Recurrence of Primary Epididymal Leiomyosarcoma to Colon and Stomach

Abstract

Leiomyosarcomas (LMS) are malignant soft tissue sarcomas arising from tissues containing smooth muscle. Epididymal leiomyosarcoma is a rare entity, and recurrence to the gastrointestinal tract is extremely rare. An 88-year-old man with a past medical history significant for congestive heart failure, coronary artery disease, COPD, hypertension, and epididymal leiomyosarcoma diagnosed 1 year prior, treated with orchiectomy and chemotherapy presented to the GI clinic for a follow-up colonoscopy after a previously resected 2.5 cm sessile adenomatous polyp. He also complained of dyspepsia of 3 months duration. Patient is a former smoker. No relevant family history was reported, and physical exam was unremarkable. On repeat colonoscopy, a total of 8 subcentimeter polyps were removed from different sections of the colon. On EGD there were 2 gastric polyps removed. Pathology of 2 polyps in the transverse colon and 2 gastric polyps revealed inflammatory cells and spindle cells with nuclei pleomorphism and abnormal mitotic figures. Immunohistochemical stains for Muscle Actin Antibody (HHF35) and Smooth Muscle Actin (SMA) were positive, and stains for S100, DOG1, CD117, and CD34 were negative which is consistent with leiomyosarcoma. Review of past pathology reports from his epididymal leiomyosarcoma were compatible with these findings. Subsequent CT scan of chest, abdomen and pelvis revealed multiple lung nodules. All routine laboratory examinations were normal including CBC, chemistry, and liver profile. His alpha-fetoprotein and hCG were also normal. Considering his age, comorbidities, imaging findings, spectrum of treatment toxicity and patient wishes, adjuvant therapy was not pursued and instead opted for palliative care. After a thorough review of the literature, to date there has never been a reported case of epididymal leiomyosarcoma recurrence to the stomach and colon. The limited number of cases of this uncommon disease and lack of established management strategy will require further research to formulate a treatment protocol.1918_A Figure 1. Adenomatous polyp in the transverse colon1918_B Figure 2. Polypoid fragment of colonic mucosa with spindle cell proliferation in lamina propria showing focal pleomorphism and mitotic figures. Immunohistochemistry positive for muscle actin and SMA, while negative for S100, CD117, DOG1 and CD34. These results support smooth muscle differentiation and with the morphologic findings are consistent with leiomyosarcoma.1918_C Figure 3. Polypoid fragment of gastric mucosa with spindle cell proliferation in lamina propria showing focal pleomorphism. This proliferation is morphologically similar to that seen in the patient's colon biopsy which was also consistent with leiomyosarcoma.