Nassau University Medical Center East Meadow, NY, United States
Bobby Jacob, MD1, Charudatta Wankhade, MD1, Kevin Yeroushalmi, MD1, Pranay Srivastava, MD1, Shino Prasandhan, MD1, Tarek Alansari, MD2, Stavros Stavropoulos, MD2, Nausheer Khan, MD1 1Nassau University Medical Center, East Meadow, NY; 2Winthrop University Hospital, Mineola, NY
Introduction: Physicians have encountered an increasing number of advanced neoplasia with the expansion of colorectal cancer screening. Various classification systems, including Paris, NICE, and Kudo classification, have provided a universal means by which gastroenterologists can describe these lesions. These classification systems, in turn, have aided gastroenterologists in stratifying which polyps are higher risk for malignant potential. Appropriate evaluation of these lesions will help assess an optimal management strategy to provide the best outcome for the patient.
Case Description/Methods: A 71 year-old Caucasian male presented for routine colorectal cancer surveillance. Three years prior, his surveillance colonoscopy had revealed a 2 cm sessile adenomatous polyp, which was tattooed and removed via snare polypectomy. Repeat surveillance colonoscopy revealed the previously tattooed site with an adjacent 3 cm x 2 cm Paris IIc + Kudo IIIL non-granular laterally spreading tumor (LST). The lesion was noted to have a central depression. An EUS probe was performed and it was felt this could represent T1b carcinoma versus deep scar from biopsy or other manipulation. The decision made to pursue endoscopic submucosal dissection (ESD) for complete en bloc removal using the DiLumen device. The pathology showed 2.3 cm tubular adenoma with focal high grade dysplasia and negative margins for adenomatous or dysplastic changes consistent with R0 resection. The patient was recommended to repeat surveillance colonoscopy in 1 year.
Discussion: LSTs spread superficially along the colonic wall rather than invading the submucosa and can present as early colonic neoplasia. There are four subtypes of LSTs, with non-granular LSTs carrying the highest risk for covert cancer. Endoscopic resection can be effectively employed as a minimally invasive approach in managing LSTs, thus minimizing the need for surgical intervention. However, due to limited experience at some centers, patients may undergo surgical resection. With more gastroenterologists seeking advanced training and continued developments in submucosal lifting agents and endoscopic devices to assist in EMR and ESD, endoscopic management of these lesions may become more widely available.
Figure: Images A&B reveal flat non-granular laterally spreading tumor with a central depression. Image C EUS probe evaluation of central depression reveals possible T1b carcinoma versus manipulation from prior intervention. Image D reveals gross specimen after en bloc resection.
Bobby Jacob indicated no relevant financial relationships.
Charudatta Wankhade indicated no relevant financial relationships.
Kevin Yeroushalmi indicated no relevant financial relationships.
Pranay Srivastava indicated no relevant financial relationships.
Shino Prasandhan indicated no relevant financial relationships.
Tarek Alansari indicated no relevant financial relationships.
Stavros Stavropoulos: Boston Scientific – Consultant, consultant for Boston Scientific and the recipient of honoraria from ERBE USA.
Nausheer Khan indicated no relevant financial relationships.
Bobby Jacob, MD1, Charudatta Wankhade, MD1, Kevin Yeroushalmi, MD1, Pranay Srivastava, MD1, Shino Prasandhan, MD1, Tarek Alansari, MD2, Stavros Stavropoulos, MD2, Nausheer Khan, MD1. P2783 - Successful Endoscopic Submucosal Dissection of Non-Granular Laterally Spreading Tumor, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.