Observational Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Sep 16, 2016; 8(17): 628-634
Published online Sep 16, 2016. doi: 10.4253/wjge.v8.i17.628
Clinical relevance of aberrant polypoid nodule scar after endoscopic submucosal dissection
Vitor Arantes, Noriya Uedo, Moises Salgado Pedrosa, Yasuhiko Tomita
Vitor Arantes, Endoscopy Unit, Alfa Institute of Gastroenterology, School of Medicine, Federal University of Minas Gerais, Hospital Mater Dei Contorno, Belo Horizonte 30130-100, Brazil
Noriya Uedo, Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka 537-8511, Japan
Moises Salgado Pedrosa, Laboratory CEAP, Department of Pathology, School of Medicine, Federal University of Minas Gerais, Belo Horizonte 30130-090, Brazil
Yasuhiko Tomita, Department of Pathology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka 537-8511, Japan
Author contributions: Arantes V and Uedo N designed the study and contributed equally to data acquisition, analysis, interpretation of the data, writing the article, critical revision and final approval of the manuscript; Pedrosa MS and Tomita Y contributed equally to the histopathological analysis and interpretation of histological findings and study results.
Institutional review board statement: The data was extracted retrospectively from the endoscopy database. Our Ethics and Research Committee does not require IRB submission for such kind of study. Patients signed a consent form for the procedure and the study was conducted according to Helsinque Declaration.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: There are no conflicts of interest to report.
Data sharing statement: No data were created so no data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Vitor Arantes, MD, MSc, PhD, Endoscopy Unit, Alfa Institute of Gastroenterology, School of Medicine, Federal University of Minas Gerais, Hospital Mater Dei Contorno, Rua Florália 18, apt. 1201, Anchieta, Belo Horizonte 30130-100, Brazil. arantesvitor@ufmg.br
Telephone: +55-319-96173441
Received: March 21, 2016
Peer-review started: March 23, 2016
First decision: April 20, 2016
Revised: April 26, 2016
Accepted: July 11, 2016
Article in press: July 13, 2016
Published online: September 16, 2016
Processing time: 175 Days and 19.1 Hours
Abstract
AIM

To describe a series of patients with aberrant polypoid nodule scar developed after gastric endoscopic submucosal dissection (ESD), and to discuss its pathogenesis and clinical management.

METHODS

We reviewed retrospectively the endoscopic database of two academic institutions located in Brazil and Japan and searched for all patients that underwent ESD to manage gastric neoplasms from 2003 to 2015. The criteria for admission in the study were: (1) successful en bloc ESD procedure with R0 and curative resection confirmed histologically; (2) postoperative endoscopic examination with identification of a polypoid nodule scar (PNS) at ESD scar; (3) biopsies of the PNS with hyperplastic or regenerative tissue, reviewed by two independent experienced gastrointestinal pathologists, one from each Institution. Data were examined for patient demographics, Helicobacter pylori status, precise neoplastic lesion location in the stomach, tumor size, histopathological assessment of the ESD specimen, and postoperative information including medical management, endoscopic and histological findings, and clinical outcome.

RESULTS

A total of 14 patients (10 men/4 women) fulfilled the inclusion criteria and were enrolled in this study. One center contributed with 8 cases out of 60 patients (13.3%) from 2008 to 2015. The second center contributed with 6 cases (1.7%) out of 343 patients from 2003 to 2015. Postoperative endoscopic follow-up revealed similar findings in all patients: A protruded polypoid appearing nodule situated in the center of the ESD scar surrounded by convergence of folds. Biopsies samples were taken from PNS, and histological assessment revealed in all cases regenerative and hyperplastic tissue, without recurrent tumor or dysplasia. Primary neoplastic lesions were located in the antrum in 13 patients and in the angle in one patient. PNS did not develop in any patient after ESD undertaken for tumors located in the corpus, fundus or cardia. All patients have been followed systematically on an annual basis and no malignant recurrence in the ESD scar has been identified (mean follow-up period: 45 mo).

CONCLUSION

PNS may occur after ESD for antral lesions and endoscopically look concerning, especially for the patient or the family doctor. However, as long as curative R0 resection was successfully achieved and histology demonstrates only regenerative and hyperplastic tissue, PNS should be viewed as a benign alteration that does not require any type of intervention, other than endoscopic surveillance.

Keywords: Endoscopic submucosal dissection; Early gastric cancer; Endoscopic treatment; Healing; Scar

Core tip: Endoscopic submucosal dissection is the treatment of choice for superficial gastric neoplasms. After curative endoscopic submucosal dissection (ESD), postoperative scar is expected to look consolidated and homogeneous. We describe a series of 14 patients that underwent curative gastric ESD with R0 resection and surprisingly developed an aberrant polypoid nodule at the ESD scar. We denominated this new entity as polypoid nodule scar (PNS). It is noteworthy that PNS occurred only after ESD undertaken for tumors located in the antrum. We reviewed the hypothesis and pathogenic factors that could explain the occurrence of this unusual phenomenon, and discuss propositions about patient’s postoperative clinical management.