Katsinelos P, Chatzimavroudis G, Zavos C, Pilpilidis I, Lazaraki G, Papaziogas B, Paroutoglou G, Kountouras J, Paikos D. Cecal lipoma with pseudomalignant features: A case report and review of the literature. World J Gastroenterol 2007; 13(17): 2510-2513
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Dr. Panagiotis Katsinelos, Department of Endoscopy and Motility Unit, Central Hospital, Ethnikis Aminis 41, 54635, Thessaloniki, Greece. email@example.com
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Cecal lipoma with pseudomalignant features: A case report and review of the literature
Panagiotis Katsinelos, Grigoris Chatzimavroudis, Christos Zavos, Ioannis Pilpilidis, Georgia Lazaraki, Basilis Papaziogas, George Paroutoglou, Jannis Kountouras, Dimitris Paikos
Panagiotis Katsinelos, Ioannis Pilpilidis, Georgia Lazaraki, George Paroutoglou, Dimitris Paikos, Department of Endoscopy and Motility Unit, Central Hospital, Thessaloniki, Greece
Grigoris Chatzimavroudis, Basilis Papaziogas, 2nd Surgical Clinic, Medical School, Aristotle University of Thessaloniki, Greece
Christos Zavos, Jannis Kountouras, 2nd Clinic of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
ORCID number: $[AuthorORCIDs]
Author contributions: All authors contributed equally to the work.
Correspondence to: Dr. Panagiotis Katsinelos, Department of Endoscopy and Motility Unit, Central Hospital, Ethnikis Aminis 41, 54635, Thessaloniki, Greece. firstname.lastname@example.org
Telephone: +30-2310-211221 Fax: +30-2310-210401
Received: January 28, 2007 Revised: January 31, 2007 Accepted: February 14, 2007 Published online: May 7, 2007
Colonic lipoma is a well-documented benign neoplasia, endoscopically appearing as a smooth round yellowish polyp with a thick stalk or broad-based attachment. We describe a 63-year old woman with persistent abdominal pain, in whom colonoscopy revealed a cecal mass with malignant features. Based on the colonoscopy findings, right hemicolectomy was laparoscopically performed for a presumptive diagnosis of a cecal adenocarcinoma, but histological examination revealed a colonic lipoma with overlying mucosal ulceration.
Citation: Katsinelos P, Chatzimavroudis G, Zavos C, Pilpilidis I, Lazaraki G, Papaziogas B, Paroutoglou G, Kountouras J, Paikos D. Cecal lipoma with pseudomalignant features: A case report and review of the literature. World J Gastroenterol 2007; 13(17): 2510-2513
Lipomas are rare and slow-growing benign nonepithelial tumors that can be found in the gastrointestinal tract[1,2]. Lipomas develop only infrequently in the colon, and are usually asymptomatic and detected incidentally at colonoscopy, surgery or autopsy. The occurrence of symptoms appears to be related to the size of lipoma. Those larger than 2 cm may occasionally cause abdominal pain, changes of bowel habits, rectal bleeding and bowel obstruction, intussusception or prolapse[3-5]. The common endoscopic picture consists of a smooth, spherical polyp, usually sessile and rarely penduculated that is slightly yellow, while the overlying mucosa is intact[1-6]. In rare cases the mucosa presents necrotic and/or ulcerative lesions that resemble malignant tumors[7,8]. The decision for selecting the most suitable treatment of a colonic lipoma mainly depends on the tumor's size and is either endoscopic resection or surgical removal. Lipomas with a diameter less than 2 cm can be safely removed endoscopically, whereas larger lesions should be removed by segment resection[9-11].
We describe a patient with persistent abdominal pain who underwent laparoscopic right hemicolectomy for the presumptive endoscopic diagnosis of cecal adenocarcinoma that turned out to be a lipoma on histological examination.
A 63-year old woman with abdominal pain for several weeks was referred to our department by a private gas-troenterologist for further investigation of a 2 cm broad-based cecal polypoid mass, revealed during colono-scopy.
The patient did not report any episodes of constipation, diarrhea, hematochezia or melena, and her medical history did not include consumption of alcohol or non-steroid anti-inflammatory drugs (NSAIDs). Examination of the abdomen revealed no mass or tenderness. Detailed laboratory studies were within normal ranges, including complete peripheral blood cell count, blood coagulation and carcinoembryonic antigen (CEA). Colonoscopy performed in our department revealed a sessile tumor of about 2 cm in diameter, proximal to the ileocecal valve. The overlying mucosa was ulcerated and nodular with red color, while on palpation with biopsy forceps, the mass was felt to be stiff, not compressible and easy bleeding (Figure 1A and B). Although histopathological examination of biopsy specimens showed only non-specific ulcerations, malignancy could not be excluded according to the endoscopic findings. Further investigation included an abdominal ultrasound, which was negative for liver metastases and a computed tomography (CT) scan which showed a sessile neoplasm protruding into the lumen of cecum with a medium tissue density.
Figure 1 Endoscopic view of a broad-attachment polypoid tumor (A) and bleeding from the lesion on compression with biopsy forceps on compression with biopsy forceps (B).
The overlying mucosa was nodular with ulcerations.
Given the suspicion of the malignant nature of the tumor, the patient underwent a laparoscopic right hemicolectomy. Macroscopic assessment of the resected specimen revealed a round polypioid tumor of 2.1 cm × 2.4 cm × 1.8 cm in size, with firm characteristics and nodular surface. Pathological examination of the resected lesion revealed a cecal lipoma with ulcerative lesions on the overlying mucosa (Figure 2A and B). The postoperative course was uneventful, and the patient was free of symptoms during a 10-month follow-up period.
Figure 2 Endoscopic view of a broad-attachment polypoid tumor (A) and bleeding from the lesion on compression with biopsy forceps on compression with biopsy forceps (B).
The overlying mucosa was nodular with ulcerations.
Colonic lipomas are relatively uncommon tumors of mesenchymal origin, composed of well-differentiated adipose tissue supported by fibrous tissue, that rarely cause symptoms and are usually detected incidentally[1-3]. They arise from the submucosa, but occasionally extend into the muscularis propria; up to 10% are subserosal. The incidence of lipomas relative to all polypioid lesions of the large intestine is reported to range from 0.035% to 4.4%[1,2]. However, they represent the third most common benign tumors after hyperplastic and adenomatous polyps. They are usually solitary, but multiple lesions are reported in 10% to 25% of cases[1,3]. A rare polyposis syndrome has been described, with numerous lipomas throughout the bowel (colonic lipomatosis). Colonic lipomas are mainly found on the right-side of the colon and cecum. Most of these tumors are asymptomatic and usually detected incidentally during colonoscopy and laparotomy. Only 25% of patients with colonic lipoma develop symptoms. When lipomas are larger than 2 cm in diameter, they may cause symptoms including bleeding with anemia, diarrhea or constipation, abdominal intestinal obstruction, and rarely, intussusception.
Various imaging modalities can imply the diagnosis of colonic lipomas. Barium enema may reveal an ovoid filling defect with well-defined borders. A so-called squeeze sign, indicating a change in size and shape of a radiolucent lesion in response to peristalsis, is frequently noted. CT scans of colonic lipomas can provide a definite diagnosis because the mass typically has characteristic fatty densitometric values[18,19]. On CT, lipomas appear ovoid or pear shaped, with sharp margins and absorption densities of -40 to -120 Hounsfield units, typical of fatty composition[20,21]. However, these features are evident only in large lesions, as smaller tumors are not detectable due to artifacts and partial volume averaging. Correspondingly, in our case, abdominal CT was not diagnostic for lipoma possibly due to the tumor's relatively small size. Magnetic resonance imaging (MRI) may be particularly useful in the detection of lipomas as the signal intensity is characteristic of adipose tissue on T1-weighted and fat-suppressing images[23,24]. Endoscopic ultasonography (EUS) is a potent adjunct modality for characterization of submucosal tumors. Colonic lipomas appear as hyperechoic lesions with regular borders in the three layers and can be distinguished from smooth muscle tumors, lymphangiomata, and invasive or metastatic malignancies. EUS can be used to determine any extension into the muscularis propria before injection-assisted polypectomy of symptomatic lipomas. Recently, CT colonographic examination (virtual colonoscopy) has been performed to detect colonic lipomas.
Endoscopy can usually distinguish lipomas from gas-trointestinal cancer or other tumors. Lipomas are seen as smooth, rounded yellowish polyps with a thick stalk or broad-based attachment[1-6]. Typical colonoscopic features are the "cushion sign" or "pillow sign" (pressing forceps against the lesion results in depression or pillowing of the mass) and the naked fat sign (extrusion of yellowish fat at biopsy site)[4,12,28,29]. Although the mucosa overlying a colonic lipoma is usually not involved, in rare cases, as in our patient, colonoscopy may reveal ulcerations and stiffness on palpation that may lead to a mistaken impression of carcinoma. Eleven such cases[7,8,30-36] reported over 3 decades are summarized in Table 1. Among these patients the most common indications for endoscopy were hematochezia and persistent abdominal pain. The location of lesion was in the cecum in three cases, ascending and transverse colon in one respectively, descending colon in two and rectosigmoid in four cases. In cases where biopsy specimens were taken, only hemorrhagic necrosis or ulceration of the mucosa was identified. In all but one case treatment consisted of operative resection.
Table 1 Reported cases of colonic lipomas with pseudomalignant features.
The indications for performing colonoscopic snare polypectomy to remove colonic lipomas remain con-troversial[9,28,37]. Most authors agree that colonic lipomas with a diameter larger than 2 cm should be removed surgically, because in these cases endoscopic resection is associated with a high rate of complications[9,10,38,39]. However, especially for large penduculated lipomas, the size of the stalk seems to be a more important factor than the diameter of the lipoma when colonoscopic removal is considered[10,38]. In our opinion, if a lipoma is sessile or broadly-based, endoscopic removal is risky because the fatty tissue is an inefficient conductor for electric current and may result in a significantly high rate of complications like perforation or hemorrhage.
A wide range of operative techniques using conventional laparotomy and mini-laparotomy have been described including enucleation, colostomy, excision and segmental colonic resection. However, only a few cases of laparosco-pic resection of colonic lipomas have been reported so far[13,15,39,41-47]. Advantages of laparoscopic surgery include less postoperative pain, shorter hospitalization and faster recovery than conventional laparotomy. The latest publish-ed data referring to the comparison of laparoscopic versus open colorectal resection for cancer[48-49] indicate that laparoscopic resection of colonic lipomas should become the gold standard method for removal of lipomas greater than 2-3 cm in diameter, even in cases where the malignancy of the tumor could not be excluded preoperatively.
In conclusion, our case emphasizes that a colonic lipoma can simulate a malignant neoplasm and underscores the laparoscopic resection as the recommended operation for symptomatic colonic lipomas.
S- Editor Liu Y L- Editor Wang XL E- Editor Zhou T
LoIudice TA, Lang JA. Submucous lipoma simulating carcinoma of the colon.South Med J. 1980;73:521-523.
Snover DC. Atypical lipomas of the colon. Report of two cases with pseudomalignant features.Dis Colon Rectum. 1984;27:485-488.
Chung YF, Ho YH, Nyam DC, Leong AF, Seow-Choen F. Management of colonic lipomas.Aust N Z J Surg. 1998;68:133-135.
Stone C, Weber HC. Endoscopic removal of colonic lipomas.Am J Gastroenterol. 2001;96:1295-1297.
de Ruijter SH, van Marle AG, Doornewaard H, Melse JC. Submucosal lipoma of the colon: abdominal cramps with rectal bleeding and weight loss.Ned Tijdschr Geneeskd. 2006;150:1990-1993.
De Beer RA, Shinya H. Colonic lipomas. An endoscopic analysis.Gastrointest Endosc. 1975;22:90-91.
Chiba T, Suzuki S, Sato M, Tsukahara M, Saito S, Inomata M, Orii S, Suzuki K. A case of a lipoma in the colon complicated by intussusception.Eur J Gastroenterol Hepatol. 2002;14:701-702.
Tatsuguchi A, Fukuda Y, Moriyama T, Yamanaka N. Lipomatosis of the small intestine and colon associated with intussusception in the ileocecal region.Gastrointest Endosc. 1999;49:118-121.
Cossavella D, Clerico G, Rosato L, Galetto PV, Paino O, Trompetto M, Luc AR, Pozzo M. Lipoma of the colon as an unusual cause of recurring partial intestinal occlusion. Clinical case and review of the literature.Minerva Chir. 1998;53:277-280.
Huh KC, Lee TH, Kim SM, Im EH, Choi YW, Kim BK, Jung DJ, Choi WJ, Kang YW. Intussuscepted sigmoid colonic lipoma mimicking carcinoma.Dig Dis Sci. 2006;51:791-795.
Kaplan P. Submucous lipoma of the colon. Report of a case.Int Surg. 1971;56:113-117.
Buetow PC, Buck JL, Carr NJ, Pantongrag-Brown L, Ros PR, Cruess DF. Intussuscepted colonic lipomas: loss of fat attenuation on CT with pathologic correlation in 10 cases.Abdom Imaging. 1996;21:153-156.
Kakitsubata Y, Kakitsubata S, Nagatomo H, Mitsuo H, Yamada H, Watanabe K. CT manifestations of lipomas of the small intestine and colon.Clin Imaging. 1993;17:179-182.
Wulff C, Jespersen N. Colo-colonic intussusception caused by lipoma. Case reports.Acta Radiol. 1995;36:478-480.
Heiken JP, Forde KA, Gold RP. Computed tomography as a definitive method for diagnosing gastrointestinal lipomas.Radiology. 1982;142:409-414.
Megibow AJ, Redmond PE, Bosniak MA, Horowitz L. Diagnosis of gastrointestinal lipomas by CT.AJR Am J Roentgenol. 1979;133:743-745.
Younathan CM, Ros PR, Burton SS. MR imaging of colonic lipoma.J Comput Assist Tomogr. 1991;15:492-494.
Liessi G, Pavanello M, Cesari S, Dell'Antonio C, Avventi P. Large lipomas of the colon: CT and MR findings in three symptomatic cases.Abdom Imaging. 1996;21:150-152.
Kameyama H, Niwa Y, Arisawa T, Goto H, Hayakawa T. Endoscopic ultrasonography in the diagnosis of submucosal lesions of the large intestine.Gastrointest Endosc. 1997;46:406-411.
Ochiai T, Akahoshi K, Hamada S, Chijiiwa Y, Nawata H, Namoto M. Endoscopic resection of a colonic lipoma under endoscopic ultrasound guidance.Endoscopy. 1998;30:S65-S66.
Johnson CD, Hara AK, Reed JE. Computed tomographic colonography (Virtual colonoscopy): a new method for detecting colorectal neoplasms.Endoscopy. 1997;29:454-461.
Christie JP. The removal of lipomas.Gastrointest Endosc. 1990;36:532-533.
Zhang H, Cong JC, Chen CS, Qiao L, Liu EQ. Submucous colon lipoma: a case report and review of the literature.World J Gastroenterol. 2005;11:3167-3169.
Lera JM, Gómez-Portilla A, Fakih A, Vicente F, Zornoza G. Submucosal lipomas of the colon.Rev Med Univ Navarra. 1982;26:185-187.
McGrew W, Dunn GD. Colonic lipomas: clinical significance and management.South Med J. 1985;78:877-879.
Taylor BA, Wolff BG. Colonic lipomas. Report of two unusual cases and review of the Mayo Clinic experience, 1976-1985.Dis Colon Rectum. 1987;30:888-893.
El-Khalil T, Mourad FH, Uthman S. Sigmoid lipoma mimicking carcinoma: case report with review of diagnosis and management.Gastrointest Endosc. 2000;51:495-496.
Caterino S, Tiziano G, Mercantini P, Ziparo V. Rectorrhagia caused by lipoma of the hepatic flexure of the colon. A case report and review of the literature.G Chir. 2002;23:205-208.
Meghoo CA, Cook PR, McDonough CA, Bowser LK, Waddell BE. Large colonic lipoma with mucosal ulceration mimicking carcinoma.Gastrointest Endosc. 2003;58:468-470.
Yu JP, Luo HS, Wang XZ. Endoscopic treatment of submucosal lesions of the gastrointestinal tract.Endoscopy. 1992;24:190-193.
Tamura S, Yokoyama Y, Morita T, Tadokoro T, Higashidani Y, Onishi S. "Giant" colon lipoma: what kind of findings are necessary for the indication of endoscopic resection?Am J Gastroenterol. 2001;96:1944-1946.
Abou-Nukta F, Gutweiler J, Khaw J, Yavorek G. Giant lipoma causing a colo-colonic intussusception.Am Surg. 2006;72:83-84.
Nakagoe T, Sawai T, Tsuji T, Tanaka K, Nanashima A, Shibasaki S, Yamaguchi H, Yasutake T. Minilaparotomy approach for removal of a large colonic lipoma: report of two cases.Surg Today. 2004;34:72-75.
Peters MB, Obermeyer RJ, Ojeda HF, Knauer EM, Millie MP, Ertan A, Cooper S, Sweeney JF. Laparoscopic management of colonic lipomas: a case report and review of the literature.JSLS. 2005;9:342-344.
Hackam DJ, Saibil F, Wilson S, Litwin D. Laparoscopic management of intussusception caused by colonic lipomata: a case report and review of the literature.Surg Laparosc Endosc. 1996;6:155-159.
Ladurner R, Mussack T, Hohenbleicher F, Folwaczny C, Siebeck M, Hallfeld K. Laparoscopic-assisted resection of giant sigmoid lipoma under colonoscopic guidance.Surg Endosc. 2003;17:160.
Saclarides TJ, Ko ST, Airan M, Dillon C, Franklin J. Laparoscopic removal of a large colonic lipoma. Report of a case.Dis Colon Rectum. 1991;34:1027-1029.
Jelenc F, Brencic E. Laparoscopically assisted resection of an ascending colon lipoma causing intermittent intussusception.J Laparoendosc Adv Surg Tech A. 2005;15:173-175.
Chiu CC, Wei PL, Huang MT, Wang W, Chen TC, Lee WJ. Colonoscopic-assisted laparoscopic resection of a colon lipoma.J Laparoendosc Adv Surg Tech A. 2006;16:37-40.
Scoggin SD, Frazee RC. Laparoscopically assisted resection of a colonic lipoma.J Laparoendosc Surg. 1992;2:185-189.
Zerey M, Burns JM, Kercher KW, Kuwada TS, Heniford BT. Minimally invasive management of colon cancer.Surg Innov. 2006;13:5-15.
Lezoche E, Guerrieri M, De Sanctis A, Campagnacci R, Baldarelli M, Lezoche G, Paganini AM. Long-term results of laparoscopic versus open colorectal resections for cancer in 235 patients with a minimum follow-up of 5 years.Surg Endosc. 2006;20:546-553.