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Endoscopic removal of rectal leiomyoma: case report
Brief Reports
A Ishiguro, Y Uno, Y Ishiguro, et al.
Endoscopic removal of rectal leiomyoma: case report Ayako Ishiguro, MD, Yoshiharu Uno, MD, Yoh Ishiguro, MD, Akihiro Munakata, MD
Although leiomyomas of the stomach or small intestine are relatively common, those of the colon or rectum are rare.1-4 Several cases of endoscopic resection of colorectal leiomyomas have been described.5-7 However, conventional polypectomy of leiomyomas can result in perforation.8 To reduce the risk of perforation, submucosal injection can be performed before removal. We report a case of rectal leiomyoma in which complete enucleation was performed endoscopically using this method. CASE REPORT A 63-year-old man, found to have a rectal submucosal tumor (SMT) on colonoscopic examination for constipaFrom the First Department of Internal Medicine, Hirosaki University School of Medicine, Hirosaki, Japan. Reprint requests: Ayako Ishiguro, MD, First Department of Internal Medicine, Hirosaki University School of Medicine, 5 Zaifu-Cyo, Hirosaki 036-8216, Japan. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/54/97953 VOLUME 50, NO. 3, 1999
tion, was referred for endoscopic therapy. Colonoscopy revealed that the rectal tumor was semipedunculated and about 20 mm in diameter. It appeared to be submucosal, was reddish in color and smooth with a normal overlying mucosa, and, when manipulated with biopsy forceps, it felt relatively firm and mobile. Two weeks later, endoscopy with a two-channel colonoscope was performed to remove the lesion. A snare loop was passed over the neck of the polypoid tumor and then closed until it encircled the lesion snugly (Fig. 1). Tractive force suggested that the mass was not connected to the muscularis propria. Eight milliliters of 0.05% methylene blue solution was injected beneath the lesion at a site above the muscularis propria (Fig. 2). The snare loop was then unfastened, passed over the polyp again, and closed. The lesion was resected with electrosurgical cutting current in bipolar mode. The enucleated tumor measured 20 × 16 × 15 mm. The line of resection was stained by methylene blue (Fig. 3). Histologic examination revealed normal colonic mucosa surrounding a tumor composed of well-defined spindle-shaped smooth muscle cells, with complete obliteration of the muscularis mucosae (Fig. 4).
DISCUSSION The technique of submucosal injection for colonic SMT separates the line of resection from the muscularis propria and thereby makes it possible to GASTROINTESTINAL ENDOSCOPY
433
A Ishiguro, Y Uno, Y Ishiguro, et al.
Figure 1. Colonoscopic view of 20 mm semipedunculated tumor in rectum. Via one accessory channel of a two-channel colonoscope, the tumor was trapped and retracted with a snare.
Figure 2. Colonoscopic view of methylene blue solution being injected beneath the lesion while traction on the tumor was maintained with a snare.
resect a lesion safely by electrosurgical snare polypectomy. For reasons of safety, we have utilized this technique since 1992 to resect 19 colonic SMTs including 7 lipomas, 5 lymphangiomas, 6 carcinoid tumors and 1 leiomyoma.9 All lesions were removed completely without complication. The disadvantage of the submucosal injection technique is that the tumor becomes difficult to trap with a snare because the stalk is thickened as a result of the injection. Therefore, in the present case, the tumor was trapped with a snare before injection of the dye solution beneath the lesion. The two-channel colonoscope was used in the following manner. Using one channel, the base of the tumor was trapped and retracted with a snare so that the dis434
GASTROINTESTINAL ENDOSCOPY
Brief Reports
Figure 3. The enucleated tumor measured 20 × 16 × 15 mm. The resection margin is stained by methylene blue.
tance between the lesion and the muscularis propria increased. Via the second channel, the dye solution was injected into the submucosal layer beneath the lesion. This approach facilitated the submucosal injection. The presence of the injected solution in the submucosa provides some protection against deep thermal tissue injury and decreases the risk of perforation.10 The reason for using methylene blue as opposed to saline alone for the submucosal injection is that this establishes a clearly defined border between the tumor and the surrounding tissue, which allows correct positioning of the snare. Furthermore, the submucosal layer is dyed blue. Therefore, it can be confirmed that the lesion has been completely resected from the submucosal layer when the resected surface is dyed blue. EUS can provide valuable information when contemplating the endoscopic resection of any large mass. EUS would confirm the submucosal nature of the lesion. Unfortunately, in this case, EUS was not done. However, it is difficult to distinguish leiomyomas from leiomyosarcomas even by histologic analysis.1,11,12 Kusminsky et al.11 suggested that tumors larger than 5 cm should be considered malignant even if biopsies suggest that they are benign, and that such tumors should be surgically resected. Sugimoto et al.13 suggested that hemispherical tumors smaller than 20 mm or pedunculated tumors smaller than 30 mm might be amenable to endoscopic removal. Hoshika et al.14 suggested that, if a tumor can be lifted with a snare and it is either pedunculated or semipedunculated, then endoscopic resection might be a safe option. The tumor in the present case was 20 mm in size VOLUME 50, NO. 3, 1999
pletely and surgery was not performed. Colonoscopy will be repeated in about 6 months after endoscopic resection for surveillance. REFERENCES
A
B Figure 4. A, Photomicrograph of resected tumor covered by normal mucosa (H&E, orig. mag. ×1); B, well-defined spindle-shaped smooth muscle cells (H&E, orig. mag. ×200).
and semipedunculated and was within the size limit for endoscopic removal. A benign SMT can be subjected to partial resection of its luminal half, a technique referred to as “unroofing.”15 However, the leiomyoma under discussion required complete removal because of the possibility of malignancy. As there was no evidence of malignant potential, the tumor was removed com-
VOLUME 50, NO. 3, 1999
1. Golden TS, Stout AP. Smooth muscle tumors of the gastrointestinal tract and retroperitoneal tissues. Surg Gynecol Obstet 1941;73:784-810. 2. Lee FI. Gastric leiomyomas and leiomyosarcoma: five cases. Postgrad Med J 1979;55:575-8. 3. Sasaki K, Gotoh Y, Nakayama Y, Hayasaka H, Ishiyama Y, Miyashita H. Leiomyoma of the rectum. Int Surg 1985;70: 149-52. 4. Freni SC, Keeman JN. Leiomyomatosis of the colon. Cancer 1977;39:263-6. 5. Friedman CJ, Cunningham WN, Sperling MH. Colonoscopic removal of a colonic leiomyoma: report of a case. Gastrointest Endosc 1979;25:107-8. 6. Kadakia SC, Kadakia AS, Kevin Seargent. Endoscopic removal of colonic leiomyoma. J Clin Gastroenterol 1992;15:59-62. 7. Bjornsdottir H, Bjornsson J, Gudjonsson H. Leiomyomatous colonic polyp. Dig Dis Sci 1993;38:1945-7. 8. Commings SP, Lally KP, Pineiro-Carrero V, Beck DE. Colonic leiomyoma: an unusual cause of gastrointestinal hemorrhage in childhood. Dis Colon Rectum 1989;32:884-7. 9. Uno Y, Sasaki Y, Munakata A. A study of endoscopic resection of the colonic submucosal tumor by local methylene blue injection [in Japanese]. Gastroenterol Endosc 1992;34:1888-92. 10. Waye JD. Polypectomy techniques. In: Raskin JB, Nord HJ, editors. Colonoscopy: principles and techniques. New York: Igaku-Shoin; 1995. p. 293-315. 11. Kusminsky RE, Bailey W. Leiomyomas of the rectum and anal canal: report of six cases and review of the literature. Dis Colon Rectum 1977;20:580-99. 12. Stavorovsky M, Jaffa AJ, Papo J, Baratz M. Leiomyosarcoma of the rectum. Dis Colon Rectum 1980;23:249-54. 13. Sugimoto N, Horimukai F, Nakamura H. Submucosal tumor [in Japanese]. Progress of Digestive Endoscopy 1981;18:161-4. 14. Hoshika K, Murakami M, Hosobe M, Honda K, Kihara T. A case of pedunculated leiomyoma in the descending colon removed by endoscopic polypectomy [in Japanese]. Gastroenterol Endosc 1990;32:1447-52. 15. Miura T, Kuramoto S, Hashimoto M, Yamasaki K, Kobayashi K, Kobayashi M, Oohara T. Unroofing for lymphangioma of the large intestine: a new approach to endoscopic treatment. Gastrointest Endosc 1997;46:259-63.
GASTROINTESTINAL ENDOSCOPY
435
A Ishiguro, Y Uno, Y Ishiguro, et al.
Endoscopic removal of rectal leiomyoma: case report Ayako Ishiguro, MD, Yoshiharu Uno, MD, Yoh Ishiguro, MD, Akihiro Munakata, MD
Although leiomyomas of the stomach or small intestine are relatively common, those of the colon or rectum are rare.1-4 Several cases of endoscopic resection of colorectal leiomyomas have been described.5-7 However, conventional polypectomy of leiomyomas can result in perforation.8 To reduce the risk of perforation, submucosal injection can be performed before removal. We report a case of rectal leiomyoma in which complete enucleation was performed endoscopically using this method. CASE REPORT A 63-year-old man, found to have a rectal submucosal tumor (SMT) on colonoscopic examination for constipaFrom the First Department of Internal Medicine, Hirosaki University School of Medicine, Hirosaki, Japan. Reprint requests: Ayako Ishiguro, MD, First Department of Internal Medicine, Hirosaki University School of Medicine, 5 Zaifu-Cyo, Hirosaki 036-8216, Japan. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/54/97953 VOLUME 50, NO. 3, 1999
tion, was referred for endoscopic therapy. Colonoscopy revealed that the rectal tumor was semipedunculated and about 20 mm in diameter. It appeared to be submucosal, was reddish in color and smooth with a normal overlying mucosa, and, when manipulated with biopsy forceps, it felt relatively firm and mobile. Two weeks later, endoscopy with a two-channel colonoscope was performed to remove the lesion. A snare loop was passed over the neck of the polypoid tumor and then closed until it encircled the lesion snugly (Fig. 1). Tractive force suggested that the mass was not connected to the muscularis propria. Eight milliliters of 0.05% methylene blue solution was injected beneath the lesion at a site above the muscularis propria (Fig. 2). The snare loop was then unfastened, passed over the polyp again, and closed. The lesion was resected with electrosurgical cutting current in bipolar mode. The enucleated tumor measured 20 × 16 × 15 mm. The line of resection was stained by methylene blue (Fig. 3). Histologic examination revealed normal colonic mucosa surrounding a tumor composed of well-defined spindle-shaped smooth muscle cells, with complete obliteration of the muscularis mucosae (Fig. 4).
DISCUSSION The technique of submucosal injection for colonic SMT separates the line of resection from the muscularis propria and thereby makes it possible to GASTROINTESTINAL ENDOSCOPY
433
A Ishiguro, Y Uno, Y Ishiguro, et al.
Figure 1. Colonoscopic view of 20 mm semipedunculated tumor in rectum. Via one accessory channel of a two-channel colonoscope, the tumor was trapped and retracted with a snare.
Figure 2. Colonoscopic view of methylene blue solution being injected beneath the lesion while traction on the tumor was maintained with a snare.
resect a lesion safely by electrosurgical snare polypectomy. For reasons of safety, we have utilized this technique since 1992 to resect 19 colonic SMTs including 7 lipomas, 5 lymphangiomas, 6 carcinoid tumors and 1 leiomyoma.9 All lesions were removed completely without complication. The disadvantage of the submucosal injection technique is that the tumor becomes difficult to trap with a snare because the stalk is thickened as a result of the injection. Therefore, in the present case, the tumor was trapped with a snare before injection of the dye solution beneath the lesion. The two-channel colonoscope was used in the following manner. Using one channel, the base of the tumor was trapped and retracted with a snare so that the dis434
GASTROINTESTINAL ENDOSCOPY
Brief Reports
Figure 3. The enucleated tumor measured 20 × 16 × 15 mm. The resection margin is stained by methylene blue.
tance between the lesion and the muscularis propria increased. Via the second channel, the dye solution was injected into the submucosal layer beneath the lesion. This approach facilitated the submucosal injection. The presence of the injected solution in the submucosa provides some protection against deep thermal tissue injury and decreases the risk of perforation.10 The reason for using methylene blue as opposed to saline alone for the submucosal injection is that this establishes a clearly defined border between the tumor and the surrounding tissue, which allows correct positioning of the snare. Furthermore, the submucosal layer is dyed blue. Therefore, it can be confirmed that the lesion has been completely resected from the submucosal layer when the resected surface is dyed blue. EUS can provide valuable information when contemplating the endoscopic resection of any large mass. EUS would confirm the submucosal nature of the lesion. Unfortunately, in this case, EUS was not done. However, it is difficult to distinguish leiomyomas from leiomyosarcomas even by histologic analysis.1,11,12 Kusminsky et al.11 suggested that tumors larger than 5 cm should be considered malignant even if biopsies suggest that they are benign, and that such tumors should be surgically resected. Sugimoto et al.13 suggested that hemispherical tumors smaller than 20 mm or pedunculated tumors smaller than 30 mm might be amenable to endoscopic removal. Hoshika et al.14 suggested that, if a tumor can be lifted with a snare and it is either pedunculated or semipedunculated, then endoscopic resection might be a safe option. The tumor in the present case was 20 mm in size VOLUME 50, NO. 3, 1999
pletely and surgery was not performed. Colonoscopy will be repeated in about 6 months after endoscopic resection for surveillance. REFERENCES
A
B Figure 4. A, Photomicrograph of resected tumor covered by normal mucosa (H&E, orig. mag. ×1); B, well-defined spindle-shaped smooth muscle cells (H&E, orig. mag. ×200).
and semipedunculated and was within the size limit for endoscopic removal. A benign SMT can be subjected to partial resection of its luminal half, a technique referred to as “unroofing.”15 However, the leiomyoma under discussion required complete removal because of the possibility of malignancy. As there was no evidence of malignant potential, the tumor was removed com-
VOLUME 50, NO. 3, 1999
1. Golden TS, Stout AP. Smooth muscle tumors of the gastrointestinal tract and retroperitoneal tissues. Surg Gynecol Obstet 1941;73:784-810. 2. Lee FI. Gastric leiomyomas and leiomyosarcoma: five cases. Postgrad Med J 1979;55:575-8. 3. Sasaki K, Gotoh Y, Nakayama Y, Hayasaka H, Ishiyama Y, Miyashita H. Leiomyoma of the rectum. Int Surg 1985;70: 149-52. 4. Freni SC, Keeman JN. Leiomyomatosis of the colon. Cancer 1977;39:263-6. 5. Friedman CJ, Cunningham WN, Sperling MH. Colonoscopic removal of a colonic leiomyoma: report of a case. Gastrointest Endosc 1979;25:107-8. 6. Kadakia SC, Kadakia AS, Kevin Seargent. Endoscopic removal of colonic leiomyoma. J Clin Gastroenterol 1992;15:59-62. 7. Bjornsdottir H, Bjornsson J, Gudjonsson H. Leiomyomatous colonic polyp. Dig Dis Sci 1993;38:1945-7. 8. Commings SP, Lally KP, Pineiro-Carrero V, Beck DE. Colonic leiomyoma: an unusual cause of gastrointestinal hemorrhage in childhood. Dis Colon Rectum 1989;32:884-7. 9. Uno Y, Sasaki Y, Munakata A. A study of endoscopic resection of the colonic submucosal tumor by local methylene blue injection [in Japanese]. Gastroenterol Endosc 1992;34:1888-92. 10. Waye JD. Polypectomy techniques. In: Raskin JB, Nord HJ, editors. Colonoscopy: principles and techniques. New York: Igaku-Shoin; 1995. p. 293-315. 11. Kusminsky RE, Bailey W. Leiomyomas of the rectum and anal canal: report of six cases and review of the literature. Dis Colon Rectum 1977;20:580-99. 12. Stavorovsky M, Jaffa AJ, Papo J, Baratz M. Leiomyosarcoma of the rectum. Dis Colon Rectum 1980;23:249-54. 13. Sugimoto N, Horimukai F, Nakamura H. Submucosal tumor [in Japanese]. Progress of Digestive Endoscopy 1981;18:161-4. 14. Hoshika K, Murakami M, Hosobe M, Honda K, Kihara T. A case of pedunculated leiomyoma in the descending colon removed by endoscopic polypectomy [in Japanese]. Gastroenterol Endosc 1990;32:1447-52. 15. Miura T, Kuramoto S, Hashimoto M, Yamasaki K, Kobayashi K, Kobayashi M, Oohara T. Unroofing for lymphangioma of the large intestine: a new approach to endoscopic treatment. Gastrointest Endosc 1997;46:259-63.
GASTROINTESTINAL ENDOSCOPY
435