Ileocolic intussusception due to cecal leiomyosarcoma

Clinical History

A 69-year-old female patient presented with abdominal pain, distention and rectal bleeding.

Imaging Findings

A 69-year-old female patient, who visited our emergency set with abdominal pain and rectal bleeding during the last four days, without haemodynamic instability. A contrast enhanced computed tomography (CT) found ileocolic intussusception, with no signs of complete obstruction (Figs. 1-3). In the head of intussusception a 4 cm tumour-like lesion was found.
Under general anaesthesia with endotracheal intubation a right hemicolectomy was performed and histological confirmed high-grade leiomyosarcoma with complete wall invasion without lymph node extension. Immunohistochemistry was positive for vimentin, muscle-specific actin and calponin, with a negative result for c-kit. The postoperative course was uneventful and 54 days after hemicolectomy adjuvant treatment with ifosfamide was started.

Discussion

Intussusception must be assessed in different ways in children and adults, as subjacent aetiology and physiopathology are not the same in these two age groups. In the former it occurs typically between 6 months and 2 years of age. Most cases are ileocolic and idiopathic [1]. In the latter, aetiology is different depending on the affected segment [2]. Most intussusceptions affecting the small bowel are transient, nonobstructing and idiopathic, without identifiable cause, very probably secondary to normal peristalsis. Causes of small bowel intussusception are polyps, Meckel´s diverticulum, celiac and Crohn disease, or metastases of melanoma.
In the cases affecting the colon, the leading lesion is identified in up to 95% of cases, and in 50-75% of them a malignant lesion is present, as in this case.

Intestinal leiomyosarcoma is an uncommon mesenchymal tumour that represents about 1% of intestinal tumors [3, 4], with higher incidence in men between the fourth and sixth decades [3, 5]. About 60% of cases develop in the stomach [3-5]. Those in the small bowel and colon are located more frequently in the duodenum and rectum, respectively [3]. The clinical symptoms are nonspecific [3, 5] and may present with pain, changes in bowel habits, rectal bleeding, or obstruction. Intussusception secondary to metastases [6] may even be asymptomatic. Immunohistochemistry analysis is negative for c-kit, unlike intestinal stromal tumours (GIST) in which it is positive [6]. Surgical resection is the treatment of choice, with recurrence rates of up to 40% [6].

Differential Diagnosis List

Final Diagnosis

Ileocolic intussusception due to cecal leiomyosarcoma

URL:	https://www.eurorad.org/case/8432
DOI:	10.1594/EURORAD/CASE.8432
ISSN:	1563-4086