Endoscopic submucosal dissection (ESD) is an effective, safe technique for treating gastric lesions [1]. Hyperplastic polyps have an underestimated risk for malignancy, which has been reported to be 3.7 % in 809 lesions measuring more than 1 cm [2]. Thus, complete en bloc resection with ESD is an option to avoid local recurrence [3], particularly when hyperplasia is associated with dysplasia.
We report the case of a 68-year-old man who underwent a complete R0 resection by ESD of a 2-cm hyperplastic polyp with low grade dysplasia that was located on the posterior wall of the antrum ([Fig. 1]). The specimen was 6 cm in size, with large safety margins ([Fig. 2]). Follow-up endoscopy 3 months later revealed good scarring without any local recurrence histologically. Biopsy revealed antral atrophic gastritis and intestinal metaplasia.
Fig. 1 Endoscopic submucosal dissection (ESD) of a hyperplastic polyp with low grade dysplasia located on the posterior wall of the antrum in a 68-year-old man. a White light imaging of the lesion. b Virtual chromoendoscopy with narrow-band imaging. c Resection bed after ESD. d Specimen with large free margins.
Fig. 2 Histology of the initial endoscopic resection in 2013. a Hyperplastic peduncular polyp with low grade dysplasia. b Proliferation of surface foveolar cells, which are elongated and tortuous.
At 1-year follow-up, extensive recurrence had appeared on the whole posterior wall of the antrum that measured more than 8 cm and crossed the pylorus ([Fig. 3], [Fig. 4]). We attempted a new ESD procedure, but severe fibrosis prevented submucosal access. To differentiate recurrence from a profuse scarring process, we performed a snare resection of a 25-mm fragment, which confirmed hyperplasia without dysplasia, in addition to granulation scarring tissue. Such recurrence has previously been described after surgery, but never after endoscopic resection [4]. Because of the significant size of the lesion, the fibrosis, and the potential for malignancy, surgery was scheduled.
Fig. 3 Endoscopic examination for the recurrence of hyperplasia. a Proximal margin at the level of the angulus on white light imaging. b Proximal margin at the level of the angulus on narrow-band imaging. c Middle view in the antrum. d Retroflexion view in the duodenum, with the lesion extending across the pylorus.
Fig. 4 Recurrence histology. a Diffuse recurrence with both a scarring granulation process and hyperplastic tissue. b Same aspect with low magnification.
Various risk factors for hyperplastic gastric polyps have been proposed, such as chronic active gastritis and concomitant Helicobacter pylori infection [5]. In our patient, earlier biopsies never revealed such an infection, but he had a long history of proton pump inhibitor use.
To summarize, we report a profuse recurrence of hyperplasia after curative en bloc ESD of a hyperplastic polyp with low grade dysplasia. This uncommon evolution might be linked to the large area of resection by ESD, which led to a significant scarring process. Long-term follow-up appears to be justified in patients who undergo resections of this type.
Endoscopy_UCTN_Code_CPL_1AH_2AZ
