924–8.272; p = 0.069).

Conclusions

Colonic leiomyosarcomas are rare neoplasms with aggressive clinical behaviors. Age < 60 years and tumor size < 8 cm were favorable factors for patients’ better survival.

Mesenteric Lymph Node Recurrence of a Primary Colorectal Leiomyosarcoma

Primary colorectal leiomyosarcoma is an excessively rare entity. It is associated with an aggressive behavior and typically favor hematogenous spread. The current standard of care is surgical resection. A 49-year-old patient presented with a 2-month history of fever. A PET-scan revealed a hypermetabolic mass in the transverse colon, and colonoscopy confirmed a tumor. A right hemicolectomy was performed. Histopathological diagnosis was of a leiomyosarcoma. Fourteen months after the surgery, a follow-up abdominal scan revealed a 2 cm mesenteric lymph node that was hypermetabolic on PET-scan. The mesenteric lymph node was resected and histopathology confirmed a leiomyosarcoma metastasis. This case opens the controversy on the management of rare lymph node recurrences in colorectal leiomyosarcoma.

Laparoscopic surgery to treat leiomyosarcomas of the sigmoid colon:a case report and literature review

Background

Leiomyosarcomas (LMSs) of the colon are extremely rare and highly aggressive. Although treatment of gastrointestinal LMS is not standardized, surgical resection is generally performed. The fact that the tumors are usually large at the time of diagnosis may explain why no report on laparoscopic resection of a colonic LMS has appeared.

Case presentation

A 46-year-old male presented with hematochezia 1 month in duration. Abdominal examination including palpation was normal. The levels of several blood tumor markers were normal. Colonoscopy revealed a polypoid lesion approximately 30 mm in diameter in the sigmoid colon 30 cm from the anal verge. Contrast-enhanced computed tomography revealed that the tumor was 28 mm in diameter, and that no lymph node or distant metastasis was apparent. Histopathological examination of a biopsy specimen revealed spindle-shaped cells exhibiting significant nuclear atypia and a trabecular proliferation pattern upon hematoxylin-eosin staining. Immunohistochemically, the sample was positive for SMA and desmin, and negative for c-kit, DOG-1, CD34, and S-100. Furthermore, the Ki-67 index was > 50%. We thus diagnosed a leiomyosarcoma of the sigmoid colon without any metastasis. We performed laparoscopic sigmoid colectomy and regional lymphadenectomy using five trocars. After complete curative resection, a colorectal end-to-end anastomosis was created employing the double-stapling technique. All surgical margins were negative, and no lymph node metastasis was observed. The postoperative course was uneventful, and the patient was discharged 9 days after operation. No recurrence was noted to 1 year after surgery.

Conclusions

We report the first case of a colonic LMS treated via laparoscopic surgery. Although further work is necessary to assess prognosis and to develop the treatment further, laparoscopic surgery to treat small colonic LMSs may be feasible, being both minimally invasive and curative.

Pleomorphic undifferentiated soft tissue sarcoma in patient with long standing inflammatory bowel disease

Inflammatory bowel disease (IBD) has been associated with the development of both gastrointestinal and extraintestinal malignancy. The role of therapy in the development of malignancy in IBD has been controversial. We present the case of a 40-year-old female patient with long-standing mild IBD, who developed an undifferentiated pleomorphic sarcoma of the inguinal region and provide a brief review of the relevant literature. While our case likely represents a coincidence of two unrelated pathological entities, clinicians should keep in mind the possibility of soft tissue sarcomas in patients chronically treated with anti-inflammatory agents.

Primary Leiomyosarcoma of the Colon: A Report of Two Cases, Review of the Literature, and Association with Immunosuppression for IBD and Rheumatoid Arthritis

Primary leiomyosarcomas (LMS) of the colon are rare and aggressive neoplasms and have been infrequently reported in the literature. These tumors are more aggressive and have poorer prognoses than adenocarcinoma of the colon and are often mistaken as such on initial evaluation. While the former has a clear association with inflammatory bowel disease (IBD), this correlation is not known to exist with LMS and IBD. Nor is there a known link between LMS and the immunosuppression for IBD, despite the known association between malignancy and immunosuppression for other diseases. Due to the low prevalence of this disease entity, there is limited knowledge and literature on the approach to diagnosing and treating these neoplasms, especially in the setting of the aforementioned comorbidities. Here, we describe two cases of this rare entity, presenting in two different circumstances: one in the setting of immunosuppression for IBD and arthritis, with a synchronous urothelial carcinoma, and the second appearing as the source of an acute abdomen. Both diagnoses were established following pathologic analysis.