Published online Sep 16, 2016. doi: 10.4253/wjge.v8.i17.628
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
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.
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.
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).
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.
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.