Clin Endosc > Volume 54(6); 2021 > Article
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Jeong, Bang, and Baik: Hematochezia in Patient with Rectal Tumor: Consideration of Various Diagnostic Possibilities

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A 74-year-old woman presented with hematochezia. The patient had bloody stool (approximately 50 cc) for the past 10 days. The patient had hypertension and was taking antihypertensive medications. The patient underwent total laparoscopic hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer 2 years ago. After presentation, the patient underwent a colonoscopy. Approximately 3 cm mass was found near the anal canal (Fig. 1A). The mass was round and covered with exudate (Fig. 1B). Endoscopic ultrasonography showed a heterogeneous hypoechoic lesion located in the submucosal layer (Fig. 1C). Histopathological examination revealed small malignant oval-shaped cells with high nuclear-to-cytoplasmic ratio and poor differentiation (normal glandular structure was not observed) (Fig. 2). Computed tomography revealed a 3.5 cm enhancing lesion involving the distal rectum and anorectal junction (Fig. 3). Positron emission tomography revealed a mass of approximately 3-3.5 cm with increased FDG uptake (SUVmax =10.79) in the distal rectum (Fig. 4). Transanal excision was performed, and the resected lesion showed an ill-demarcated ulcerative and fungating mass, measuring 3.3 × 2.7 cm extending to the pericolic soft tissue (Fig. 5). In the final pathological examination, round cells with a high nuclear-to-cytoplasmic ratio without macronucleoli, which invaded the entire mucosal layer, were observed (Fig. 2, 6A and B). Immunohistochemistry for CD-3 and CD-20 was negative. Diffuse brown colored pigmentation was observed (Fig. 6C), and immunohistochemistry for HMB-45 and S-100 was positive (Fig. 7). What is the most probable diagnosis?
 

NOTES

Conflicts of Interest
The authors have no potential conflicts of interest.
Funding
None.

Fig. 1.
(A, B) Colonoscopy demonstrating 3 cm mass covered with exudates near anal canal. (C) Endoscopic ultrasonography demonstrating heterogenous hypoechoic lesion in the submucosal layer.
ce-2021-243f1.jpg
Fig. 2.
Histopathological findings of the biopsy specimens. Small malignant oval-shaped cells with high nuclear-to-cytoplasmic ratio with poor differentiation (normal glandular structure was not observed) (hematoxylin and eosin stain ×200).
ce-2021-243f2.jpg
Fig. 3.
(A, B) Contrast-enhanced computed tomography demonstrating 3.5 cm enhancing lesion involving distal rectum and anorectal junction.
ce-2021-243f3.jpg
Fig. 4.
(A, B) Positron emission tomography demonstrating 3-3.5 cm mass with increased FDG uptake (SUVmax=10.79) in the distal rectum.
ce-2021-243f4.jpg
Fig. 5.
Surgical specimen demonstrates an ill demarcated ulcerative and fungating mass, measuring 3.3×2.7 cm extending to the pericolic soft tissue.
ce-2021-243f5.jpg
Fig. 6.
Histopathological findings of the surgically resected specimen. (A, B) Round cells with a high nuclear-to-cytoplasmic ratio without macronucleoli which invaded whole mucosal layer (hematoxylin and eosin stain ×100). (C) Diffuse brown colored pigmentation (hematoxylin and eosin stain ×200)
ce-2021-243f6.jpg
Fig. 7.
Immunohistochemistry findings of the surgically resected specimen. (A, B) The tumor cells are diffusely positive for HMB-45 and S-100 (hematoxylin and eosin stain ×100).
ce-2021-243f7.jpg

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