J. Coloproctol. (Rio J.) vol.36 número4

jcoloproctol(rioj).2016;36(4):240–243

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Case

Report

Submucosal

lipoma

simulating

a

malignant

tumor

of

the

left

colon:

a

case

report

Victor

Minari

Campos

,

Sergio

Mazzola

Poli

de

Figueiredo

,

Rodrigo

Salmeron

de

Toledo

Aguiar

_,

_Augusto

_Canton

_Gonc¸alves

_,

Thiago

Manzione

_,

_Fang

_Chia

_Bin

a_{FaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo(FCMSCSP),SãoPaulo,SP,Brazil}

b_{IrmandadedeMisericórdiadaSantaCasadeSãoPaulo,DepartmentodeColoproctologia,SãoPaulo,SP,Brazil}

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o

Articlehistory:

Received1February2016 Accepted20April2016 Availableonline30June2016

Keywords: Lipoma Colontumor Benigntumor Colon

Descendingcolon

a

b

s

t

r

a

c

t

Intestinallipomascanoccuranywhereinthegastrointestinaltract,andthesetumorsare morefrequentinthecolon.Bybeinglargelyasymptomatic,colonic lipomasareusually foundincidentally,asfindingsincolonoscopyexaminations,inassociationwithbiopsy. Endoscopicorsurgicalresectionisthetherapeuticoption,dependingonthesizeofthe tumor,itslocation,andthepresenceorabsenceofsymptoms.Inthisstudy,wepresenta caseofa59-yearoldwoman,withadescendingcolonlipomahistologicallydiagnosedonly aftersurgicalresectionofthelesion.Theapproachwasadoptedaccordingtothepatient’s clinicalpicture(intestinalbleeding,vomitingandweightloss),inadditiontotheocclusion of80%ofthecoloniclumenobservedinacolonoscopy.

©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Lipoma

submucoso

simulando

tumor

maligno

de

cólon

esquerdo:

relato

de

caso

Palavras-chave: Lipoma Tumordecolon Tumorbenigno Colon

Colondescendente

r

e

s

u

m

o

Oslipomasintestinaispodemocorreremqualquerpartedotratogastrointestinal,sendo maisfrequentenocólon.Porserememgrandeparteassintomáticos,oslipomas colôni-cossãousualmenteencontradosacidentalmentecomoachadosdeexamedecolonoscopia associadaà biópsia.Como opc¸õesdetratamento,háaressecc¸ão endoscópicaou cirúr-gica,adependerdotamanhodotumor,sualocalizac¸ãoepresenc¸a(ounão)desintomas. Nesserelato,éapresentado umcasodeumamulher de59 anoscomlipomade cólon

∗ _{Correspondingauthor.}

E-mail:victormcampos@hotmail.com(V.M.Campos).

http://dx.doi.org/10.1016/j.jcol.2016.04.014

jcoloproctol(rioj).2016;36(4):240–243

241

descendente,diagnosticadohistologicamenteapenasapósressecc¸ãocirúrgicadalesão.A condutafoiadotadapeloquadroclínicodeenterorragia,vômitoseperdaponderal,alémda oclusãode80%daluzdocólonobservadaemexamedecolonoscopia.

©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Introduction

Colonic lipomas are benign tumors arising from the con-nective tissue of the intestinal wall,1 _{representing 2.6% of}

non-malignanttumorsofthegastrointestinaltract.2_Although

this is the most frequent non-malignant intramural mes-enchymaltumorofthe gastrointestinaltract and the third in frequency, coming after adenomatous and hyperplastic polyps, are few the cases described inthe literature.2–4 _In

mostcases,thetumorisasymptomatic,1,3,5_{generallybeing}

anaccidentalfindingofimagingstudies,3–7_{butthesetumors}

mayshowsymptomssuchasabdominalpain,rectal bleed-ing,changeinbowelhabits,abdominalbloating,anorexia,and weightloss.3–6,8

Case

report

Ourpatientwasa59-yearoldbrown-coloredfemaleseenat theColoproctologyoutpatientclinicofatertiaryhospitalwith ahistoryofhypogastric colicpain fora year,accompanied byvomiting,diarrhea, and rectalbleeding. Inaddition, the patientmentionedaweightlossof5kginayear.Thispatient ishypertensive,withlactoseintolerance andhasnofamily historyofgastrointestinaldisease.Onphysicalexamination, theabdomenwasflat,flaccid,andpainlesstopalpationand withhydro-aerialsoundspresent.Theproctologic examina-tionrevealedanormalstaticanddynamicinspectionandthe digitalrectalexaminationwaswithoutpalpablelesions.Three colonoscopieswereperformed;thefirsttwowereperformed inotherservices,indicatingabenigntumorofapproximately 5cm, at the transition between the descending colon and thesigmoid,occluding40% ofthe coloniclumen. However, the biopsies produced unspecificresults. Between the first andthelastcolonoscopy,7monthshavepassed,anditwas noted a substantial increase of 80% in the colonic lumen occlusion.Thelastcolonoscopywasperformedinourservice, inordertoattainabetterdirectvisualizationofthelesion, in an attempt for the histological diagnosis, and also for tattooing the lesion found, in order to facilitatethe intra-operativemanagementoftheinjury.ACTscanshowedleft colonthickening(Fig.1).Thelaboratoryworkupshowedno changes,withCEA=1.8before surgery.Tumorexcision and primaryanastomosisoftheresectedcolonicportionwere car-ried out.Postoperatively, there were no complications and thepatientwasdischargedinagoodcondition.The patho-logicalexaminationshowedapolypoid-likelesionmeasuring 4.5cm×3.5cm,withayellow,softtocut,tissue(Figs.2and3). Amucosawithreducedwrinklingandagrayareaandwith parietalinfiltrationwasalsoobserved.Theadiposetissuewas

Fig.1–AbdominalCTwithleftcolonthickening.

Fig.2–Surgicalspecimen.

242

lobedandwithoutspecialfeatures.Thediagnosisofintestinal submucosallipomawasconfirmed,withprocess-freesurgical margins.

Discussion

Ourpatientisa59-yearoldfemale,whichcorrespondstothe mostfrequentgenderand agegroup ofpatients diagnosed withlipoma:womenbetweenthefifthandsixthdecade of life.1,6,7

Intestinallipomasarecommonlydiagnosedthrough find-ingsincolonoscopyprocedures indicatedforthetreatment ofotherdiseasesorforscreeningpurposes,consideringthat these tumorsare more prevalent inthe colon than inthe smallintestine,2,5,7,8_{beingasymptomaticinmostcases.}1,3,5,7

Clinicalmanifestationsareevidentinapproximately 6–25% ofdiagnoses.1,5 _{However, the case atissue corresponds to}

agiantlipoma, anatomopatologicallyprovenbythe sizeof thesurgicalspecimen,a piecemeasuringover 4cm. Inthe faceoftumorsofsuchsize,thepercentageofsymptomatic cases is75%.5,6 _{The patient complained ofan hypogastric}

pain,episodesofrectalbleeding,diarrheaandamildweight loss–normalfindingsinsymptomaticcasesoflipoma.4–6,8_in

addition,thepatienthadvomitepisodes,whichisnotoften describedintheliterature.

Colonoscopyistheprimarymethodfordiagnosisofcolonic lipomas. The characteristic findings are the presence of a wide-basetumor,withayellowishtintduetothe underly-ingfattytissue.Furthermore,a“tentingsign”anda“cushion sign”arealsoobserved:thefirstsignaliselicitedifonepulls themucosaoverlyingthelipoma,whichdetachesitself eas-ily, asseenin othersubmucosal lesions;the secondsignal consistsintouching the lipomawitha biopsy fórceps;the lipomaisdepressed easilyand quicklyreturns toits origi-nalform.3,4,6,9_{Aftertheestablishmentofthediagnosis,one}

mustconsiderasurgicalapproach.Tumorresectionis indi-cated in casesof a symptomaticlipoma, particularly with obstruction or bleeding; if the mass measures more than 2.5cm; or if the injury is mimicking malignancy.1,2,5,6,8 _In

the case reported, with the first two consecutive colonos-copies a 4-cm diameter protruding injury with a 40% of occlusion of the lumen of the descending colon – site of 20% ofcoloniclipomas –was diagnosed.1,4–7 _{Atthis point,}

asurgerycould havebeen performed,bothconsideringthe clinical manifestations and the tumor size. However, this was not done due to the irregular follow-up in another service. After 7 months, a new colonoscopy showed a 6-cmlesion with80% ofocclusion; thistime, the lesionwas resected,despitetheabsenceofahistologicaldiagnosiswith the colonoscopy examinations performed prior to surgery. Thus, alaparotomy wasperformed, along witha segmen-talleft colectomywithprimaryanastomosis.Lipomaswith a less than 2-cm diameter can be removed endoscopi-cally;on the other hand,larger lesions must be surgically resected.4

The pathological examination of the surgical specimen confirmed a description macro- and microscopically con-sistent with a diagnosis of intestinal submucosal lipoma, which isin accordance withthe highestfrequency among

Fig.4–Histologyoflesioncompatiblewithsubmucosal lipoma.

its subtypes. Submucosal lipomas are more frequent than subserosal andmixed lipomas.1,4 _{Histologically,the lipoma}

showsadenseaccumulationofenlargedandroundedfatcells with cytoplasmand nucleus inthe cell periphery (Fig. 4).1

Grossly, the tumor may present itself in different forms: rounded,sessileorcoveredbyafibroustissuecapsule branch-ingovertheadiposetissuemass,whichresultsintheirlobate appearance.1,4

Conclusion

Lipomasarerarebenigntumors.Inmostcases,thesetumors are asymptomatic and are accidentallydiagnosed, particu-larly by colonoscopy.Their treatment isbased on the size of the lesion, presence of symptoms, and if there is sus-picion of malignancy, and the evaluated criteria point to an endoscopic or surgical resection. The gender and age group ofour patient were the mostprevalent for this dis-ease,andherswasagiantandsymptomatictumor;however, it tumor was not localized in the most frequent position in the colon. For all thesereasons, wechoseto performa surgery.

Conflicts

of

interest

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3.DultzLA,UlleryBW,SunHH,HustonTL,EachempatiSR,Barie PS.Ileocecalvalvelipomawithrefractoryhemorrhage.JSLS. 2009;13:80–3.

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5.MorimotoT,FuKI,KonumaH,IzumiY,MatsuyamaS,OguraK, etal.Peelingagiantileallipomawithendoscopicunroofing andsubmucosaldissection.WorldJGastroenterol.

2010;16:1676–9.

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7.JiangL,JiangL-S,LiF-Y,YeH,LiN,ChengNS,etal.Giant submucosallipomalocatedinthedescendingcolon:acase reportandreviewoftheliterature.WorldJGastroenterol. 2007;13:5664–7.

8.PaˇskauskasS,LatkauskasT,Valeikait ˙eG,Parˇseli ¯unasA, Svag ˇzdysS,Salad ˇzinskasZ,etal.Colonicintussusception causedbycoloniclipoma:acasereport.Medicina(Kaunas). 2010;46:477–81.