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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

SUBMUCOSAL RECTAL TUMOR


J Leroy, MD, F Jamali, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Summary


Submucosal rectal tumors are rare. Preoperative workup must differentiate between benign and malignant tumors in order to choose the most effective treatment. Benign tumors, even large ones, can be treated by limited local and conservative methods.

2. Keywords


Colon, emergency, cancer

3. Patient


57-year-old male patient

4. Past medical history


- syringomyelia, 1985;
- scoliosis.

5. History of present illness


During routine physical examination, a right lateral rectal lesion is palpated.
The patient is symptom-free.
The mass is firm and large, measuring 6 cm to 7 cm in the right lateral rectum. It is not movable and extends 2 cm to 7 cm from the anal verge.

6. Workup


6.1. Rectoscopy and colonoscopy

Rectoscopy and colonoscopy: submucosal rectal lesion. Mucosa intact but slightly thickened. Remainder of rectum normal.

6.2. Endorectal ultrasound

Endorectal ultrasound: Right pararectal tumor originating from the muscular wall of the rectum, size 7x6x5 cm. Prostate and seminal vesicles uninvolved.

6.3. Endorectal MRI

Endorectal MRI: Right pararectal solid lesion within the muscular wall of the rectum. No evidence of invasion into pararectal tissues or seminal vesicles.

6.4. CT scan

CT scan identifies the retrovesical mass.

7. Clinical progress


Transrectal core (Tru-cut) biopsy: leiomyoma with no malignant features.

8. Treatment


Following debate (enucleation versus radical resection), we elect to perform a transanal enucleation of the lesion.

9. Pathology


Pathological examination confirms the benign character of the tumor: leiomyoma, size 6x5x4 cm, weight 65 g. The node is constituted of smooth muscle cells, with rare mitoses (1 for 20 field).

10. Discussion


Leiomyomas of the rectal wall are exceedingly rare lesions (0.1-0.3% of gastrointestinal tract tumors, the incidence of smooth muscle tumors being 7% in the digestive tract). A review of the literature came up with 148 reported cases. Benign leiomyomas are usually asymptomatic; discomfort or pain, related or not to defecation, sensation of a foreign body, changes in bowel habits or rectal bleeding are rarely reported. In most cases rectal leiomyomas are detected incidentally in the course of a rectal examination.
The major issue in the treatment of these lesions is making the distinction between benign or malignant lesions. Benign leiomyomas can be treated by enucleation or limited resection while leiomyosarcomas need aggressive therapy with wide resection margins and possible adjuvant radiotherapy. Clinically, ulceration and bleeding are more commonly associated with malignancy. Endorectal ultrasound and (more recently) endorectal MRI can be helpful in evaluating the origin and nature of these lesions. They can demonstrate invasion of the rectal wall or perirectal structures and provide exact assessment of tumor size and expansion and therefore are of great value in selecting the appropriate treatment. Endorectal MRI appears to be equivalent to endorectal ultrasound in defining rectal wall invasion and may be superior in defining lymph node involvement. Because of the high risk of local recurrence associated with these lesions (10-31%), close follow-up is recommended.

11. References


  1. Hsieh JS, Huang CJ, Wang JY, Huang TJ. Benefits of endorectal ultrasound for management of smooth-muscle tumor of the rectum: report of three cases. Dis Colon Rectum 1999;42:1085-8.
  2. Maldjian C, Smith R, Kilger A, Schnall M, Ginsberg G, Kochman M. Endorectal surface coil MR imaging as a staging technique for rectal carcinoma: a comparison study to rectal endosonography. Abdom Imaging 2000;25:75-80.
  3. Tarasidis G, Brown BC, Skandalakis LJ, Mackay G, Lauer RC, Gray SW, Skandalakis JE. Smooth muscle tumors of the rectum and anus: a collective review of the world literature. J Med Assoc Ga 1991;80:685-99.
  4. Vorobyov GI, Odaryuk TS, Kapuller LL, Shelygin YA, Kornyak BS. Surgical treatment of benign, myomatous rectal tumors. Dis Colon Rectum 1992;35:328-31.
  5. Zerilli M, Lotito S, Scarpini M, Mingazzini PL, Meli C, Lombardi A, Picchio M, Di Giorgio A, Flammia M. Recurrent leiomyoma of the rectum treated by endoscopic transanal microsurgery. G Chir 1997;18:433-6.