Society: ASGE

Introduction
Malignant colorectal polyps are defined as lesions that invade into the submucosa and represent early colorectal cancer (T1 by the TNM Classification of Malignant Tumors system). Management of these lesions depends on the depth of invasion which can be estimated endoscopically using various classification methods that assess lesion morphology and surface features. Superficially invasive lesions are generally amenable to endoscopic resection techniques whereas deeply invasive lesions are typically managed with surgical resection given the high risk of invasion beyond the submucosa. Here, we describe successful endoscopic resection of a deeply invasive colon lesion in a non-surgical candidate using hybrid endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) with the full-thickness resection device (FTRD).

Case
A 71-year-old male with a history of chronic kidney disease stage IV, type II diabetes mellitus, peripheral arterial disease and below-the-knee amputation, and recently diagnosed pulmonary embolism was found to have a colon mass on imaging after presenting with acute on chronic anemia. Colonoscopy revealed a 30 mm polypoid lesion (Paris classification 0-Is) in the hepatic flexure with features concerning for submucosal invasion (NICE classification Type III), including superficial ulceration and oozing with minimal contact (Figure 1A). After multidisciplinary discussion, the patient was felt to be a poor surgical candidate and thus endoscopic resection using endoscopic submucosal dissection (ESD) was pursued in case the invasion of the cancer was limited to superficial submucosa.

Procedure
A circumferential incision surrounding the lesion was made and endoscopic submucosal dissection was performed (Figure 1B). During dissection, invasion into the muscularis propria was visualized (Figure 1C) and thus the decision was made to use the full-thickness resection device (FTRD) to complete the resection.

The grasping forceps were used to pull the lesion into the device cap and the clip was deployed. Given the presence of submucosal invasion, gentle intermittent suction was applied to ensure complete entrapment of the lesion into the FTRD cap. The snare was closed and the lesion was resected using electrocautery (Figure 1D). The final pathology report revealed T2 invasive adenocarcinoma (Figure 2) with negative resection margins (R0).

Conclusions
While deeply invasive colon lesions are traditionally removed surgically, endoscopic resection using hybrid ESD-EFTR may offer an alternative treatment approach in select patients who are non-surgical candidates. In this case, initial submucosal dissection allows for the lesion to be more pliable and hence more amenable to be completely pulled into the FTRD cap which allowed for complete endoscopic resection of a T2 adenocarcinoma.

Figure 1. A) A 30 mm polypoid lesion with overlying ulceration is seen at the hepatic flexure (Paris classification 0-Is, NICE Type III). B) An initial circumferential incision around the lesion is made for ESD. C) Lesion invasion into the muscularis propria is visualized during submucosal dissection. D) Final view of the resection site showing appropriate position of the clip.

Figure 1. A) A 30 mm polypoid lesion with overlying ulceration is seen at the hepatic flexure (Paris classification 0-Is, NICE Type III). B) An initial circumferential incision around the lesion is made for ESD. C) Lesion invasion into the muscularis propria is visualized during submucosal dissection. D) Final view of the resection site showing appropriate position of the clip.

Figure 2. Final pathology of the lesion shows T2 invasive adenocarcinoma with negative (R0) resection margins

Figure 2. Final pathology of the lesion shows T2 invasive adenocarcinoma with negative (R0) resection margins

Mohamed Abdallah

Appearances

HYBRID ENDOSCOPIC SUBMUCOSAL DISSECTION AND ENDOSCOPIC FULL-THICKNESS RESECTION FOR COMPLETE RESECTION OF A T2 COLON ADENOCARCINOMA IN A NON-SURGICAL CANDIDATE

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