PICTURES IN DIGESTIVE PATHOLOGY

 

Non granular laterally spreading tumor resected by endoscopic submucosal dissection: An unusual treatment for an atypical lesion

Tumor rectal de crecimiento lateral tipo no granular resecado mediante disección endoscópica submucosa pura: un tratamiento inusual para una lesión atípica

 

 

Enrique Vázquez-Sequeiros¹, Takahisa Matsuda², Naoko Maruyama³, Akiko Ono⁴, Héctor Gerardo Pian⁵, Beatriz Peñas¹, José Ramón Foruny¹, Juan Ángel González-Martín¹, Daniel Boixeda-de-Miquel¹, Rosario Carrillo-Gijón⁵, Javier Die-Trill⁶ and Agustín Albillos¹

¹Consulta de Alto Riesgo de Cáncer Colorrectal. Unidad de Endoscopia. Department of Gastroenterology. Hospital Universitario Ramón y Cajal. Madrid. Universidad de Alcalá, IRYCIS. Madrid, Spain.
²Endoscopy Division. National Cancer Center Hospital. Tokyo, Japan.
³Department of Gastroenterology. Fujita Health University University School of Medicine. Aichi, Japan.
⁴Department of Gastroenterology. Hospital Virgen de la Arrixaca. Murcia, Spain.
⁵Department of Pathology. Hospital Universitario Ramón y Cajal. Madrid. Universidad de Alcalá, IRYCIS. Madrid, Spain.
⁶Departmento of General and Digestive Surgery. Hospital Universitario Ramón y Cajal. Madrid. Universidad de Alcalá, IRYCIS. Madrid, Spain

 

 

Case report

We present the case of an 82 years old male, with a past medical history remarkable for colonic polypectomies until the year 2003 when, after being operated and radiated due to a prostate adenocarcinoma, the patient discontinued surveillance. He was referred for control colonoscopy in the year 2012, identifying a flat tumor with elevated margins and central depression (IIa + IIc Paris classification) (laterally spreading tumor: LST), measuring 35 mm and localized 15 mm from the anal verge (1) (Fig. 1 A and B). Biopsies from the lesion were diagnosed as tubular adenoma with high grade dysplasia. Careful examination of the lesion with magnification, chromoendoscopy (indigo carmine) and narrow band imaging/NBI, and lifting of the lesion with a mixture of glycerol/indigo/hyaluronic acid, determined that the lesion was not infiltrating the submucosa, and an endoscopic submucosal dissection (ESD) of the lesion was performed by experts in this technique (T.M./N.M.) as previously reported (2) (Fig. 2 A-C). For such purpose, Dual knife and IT-2 knife Olympus^® were employed, achieving a complete resection of the lesion in one piece (Fig. 3). Pathology report of the resected lesion demonstrated high grade dysplasia/in situ carcinoma with no residual tumor on the margins of resection (Fig. 4), therefore as the tumor was not infiltrating the submucosa (limit point for lymphatic spread) it was considered that ESD had been curative, and more aggressive surgery was avoided (3).

 

 

Discussion

LST of the colon (lesions with a short vertical axis and > 10 mm of lateral spread), may be classified as granular type (multiple nodules and less invasive) and non granular type (flat/plane, higher potential for infiltration), being this last one localized in the rectum in only a few number of patients (4). ESD performance is anecdotal in our country, as the learning curve for this technique is large and complicated, being necessary in our opinion to organize a teaching program for this difficult technique (5).

 

References

1. The Paris endoscopic classification of superficial neoplastic lesions: Esophagus, stomach, and colon. Gastrointest Endosc 2003;58(Supl. 6):S3-27.         [ Links ]

2. Saito Y, Uraoka T, Matsuda T, Emura F, Ikehara H, Mashimo Y, et al. Endoscopic treatment of large superficial colorectal tumors: A case series of 200 endoscopic submucosal dissections (with video). Gastrointest Endosc 2007;66(5):966-73.         [ Links ]

3. Yamamoto S, Watanabe M, Hasegawa H, Baba H, Yoshinare K, Shiraishi J, et al. The risk of lymph node metastasis in T1 colorectal carcinoma. Hepatogastroenterology 2004;51:998-1000.         [ Links ]

4. Uraoka T, Saito Y, Matsuda T, Ikehara H, Gotoda T, Saito D, et al. Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum. Gut 2006;55:1592-7.         [ Links ]

5. Vázquez-Sequeiros E, de Miquel DB, Foruny JR, González JA, García M, Juzgado D, et al. Training model for teaching endoscopic submucosal dissection of gastric tumors. Rev Esp Enferm Dig 2009;101(8):546-52.         [ Links ]