Late Recurrence after Underwater EMR also Treated by Underwater EMR

Case Description

A 58-year-old male patient underwent an urgent Hartmann proctosigmoidectomy for obstructive neoplasia. Postoperative colonoscopy showed a granular homogeneous laterally spread tumor measuring 18 mm at the transverse colon. The lesion was removed by piecemeal UEMR without margin thermal ablation ([Fig. 1A–C]). No adverse events were observed. Histology revealed a tubulovillous adenoma with low-grade dysplasia ([Fig. 1D]). The patient was included in a clinical trial in our service (NCT03021135). According to the study protocol, a tattoo was done 3 cm distal to the lesion bed. At his 6-month surveillance colonoscopy, a scar was found at the site of resection. This scar was carefully examined using white light ([Fig. 2A]), narrow band imaging ([Fig. 2B]), and indigo carmine dye ([Fig. 2C]). No suspicious residual lesion was detected. Biopsies were negative for adenomatous tissue ([Fig. 2D]). Patient was lost after 1-year follow-up, returning 3 years after the first UEMR and 30 months after the first surveillance. This colonoscopy demonstrated an elevated lesion with a villous surface, measuring approximately 7 mm, along with the scar. New UEMR en bloc was performed ([Fig. 3A–C]). Histology confirmed tubulovillous adenoma with low-grade dysplasia ([Fig. 3D]). One year after the second UEMR, another surveillance colonoscopy revealed no residual lesion.

Fig. 1 A A granular homogeneous laterally spread tumor measuring 18 mm at the transverse colon in the white light. (B) Lesion seen with indigo carmine. (C) Piecemeal UEMR procedure. (D) Histology revealed a tubulovillous adenoma with low-grade dysplasia.

Fig. 2 A Scar carefully examined using white light. (B) Scar at narrow band imaging. (C) Indigo carmine dye using to examine the scar. (D) Biopsies negative for adenomatous tissue, with only fibrosis.

Fig. 3 (A,B) An elevated lesion with villous surface. (C) After UEMR en bloc procedure. (D) Histology confirmed tubulovilllous adenoma with low-grade dysplasia.

 

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Practical Implications for Endoscopists

1. Do not lose sight of your patient. Follow-up should be early (6 months) but also long term (1 year and then 3 years after piecemeal EMR), as late recurrence may be due to slow tissue growth.[1]

2. Do a careful examination of the post-mucosectomy scar using enhanced imaging, such as electronic-based methods or dye-based chromoendoscopy, as well as obtaining targeted biopsies. Even after negative biopsies, late recurrences can occur.[1]

3. Do UEMR to reduce early recurrence. However, late recurrence has not yet been evaluated with this technique. Therefore, continue to follow patients who have undergone this technique.[2] [3]

4. Do UEMR to treat residual lesions. UEMR is more effective on these lesions compared with CEMR. Other techniques such as endoscopic submucosal dissection (ESD), full-thickness resection, endoscopic powered resection, and ablation techniques can also be used.[3] [4]

5. En bloc UEMR can be used to successfully treat recurrence after initial piecemeal UEMR.

 

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Conflict of Interest

None declared.

• References

• 1 Gupta S, Lieberman D, Anderson JC. et al. Recommendations for follow-up after colonoscopy and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115 (03) 415-434
• 2 Lenz L, Martins B, Andrade de Paulo G. et al. Underwater versus conventional EMR for nonpedunculated colorectal lesions: a randomized clinical trial. Gastrointest Endosc 2023; 97 (03) 549-558
• 3 de Souza MHG, do Espirito Santo PA, Maluf-Filho F, Lenz L. Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis of randomized clinical trials. Int J Colorectal Dis 2023; 38 (01) 208
• 4 Kim HG, Thosani N, Banerjee S, Chen A, Friedland S. Underwater endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps (with video). Gastrointest Endosc 2014; 80 (06) 1094-1102

Publication History

Article published online:
22 July 2025