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Endoscopic submucosal dissection of an unusual flat rectal neoplasm
  1. Francesco Azzolini1,
  2. Paolo Cecinato1,
  3. Veronica Iori1,
  4. Loredana De Marco2,
  5. Ramona Zecchini1,
  6. Cristina Fodero3,
  7. Cristiana Tioli1,
  8. Romano Sassatelli1
  1. 1Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
  2. 2Unit of Pathology, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
  3. 3Cervical Cancer Screening Centre, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
  1. Correspondence to Dr Francesco Azzolini, Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, 42123, Italy; francesco.azzolini{at}asmn.re.it

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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 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).

Figure 2

Endoscopic view using narrow band imaging.

Question

What is the nature of the lesion?

See page 183 for answer

Answer

See page 180 for question

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 3

Histopathological features of the condyloma acuminatum.

Figure 4

Histopathological evidence of low-grade dysplasia.

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 well-differentiated 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.

References

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Supplementary materials

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Footnotes

  • 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 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.

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