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Ulcerative colitis–associated flat-appearing rectal cancer with submucosal extension

Published:August 23, 2022DOI:https://doi.org/10.1016/j.gie.2022.08.027
      A 78-year-old man with ulcerative colitis (UC) in clinical remission underwent annual cancer surveillance colonoscopy. Histopathologic evaluation of an endoscopic forceps biopsy specimen from a nearly unrecognizable but slightly discolored rectal area adjacent to the dentate line showed high-grade dysplasia (A). Magnifying endoscopy with narrow-band imaging revealed a lesion (approximately 15 mm in diameter) with small round glandular orifices (B). Considering the small size and flat morphology, which resembled that of a noninvasive tumor, the patient’s age, and the surgical invasiveness, we performed preceding endoscopic submucosal dissection (ESD) as a total excision biopsy. ESD-assisted en bloc resection revealed superficial well-differentiated adenocarcinoma and a submucosal mucin lake covered by tumor cells (depth of penetration at least 1,300 μm), with a positive vertical margin (C, H&E, orig. mag. X60). Immunohistochemical analysis showed cells with strong Ki-67 and p53 immunopositivity (D, p53, orig. mag. X60), confirming a UC-associated cancer diagnosis. Additionally, a laparoscopic total proctocolectomy was performed, and histopathologic evaluation of the post-ESD scar showed cells with low-grade dysplasia and strong p53 immunopositivity. This study highlights that the surface pattern may not accurately indicate histopathologic changes in deep-seated tissue in UC-associated neoplasms and that ESD may be an accurate minimally invasive diagnostic procedure to determine the appropriateness of invasive surgery.
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