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Pseudoinvasion appearing as a deeply invasive malignant colorectal polyp
Accepted Manuscript Pseudoinvasion appearing as a deeply invasive malignant colorectal polyp Eelco C. Brand, Raouf E. Nakhleh, MD, Michael B. Wallace, MD, MPH PII:
S0016-5107(16)30477-1
DOI:
10.1016/j.gie.2016.08.010
Reference:
YMGE 10186
To appear in:
Gastrointestinal Endoscopy
Received Date: 6 July 2016 Accepted Date: 12 August 2016
Please cite this article as: Brand EC, Nakhleh RE, Wallace MB, Pseudoinvasion appearing as a deeply invasive malignant colorectal polyp, Gastrointestinal Endoscopy (2016), doi: 10.1016/j.gie.2016.08.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Pseudoinvasion appearing as a deeply invasive malignant colorectal polyp Eelco C. Brand1,2, Raouf E. Nakhleh, MD3, Michael B. Wallace, MD, MPH1 1. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States.
RI PT
2. University Medical Center Utrecht, Utrecht, the Netherlands.
Corresponding author M.B. Wallace, MD, MPH, Professor of Medicine
Mayo Clinic, Jacksonville, Florida 4500 San Pablo Road Jacksonville, FL 32224 Telephone: +1 904 953 2221
M AN U
Editor in Chief of Gastrointestinal Endoscopy
EP
TE D
E-mail address: [email protected]
AC C
SC
3. Division of Pathology, Mayo Clinic, Jacksonville, Florida, United States.
ACCEPTED MANUSCRIPT
Pseudoinvasion appearing as a deeply invasive malignant colorectal polyp Eelco C. Brand1,2, Raouf E. Nakhleh, MD3, Michael B. Wallace, MD, MPH1
2. University Medical Center Utrecht, Utrecht, the Netherlands.
RI PT
1. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States.
3. Division of Pathology, Mayo Clinic, Jacksonville, Florida, United States.
SC
A 50-year-old man with alcoholic liver cirrhosis, MELD score of 15, underwent colonoscopy for liver transplantation evaluation and screening.
M AN U
A malignant appearing 20mm sessile polyp with an ulcerated surface, Paris IIa/III, was found in a tight area of the sigmoid. Due to notable contractions the polyp prolapsed into the lumen. The polyp surface, assessed with high-definition near-focus white-light and narrow-band imaging (CF-HQ190, Olympus Corp, Center Valley, Pa), demonstrated a Sano IIIb and Kudo Vn pattern for the ulcer and Sano II for the sharply demarcated margins, suggestive of deep submucosal invasion (Figure A).
TE D
Because the patient was considered a poor colectomy candidate, the lesion was lifted with 10 mL saline-methylene blue and removed en-bloc with a 2.5 cm stiff snare (Snaremaster, Olympus Corp, Center Valley, Pa) to obtain histology (Figure B). Surprisingly, the histology revealed a low-grade dysplastic tubulovillous adenoma with pseudoinvasion, probably representing ulceration from polyp prolapse. Although the architecture was disrupted, the epithelium appeared entrapped in fibrous stroma without evidence of true invasion (figures C-D hematoxylin and eosin stain, magnification 20x). Desmoplasia was not identified.
AC C
EP
Endoscopic assessment may occasionally be incorrect when, mechanically caused, pseudoinvasion appears as an invasive surface pattern. En-bloc resection for histology should then be considered.
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
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M AN U
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ACCEPTED MANUSCRIPT
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This case illustrates a colonic polyp that I assume most readers would have assumed was malignant given its size, shape, central depression, and overall appearance. Histologic analysis only revealed a tubulovillous adenoma with low-grade dysplasia and no evidence of deep invasion. The atypical appearance of the lesion may be due to a variety of factors as suggested by the authors, but the exact cause may never be known. Several lesions are known to occasionally mimic malignancy in the colon, including solitary rectal ulcer syndrome (SRUS), acute diverticulitis, and large colonic lipomas (among other causes). It should be stressed that even the most expert endoscopist among us can be fooled by these processes on occasion. The lesion in this case was resected endoscopically given the patient’s comorbidities, which ultimately saved him from undergoing a surgical procedure that, in light of the histology results, would have been unnecessary.
M AN U
Douglas G. Adler, MD, FASGE GIE Associate Editor University of Utah School of Medicine Salt Lake City, Utah
AC C
EP
TE D
Massimo Raimondo, MD Associate Editor for Focal Points
S0016-5107(16)30477-1
DOI:
10.1016/j.gie.2016.08.010
Reference:
YMGE 10186
To appear in:
Gastrointestinal Endoscopy
Received Date: 6 July 2016 Accepted Date: 12 August 2016
Please cite this article as: Brand EC, Nakhleh RE, Wallace MB, Pseudoinvasion appearing as a deeply invasive malignant colorectal polyp, Gastrointestinal Endoscopy (2016), doi: 10.1016/j.gie.2016.08.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Pseudoinvasion appearing as a deeply invasive malignant colorectal polyp Eelco C. Brand1,2, Raouf E. Nakhleh, MD3, Michael B. Wallace, MD, MPH1 1. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States.
RI PT
2. University Medical Center Utrecht, Utrecht, the Netherlands.
Corresponding author M.B. Wallace, MD, MPH, Professor of Medicine
Mayo Clinic, Jacksonville, Florida 4500 San Pablo Road Jacksonville, FL 32224 Telephone: +1 904 953 2221
M AN U
Editor in Chief of Gastrointestinal Endoscopy
EP
TE D
E-mail address: [email protected]
AC C
SC
3. Division of Pathology, Mayo Clinic, Jacksonville, Florida, United States.
ACCEPTED MANUSCRIPT
Pseudoinvasion appearing as a deeply invasive malignant colorectal polyp Eelco C. Brand1,2, Raouf E. Nakhleh, MD3, Michael B. Wallace, MD, MPH1
2. University Medical Center Utrecht, Utrecht, the Netherlands.
RI PT
1. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States.
3. Division of Pathology, Mayo Clinic, Jacksonville, Florida, United States.
SC
A 50-year-old man with alcoholic liver cirrhosis, MELD score of 15, underwent colonoscopy for liver transplantation evaluation and screening.
M AN U
A malignant appearing 20mm sessile polyp with an ulcerated surface, Paris IIa/III, was found in a tight area of the sigmoid. Due to notable contractions the polyp prolapsed into the lumen. The polyp surface, assessed with high-definition near-focus white-light and narrow-band imaging (CF-HQ190, Olympus Corp, Center Valley, Pa), demonstrated a Sano IIIb and Kudo Vn pattern for the ulcer and Sano II for the sharply demarcated margins, suggestive of deep submucosal invasion (Figure A).
TE D
Because the patient was considered a poor colectomy candidate, the lesion was lifted with 10 mL saline-methylene blue and removed en-bloc with a 2.5 cm stiff snare (Snaremaster, Olympus Corp, Center Valley, Pa) to obtain histology (Figure B). Surprisingly, the histology revealed a low-grade dysplastic tubulovillous adenoma with pseudoinvasion, probably representing ulceration from polyp prolapse. Although the architecture was disrupted, the epithelium appeared entrapped in fibrous stroma without evidence of true invasion (figures C-D hematoxylin and eosin stain, magnification 20x). Desmoplasia was not identified.
AC C
EP
Endoscopic assessment may occasionally be incorrect when, mechanically caused, pseudoinvasion appears as an invasive surface pattern. En-bloc resection for histology should then be considered.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
SC
RI PT
This case illustrates a colonic polyp that I assume most readers would have assumed was malignant given its size, shape, central depression, and overall appearance. Histologic analysis only revealed a tubulovillous adenoma with low-grade dysplasia and no evidence of deep invasion. The atypical appearance of the lesion may be due to a variety of factors as suggested by the authors, but the exact cause may never be known. Several lesions are known to occasionally mimic malignancy in the colon, including solitary rectal ulcer syndrome (SRUS), acute diverticulitis, and large colonic lipomas (among other causes). It should be stressed that even the most expert endoscopist among us can be fooled by these processes on occasion. The lesion in this case was resected endoscopically given the patient’s comorbidities, which ultimately saved him from undergoing a surgical procedure that, in light of the histology results, would have been unnecessary.
M AN U
Douglas G. Adler, MD, FASGE GIE Associate Editor University of Utah School of Medicine Salt Lake City, Utah
AC C
EP
TE D
Massimo Raimondo, MD Associate Editor for Focal Points