|Year : 2014 | Volume
| Issue : 1 | Page : 34-36
Minimal invasive endoscopic management of synchronous granular cell tumours in the colon and posterior mediastinum
Ali Kocatas1, Ahmet Cem Dural1, Nurten Sever2, Burak Kankaya1, Mahmut Dogan1, Gulcin Yegen3, Murat Gonenc1, Bilge M Bilgic3, Mehmet Ali Bedirhan4, Halil Alis1
1 Department of General Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
2 Department of Pathology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
3 Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
4 Department of Chest Surgery, Yedikule Chest Diseases and Chest Surgery Training and Research Hospital, Istanbul, Turkey
|Date of Submission||29-Nov-2012|
|Date of Acceptance||27-May-2013|
|Date of Web Publication||6-Jan-2014|
Ahmet Cem Dural
Tevfik Saglam Cad. No: 11, Zuhuratbaba, 34147, Istanbul
Source of Support: None, Conflict of Interest: None
Granular cell tumour (GCT), which is a rare benign soft tissue neoplasm, is mostly found in the skin and soft tissue but may develop anywhere in the body. There are less than 10 reported cases of mediastinal GCTs in the current literature. Furthermore, colonic GCTs have recently gained attention due to the increased public awareness on the importance of colonoscopy screening. We report a case of a 52-year-old woman diagnosed incidentally with synchronous GCTs of the mediastinum and the hepatic flexure on her routine screening for post-operative follow-up for status-post right modified radical mastectomy due to a T 2 N 1 M 0 , Stage 2B breast cancer.
Keywords: Granular cell tumour, S100 protein, synchronous tumour
|How to cite this article:|
Kocatas A, Dural AC, Sever N, Kankaya B, Dogan M, Yegen G, Gonenc M, Bilgic BM, Bedirhan MA, Alis H. Minimal invasive endoscopic management of synchronous granular cell tumours in the colon and posterior mediastinum. J Min Access Surg 2014;10:34-6
|How to cite this URL:|
Kocatas A, Dural AC, Sever N, Kankaya B, Dogan M, Yegen G, Gonenc M, Bilgic BM, Bedirhan MA, Alis H. Minimal invasive endoscopic management of synchronous granular cell tumours in the colon and posterior mediastinum. J Min Access Surg [serial online] 2014 [cited 2020 May 31];10:34-6. Available from: http://www.journalofmas.com/text.asp?2014/10/1/34/124469
| ¤ Introduction|| |
Granular cell tumour (GCT)s are usually benign soft-tissue neoplasms that appear in the form of solitary small nodules which may arise at any sites of the body and at most detected in the oral cavity.  Mediastinum and colorectal tract involvement are uncommon. This tumour often presents as a single lesion, while multifocal or synchronous presentations are very rare.  Furthermore, malignant counterpart of GCTs rarely have been reported. 
Through subsequent immunohistochemical methods, characteristic of GCT has been identified as a neural lesion and thought to derivate from nerve sheath but histogenesis still remains controversial. 
Here, we report the first case of synchronous mediastinal and colonic GCTs diagnosed by routine screening in a patient with a prior surgery for breast cancer.
| ¤ Case Report|| |
A 3 × 2-cm posterior mediastinal mass was discovered in January 2011 on a computed tomography (CT) scan in a 52-year-old woman with a medical history of status-post right modified radical mastectomy in November 2007 for a T2N1M0, stage 2B invasive ductal carcinoma of the breast. She had no significant complaints. Due to the prior history of breast cancer, video-assisted thoracoscopic removal was planned and performed under general anaesthesia with double-lumen endotracheal tube. Inspection of the left hemithorax revealed a 2.5 cm mass in the left paravertebral area near the apex of the lung [Figure 1]. Excision was carried out using a combination of blunt and sharp dissection. Initial histopathological diagnosis yielded a spindle-cell neoplasm. After a 9 month of follow-up, screening colonoscopy revealed a submucosal mass measuring approximately 1 cm in diameter [Figure 2]a. The patient was over 40-years old and had a history of breast cancer. Because of this, the colon was evaluated as a part of the screening program. The mass was excised en bloc by endoscopic mucosal resection (EMR) using a snare [Figure 2]b. No other similar lesions were detected on her esophagogastroduodenoscopy.
|Figure 1: Video-assisted thoracoscopic image of the posterior mediastinal mass|
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|Figure 2: (a) Submucosal mass in hepatic flexure (b) Endoscopic appearance of the operative field after excision|
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Macroscopic examination revealed submucosal lesion measuring 1.0 × 1.0 × 0.8 cm with a hard consistency. In cut sections, a solid lesion that was composed of yellowish and whitish portions was detected. H and E-stained sections of the lesion revealed a tumour, which was located in the submucosa and partly in the mucosa [Figure 3]a. The tumour was characterized by solid masses of plump histiocyte-like cells. The tumour cells with abundant granular eosinophilic cytoplasm were containing acidophilic Periodic acid-Schiff (PAS)-positive diastase-resistant granules [Figure 3]b. Immunohistochemical analysis revealed diffuse expression of S100 protein [Figure 3]c. Desmin and cytokeratin stains remained negative.
|Figure 3: (a) Tumour with granular cells, beneath the colonic surface epithelium (H and E ×200), (b) Positive for Periodic acid-Schiff (PAS ×200), (c) Diffuse and strong S-100 protein positivity in the tumour (immunohistochemical staining, S-100 protein)|
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Immunohistochemical evaluation with a broader panel of antibodies of the mediastinal and colonic lesion were carried out again and revealed similar and immunohistological patterns, and the diagnosis was consistent with GCT.
| ¤ Discussion|| |
Lesions of mediastinum described in the literature previously were located mostly in the posterior mediastinum, upper mediastinum close to trachea and recurrent nerve.  Although there have been reports of asymptomatic patients, cough, dyspnoea, wheezing, chest pain, dysphagia, hoarseness are the most often symptoms. Video-assisted thoracoscopic surgery (VATS), mediastinoscopy, transtracheal biopsy, CT-guided biopsy are some of the diagnostic modalities. In our case, asymptomatic mediastinal GCT was located in the posterior mediastinum and video-assisted thoracoscopic excision was performed.
In general, gastrointestinal GCTs are submucosal lesions that measure less than 2 cm in diameter and are covered by normal mucosa.  It is widely accepted that the endoscopic resection is the best treatment modality for colonic GCTs, since they are usually benign. Polypectomy or EMR are safe endoscopic options for successful treatment as well. Although there are no established guidelines for the endoscopic treatment of colorectal GCTs, benign lesions that are <2 cm in diameter and separated from the muscularis propria can be removed by EMR.  In the present report, a yellowish submucosal lesion measuring 1 cm in diameter was detected in screening colonoscopy and resected by EMR for histological diagnosis.
Fust and Custer argued in 1946 that GCTs may have a neural origin. Afterwards, many studies in the literature have reinforced their hypothesis.  However, Vered et al., did not confirm any particular cell type for the histogenesis of GCT via immunohistochemical analysis of a broad panel of antibodies, including S-100 protein, CD 68, vimentin, calretinin, NKI/C3, protein gene product 9.5, nerve growth factor receptor and inhibin-a in their study.  In our case, the characteristic morphological findings, in addition to the immunohistochemical staining pattern, were indeed compatible with GCT.
In conclusion, we reported the first case of synchronous GCTs of the colon and mediastinum in a patient with a prior cancer history. Both lesions were removed by minimal invasive methods and diagnosis was corroborated by accurate histopathological evaluation. This case aside, incidental determination of these tumours is increasing due to widespread screening programs. Clinicians and pathologists should consider the likelihood of GCT in the differential diagnosis and remember the possibility of rare clinical presentations, such as multiple, synchronous lesions or coexistence with other lesions.
| ¤ References|| |
|1.||Cha JM, Lee JI, Joo KR, Choe JW, Jung SW, Shin HP, et al. Granular cell tumor of the descending colon treated by endoscopic mucosal resection: A case report and review of the literature. J Korean Med Sci 2009;24:337-41. |
|2.||Smith AR, Gilbert CF, Strausbauch P, Silverman JF. Fine needle aspiration cytology of a mediastinal granular cell tumor with histologic confirmation and ancillary studies. A case report. Acta Cytol 1998;42:1011-6. |
|3.||Jardines L, Cheung L, LiVolsi V, Hendrickson S, Brooks JJ. Malignant granular cell tumors: Report of a case and review of the literature. Surgery 1994;116:49-54. |
|4.||Hong R, Lim SC. Granular cell tumor of the cecum with extensive hyalinization and calcification: A Case report. World J Gastroenterol 2009;15:3315-8. In: Tumors. St Louis: Mosby Inc.; 2008. p. 878-88. |
|5.||Segawa M, Kusajima Y, Senda K, Saito K. Mediastinal granular cell tumor arising from the left recurrent nerve: Report of a case. Kyobu Geka 2007;60:595-8. |
[Figure 1], [Figure 2], [Figure 3]