Malignant Degeneration to Leiomyosarcoma of the Anorectal Junction Invading the Prostate

While colonic leiomyomas are common, leiomyosarcomas of the GI tract are rare. Increased mitotic rate, as well as lymph node involvement, portend a worse prognosis in leiomyosarcomas. They can arise anywhere along the GI tract, but anal canal occurrence is extremely rare. We present the case of a 75-year-old male diagnosed eight years prior with leiomyoma of the anorectal junction. There was a recurrence after endoscopic resection. He was referred to colorectal surgery due to symptoms of bleeding, skin irritation, anal pruritus, and rectal pain. On exam, he had a palpable mass at the dentate line. Workup revealed a 3.5 cm mass at the anorectal junction with pathology showing a leiomyosarcoma with moderate atypia and a high mitotic rate. MRI revealed invasion into the prostate. Robotic pelvic exenteration, including cystoprostatectomy, abdominoperineal resection, and ileal conduit, was performed. Final pathology results showed a grade 2 leiomyosarcoma invading the prostate and skeletal muscle and incidentally found Gleason 3+4 prostate cancer, pT2.  A very small percentage of anorectal leiomyosarcoma cases were located in the anal canal. Surgery remains the best curative option, as chemotherapy and radiation data are limited. This rare tumor, which previously has not been documented to have degenerated from a benign rectal leiomyoma, was diagnosed as a result of close monitoring after previous local resections and cured by local resection and radiation.