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Giant cell reaction subsequent to ORISE gel lifting agent captured on endoscopic ultrasound

      To the Editor:
      We read with interest the article by Olivas et al,
      • Olivas A.D.
      • Setia N.
      • Weber C.R.
      • et al.
      Histologic changes caused by injection of a novel submucosal lifting agent for endoscopic resection in GI lesions.
      which discusses ORISE gel–related foreign body giant cell reaction (FBGCR) leading to submucosal findings that may be misinterpreted during surveillance endoscopy. FBGCR is increasingly documented in the literature as lifting agents become more commonly used in endoscopic practice.
      • Westbrook L.M.
      • Henn P.A.
      • Cornish T.C.
      Lifting agent granuloma.
      We demonstrate a case of lifting agent–related FBGCR leading to an EUS finding of an 8-mm submucosal thickness.
      A 56-year-old woman was undergoing colonoscopy after a positive fecal immunochemical test result. She was found to have a 1-mm polyp in the ascending colon and 2 polyps in the rectum (4 mm proximal and 14 mm distal) (Fig. 1). The rectal polyps were removed by the use of EMR with ORISE gel (Boston Scientific, Marlborough, Mass, USA) (Fig. 2). Histologic analysis revealed tubular adenomas with high-grade dysplasia.
      Figure thumbnail gr2
      Figure 2Rectal polyp after submucosal injection with ORISE gel.
      Colonoscopy in December 2020 revealed a submucosal nodule in the rectum 50 mm from the anal verge (Fig. 3). EUS demonstrated 8 mm of rectal wall submucosal thickening (Fig. 4). After the patient was lost to follow-up, she underwent repeated colonoscopy in October 2021, which showed postmucosectomy scars in the rectum. Histologic analysis did not demonstrate any residual adenomatous tissue at the scar site; however, the submucosal nodule in the distal part of the rectum was still present.
      Figure thumbnail gr3
      Figure 3Submucosal lesion at the post-EMR site as seen on surveillance colonoscopy.
      Figure thumbnail gr4
      Figure 4Submucosal lesion at the post-EMR site as seen on endosonographic imaging.
      Subsequent MRI demonstrated an area in the distal part of the rectum suggestive of lymphadenopathy. After referral to a colorectal surgeon, the patient underwent full-thickness biopsy. A final histologic examination demonstrated FBGCR, negative for dysplasia or malignancy.
      This case demonstrates FBGCR due to ORISE visualized endoscopically, histologically, and endosonographically.
      • Castrodad-Rodríguez C.A.
      • Panarelli N.C.
      • Gersten A.J.
      • et al.
      Features of endoscopic procedure site reaction associated with a recently approved submucosal lifting agent.
      ,
      • Sun B.L.
      Submucosal lifting agent ORISE gel causes extensive foreign body granuloma post endoscopic resection.
      Identification of the abnormal US findings detailed here is of important clinical benefit. In patients undergoing endoscopic procedures where ORISE gel is used, endoscopists should recognize the potential of FBGCR leading to submucosal abnormalities on EUS. Awareness of this artifact can help reduce misidentification of pathologic tissue and decrease the need for unnecessary diagnostic interventions.

      Disclosure

      Both authors disclosed no financial relationships.

      References

        • Olivas A.D.
        • Setia N.
        • Weber C.R.
        • et al.
        Histologic changes caused by injection of a novel submucosal lifting agent for endoscopic resection in GI lesions.
        Gastrointest Endosc. 2021; 93: 470-476
        • Westbrook L.M.
        • Henn P.A.
        • Cornish T.C.
        Lifting agent granuloma.
        Am J Clin Pathol. 2020; 153: 630-638
        • Castrodad-Rodríguez C.A.
        • Panarelli N.C.
        • Gersten A.J.
        • et al.
        Features of endoscopic procedure site reaction associated with a recently approved submucosal lifting agent.
        Mod Pathol. 2020; 33: 1581-1588
        • Sun B.L.
        Submucosal lifting agent ORISE gel causes extensive foreign body granuloma post endoscopic resection.
        Int J Colorectal Dis. 2021; 36: 419-422

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