INTRODUCTION
Traditional endoscopic resection techniques have historically been limited to lesions no deeper than the submucosa.1 The full-thickness resection device (FTRD; Ovesco, Tuebingen, Germany) has emerged as an option for definitive therapy for endoscopic removal of lesions penetrating deeper into the mucosa propria. FTRD has recently been used to successfully resect colonic lesions in patients who are poor surgical candidates because of advanced age or other existing comorbidities.2,3 Another emerging technique, endoscopic morcellation (EndoRotor), has been developed to remove unwanted tissue and has been used in practice to clear lateral margins and excise scarred tissue after traditional endoscopic mucosal resection.3 The 2 technologies, however, have yet to be used in sequence for the removal of a malignant mass that cannot be surgically excised. We present the serial use of these techniques as a palliative and potentially curative treatment option in a patient deemed to be a nonsurgical candidate.
CASE REPORT
An 80-year-old man with numerous comorbidities, including an orthotopic heart transplant, atrial flutter postablation, and a history of arteriovenous malformations in the upper gastrointestinal (GI) tract presented for evaluation of acute-on-chronic iron deficiency anemia. A colonoscopy revealed a 25 × 40 mm sessile lesion with a centrally located ulcerated component. The mass was nonobstructing and partially circumferential, involving upwards of half of the lumen circumference. The central ulceration suggested deep layer involvement and neither the central nor peripheral aspect lifted with submucosal injection, precluding traditional endoscopic resection techniques. Sampling of the peripheral mass confirmed tubular adenoma with high-grade dysplasia.
The surgical team deemed the patient to be a poor surgical candidate and referred the patient to the advanced endoscopy team for further management. Sequential colonoscopies were planned, with the first to address the overtly malignant component and the second to remove surrounding adenoma. One month after the initial colonoscopy, a repeat colonoscopy again revealed the lesion, which was marked using electric cautery before attaching the full-thickness resection device (Figure 1). With the FTRD in place, the lesion was targeted, captured by a grasper forceps, and pulled into the cap without difficulty (Figure 1). An over-the-scope clip was deployed allowing for subsequent safe resection of overlying tissues. The resection device was removed, and a relook endoscopy with tandem fluoroscopy was without concern of perforation or bleeding (Figure 1). Histological evaluation of the resected tissue (Figure 2) returned consistent with adenocarcinoma (small blue boxes) with margins clear of malignancy but involving superficial adenoma with high-grade dysplasia (green and orange boxes). The adenocarcinoma invaded one-third of the submucosa, staged as pT1, and with no histological or radiological evidence of malignant dissemination was deemed as low risk for metastasis. We allowed time for the clip to spontaneously release, proven by 3-month interval imaging. Four months after the full-thickness resection, the patient returned for a subsequent colonoscopy, during which all adenomatous tissues were removed using endoscopic morcellation (Figure 3). The morcellated tissue was collected, and pathological evaluation confirmed tubular adenoma with no residual malignancy or dysplasia. The patient did not experience any immediate or delayed complications throughout his sequential colonoscopies, and an additional repeat colonoscopy has yet to be organized.
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Figure 1.: Endoscopic visualization of lesion. (A) Lesion marked using electric cautery before attaching the full-thickness resection device. (B) The lesion targeted, captured by a forceps, and pulled into the FTRD cap. (C) Relook endoscopy after FTRD removal was without concern of perforation or bleeding. FTRD, full-thickness resection device.
Figure 2.: Histological evaluation of the resected tissue; hematoxylin and eosin stain. Tissue consistent with adenocarcinoma (small blue boxes), with margins clear of malignancy but involving superficial adenoma with high-grade dysplasia (green and orange boxes).
Figure 3.: Endoscopic morcellation used to remove all remaining adenomatous tissues during subsequent colonoscopy. Before endoscopic morcellation, with a yellow arrow indicating the scar of endoscopic full-thickness resection surrounded by a tubular adenoma (A) and after endoscopic morcellation (B).
DISCUSSION
Traditional endoscopic resection techniques, including endoscopic mucosal resection and endoscopic submucosal dissection, have been well-documented for the treatment of various GI neoplasms.1 These methodologies, however, are limited to the mucosal and submucosal layers of the GI wall. Lesions that involve deeper layers, or that are difficult to access anatomically, prove a challenge to resect by traditional endoscopic techniques and are often referred for surgical removal. Moreover, there are populations of patients who are poor surgical candidates, who do not have robust treatment options for the resection of GI neoplasms. Endoscopic full-thickness resection (EFTR), however, has emerged as a potential treatment option for endoscopic resection of lesions that have been traditionally reserved for surgery.2 In this setting, EFTR acts as an intersection between surgery and endoscopy. However, precise indications for when to use EFTR have not yet reached a consensus.4 Still, EFTR has been used in cases when traditional endoscopic techniques have had limited successful resections, with positive clinical outcomes.1,3 Over-the-scope clip-assisted EFTR has been deemed suitable for lesions that are <2 cm in the colorectum.5 One multicenter prospective study demonstrated that the FTRD device had an overall technical efficacy of 89.5% and an R0 resection rate of 76.9%.6 In this study, lesions <2 cm had an R0 rate of 81.2% while lesions >2 cm had an R0 rate of 58.11%. Smaller lesions may, therefore, be more ideal for EFTR use without an adjunct intervention. There is, however, currently no consensus for the maximum lesion size amenable to EFTR. There are also no absolute contraindications unique to EFTR that would not also contraindicate a standard endoscopic procedure to the same patient.
The EndoRotor acts as a nonthermal, automated endoscopic resection device that excises tissue using an automated rotating morcellator and uses suction pressure to capture excised tissue for histologic evaluation.7 While scarred adenomas often pose a challenge for removal, endoscopic morcellation takes advantage of differences in the elasticity between scarred and adenomatous tissues to resect the GI mucosa and leave behind the stiffer muscular layer.8 Therefore, morcellation may serve as an important technique for the removal of residual margins of previously resected adenomatous lesions to supplement endoscopic mucosal resection and endoscopic submucosal dissection.7
In this case, we present a unique combination of EFTR and morcellation as a palliative and potentially curative treatment option for an adenocarcinoma with laterally spreading adenoma in a patient who was deemed a poor surgical candidate. Although the FTRD was unable to excise the lateral margins because of the size, it was successful in removing the full depth of the lesions penetrating the component. A subsequent colonoscopy and use of the morcellator was successful in removing the lateral margins of the tubular adenoma surrounding the EFTR scar from the previous resection. The unique combination of EFTR and morcellation endoscopic techniques offers a promising and novel solution for endoscopic neoplastic excisions when surgical intervention cannot be performed.
DISCLOSURES
Author contributions: AW Scott and SK Amateau wrote the manuscript. SK Amateau and JR Howard conducted the procedures. K. Amin provided the pathology interpretation. All authors contributed to the editing of the manuscript. AW Scott is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
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