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Granular Cell Tumor

A 50-year-old African-American woman was incidentally found to have a 1.5 cm lesion in transverse colon on a CT scan which was carried out during the workup for recurrent urinary tract infection. On further questioning, she complained of colicky abdominal pain on and off for several months. There was also history of loose stools two to three times a day although there was no history of lower gastrointestinal bleed, anorexia, or weight loss. Colonoscopy done revealed a 2 cm sessile polyp in the transverse colon, which was biopsied. The site was tattooed with India ink. Biopsy turned out to be unequivocal and carcinoembryonic antigen (CEA) level came back as normal. After preoperative workup and informed consent, the patient underwent extended right hemicolectomy with two layer ileo-transverse colon sutured anastamosis. Postoperative period was uneventful except for an episode of urinary tract infection. Histopathology report of the surgical specimen showed a 2 · 1.8 cm discoid mass involving the full thickness of the bowel. The tumor cells were large with abundant granular eosinophilic cytoplasm and central nucleus (Fig. 1). The cytoplasmic granules stained positive with periodic acid Schiff (PAS). The cells showed low nucleus: cytoplasmic (N/C) ratio, low mitotic activity, and no necrosis. The tumor cells were immunoreactive to S-100 protein and neuron specific enolase (Fig. 2). The author (MG) had published a case report in 19901 of a patient with granular cell tumor (GCT) of cystic duct. This is his second encounter with visceral granular cell tumors in over 30 years of practice. A review of the pathology database at our hospital over the last 10 years yielded 15 cases of GCT: cutaneous (5), tongue (4), esophagus (2), colon (2), breast (1), and vulva (1). The only other colonic GCT was a 3 mm splenic flexure polyp biopsied during screening colonoscopy in a 77year-old woman. Granular cell tumors are rare. They were first described by Abrikossof in 1926.2 In a study from two hospitals, 118 GCT were described over a 32-year period.3 Age ranged between 16 and 52, averaging 32. They are more common in black women. They predominantly arise from the oral cavity (tongue being the commonest site), skin, and subcutaneous tissue, although they have been reported from many other organs like breast, bronchus, pituitary, genitourinary, gastrointestinal, and biliary tract.1 They are ubiquitous, small (typically less than 3 cm), solitary (5 to 15% multiple), mostly benign (;2% are malignant) tumors. GCTs are recognized readily by simple light microscopy due to a cytoplasm filled with lysosomes giving it the granular appearance. They are located along a nerve twig usually within the perineurium. These granules stain with periodic acid Schiff or sudan black. However, there has been uncertainty about the cell of origin of these tumors. Immunohistochemistry and electron microscopy show these tumors are possibly Schwann cell in origin. They stain for S-100 protein, neuron specific enolase, and vimentin.