Hybrid endoscopic submucosal dissection and endoscopic full-thickness resection for R0 resection of T1 colonic adenocarcinoma

Abstract

Background and Aims

Malignant colorectal polyps limited to superficial submucosa can undergo endoscopic resection as a curative strategy. Endoscopic full-thickness resection (EFTR) allows en bloc resection of malignant polyps; however, the technique is challenging in lesions with submucosal invasion or those >20 mm in size.

Methods

This original article and accompanying video reviews the technique for hybrid endoscopic submucosal dissection (ESD) and EFTR to allow R0 resection of T1 colonic adenocarcinoma.

Results

In the case example, ESD was performed to make a 35-mm lesion pliable. This step allowed the lesion to be pulled into the cap and complete en bloc resection using the full-thickness resection device.

Conclusions

The case highlights that hybrid ESD-EFTR technique is feasible and allows for en bloc removal of superficially invasive submucosal colon adenocarcinoma with lesions >20 mm in size. Initial mucosal incision and partial submucosal dissection can make the lesions with underlying submucosal invasion pliable and hence amenable to full-thickness resection using a full-thickness resection device.

Introduction

Management of colorectal polyps depends on an optical diagnosis to determine submucosal invasive cancer. En bloc resection of malignant colorectal polyps limited to the superficial submucosa can be performed as curative resection strategy. Endoscopic full-thickness resection (EFTR) using a full-thickness resection device (FTRD; Ovesco Endoscopy, Tübingen, Germany) can allow for transmural resection of lesions. However, the procedure can only be performed for lesions up to 20 mm.¹ In addition, lesions with significant fibrosis or invasion are challenging to pull into the cap because of lack of pliability. This limitation can be overcome by initial circumferential mucosal incision and partial endoscopic submucosal dissection (ESD) to make the lesion more pliable, thus allowing it to be pulled into the cap and complete the en bloc resection.² Andrisani and Di Matteo³ reported resection of T1 colorectal adenocarcinoma in 3 patients with lesions 27 to 28 mm in size using a hybrid ESD-EFTR technique. This case is a video demonstration of the hybrid ESD-EFTR technique, which allowed R0 resection of a T1 adenocarcinoma measuring 35 mm in diameter.

Case presentation

A 72-year-old man with a history of diabetes mellitus, hypertension, coronary artery disease, chronic obstructive pulmonary disease, and chronic kidney disease was referred for the management of a malignant polyp. Colonoscopy revealed a 35-mm nonpolypoid lesion (Paris classification IIa+IIc) in the transverse colon with features concerning for submucosal invasion (Narrow Band Imaging International Colorectal Endoscopic classification type III) (Fig. 1A and B). The lesion was classified as Japanese Narrow Band Imaging Expert Team classification 2B with Kudo pit pattern type V. A multidisciplinary discussion was held between medical oncology, colorectal surgery, and gastroenterology. Given the size of the lesion, the decision was made to attempt initial endoscopic resection.

Figure 1.

A, White-light image shows a 35-mm nonpolypoid lesion, Paris IIa+IIc in transverse colon. B, Narrow-band imaging shows Narrow Band International Colorectal Endoscopic classification type III.

Procedure

The patient presented for colonoscopy under general anesthesia (Video 1, available online at www.videogie.org). Endoscopic examination of the entire colon was performed carefully under white-light and narrow-band imaging. The borders of the lesion were marked carefully with a marking probe, revealing a target area of resection approximately 35 mm in diameter. Submucosal injection with a lifting agent (EndoClot SIS; Olympus America, Center Valley, Pa, USA) followed by initial circumferential mucosal incision (Fig. 2A and B) and partial submucosal dissection was performed using an ESD knife (DualKnife J; Olympus America) to increase tissue pliability before full-thickness resection (Fig. 2C). The Erbe VIO 3 (Tübingen, Germany) was used with EndoCut I (effect 2, duration 3, interval 1) current for circumferential mucosal incision and the PreciseSECT effect 4.0 for partial submucosal dissection. The FTRD was mounted on the colonoscope and advanced to the lesion. Grasping forceps were advanced through the working channel of colonoscope to the lesion. The lesion was grasped and pulled into the FTRD cap with the aid of intermittent suction through the working channel of the colonoscope (Fig. 2D). Given the degree of submucosal invasion and resultant fibrosis, judicious use of intermittent suction was necessary to completely retract the lesion into the FTRD cap. The clip was then deployed, followed by closure of the premounted snare and electrocautery-enhanced resection of the lesion. The specimen was retrieved and target site examined for any adverse events (Fig. 2E and F). The resection site revealed a properly deployed clip and fatty tissue consistent with full-thickness resection. The total procedure time was 80 minutes.

Figure 2.

A, The lesion was marked and submucosal injection was performed. B, Initial circumferential submucosal incision being performed. C, Partial submucosal dissection being performed. D, Grasping forceps used to bring lesion into the full-thickness resection device cap followed by resection. E, Fatty tissue at the site consistent with full-thickness resection. F, Resected specimen.

Pathology showed a moderately differentiated adenocarcinoma infiltrating into the outer half of the submucosa, with a depth of invasion 1.5 mm and low tumor budding (Fig. 3A and B). Lateral and deep margins were negative (Fig. 3C) without lymphovascular invasion, but perineural invasion was observed. There were no adverse events associated with the procedure. Staging computed tomography scan after endoscopic resection did not show any distant metastasis or pathologic lymph nodes. The patient underwent extended right-hemicolectomy, given the presence of high-risk features on pathology. The right hemicolectomy specimen showed benign colonic mucosa with the previous biopsy site, regenerative changes, and no evidence of dysplasia or malignancy. A total of 18 lymph nodes were evaluated, which were negative for metastasis. The patient was referred to oncology for adjuvant chemoradiation.

Figure 3.

A, Microscopic image of specimen after hematoxylin and eosin stain (orig. mag. ×20) shows normal colonic mucosa (red arrow), adenocarcinoma infiltrating into outer half of submucosa (blue arrow), muscularis propria at bottom without invasion. Deep margin negative by 0.1 cm (black double-headed arrow). B, Magnified image (orig. mag. ×40) shows depth of submucosal invasion 1.5 mm (black bar). C, Peripheral margin (orig. mag. X 40) at left negative by 0.5 cm (black double-headed arrow).

Conclusion

While the patient underwent surgery, our case highlights that hybrid ESD-EFTR technique can be safe and effective for the removal of superficially invasive colon adenocarcinoma for lesions ≥20 mm in size. Performance of initial mucosal incision and partial ESD can make fibrotic and superficially invasive lesions more pliable to be pulled into the FTRD cap, hence making the lesion more amenable to resection.

Disclosure

M. Bilal is a consultant for Boston Scientific, Steris Endoscopy, and a paid speaker for Cook Endoscopy. The other authors disclosed no financial relationships.

Supplementary data

Video 1

Hybrid endoscopic submucosal dissection and endoscopic full-thickness resection technique for R0 resection of T1 colonic adenocarcinoma.