Downloaded from gut.bmj.com on October 18, 2014 - Published by group.bmj.com
Gut Online First, published on October 15, 2014 as 10.1136/gutjnl-2014-308298 Editor’s quiz: GI snapshot
Endoscopic submucosal dissection of an unusual flat rectal neoplasm
benign change such as low-grade dysplasia with a probability of approximately 50% (figure 2).1 The lesion involved half of the circumference of the rectum and the dentate line and the anal squamous epithelium for about 10 mm. We decided not to biopsy to avoid fibrosis. For the benign appearance and in order to avoid surgery, an endoscopic submucosal dissection (ESD) was performed (see online supplementary video).
QUESTION CLINICAL PRESENTATION A 63-year-old woman was admitted to our gastroenterology unit to undergo a screening colonoscopy, scheduled for faecal occult blood test positivity. During the procedure, a flat, rectal granular lesion was found. With the use of magnification and narrow band image (NBI) technology, the lesion was diagnosed as a laterally spreading tumour (LST), granular mixed type, 30 mm in maximum diameter (figure 1). The pit pattern was unclassifiable and vascular pattern was similar to the type IV of the classification proposed by Inoue regarding the microvasculature pattern of the oesophagus for diagnosis and evaluation of the squamous cell carcinoma. The type IV shows initial irregularity and dilated intra-papillary capillary loops and indicates
What is the nature of the lesion?
ANSWER Histopathology examination revealed squamous epithelium with papillary formations and marked acanthosis extended to the glandular structures of the rectal mucosa; cells presented vacuolated cytoplasm, irregular and hypercromatic nucleus, binucleate cells, all characteristics of human papillomavirus (HPV) infection (figure 3). Furthermore, nuclei showed focal atypia, pleomorphism and partial loss of surface maturation, indicative of low-grade intraepithelial dysplasia (figure 4). Genotyping revealed HPV type 11. Diagnosis was condyloma acuminatum with low-grade dysplasia.
Figure 1 Endoscopic view.
Figure 3
Histopathological features of the condyloma acuminatum.
Figure 2 Endoscopic view using narrow band imaging.
Figure 4
Histopathological evidence of low-grade dysplasia.
Azzolini F, et Produced al. Gut Month 2014 Vol 0 NoPublishing 0 1 Copyright Article author (or their employer) 2014. by BMJ Group Ltd (& BSG) under licence.
Downloaded from gut.bmj.com on October 18, 2014 - Published by group.bmj.com
Editor’s quiz: GI snapshot Clinical presentation of condyloma is variable; the flat shape and the involvement of the rectal mucosa are rare. Furthermore, their identification often requires the use of high-definition endoscopy.2 In our case, the involvement of the rectal mucosa, the extension and the pattern of the lesion were well recognised using NBI. Both low-risk (subtypes 6 and 11) and high-risk (subtypes 16 and 18) HPV subtypes have also been associated with welldifferentiated squamous cell carcinoma.3 Therefore, treatment modalities are primarily focused on destroying or removing the lesions locally. In this unusual localisation, in addition to topical and surgical options,4 an endoscopic treatment with argon plasma coagulation has been proposed.5 6 In our case, lesion appearance, mimicking an LST with a microvascular pattern of unsure dysplastic nature, induced us to perform an ESD, which was safely and successfully completed.
intellectual content: RS. All authors have approved the final draft submitted for publication. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/gutjnl-2014-308298). To cite Azzolini F, Cecinato P, Iori V, et al. Gut Published Online First: [ please include Day Month Year] doi:10.1136/gutjnl-2014-308298 Received 21 August 2014 Revised 9 September 2014 Accepted 19 September 2014 Gut 2014;0:1–2. doi:10.1136/gutjnl-2014-308298
REFERENCES 1
Francesco Azzolini,1 Paolo Cecinato,1 Veronica Iori,1 Loredana De Marco,2 Ramona Zecchini,1 Cristina Fodero,3 Cristiana Tioli,1 Romano Sassatelli1
2
1
Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria NuovaIRCCS, Reggio Emilia, Italy 2 Unit of Pathology, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy 3 Cervical Cancer Screening Centre, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
3 4
Correspondence to Dr Francesco Azzolini, Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, 42123, Italy; [email protected]
5
Contributors Guarantor of the article: FA. Specific author contributions—study concept and design: FA; drafting of the manuscript: FA and PC; acquisition of data: PC, VI, LD, RZ, CT and CF; critical revision of the manuscript for important
6
2
Inoue H. Magnification endoscopy in the esophagus and stomach. Dig Endosc 2001;13(Suppl):40–1. Echenique I, Phillips BR. Anal warts and anal intradermal neoplasia. Clin Colon Rectal Surg 2011;24:31–8. Dubina M. Viral-associated non-melanoma skin cancers: a review. Am J Dermatopathol 2009;31:561–73. Leszczyszyn J, Lebski I, Lysenko L, et al. Anal warts (condylomata acuminata)— current issues and treatment modalities. Adv Clin Exp Med 2014;23:307–11. Review. Viazis N, Vlachogiannakos J, Vasiliadis K, et al. Earlier eradication of intra-anal warts with argon plasma coagulator combined with imiquimod cream compared with argon plasma coagulator alone: a prospective, randomized trial. Dis Colon Rectum 2007;50:2173–9. Pontone S, Pironi D, Pontone P, et al. Combined approach for the treatment of anorectal condyloma. Carbon dioxide laser excision and endoscopic argon plasma coagulation in a case report. Ann Ital Chir 2011;82:159–62.
Azzolini F, et al. Gut Month 2014 Vol 0 No 0
Downloaded from gut.bmj.com on October 18, 2014 - Published by group.bmj.com
Endoscopic submucosal dissection of an unusual flat rectal neoplasm Francesco Azzolini, Paolo Cecinato, Veronica Iori, et al. Gut published online October 15, 2014
doi: 10.1136/gutjnl-2014-308298
Updated information and services can be found at: http://gut.bmj.com/content/early/2014/10/15/gutjnl-2014-308298.full.html
These include:
Data Supplement
"Supplementary Data" http://gut.bmj.com/content/suppl/2014/10/15/gutjnl-2014-308298.DC1.html
References
This article cites 6 articles http://gut.bmj.com/content/early/2014/10/15/gutjnl-2014-308298.full.html#ref-list-1
P
Gut Online First, published on October 15, 2014 as 10.1136/gutjnl-2014-308298 Editor’s quiz: GI snapshot
Endoscopic submucosal dissection of an unusual flat rectal neoplasm
benign change such as low-grade dysplasia with a probability of approximately 50% (figure 2).1 The lesion involved half of the circumference of the rectum and the dentate line and the anal squamous epithelium for about 10 mm. We decided not to biopsy to avoid fibrosis. For the benign appearance and in order to avoid surgery, an endoscopic submucosal dissection (ESD) was performed (see online supplementary video).
QUESTION CLINICAL PRESENTATION A 63-year-old woman was admitted to our gastroenterology unit to undergo a screening colonoscopy, scheduled for faecal occult blood test positivity. During the procedure, a flat, rectal granular lesion was found. With the use of magnification and narrow band image (NBI) technology, the lesion was diagnosed as a laterally spreading tumour (LST), granular mixed type, 30 mm in maximum diameter (figure 1). The pit pattern was unclassifiable and vascular pattern was similar to the type IV of the classification proposed by Inoue regarding the microvasculature pattern of the oesophagus for diagnosis and evaluation of the squamous cell carcinoma. The type IV shows initial irregularity and dilated intra-papillary capillary loops and indicates
What is the nature of the lesion?
ANSWER Histopathology examination revealed squamous epithelium with papillary formations and marked acanthosis extended to the glandular structures of the rectal mucosa; cells presented vacuolated cytoplasm, irregular and hypercromatic nucleus, binucleate cells, all characteristics of human papillomavirus (HPV) infection (figure 3). Furthermore, nuclei showed focal atypia, pleomorphism and partial loss of surface maturation, indicative of low-grade intraepithelial dysplasia (figure 4). Genotyping revealed HPV type 11. Diagnosis was condyloma acuminatum with low-grade dysplasia.
Figure 1 Endoscopic view.
Figure 3
Histopathological features of the condyloma acuminatum.
Figure 2 Endoscopic view using narrow band imaging.
Figure 4
Histopathological evidence of low-grade dysplasia.
Azzolini F, et Produced al. Gut Month 2014 Vol 0 NoPublishing 0 1 Copyright Article author (or their employer) 2014. by BMJ Group Ltd (& BSG) under licence.
Downloaded from gut.bmj.com on October 18, 2014 - Published by group.bmj.com
Editor’s quiz: GI snapshot Clinical presentation of condyloma is variable; the flat shape and the involvement of the rectal mucosa are rare. Furthermore, their identification often requires the use of high-definition endoscopy.2 In our case, the involvement of the rectal mucosa, the extension and the pattern of the lesion were well recognised using NBI. Both low-risk (subtypes 6 and 11) and high-risk (subtypes 16 and 18) HPV subtypes have also been associated with welldifferentiated squamous cell carcinoma.3 Therefore, treatment modalities are primarily focused on destroying or removing the lesions locally. In this unusual localisation, in addition to topical and surgical options,4 an endoscopic treatment with argon plasma coagulation has been proposed.5 6 In our case, lesion appearance, mimicking an LST with a microvascular pattern of unsure dysplastic nature, induced us to perform an ESD, which was safely and successfully completed.
intellectual content: RS. All authors have approved the final draft submitted for publication. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/gutjnl-2014-308298). To cite Azzolini F, Cecinato P, Iori V, et al. Gut Published Online First: [ please include Day Month Year] doi:10.1136/gutjnl-2014-308298 Received 21 August 2014 Revised 9 September 2014 Accepted 19 September 2014 Gut 2014;0:1–2. doi:10.1136/gutjnl-2014-308298
REFERENCES 1
Francesco Azzolini,1 Paolo Cecinato,1 Veronica Iori,1 Loredana De Marco,2 Ramona Zecchini,1 Cristina Fodero,3 Cristiana Tioli,1 Romano Sassatelli1
2
1
Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria NuovaIRCCS, Reggio Emilia, Italy 2 Unit of Pathology, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy 3 Cervical Cancer Screening Centre, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
3 4
Correspondence to Dr Francesco Azzolini, Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, 42123, Italy; [email protected]
5
Contributors Guarantor of the article: FA. Specific author contributions—study concept and design: FA; drafting of the manuscript: FA and PC; acquisition of data: PC, VI, LD, RZ, CT and CF; critical revision of the manuscript for important
6
2
Inoue H. Magnification endoscopy in the esophagus and stomach. Dig Endosc 2001;13(Suppl):40–1. Echenique I, Phillips BR. Anal warts and anal intradermal neoplasia. Clin Colon Rectal Surg 2011;24:31–8. Dubina M. Viral-associated non-melanoma skin cancers: a review. Am J Dermatopathol 2009;31:561–73. Leszczyszyn J, Lebski I, Lysenko L, et al. Anal warts (condylomata acuminata)— current issues and treatment modalities. Adv Clin Exp Med 2014;23:307–11. Review. Viazis N, Vlachogiannakos J, Vasiliadis K, et al. Earlier eradication of intra-anal warts with argon plasma coagulator combined with imiquimod cream compared with argon plasma coagulator alone: a prospective, randomized trial. Dis Colon Rectum 2007;50:2173–9. Pontone S, Pironi D, Pontone P, et al. Combined approach for the treatment of anorectal condyloma. Carbon dioxide laser excision and endoscopic argon plasma coagulation in a case report. Ann Ital Chir 2011;82:159–62.
Azzolini F, et al. Gut Month 2014 Vol 0 No 0
Downloaded from gut.bmj.com on October 18, 2014 - Published by group.bmj.com
Endoscopic submucosal dissection of an unusual flat rectal neoplasm Francesco Azzolini, Paolo Cecinato, Veronica Iori, et al. Gut published online October 15, 2014
doi: 10.1136/gutjnl-2014-308298
Updated information and services can be found at: http://gut.bmj.com/content/early/2014/10/15/gutjnl-2014-308298.full.html
These include:
Data Supplement
"Supplementary Data" http://gut.bmj.com/content/suppl/2014/10/15/gutjnl-2014-308298.DC1.html
References
This article cites 6 articles http://gut.bmj.com/content/early/2014/10/15/gutjnl-2014-308298.full.html#ref-list-1
P
