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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 241-243

Oleogranuloma of rectum co-existing with primary malignant melanoma: Report of a rare occurrence


Department of Pathology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Date of Web Publication20-Dec-2016

Correspondence Address:
Kavita Mardi
Set No. 14, Type VI Quarters, IAS Colony, Meheli, Shimla - 171 009, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.196194

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  Abstract 

Oleogranulomas are rare in rectum and usually present as pseudotumor as a result of foreign body reaction secondary to injection into wall of any oily substance, most commonly mineral oil for treatment of hemorrhoids or oil enemas for constipation. Their occurrence along with malignant melanomas which are also uncommon tumors in the rectum have not been reported in the literature so far. We report one such rare occurrence in a 55-year-old female who presented with alteration of bowel habits and passage of blood in the stool. Clinical and radiological examination suggested a tumor in the rectum. The biopsy report was suggestive of malignant melanoma. The patient underwent abdominoperineal resection. Gross examination of resected specimen revealed blackish ulceroproliferative growth in the lower part of the rectum. Histopathological examination revealed characteristic features of malignant melanoma along with oleogranulomas comprising of multinucleated foreign body giant cells and epithelioid cell granulomas surrounding large clear spaces giving “swiss cheese appearance.”

Keywords: Malignant, melanoma, oleogranuloma, rectum


How to cite this article:
Mardi K, Chauhan P, Sharma M. Oleogranuloma of rectum co-existing with primary malignant melanoma: Report of a rare occurrence. Arch Med Health Sci 2016;4:241-3

How to cite this URL:
Mardi K, Chauhan P, Sharma M. Oleogranuloma of rectum co-existing with primary malignant melanoma: Report of a rare occurrence. Arch Med Health Sci [serial online] 2016 [cited 2017 May 24];4:241-3. Available from: http://www.amhsjournal.org/text.asp?2016/4/2/241/196194


  Introduction Top


Oleogranulomas of the gastrointestinal tract are relatively rare arising under a variety of circumstances.[1],[2] In the rectum, the oleogranulomas are usually found proximal to the dentate line [3] and present as intramural pseudotumor that develops as a foreign body reaction secondary to injection into wall of any oily substance, most commonly mineral oil for treatment of hemorrhoids or oil enemas for constipation.[4],[5] Oleogranulomas may simulate carcinomas. However, primary malignant melanomas which are also uncommon tumors in the rectum with coexistent oleogranulomas have not been reported so far. We report one such rare occurrence in a 55-year-old female.


  Case Report Top


A 55-year-old female patient presented with chief complaints of alteration of bowel habits and passing blood stained stools since one and half year. She had a history of hemorrhoids and was frequently suffering from constipation. On digital rectal examination, a growth identified from 7 to 11 o'çlock at about 5-6 cm from the anal verge. Growth was mobile, firm in consistency, had a smooth surface with ulcer over it.

Contrast enhanced computed tomography abdomen showed a 2.5 cm × 2.5 cm well-defined hypodense and heterogenously enhancing mass in the rectum arising from the right lateral wall and protruding into the lumen [Figure 1]. Biopsy from polypoidal growth in rectum revealed tumor cells in lobules and nests with vesicular nuclei, prominent nucleoli and scant cytoplasm, with few cells containing brownish-black pigment. Hence, possibility of malignant melanoma was suggested. On immunohistochemistry, the tumor was negative for the compact disc 45 and cytokeratin and positive for S-100, melan A, HMB 45; thus confirming the diagnosis of melanoma. Patient underwent abdominoperineal resection. On gross examination of the specimen, a gray-brown to black ulceroproliferative growth, 3 cm in diameter, invading up to muscularis propria was identified. Histopathological examination of the growth revealed sheets and isolated pleomorphic tumor cells with a hyperchromatic nucleus, prominent nucleoli, moderate eosinophilic cytoplasm and intracellular and extracellular melanin pigment [Figure 2]. In addition, there are transmural dense chronic inflammatory cells and submucosal foreign body granulomas showing foreign body giant cells surrounding clear spaces [Figure 3].
Figure 1: Gross specimen revealing blackish ulcerated growth in rectum.

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Figure 2: Photomicrograph showing both malignant melanoma and oleogranulomas (H and E, ×10).

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Figure 3: Higher magnification showing multinucleated foreign boy giant cells and epithelioid granulomas surrounding clear spaces (Swiss cheese appearance) (H and E, ×40).

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  Discussion Top


Oleogranulomas (L.oleum, oil) sometimes called paraffinomas or eleomas (Gr.eleoin, oil) of the gastrointestinal tract are relatively rare arising under a variety of circumstances.[1],[2] In the gastrointestinal tract, eleomas are usually found proximal to the dentate line in the lower portion of the rectum.[3]

Primary anorectal melanomas are rare representing 1% of all anorectal malignancies.[6] Malignant melanoma with coexistent oleogranulomas in the rectum has not been reported so far.

In the rectum, the oleogranulomas may be defined as an intramural pseudotumor that develops as a foreign body reaction secondary to injection into wall of any oily substance, most commonly mineral oil for treatment of hemorrhoids or oil enemas for constipation.[4],[5] Occasionally the lesion produced may be cystic (oleocyst).[7]

The lesion is induced by the submucosal reaction to the vegetable oil in which the sclerosant is suspended and is usually localized to the submucosa, but there may be a considerable inflammation of the mucosa and even the perianal skin. The reaction is characterized by large mononuclear phagocytes, epithelioid cells, eosinophils and multinuclead foreign body giant cells surrounding large clear spaces giving “swiss cheese appearance.” These vacuoles contain oil which is removed during routine processing. Frozen sections stained with oil red O will verify the presence of lipid. Oil granulomas can also be found in lymph nodes draining primary eleomas.[8] The presence of coagulative tumor necrosis with epithelioid granulomas simulated tuberculosis in the present case. However on closer examination, the granulomas showed typical features of oleogranulomas and Zeil Neelson stain was also negative for tubercle bacilli.

The patient may present with the sensation of a mass, or the lesion may be incidental finding. On palpation, it is a submucosal tumor, just above the dentate line, and on occasions may be annular or ulcerating. Hernandez et al. have described two cases of oleogranulomas in rectum simulating malignancy.[9]

Anorectal melanoma is an uncommon and aggressive disease. The anorectum is the third most common location of malignant melanoma after the skin and retina. Malignant melanomas occur in the anorectum because of the presence of abundant melanocytes in the mucosa of the anal canal. The most common symptom is rectal bleeding, which is often mistaken for bleeding associated with hemorrhoids. Nonspecific symptoms cause delayed diagnosis, which is also caused by the similarity of histological findings to those of other malignancies. Because of delayed diagnosis and rapid progression, malignant rectal melanomas have been accompanied by distant metastases in 60% of patients at the time of final diagnosis.[6]

Simple excision is the recommended treatment for oleogranuloma of the rectum, but because of the adhesion and scarring, operative removal may be rather difficult. For patients with anorectal malignant melanoma, the first choice, among surgical treatments, seems to be local excision with adjuvant radiotherapy. Only in the case of large and obstructing tumors one should perform an abdominoperineal resection. However, the tumor tends to be considerably resistant to radiotherapy and shows a poor response to chemotherapy.[10] The prognosis is very poor, with less than 20% survival 5 years after diagnosis.


  Conclusion Top


Both oleogranulomas as well as primary malignant melanomas are rare in the rectum. We report the first case documenting their coexistence. This case is also presented to create awareness regarding oleogranulomas as they can be confused with other granulomatous conditions occurring in this region.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mazier WP, Sun KM, Robertson WG. Oil-induced granuloma (eleoma) of the rectum: Report of four cases. Dis Colon Rectum 1978;21:292-4.  Back to cited text no. 1
    
2.
Yasuoka R, Morita S, Kadotani Y. Two cases of rectal oleogranuloma. Nippon Daicho Komonbyo Gakkai Zasshi 2007;60:234-8.  Back to cited text no. 2
    
3.
Jackman RJ, Clark PL 3rd, Smith ND. Retrorectal tumors. J Am Med Assoc 1951;145:956-62.  Back to cited text no. 3
    
4.
Wood DA. Tumors of the intestine. Atlas of Tumor Pathology. Sec. 6, Fasc 22. Washington, DC: Armed Forces Institute of Pathology; 1967. p. 239.  Back to cited text no. 4
    
5.
Greaney MG, Jackson PR. Oleogranuloma of the rectum produced by Lasonil ointment. Br Med J 1977;2:997-8.  Back to cited text no. 5
    
6.
Takahashi T, Velasco L, Zarate X, Medina-Franco H, Cortes R, de la Garza L, et al. Anorectal melanoma: Report of three cases with extended follow-up. South Med J 2004;97:311-3.  Back to cited text no. 6
    
7.
Webb AJ. Oleocysts presenting as rectal tumours. Br J Surg 1966;53:410-3.  Back to cited text no. 7
    
8.
Graham JH, Johnson WC, Helwig EB, editors. Dermal Pathology. Hagerstown, Maryland: Harper & Row Publishers; 1972. p. 441.  Back to cited text no. 8
    
9.
Hernandez V, Hernandez IA, Berthrong M. Oleogranuloma simulating carcinoma of the rectum. Dis Colon Rectum 1967;10:205-9.  Back to cited text no. 9
    
10.
van Schaik PM, Ernst MF, Meijer HA, Bosscha K. Melanoma of the rectum: A rare entity. World J Gastroenterol 2008;14:1633-5.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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