Clin Endosc.  2017 Jan;50(1):91-95. 10.5946/ce.2016.054.

Unusual Local Recurrence with Distant Metastasis after Successful Endoscopic Submucosal Dissection for Colorectal Mucosal Cancer

• Lee HJ
• Ye BD
• Byeon JS
• Kim J
• Park YS
• Hong YS
• Yoon YS
• Yang DH

• KMID: 2383497
• DOI: http://doi.org/10.5946/ce.2016.054

Abstract

Intramucosal colorectal cancer (CRC) is thought not to metastasize because the colonic lamina propria lacks lymphatics. Only a few recent case reports have suggested lymph node metastasis from intramucosal CRC, but there is no clear evidence supporting the metastatic potential of intramucosal CRC. Hence, endoscopic resection is regarded as curative treatment for intramucosal CRC. This report describes two cases of unusual local recurrence with distant metastasis in patients who had previously undergone successful endoscopic submucosal dissection for intramucosal CRC. The recurrent colorectal lesions developed at the site of the previous endoscopic submucosal dissection scars in a relatively short-term period, and the pathologic findings showed an "undermining" invasion pattern without surrounding mucosal change. Based on the clinical course and pathological findings, we concluded that the second colorectal lesions were recurrences rather than de novo cancers.

Keyword

Colorectal neoplasms; Intramucosal carcinoma; Endoscopic submucosal dissection; Recurrence; Neoplasm metastasis

MeSH Terms

Cicatrix
Colon
Colorectal Neoplasms
Humans
Lymph Nodes
Mucous Membrane
Neoplasm Metastasis*
Recurrence*

Figure

• 

  Fig. 1. (A) Colonoscopic finding showing a mixed-nodular type laterally spreading tumor measuring 5.6 cm in diameter. (B) Gross endoscopic submucosal dissection (ESD) specimen of the primary lesion. (C) Pathological findings for the ESD specimen showing multiple foci of adenocarcinoma component in the bulky laterally spreading adenoma. The least-differentiated component is highlighted by a dashed line (H&E stain, ×10). Higher magnification of the least-differentiated area, showing solid and cribriform architecture and multiple foci of the invasive front, consisting of small, infiltrative tumor glands (arrowheads) (inset: H&E stain, ×200). (D) Follow-up sigmoidoscopy in 8 months shows a scar. (E) Sigmoidoscopy performed 17 months after ESD, showing mucosal elevation with central ulceration at the previous procedure site, which is suggestive of extrinsic infiltrative cancer. (F) Endoscopic biopsy obtained from the previous ESD site, showing a poorly differentiated adenocarcinoma sitting under normal colonic crypts (H&E stain, ×100). Needle biopsy specimen of a pulmonary metastasis showing similar morphology of tumor glands to that of the previous ESD specimen in terms of solid and cribriform architecture (inset: H&E stain, ×200).

• 

  Fig. 2. (A) Colonoscopic finding showing a mixed-nodular type laterally spreading tumor measuring 6.0 cm in diameter. (B) Severe cauterization at the margin and the middle of the tumor is suspected in the endoscopic image (arrows). (C) Pathological findings for the endoscopic submucosal dissection (ESD) specimen showing a laterally spreading adenoma with a frankly invasive adenocarcinoma component (dashed line, H&E stain, slide scan without magnification). At higher magnification, invasive tumor cells form large, irregularly shaped tubules and have occasional goblet cells. The surrounding stroma is desmoplastic (inset: H&E stain, ×200). (D) Follow-up colonoscopy at 12 months shows only a scar. (E) Colonoscopy at 34 months after ESD shows an ulcerofungating mass that encircles the lumen at the previous ESD site. (F) Pathological findings of resected tumor show an “undermining” invasion pattern without surrounding mucosal change (H&E stain, ×10). The cytomorphology of the resected tumor is similar to that of the invasive component of the previous ESD specimen (inset: H&E stain, ×200).

Reference

1. Fenoglio CM, Kaye GI, Lane N. Distribution of human colonic lymphatics in normal, hyperplastic, and adenomatous tissue. Its relationship to metastasis from small carcinomas in pedunculated adenomas, with two case reports. Gastroenterology. 1973; 64:51–66.

2. Engstrom PF, Arnoletti JP, Benson AB 3rd, et al. NCCN clinical practice guidelines in oncology: colon cancer. J Natl Compr Canc Netw. 2009; 7:778–831.

3. Engstrom PF, Arnoletti JP, Benson AB 3rd, et al. NCCN clinical practice guidelines in oncology: rectal cancer. J Natl Compr Canc Netw. 2009; 7:838–881.

4. Shia J, Klimstra DS. Intramucosal poorly differentiated colorectal carcinoma: can it be managed conservatively? Am J Surg Pathol. 2008; 32:1586–1588.

5. Bae JH, Yang DH, Lee JY, et al. Clinical outcomes of endoscopic submucosal dissection for large colorectal neoplasms: a comparison of protruding and laterally spreading tumors. Surg Endosc. 2016; 30:1619–1628.

6. Nivatvongs S. Surgical management of early colorectal cancer. World J Surg. 2000; 24:1052–1055.

7. Saito Y, Uraoka T, Matsuda T, et al. Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections (with video). Gastrointest Endosc. 2007; 66:966–973.

8. Seo HJ, Kim YJ, Cho KB, et al. Nodal metastasis after successful endoscopic submucosal dissection for colorectal mucosal cancer. Endoscopy. 2011; 43 Suppl 2 UCTN:E374–E375.

9. Lee KH, Kim JS, Cheon KS, Song IS, Kang DY, Kim JY. TisN0M1 sigmoid colon cancer: a case report. Ann Coloproctol. 2014; 30:141–146.

10. Gunderson LL, Jessup JM, Sargent DJ, Greene FL, Stewart AK. Revised TN categorization for colon cancer based on national survival outcomes data. J Clin Oncol. 2010; 28:264–271.

11. Matsuda A, Kishi T, Musso G, et al. The effect of intraoperative rectal washout on local recurrence after rectal cancer surgery: a meta-analysis. Ann Surg Oncol. 2013; 20:856–863.

12. Inoue T, Fujii H, Koyama F, et al. Intraluminal lavage to remove exfoliated tumor cells after colorectal endoscopic submucosal dissection. Surg Endosc. 2016; 30:2773–2778.

13. Tajika M, Niwa Y, Bhatia V, et al. A first report of tumor cell implantation after EMR in a patient with rectosigmoid cancer. Gastrointest Endosc. 2012; 75:1117–1118.

14. Yang DH, Hong SN, Kim YH, et al. Korean guidelines for postpolypectomy colonoscopy surveillance. Clin Endosc. 2012; 45:44–61.

15. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US multi-society task force on colorectal cancer. Gastroenterology. 2012; 143:844–857.

16. Hassan C, Quintero E, Dumonceau JM, et al. Post-polypectomy colonoscopy surveillance: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy. 2013; 45:842–851.