S2216 A Rare Case of Symptomatic Colonic Lymphangioma

Abstract

Introduction: Lymphangiomas are benign lymphatic lesions, most frequently identified in the head and neck. Colonic lymphangiomas occur but are rare and represent less than 1% of all lymphatic malformations. These lesions are often asymptomatic and discovered incidentally during routine colonoscopy. We present a case of a symptomatic colonic lymphangioma manifesting as a large mass requiring surgical resection. Case Description/Methods: A 42-year-old male presented with the complaint of lower abdominal pain. Associated symptoms included nausea with no vomiting, and he denied family history of gastrointestinal malignancies. At presentation, vital signs were stable and abdominal exam was benign. Laboratory studies were unremarkable, but a Computed Tomography (CT) abdomen/pelvis with contrast revealed a 6.6 x 7 x 6.6 cm colonic mass near the hepatic flexure. Follow up colonoscopy demonstrated a large, subepithelial-appearing mass in the ascending colon protruding more than 90% into the lumen. Retroflexed view revealed 2 x 2 cm ulceration on the proximal aspect of the lesion. Serum tumor markers including CEA, CA 19-9, and CA 125 were all within normal limits and additional CT imaging revealed no metastatic lesions. Biopsies resulted back demonstrating superficial portions of colonic mucosa with mild focal inflammation. However, surgical evaluation was advised given the mass size and the patient thus underwent an elective laparoscopic right hemicolectomy. Tissue samples were sent for evaluation and revealed lymphangiomatosis/lymphatic malformation/cystic lymphangioma centered in the colonic submucosa with extension into the subserosal tissue. No cellular atypia or malignancy was identified, and 24 lymph nodes were benign. These pathology findings were confirmed by expert review at a tertiary center, where it was noted that this case also lacked features of congenital lymphangiectasia. During post-operative follow-up, the patient was reported to be progressing well (Figure). Discussion: Lymphangiomas have an incidence of less than 0.20% and intra-abdominal lymphangiomas represent only a fraction of cases. Although most colonic lymphangiomas are asymptomatic and identified incidentally, they can lead to an array of symptoms and severe complications such as obstruction, intussusception, and perforation requiring surgical intervention if large. Although colonic lymphangiomas are rare, it is important to be aware of their rising incidence to help facilitate accurate and timely diagnosis to prevent complications.Figure 1.: A. Colonoscopy. Submucosal mass in the ascending colon involving more than 90% of the circumference. Figure B. CT axial image. Mass in the ascending colon/hepatic flexure. Figure C. CT coronal image. Mass in the ascending colon/hepatic flexure. Figure D. CT sagittal image. Mass in the ascending colon/hepatic flexure.