Early colon cancer within a diverticulum treated by magnifying chromoendoscopy and laparoscopy

Abstract

We report a unique case of intramucosal carcinoma in a tubulovillous adenoma arising from a single diverticulum. Endoscopic mucosal resection (EMR) was carried out successfully and completely with the assistance of laparoscopy. A 71-year-old man was admitted to our hospital because of melena and anemia. Emergent colonoscopy showed diverticulosis in the right-sided colon. However, endoscopy could not exactly detect the bleeding site. A flat elevated polyp was found within a single diverticulum located in the descending colon and diagnosed as an intramucosal carcinoma, as magnifying chromoendoscopy revealed a type IV pit pattern. As his diverticular bleeding repeated, a right-sided hemicolectomy was decided for treatment, the polyp within the diverticulum was also completely removed by EMR with the assistance of laparoscopy. Although a colonic perforation was detected immediately after EMR, the perforation was closed with endoclips intraluminally and also repaired laparoscopically from the serosal side. Histologically, the resected lesion was an intramucosal well-differentiated adenocarcinoma and the surgical margin was free of tumor.

Endoscopic Management of a Tubulovillous Adenoma Within a Diverticulum: Report of a Case and Review of Literature

“…Generally, EMR and endoscopic resection of banded tissues are considered challenging in cases of diverticula-associated CRN due to the increased risk of perforation secondary to the lack of a muscular layer [4,11,12]. On the other hand, ESD safety and feasibility has been demonstrated for these particular lesions in a more recent retrospective case series by Jimenez-Garcia et al with better en block resection rates for tumors located near a diverticulum than those extending into the diverticulum [7].…”

“…Adenomatous polyps are the most prevalent neoplastic polyps in the colon and comprise approximately two-thirds of all colonic polyps [1]. Adenomas or adenocarcinomas located within a diverticulum are a rare phenomenon that has been described in the literature [2][3][4][5]. These lesions pose a technical challenge for endoscopic management given their difficult location inside the diverticulum and the greater risk of perforation upon endoscopic resection owing to the lack of the muscular layer within the diverticulum [4][5][6].…”

“…Adenomas or adenocarcinomas located within a diverticulum are a rare phenomenon that has been described in the literature [ 2 - 5 ]. These lesions pose a technical challenge for endoscopic management given their difficult location inside the diverticulum and the greater risk of perforation upon endoscopic resection owing to the lack of the muscular layer within the diverticulum [ 4 - 6 ]. Therefore, surgery is considered the standard treatment for colorectal neoplasia (CRN) associated with a diverticulum [ 7 ].…”

Metastatic colon cancer derived from a diverticulum incidentally found at herniorrhaphy: a case report

“…Malignancies can arise in colonic diverticula. The diagnosis was made based on the endoscopic finding of a tumor within a diverticulum [ 7 ]. However, establishing the diagnosis may be complicated by abnormal findings, such as abscess formation, submucosal progression, or diverticulitis [ 8 ].…”

Endoscopic submucosal dissection in management of colorectal tumors near or involving a diverticulum: a retrospective case series

“…On the other hand, because they are associated with a negligible risk of lymph node metastasis, colorectal tumors confined to the mucosal layer can be successfully managed by endoscopic treatments such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) 4 . However, EMR is considered dangerous in cases of diverticula-associated colorectal tumors due to absence of a muscular layer in diverticulum and the consequent increased risk of perforation 5 .…”