A laterally-spreading tumor in a colonic interposition treated by endoscopic submucosal dissection

Abstract

Herein we describe an early colonic carcinoma which developed in a colonic interposition 14 years after surgery for esophageal cancer, which was successfully treated by endoscopic submucosal dissection (ESD). An 80-year-old man underwent colonic interposition between the upper esophagus and stomach after surgery for an early esophageal squamous cell carcinoma in 1994. He received a surveillance endoscopy, and a laterally-spreading tumor of granular type, approximately 20 mm in size, was identified in the colonic interposition. An endoscopic biopsy revealed moderately differentiated adenocarcinoma histologically, however, we diagnosed the lesion as an intramucosal carcinoma based on the endoscopic findings. The lesion was safely and completely removed en bloc by ESD using a bipolar knife. Histologically, the lesion was an intramucosal moderately differentiated adenocarcinoma in a tubular adenoma.

Key Words: Colonic interposition; Early colonic carcinoma; Endoscopic submucosal dissection

INTRODUCTION

Although rarely reported, adenoma and adenocarcinoma can occur as a late complication in colon segments used to replace the esophagus. Herein, we describe an early colonic carcinoma which developed in a colonic interposition 14 years after surgery for esophageal cancer, which was successfully treated by endoscopic submucosal dissection (ESD).

CASE REPORT

An 80-year-old man underwent colonic interposition between the upper esophagus and stomach after surgery for an early esophageal squamous cell carcinoma (T1, N0, M0, stage I according to the TNM classification) in 1994. He received an esophagogastroduodenoscopy for surveillance and a laterally-spreading tumor of granular type (LST-G), approximately 20 mm in size, was identified in the colonic interposition. On conventional view, a large, reddish nodule was detected in the lesion. With magnifying narrow-band imaging (NBI) observation, the lesion revealed a capillary pattern type II according to Sano’s classification[1], and a type IV pit pattern according to Kudo’s classification was detected under magnifying chromoendoscopy using 0.4% Indigo carmine dye spraying[2]. An endoscopic biopsy was taken from the large nodule and a histological diagnosis of moderately differentiated adenocarcinoma was established, however, we diagnosed the lesion as an intramucosal carcinoma based on the above endoscopic findings (Figure 1). Thus, the lesion was considered a good candidate for endoscopic resection. The lesion was safely and completely removed en bloc by ESD using a bipolar knife (B-knife^® XEMEX Co. Ltd. Tokyo, Japan)[3,4]. Histologically, the lesion was an intramucosal moderately differentiated adenocarcinoma in a tubular adenoma. Lateral and vertical margins of the specimen were negative. There was no lymphatic and venous invasion (Figure 2). The patient was hospitalized for 6 d after ESD to confirm the absence of complications such as delayed perforation, and was then discharged.

Figure 1 A laterally-spreading tumor of granular type (LST-G) in the colonic interposition was shown at colonoscopy. Narrow-band imaging with magnification revealed a capillary pattern type II. Magnifying chromoendoscopy using 0.4% indigo carmine revealed a type IV pit pattern. A: Conventional view; B: Narrow-band imaging with magnification; C: Chromoendoscopy with 0.4% indigo carmine; D: Magnifying chromoendoscopy using 0.4% indigo carmine dye spraying.

Figure 2 Histologically, the resected specimen showed an intramucosal adenocarcinoma in a tubular adenoma. Cross sectional view (HE, magnification × 5).

DISCUSSION

Despite the fact that many interposition grafts are performed for malignant esophageal disease, to the best of our knowledge, there have only been 10 reported cases, including four adenomatous polyps and six adenocarcinomas, arising in a colonic interposition (Table 1)[5-13]. Because the sizes of the adenomatous polyps in the reported cases were small, they were treated with polypectomy. Reoperation or chemoradiotherapy was performed in patients with cancers. Therefore, this is the first case of an early adenocarcinoma in a colonic interposition resected by ESD.

Table 1 Summary of reported cases of neoplasia arising in a colonic interposition.

Case	Authors	Age	Gender	Size (mm)	Histology	Period after surgery (yr)	Follow up	Therapy	Course
1	Goldsmith et al[5], 1968	48	F	50	Adenocarcinoma	2	+	Surgery	Follow up
2	Szántó et al[6], 1981	65	M	5	Adenomatous polyp	1	-	Polypectomy	Follow up
3	Haerr et al[7], 1987	72	M	NI	Adenocarcinoma	9	+	Radiation chemotherapy	Death
4	Houghton et al[8], 1989	64	M	NI	Adenocarcinoma	20	-	Surgery	Follow up
5	Theile et al[9], 1992	68	M	29	Adenocarcinoma	12	NI	Surgery	Follow up
6	Lee et al[10], 1994	75	F	NI	Adenocarcinoma	20	+	Surgery	Follow up
7	Altorjay et al[11], 1995	NI	M	60	Adenomatoid polyp	6	+	Surgery	Death
				NI	Carcinoma
8	Kovacs et al[12], 1997	8	M	9	Tubular adenoma	13	+	Polypectomy	Follow up
				11	Tubular adenoma
9	Altomare et al[13], 2006	64	M	6	Tubular adenoma	7	+	Polypectomy	Follow up
10	Present case, 2008	80	M	25	Adenocarcinoma in tubular adenoma	14	-	ESD	Follow up

ESD: Endoscopic submucosal dissection; NI: No information.

We performed ESD instead of endoscopic mucosal resection (EMR) in this case, as the lesion was not well-elevated even after submucosal injection of glycerol. This phenomenon is the so-called “non-lifting sign positive” as determined by Uno et al[14]. As our endoscopic diagnosis of an intramucosal carcinoma was established with magnifying NBI and chromoendoscopy, submucosal benign fibrosis rather than desmoplastic reaction created by invasive cancer was considered to cause the non-lifting sign positive. EMR for the lesion with the non-lifting sign positive may result in incomplete resection or unfavorable complications such as colonic perforation. During ESD, hyaluronic acid was additionally injected into the submucosal layer and a transparent hood was attached to the tip of the scope for better submucosal dissection[15]. To reduce deep burn to the muscle layer, we used a bipolar knife instead of a monopolar knife. To reduce operating time, we used a bipolar snare to remove the lesion after adequate dissection. These efforts enabled us to completely and safely remove the lesion en bloc without complication. Furthermore, the patient’s colonic interposition was reconstructed using the subcutaneous route, and thus the risk of mediastinitis even if perforation occurred was lower than that if reconstructed substantially.

Despite the fact that many interposition grafts are performed for malignant esophageal disease, few reports of adenocarcinoma arising in a colonic interposition have been reported. It is commonly thought that patients who have esophageal malignancy carry a dismal prognosis, and few of these patients will survive long enough to develop colonic adenocarcinoma. However, with recent progress in chemotherapy, many patients have long-term survival. Almost all case reports presenting with adenoma or adenocarcinoma arise five or more years after colonic interposition surgery, and there are only two case reports where adenoma or adenocarcinoma in the colonic interposition has arisen 1 or 2 years after surgery (Table 1). In our case, adenocarcinoma in a tubular adenoma was detected 14 years postoperatively. Colonoscopic screening is usually performed before colonic interposition. However, Heresbach et al[16] reported an overall miss rate of 23.4% in the colonoscopic detection of neoplasia including both adenomas and colorectal cancers. Therefore, we recommend upper endoscopic screening within 1 year of colonic interposition and periodic surveillance, as lesions may be detected early and removed safely by endoscopy.