Technique Spotlight: Tubulovillous Adenoma with Intramucosal Adenocarcinoma
By: Bridger W. Clarke, M.D. South Hills Gastroenterology Clairton, Pennsylvania, USA
A 76-year-old male presented for routine colonoscopy after a stool hemoccult returned positive at his primary care physician’s office. Colonoscopy revealed a flat, carpet-like polyp extending from the anal verge to 8cm and involving two-thirds of the rectal circumference (Figure1). Biopsies demonstrated tubulovillous adenoma. After discussing management options including surgical versus endoscopic resection, the patient opted to pursue endoscopic removal.
Propofol sedation was administered by an anesthesiologist. An Interject? Contrast Single-Use Injection Therapy Needle Catheter was used for injection into the submucosal layer deep beneath the polyp to aid in EMR (Figure 2). To ensure complete resection of the affected tissue, piecemeal resection was performed using both Captivator? II 25mm (Figure 3) and 10mm Snares. Beginning with the larger 25mm snare, the majority of the resection was performed in the retroflexed position. The caliber of wire in the Captivator II stiff snare provided secure grasp around the margin of the flat polyp and maintained its shape while working in a torqued position. To manage the small islands of tissue within the resection plane the small caliber of the 10mm Captivator Snare and Radial Jaw? Hot Biopsy Forceps were used to carefully clear all visible adenomatous tissue around the dentate line (Figures 4 and 5). Over forty resected specimens were sent for pathologic review, which demonstrated tubulovillous adenoma with high-grade dysplasia and one area of intramucosal adenocarcinoma (Figure 6).
A CT scan and rectal endoscopic ultrasound were negative for lymphadenopathy or evidence of metastatic disease. Our recommendation was to undergo close surveillance; however, given the common practice of complete resection for this condition, the patient ultimately decided to undergo abdominoperitoneal resection after consulting with an outside surgeon. Pathology from the resected rectum was completely clear of any adenomatous and cancerous tissue.
This case demonstrates the effectiveness of wide-field endoscopic mucosal resection for dysplastic polyps and intramucosal adenocarcinoma, with definitive pathologic confirmation on the resected rectum. Unfortunately, the lack of general awareness of the effectiveness of this technique may lead to unnecessary surgery and morbidity.