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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 1  |  Page : 64-66

Transverse colon xanthoma: Rare yet important


1 Department of Pathology, King Hamad University Hospital, Al Sayh, Bahrain
2 Department of Gastroenterologist, King Hamad University Hospital, Al Sayh, Bahrain

Date of Web Publication16-May-2019

Correspondence Address:
Dr. Sameer Ahmed Ansari
Department of Pathology, King Hamad University Hospital, Al Sayh
Bahrain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_69_19

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  Abstract 


Colonic xanthomas are rare, benign lesions of the gastrointestinal tract characterized by a foamy cell containing lipid in the lamina propria and mucosa. They have been commonly described in the stomach and rectosigmoid region in few case reports. Their association with adenoma and adenocarcinoma had made them a visible indicator of malignancy. Hence, a thorough investigation and follow-up of the patient are mandatory to search for such lesions.

Keywords: Benign, colon, polyp, transverse, xanthoma


How to cite this article:
Ansari SA, Waris E, Sharif O, Alghiryafi L. Transverse colon xanthoma: Rare yet important. Saudi J Health Sci 2019;8:64-6

How to cite this URL:
Ansari SA, Waris E, Sharif O, Alghiryafi L. Transverse colon xanthoma: Rare yet important. Saudi J Health Sci [serial online] 2019 [cited 2019 Aug 18];8:64-6. Available from: http://www.saudijhealthsci.org/text.asp?2019/8/1/64/257764




  Introduction Top


Gastrointestinal xanthomas are defined as benign lesions characterized by foamy cells containing lipids in their cytoplasm and are located commonly in the mucosa and lamina propria.[1] Most commonly xanthomas are seen in the stomach and are rarely present in the other parts such as esophagus, duodenum, small intestine, and colorectum.[2] Colonic xanthomas have been so far described in the sigmoid colon, rectum, and ascending colon in recent case reports and are extremely rare in the transverse colon.[3] We present a case of a 61-year-old Saudi female presented with a transverse colon xanthoma preoperatively diagnosed as submucosal lipoma on colonoscopy.


  Case Report Top


A 61-year-old female, a known case of asthma, ischemic heart disease, chronic kidney disease, and diabetes mellitus, presented with abdominal pain and constipation for the past 2 months, on and off in the gastroenterology outpatient department. The patient did not give a history of loss of appetite and loss of weight. No significant family history was present. On examination, the patient was afebrile. Her vitals were stable and her outpatient hematologic test revealed white blood cells 5800, Hb 9.7, and platelet 401/cumm. Biochemical test revealed controlled blood sugar level, and lipid profile revealed slight increase in triglycerides and normal cholesterol level. Colonoscopy was performed after explaining the procedure under sedation in aseptic environment and after the necessary preparation. It revealed well-defined polypoid lesions in the transverse colon [Figure 1] measuring 4 mm × 3 mm. The overlying mucosa and the surrounding mucosa of entire colon were normal. No evidence of colitis or adenoma was identified. Ileum was also normal. The above described lesion was diagnosed as submucosal lipoma. Excisional biopsy was performed under sedation taking all aseptic precautions. Gross examination revealed yellowish tan, polypoidal colonic mucosa-lined tissue without any necrosis and hemorrhage. Histopathological examination revealed a polyp showing the presence of xanthoma cells in the mucosa and lamina propria without any evidence of inflammation [Figure 2]. No evidence of dysplasia or malignancy present. The lesion was completely excised. Special stains periodic acid–Schiff (PAS) and Alcian blue were noncontributory. Immunohistochemistry revealed CD68-positive [Figure 3] and S 100 negative [Figure 4] and cytokeratin-negative foam cells [Figure 5]. The patient was advised follow-up in a gastroenterology clinic which is uneventful till date.
Figure 1: Colonoscopy show well-defined sessile polypoid lesions in the transverse colon measuring 4 mm × 3 mm without evidence of colitis

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Figure 2: Microscopy revealed a polyp showing the presence of xanthoma cells in the mucosa and lamina propria without any evidence of inflammation (H and E, ×10)

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Figure 3: Immunohistochemistry revealed CD68-positive foam cells in the lamina propria (H and E, ×10)

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Figure 4: Immunohistochemistry revealed S100-negative foam cells (H and E, ×10)

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Figure 5: Immunohistochemistry revealed pan-CK-negative foam cells (H and E, ×10)

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  Discussion Top


Xanthomas are innocuous lesions characterized by lipid-laden macrophages in the lamina propria. These cells are CD68-positive lipid-laden macrophages without mucin or pigment.[4] This lesion was first described as yellow nodules comprised of lipid-laden macrophages and called as gastric xanthoma, gastric xanthelasma, and other.[5] The incidence of this benign entity is extremely rare with few described cases report in the rectosigmoid region.[6] Many hypotheses have been postulated for the development of gastrointestinal xanthoma. Few authors suggested the role of chronic inflammation as gastric xanthomas are known to develop in chronic gastritis.[7] Colonic xanthomas are also hypothesized to develop from cell damage due to toxicity.[8] Nakasono et al. assumed previous mucosal damage as major etiological factor and described xanthomatous polyp associated with proliferative epithelial cells without atypia and vascular proliferation in their studies.[6] However, no other studies including our index case have proven any association of colitis with xanthoma development.[3] Hence, it is anticipated that xanthoma cells could be result of cellular regeneration rather than cell injury.[1] Nakasono et al. suggested hyperlipidemia as an etiological factor since seven out of 25 patients with colonic xanthoma had hyperlipidemia in their described study.[6] However, Isotomo et al. described that xanthomas are not related to metabolic disorders such as diabetes, hypercholesterolemia, and skin lesions.[9] Our index case is diabetic with controlled blood sugar level and normal cholesterol level, except for a slight increase in triglycerides. Additional studies should be carried out to confirm and establish the etiological role of diabetes mellitus and dyslipidemia in the development of xanthoma. Endoscopy plays a pivotal role in clinching the diagnosis of colonic xanthoma. However, at times, it is not possible to differentiate it from submucosal lipoma as was in our case. The differential diagnosis to be considered on endoscopy is submucosal lipoma, pseudomembranous colitis, and lymphomas.[10] On endoscopic examination, xanthomas are usually 5 mm in size, polypoidal lesions, red or white, and rarely yellow without areas of hemorrhage or necrosis.[6] Histopathology is gold standard for confirming the diagnosis along with special stains such as PAS, Alcan blue, and immunohistochemistry.[1],[2],[9] Xanthoma cells, at times, may be difficult to distinguish from signet ring adenocarcinoma and granular cell tumor.[11] Immunohistochemistry helps to differentiate as xanthoma cells are positive for CD68 and negative for S100 and cytokeratin.[1],[9] Other lesion which poses a differential diagnosis is Whipple disease. The foam cells in Whipple disease show PAS-positive diastase-resistant Tropheryma whipplei bacterial inclusions with dilated lacteals.[9] Associated lesions with colonic xanthoma are adenoma and adenocarcinoma as described in the literature.[6] It has been hypothesized that fat accumulation in the colon leads to the activation of protein kinase C, resulting in the development of adenocarcinoma in previous studies.[12] Although benign, their association with malignancy has made them visible indicator for such lesions. Hence, it is mandatory to do thorough colonoscopic examination whenever xanthoma is suspected and discovered. Our patient did not have any such lesions. Surgical excision is sufficient with follow-up.[1],[13]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kim SH, Kim HS, Choi YD, Choi WS, Kim BS, Park SY, et al. Acase of ascending colonic xanthoma presenting as a lateral spreading tumor. Intest Res 2014;12:162-5.  Back to cited text no. 1
    
2.
Iwamuro M, Tanaka T, Otsuka F, Okada H. Xanthoma of the duodenum. Intern Med 2016;55:2899-900.  Back to cited text no. 2
    
3.
Miliauskas JR. Rectosigmoid (colonic) xanthoma: A report of four cases and review of the literature. Pathology 2002;34:144-7.  Back to cited text no. 3
    
4.
Allibone RO, Nanson JK, Anthony PP. Multiple and recurrent inflammatory fibroid polyps in a Devon family ('Devon polyposis syndrome'): An update. Gut 1992;33:1004-5.  Back to cited text no. 4
    
5.
Lechago J. Lipid islands of the stomach: an insular issue? Gastroenterology. 1996 ;110:630-2.  Back to cited text no. 5
    
6.
Nakasono M, Hirokawa M, Muguruma N, Okahisa T, Okamura S, Ito S, et al. Colorectal xanthomas with polypoid lesion: Report of 25 cases. APMIS 2004;112:3-10.  Back to cited text no. 6
    
7.
Gencosmanoglu R, Sen-Oran E, Kurtkaya-Yapicier O, Tozun N. Xanthelasmas of the upper gastrointestinal tract. J Gastroenterol 2004;39:215-9.  Back to cited text no. 7
    
8.
Remmele W, Beck K, Kaiserling E. Multiple lipid islands of the colonic mucosa. A light and electron microscopic study. Pathol Res Pract 1988;183:336-46.  Back to cited text no. 8
    
9.
Isomoto H, Mizuta Y, Inoue K, Matsua T, Hayakawa T, Miyazaki M, et al. A close relationship between helicobacter pylori infection and gastric xanthoma. Scand J Gastroenterol.1999 : 34:346-52  Back to cited text no. 9
    
10.
Iwamuro M, Okada H, Takata K, Takenaka R, Inaba T, Mizuno M, et al. Colorectal manifestation of follicular lymphoma. Intern Med 2016;55:1-8.  Back to cited text no. 10
    
11.
De Petris G, Leung ST. Pseudoneoplasms of the gastrointestinal tract. Arch Pathol Lab Med 2010;134:378-92.  Back to cited text no. 11
    
12.
Boruchowicz A, Rey C, Fontaine M, Martin-Ponthieu A, Lecomte-Houcke M, West AB, et al. Colonic xanthelasma due to glyceride accumulation associated with an adenoma. Am J Gastroenterol 1997;92:159-61.  Back to cited text no. 12
    
13.
Iwamuro M, Tanaka T, Takei D, Sugihara Y, Harada K, Hiraoka S, et al. Two cases of rectal xanthoma presenting as yellowish to whitish lesions during colonoscopy. Case Rep Gastrointest Med 2017;2017:5975107.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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