Case Report
Copyright ©2010 Baishideng. All rights reserved
World J Gastroenterol. Jan 21, 2010; 16(3): 392-394
Published online Jan 21, 2010. doi: 10.3748/wjg.v16.i3.392
A laterally-spreading tumor in a colonic interposition treated by endoscopic submucosal dissection
Hideaki Bando, Hiroaki Ikematsu, Kuang-I Fu, Yasuhiro Oono, Takashi Kojima, Keiko Minashi, Tomonori Yano, Takahisa Matsuda, Yutaka Saito, Kazuhiro Kaneko, Atsushi Ohtsu
Hideaki Bando, Hiroaki Ikematsu, Yasuhiro Oono, Takashi Kojima, Keiko Minashi, Tomonori Yano, Kazuhiro Kaneko, Atsushi Ohtsu, Department of Gastrointestinal Oncology & Endoscopy, National Cancer Center Hospital East, Kashiwanoha 6-5-1, Kashiwa, Chiba 277-8577, Japan
Kuang-I Fu, Department of Gastroenterology, Juntendou University Nerima Hospital, Tokyo 177-0033, Japan
Takahisa Matsuda, Yutaka Saito, Endoscopy Division, National Cancer Center Hospital, Tokyo 104-0045, Japan
Author contributions: Bando H designed the research, collected, analyzed and interpreted the data; Ikematsu H, Fu KI, Oono Y, Kojima T, Minashi K, Yano T, Matsuda T, Saito Y, Kaneko K and Ohtsu A wrote and revised the paper.
Correspondence to: Hiroaki Ikematsu, MD, Department of Gastrointestinal Oncology & Endoscopy, National Cancer Center Hospital East, Kashiwanoha 6-5-1, Kashiwa, Chiba 277-8577, Japan. hikemats@east.ncc.go.jp
Telephone: +81-4-71331111 Fax: +81-4-71346928
Received: September 5, 2009
Revised: October 13, 2009
Accepted: October 20, 2009
Published online: January 21, 2010

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
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
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.
CaseAuthorsAgeGenderSize (mm)HistologyPeriod after surgery (yr)Follow upTherapyCourse
1Goldsmith et al[5], 196848F50Adenocarcinoma2+SurgeryFollow up
2Szántó et al[6], 198165M5Adenomatous polyp1-PolypectomyFollow up
3Haerr et al[7], 198772MNIAdenocarcinoma9+Radiation chemotherapyDeath
4Houghton et al[8], 198964MNIAdenocarcinoma20-SurgeryFollow up
5Theile et al[9], 199268M29Adenocarcinoma12NISurgeryFollow up
6Lee et al[10], 199475FNIAdenocarcinoma20+SurgeryFollow up
7Altorjay et al[11], 1995NIM60Adenomatoid polyp6+SurgeryDeath
NICarcinoma
8Kovacs et al[12], 19978M9Tubular adenoma13+PolypectomyFollow up
11Tubular adenoma
9Altomare et al[13], 200664M6Tubular adenoma7+PolypectomyFollow up
10Present case, 200880M25Adenocarcinoma in tubular adenoma14-ESDFollow up

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.

Footnotes

Peer reviewers: Christopher Mantyh, MD, Associate Professor, Department of Surgery, Duke University Medical Center, Box 3117, Durham, NC 2771, United States; Ming-Te Huang, Professor, Department of Surgery, Taipei Medical University-Shuang Ho Hospital, Taipei 23561, Taiwan, China

S-Editor Wang JL L-Editor Webster JR E-Editor Tian L

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