Extensive hyperplastic recurrence after complete R0 resection by endoscopic submucosal dissection of a gastric hyperplastic polyp with dysplasia

Abstract

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. 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. 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 followup appears to be justified in patients who undergo resections of this type. Endoscopy_UCTN_Code_CPL_1AH_2AZCompeting interests: None This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Risk of neoplastic change in large gastric hyperplastic polyps and recurrence after endoscopic resection

“…Moreover, unlike the observations reported for gastric adenomas and early gastric cancer, the present study showed that ESD does not seem to offer a benefit over piecemeal EMR [17,18]. Furthermore, the occurrence of profuse recurrence (i. e. more extensive than the initial lesion) suggests that these lesions are partly related to an exuberant wound healing process [16]. Medical history of liver cirrhosis was the only risk factor for recurrence.…”

“…For the latter, the goal of endoscopic resection is to diagnose and treat the GHP with neoplastic transformation. However, many cases of local recurrence are reported in the literature, sometimes with severe profuse gastric spreading, even following R0 resection with free lateral and deep margins [16]. Thus, the benefitrisk balance of the resection remains unclear.…”

Malignant gastric hyperplastic polyp: endoscopic features of the demarcated malignant component.

“…This case describes for the first time a clear endoscopic diagnosis of a malignant component within a gastric hyperplastic polyp. In view of the high risk of local recurrence [3] after endoscopic resection, reserving these resections for lesions with neoplastic transformation identified endoscopically could be a better option than a systematic resection of all large gastric hyperplastic polyps. Endoscopy_UCTN_Code_CPL_1AN_2AB…”

Large gastric hyperplastic polyps: to resect or not to resect, that is the question!

“…Although endoscopic resection is currently the recommended treatment for large GHPs, recurrence rates have been uniformly dismal, at around 50 % [8]. An alarming fact demonstrated by Forte et al is that recurrence rates were not just high, but they increased further following subsequent endoscopic resection attempts (78 % and 89 % after second and third resections, respectively, compared with 51 % after the first resection).…”