77 (;astroenterologia Japonica Vol. 10, No. l. - - 1 9 7 5 - -
--Case Report--
LEIOMYOSARCOMA OF THE TRANSVERSE COLON Tatsuo Y A M A K A W A , M.D. and M a s a h a r u H A S E B E , M.D.
Department of Surgery (Director: Prof. Jun-ichi SHIKA TA, M.D.), Teikyo University School of Medicine, Tokyo, Japan Summary A case report of ]eiomyosarcoma of the transveise colon was p~esented in view of its rarity of the occurrence. An extra-colonic, mobile abdominal mass showing a rapid growth with mild tenderness was the principal preoperative findings in the patient. The occurience of malignant tumors in smooth muscles of the colon, not including the rectum, is extremely rare. In review of the references, about thirty cases have been previously reported.
Key Words: leiomvosarcoma,colon A Case Report M.I., a 46 year old J a p a n e s e housewife, was admitted to Teikyo University Hospital on May 7, 1973 with a palpable intra-abdominai mass. Several days prior to her admission, she noted the mass by hereselfwhen she was in bed. Bowel habits remained normal and there were no anorexia, nausea, vomiting and loss of b o d y weight. On physical examination, the a b d o m e n was soft and a t u m o r measuring a r o u n d 8.0 cm in diameter was p a l p a t e d at the right lower quadrant. T h e surface of the t u m o r was smooth with well defined margins a n d mild tenderness. T h e t u m o r did not move with the respiration. On laboratory findings, the blood examination showed hemoglobin 9.9 gm/100 ml, hemat0crit 32.5%, white blood cells 5 0 0 0 / m m 3 a n d red blood cells 400 x 104/mm 3. E r y t h r o c y t e sedimentation rate was 2 9 m m / h o u r (Wintrobe). Renal a n d liver function tests were within normal limits. X - r a y examinations of the chest, the gallbladder and upper gastrointestinal series were also normal. A n intra-
venous pyelogram revealed p r o m p t function bilaterally, but slight dilatation of the right ureter was noted, which m i g h t have been caused by compression by the mass. Barium enema examination showed that a spaceoccupying lesion caused displacing of the ascending colon laterally and pressing of the hepatic flexure and a part of the transverse colon posteriorly. T h e b a r i u m flowed freely into the cecum, b u t a coarseness of the rugal pattern and a deep spastic contraction a r o u n d the hepatic flexure were noted (Fig. 1). Colonofiberscopy was performed, but no lesion was noted. Gynecological examination did not reveal any abnormality. F r o m these examinations, "Mesenteric cyst" was suspected preoperatively. Surgery was performed on M a y 16, 1973. T h e firm extra-colonic mass approximately 8.5 • 8.0 cm in diameter was a d h e r e d to the transverse colon a n d the ascending colon. T h e further exploration revealed swollen regional lymphnodes, however, it was felt that these were not metastatic. Exploration of the liver a n d other a b d o m i n a l organs was not significant. Right hemi-
78
T. Y A M A K A WA E T AL.
Fig. 2. Macroscopic findings of the cut-surface of the upper half of the tumor. The mucosa was retracted through a small opening and muscle layer fused into the tumor.
Fig. 1. Ba-Enema; Extrinsic mass displacing the ascending colon laterally and pressing the hepatic flexure and a part of the transverse colon posteriorly. colectomy with end to end anastomosis was performed. A firm capsulated t u m o r with a smooth surface showing extra-colonic growth was noted. Macroscopically this t u m o r was a t t a c h e d firmly to the wall of the colon, however, most of the t u m o r projected outside the intestinal wall. Mucosal surface of the colon close to this lesion was macroscopically n o r m a l , b u t the small o p e n i n g which looked like fistula was noted there. Mucosa was retracted into the t u m o r t h r o u g h this small o p e n i n g (Fig. 2). T h e cut surface of the t u m o r showed extensive growth a n d was a grayish-white a n d h a d a whorled appearance. T h e mucosa was retracted into this small o p e n i n g a n d muscle layer of the colon as shown in (Fig. 2) was fused into the tumor. It was considered that the t u m o r arouse from the i n n e r coat of the muscle layer. F o u r t e e n l y m p h n o d e s o b t a i n e d operatively were revealed n o metastasis histologically. By histopathological e x a m i n a t i o n , sections of the t u m o r showed i n t e r l a c i n g b u n d l e s of spindle cells i n
Fig. 3. Microscopic findings, the tumor pattern of a leiomyosarcoma showing spindle-shaped cells forming intelacing bundles and mitotic figures.
which there were m o d e r a t e p l e o m o r p h i s m and mitotic activity in some areas. T h e diagnosis was leiomyosarcoma of the transverse colon with no l y m p h n o d e metastasis (Fig. 3). T h e p a t i e n t m a d e a satisfactory recovery a n d was discharged on J u n e 6, 1973. She has b e e n doing fine for the last 20 m o n t h s .
Discussion Leiomyosarcoma of the colon is a n extremely u n c o m m o n lesion. I n review of the literature, the age r a n g e of reported cases varied from the n e o n a t a l period to 78 years old, showing no sex predominance2,3, 4). A
Leiomyosarcomaof the TransverseColon patient with leiomyosarcoma of the bowel can present abdominal pains and a mass. There may be nausea and vomiting as well as a change in bowel habits. Bloody and mucous stools may be sometimes noted. Weight loss is another possible symptom. These symptoms, however, are seen not only in leiomyosarcoma but also in other neoplastic lesions of the bowel. D u r a t i o n of symptoms, as postulated by Meszaros 4), showed considerable variation, however, they generally persisted from 1 to 6 months. In this case, a mobile abdominal mass showing rapid growth with mild tenderness was the only finding which was noted at the time the patient was admitted. There are several types of leiomyosarcoma from a pathologic point of view. According to the classification by Meszaros 4~, this case might be classified as a subserosal type (extra-colonic) growing into the abdominal cavity which communicates with the lumen of the bowel. Size of the t u m o r is normally over 5 cm and tumors 8 to 10 cm are not infrequent. Leiomyosarcoma has a tendency to metastasize to the liver 4,5) early and it can spread to the peritoneum a n d lung as well. T h e spreading to the lymphnodes is questioned b y some authors t). However, in this particular case, obvious findings of metastasis into the adjacent organs and regional lymphnodes were not observed. In reviewing the literature, the survival after discovery of the t u m o r has varied from 6 months to 9 years, but generally, prognosis is unfavorable 6). C h e m o t h e r a p y
79
and radiotherapy have not been of any demonstrable value. A reasonable chance of cure by removal of the t u m o r might be expected.
Acknowledgements We are grateful to Dr. J. Shikata, Professor of Surgery, Dr. H. Yasuda, Professor of Pathology and Dr, Y. Hiramatsu, Associate Professor of Radiology, Teikyo University School of Medicine for their cooperation.
References 1) Mackenzie, D.A., McDonald, J.R. and Waugh, J.M.: Leiomyoma and Leiomyosarcoma of the colon. Ann. Surg., 139: 67-75, 1954. 2) Kriss, N.: Leiomyosarcoma of the colon in an infant, Case report and review. Am. J. Roent., 84: 540-545, 1960. 3) Rogers, V.: Case Reports. Leiomyosarcoma of the colon. Brit. J. Radiol., 34: 748-750, 1961. 4) Meszaros, W.T.: Leiomyosarcoma of the colon. Am. J. Roent., 89: 766-770, 1963. 5) Levine, S., Kiehl, P.V. and Serfas, L.S.: Leiomyosarcoma of the colon. Am. J. Surg., 109: 816-818, 1965. 6) Lookanoff, V.A. and Tsapralis, P.C.: SmoothMuscle Tumors of the colon. Report of a case involving the cecum and ascending colon. J.A.M.A., 198: 206-207, 1966. 7) Sakamoto, T. and Yamazaki, I.: Leiomyosarcoma of the transverse colon. The Journal of the Japan Society of Colo-Proctology, 21 : 9, 1968. 8) Hanaoka, M., Hashino, H., Mitsuya, S. and Matsumoto, H. : Leimyosarcoma of the ascending colon. Japanese Journal of Gastroenterology, 67: 709, 1970.
Received November 15, 1974 Accepted January 20, 1975 Address reprints for requests to : Dr. T. Yamakawa, Department of Surgery, Teikyo University School of Medicine, 11-1, Kaga 2 chome, Itabashi-ku, Tokyo, 173Japan.
--Case Report--
LEIOMYOSARCOMA OF THE TRANSVERSE COLON Tatsuo Y A M A K A W A , M.D. and M a s a h a r u H A S E B E , M.D.
Department of Surgery (Director: Prof. Jun-ichi SHIKA TA, M.D.), Teikyo University School of Medicine, Tokyo, Japan Summary A case report of ]eiomyosarcoma of the transveise colon was p~esented in view of its rarity of the occurrence. An extra-colonic, mobile abdominal mass showing a rapid growth with mild tenderness was the principal preoperative findings in the patient. The occurience of malignant tumors in smooth muscles of the colon, not including the rectum, is extremely rare. In review of the references, about thirty cases have been previously reported.
Key Words: leiomvosarcoma,colon A Case Report M.I., a 46 year old J a p a n e s e housewife, was admitted to Teikyo University Hospital on May 7, 1973 with a palpable intra-abdominai mass. Several days prior to her admission, she noted the mass by hereselfwhen she was in bed. Bowel habits remained normal and there were no anorexia, nausea, vomiting and loss of b o d y weight. On physical examination, the a b d o m e n was soft and a t u m o r measuring a r o u n d 8.0 cm in diameter was p a l p a t e d at the right lower quadrant. T h e surface of the t u m o r was smooth with well defined margins a n d mild tenderness. T h e t u m o r did not move with the respiration. On laboratory findings, the blood examination showed hemoglobin 9.9 gm/100 ml, hemat0crit 32.5%, white blood cells 5 0 0 0 / m m 3 a n d red blood cells 400 x 104/mm 3. E r y t h r o c y t e sedimentation rate was 2 9 m m / h o u r (Wintrobe). Renal a n d liver function tests were within normal limits. X - r a y examinations of the chest, the gallbladder and upper gastrointestinal series were also normal. A n intra-
venous pyelogram revealed p r o m p t function bilaterally, but slight dilatation of the right ureter was noted, which m i g h t have been caused by compression by the mass. Barium enema examination showed that a spaceoccupying lesion caused displacing of the ascending colon laterally and pressing of the hepatic flexure and a part of the transverse colon posteriorly. T h e b a r i u m flowed freely into the cecum, b u t a coarseness of the rugal pattern and a deep spastic contraction a r o u n d the hepatic flexure were noted (Fig. 1). Colonofiberscopy was performed, but no lesion was noted. Gynecological examination did not reveal any abnormality. F r o m these examinations, "Mesenteric cyst" was suspected preoperatively. Surgery was performed on M a y 16, 1973. T h e firm extra-colonic mass approximately 8.5 • 8.0 cm in diameter was a d h e r e d to the transverse colon a n d the ascending colon. T h e further exploration revealed swollen regional lymphnodes, however, it was felt that these were not metastatic. Exploration of the liver a n d other a b d o m i n a l organs was not significant. Right hemi-
78
T. Y A M A K A WA E T AL.
Fig. 2. Macroscopic findings of the cut-surface of the upper half of the tumor. The mucosa was retracted through a small opening and muscle layer fused into the tumor.
Fig. 1. Ba-Enema; Extrinsic mass displacing the ascending colon laterally and pressing the hepatic flexure and a part of the transverse colon posteriorly. colectomy with end to end anastomosis was performed. A firm capsulated t u m o r with a smooth surface showing extra-colonic growth was noted. Macroscopically this t u m o r was a t t a c h e d firmly to the wall of the colon, however, most of the t u m o r projected outside the intestinal wall. Mucosal surface of the colon close to this lesion was macroscopically n o r m a l , b u t the small o p e n i n g which looked like fistula was noted there. Mucosa was retracted into the t u m o r t h r o u g h this small o p e n i n g (Fig. 2). T h e cut surface of the t u m o r showed extensive growth a n d was a grayish-white a n d h a d a whorled appearance. T h e mucosa was retracted into this small o p e n i n g a n d muscle layer of the colon as shown in (Fig. 2) was fused into the tumor. It was considered that the t u m o r arouse from the i n n e r coat of the muscle layer. F o u r t e e n l y m p h n o d e s o b t a i n e d operatively were revealed n o metastasis histologically. By histopathological e x a m i n a t i o n , sections of the t u m o r showed i n t e r l a c i n g b u n d l e s of spindle cells i n
Fig. 3. Microscopic findings, the tumor pattern of a leiomyosarcoma showing spindle-shaped cells forming intelacing bundles and mitotic figures.
which there were m o d e r a t e p l e o m o r p h i s m and mitotic activity in some areas. T h e diagnosis was leiomyosarcoma of the transverse colon with no l y m p h n o d e metastasis (Fig. 3). T h e p a t i e n t m a d e a satisfactory recovery a n d was discharged on J u n e 6, 1973. She has b e e n doing fine for the last 20 m o n t h s .
Discussion Leiomyosarcoma of the colon is a n extremely u n c o m m o n lesion. I n review of the literature, the age r a n g e of reported cases varied from the n e o n a t a l period to 78 years old, showing no sex predominance2,3, 4). A
Leiomyosarcomaof the TransverseColon patient with leiomyosarcoma of the bowel can present abdominal pains and a mass. There may be nausea and vomiting as well as a change in bowel habits. Bloody and mucous stools may be sometimes noted. Weight loss is another possible symptom. These symptoms, however, are seen not only in leiomyosarcoma but also in other neoplastic lesions of the bowel. D u r a t i o n of symptoms, as postulated by Meszaros 4), showed considerable variation, however, they generally persisted from 1 to 6 months. In this case, a mobile abdominal mass showing rapid growth with mild tenderness was the only finding which was noted at the time the patient was admitted. There are several types of leiomyosarcoma from a pathologic point of view. According to the classification by Meszaros 4~, this case might be classified as a subserosal type (extra-colonic) growing into the abdominal cavity which communicates with the lumen of the bowel. Size of the t u m o r is normally over 5 cm and tumors 8 to 10 cm are not infrequent. Leiomyosarcoma has a tendency to metastasize to the liver 4,5) early and it can spread to the peritoneum a n d lung as well. T h e spreading to the lymphnodes is questioned b y some authors t). However, in this particular case, obvious findings of metastasis into the adjacent organs and regional lymphnodes were not observed. In reviewing the literature, the survival after discovery of the t u m o r has varied from 6 months to 9 years, but generally, prognosis is unfavorable 6). C h e m o t h e r a p y
79
and radiotherapy have not been of any demonstrable value. A reasonable chance of cure by removal of the t u m o r might be expected.
Acknowledgements We are grateful to Dr. J. Shikata, Professor of Surgery, Dr. H. Yasuda, Professor of Pathology and Dr, Y. Hiramatsu, Associate Professor of Radiology, Teikyo University School of Medicine for their cooperation.
References 1) Mackenzie, D.A., McDonald, J.R. and Waugh, J.M.: Leiomyoma and Leiomyosarcoma of the colon. Ann. Surg., 139: 67-75, 1954. 2) Kriss, N.: Leiomyosarcoma of the colon in an infant, Case report and review. Am. J. Roent., 84: 540-545, 1960. 3) Rogers, V.: Case Reports. Leiomyosarcoma of the colon. Brit. J. Radiol., 34: 748-750, 1961. 4) Meszaros, W.T.: Leiomyosarcoma of the colon. Am. J. Roent., 89: 766-770, 1963. 5) Levine, S., Kiehl, P.V. and Serfas, L.S.: Leiomyosarcoma of the colon. Am. J. Surg., 109: 816-818, 1965. 6) Lookanoff, V.A. and Tsapralis, P.C.: SmoothMuscle Tumors of the colon. Report of a case involving the cecum and ascending colon. J.A.M.A., 198: 206-207, 1966. 7) Sakamoto, T. and Yamazaki, I.: Leiomyosarcoma of the transverse colon. The Journal of the Japan Society of Colo-Proctology, 21 : 9, 1968. 8) Hanaoka, M., Hashino, H., Mitsuya, S. and Matsumoto, H. : Leimyosarcoma of the ascending colon. Japanese Journal of Gastroenterology, 67: 709, 1970.
Received November 15, 1974 Accepted January 20, 1975 Address reprints for requests to : Dr. T. Yamakawa, Department of Surgery, Teikyo University School of Medicine, 11-1, Kaga 2 chome, Itabashi-ku, Tokyo, 173Japan.
