Introduction: Granular cell tumours are rare, usually benign neoplasms that can be located anywhere in the body. They are usually found in the oral cavity (40%), skin and subcutaneous tissue (30%), breast (15%), or respiratory tract (15%).1 In the gastrointestinal tract, the most common site being the esophagus. Involvement in other gastrointestinal locations such as the duodenum, anus, stomach, biliary tree, and colon4 are much more uncommon. Case Presentation: We report a unique case of Granular cell tumour located in the hepatic flexure of colon. A 70-year-old male presented with complaints of altered bowel habits to gastroenterology OPD. Colonoscopy was done which revealed a polyp in ascending colon and hepatic flexure of colon. Histopathological examination showed the polyp in ascending colon as tubular adenoma with low grade dysplasia and the polyp in hepatic flexure as Granular cell tumour. Immunohistochemistry (IHC) for S100 was done, which was positive. The tumour was completely excised and the patient was asymptomatic during the follow-up period of 6 months. Discussion: Granular cell tumours are rare, benign neoplasms that occur rarely in the gastrointestinal tract. They are most commonly found in stomach and small intestine. Colonic granular cell tumours, particularly located in hepatic flexure of colon are exceedingly rare. The diagnosis is solely based on histopathologic examination and confirmation by immunohistochemistry. Management involves complete surgical excision. Conclusion: Granular cell tumours of colon are rare and can present as a diagnostic challenge. Even though it is a benign entity, it has a potential for malignant transformation. Hence awareness about this condition and its histopathological features are needed for arriving at a correct diagnosis and management.
Granular cell tumours (GCT)are benign neoplasms of colon. Patients are asymptomatic and hence they are incidentally detected on colonoscopy. Only 1–2% of cases were reported malignant (2, 3). The development of endoscopic technology has provided a new perspective on diagnosis and treatment for colonic GCTs. The diagnosis of GCT depends solely on histopathology with a variable architecture ranging from small and well-circumcised nodules to larger and poorly circumscribed lesions. (4)
We present a case of a 70-year-old gentleman who came with complaints of altered bowel habits to the gastroenterology OPD. His colonoscopy revealed a polyp in ascending colon and hepatic flexure of colon. Polypectomy was one and sent for histopathologic examination.
GROSS:
We received two specimens. One was labelled as ascending colon polyp which consisted of a pale white tissue bit measuring 0.4x0.2x0.2cm. The other was labelled as hepatic flexure polyp which consisted of three pale white tissue bits aggregate measuring 0.8x0.5x0.2cm. All the specimens were embedded separately.
MICROSCOPY:
Sections from the ascending colon polyp showed mucosa lined by epithelium exhibiting low grade dysplasia. Focal area showed glandular crowding with back-to-back arrangement of glands and were lined by cells with elongated, penicillate, hyperchromatic nucleus with scant cytoplasm. Section from hepatic flexure polyp showed a well circumscribed lesion in the submucosa composed of tumour cells arranged in nests and cords, separated by thin fibrocollagenous bands. The cells are round to polygonal/spindle shaped having vesicular nucleus, few with prominent nucleoli and have abundant eosinophilic granular cytoplasm.
FIG 1: Low power view of hepatic flexure of polyp.
FIG 2: High power view of the polyp
S100 immunohistochemistry was done on the hepatic flexure polyp which was immunoreactive, Score 4+. Hence confirmed as granular cell tumour of hepatic flexure of colon.
FIG 3: IHC- S100- Immunoreactive in the neoplastic cells.
Our patient was symptomatically better and later on followed up with colonoscopy which was normal.
Granular cell tumours of the colon are extremely rare, and are usually benign. Most of these are asymptomatic, hence they are an incidental finding in colonoscopy. They may complicate with bleeding or lumen obstruction. It is a neoplasm probably derived from the schwann cells. The diagnosis is solely based on histopathological examination. These tumours can be seen in any age groups, but predilection for women between 40 to 60 years of age has been noted. These tumours show recurrent genetic mutations in the presence of specific syndromes like LEOPARD and Noonan syndrome. Characteristically, these tumours are composed of nests, cords or sheets of polygonal cells with abundant eosinophilic, finely granular cytoplasm. These granules are PAS positive and diastase resistant ( 1). These lesions can be sub classified into benign, atypical or malignant based on the histology. Fanburg- Smith et al described six features to categorize these lesions into benign, atypical or malignant. They include necrosis, nuclear pleomorphism, prominent nucleoli, vesicular nucleus, high nucleocytoplasmic ratio and increased mitotic activity ( >2/10 HPF at 200x magnification). Lesions with none of these features are categorized as benign, those with 1 or 2 features are categorized as atypical and those with 3 or more are categorized as malignant. (2) . Our case was categorized as benign as it had none of the above mentioned features.
Gastrointestinal granular cell tumours represent 8% of all the granular cell tumours. [ 5] Mucosal or submucosal nodule can arise in granular cell tumour of oesophagus, stomach, small or large intestine, gall bladder or biliary tree. This is a rare neoplasm and it should be considered in the differential diagnosis of colonic polypoidal lesions.
Our case highlights the rarity of granular cell tumour in hepatic flexure of colon, emphasizing the importance of considering this diagnosis at an unusual site and ensuring accurate management for these patients.
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