Oklahoma University Health Sciences Center Oklahoma City, OK
Award: Presidential Poster Award
Erin Tsambikos, MD, Eleanor Abreo, MD, William Tierney, MD, Lewis Hassell, MD; Oklahoma University Health Sciences Center, Oklahoma City, OK
Introduction: Early stage esophageal cancer without lymph node metastases can often be resected endoscopically. Submucosal injection is typically performed to lift lesions, enhancing safety and complete resection rates. Although normal saline and other solutions have been widely used for years, more viscous solutions have recently gained popularity.
Methods: A 58-year-old male was incidentally found to have distal esophageal wall thickening on computerized tomography. Esophagogastroduodenoscopy revealed a 1.2 cm polyp, and pathology proved intramuscular adenocarcinoma (Figure 1). During a subsequent endoscopic mucosal resection, ORISETMgel (Boston Scientific, Marlborough, MA) was injected to lift a 2 cm semi-pedunculated polypoid mass and an extensive 4 cm x 2 cm long adjacent area of nodular Barrett’s mucosa covering 80% of the circumference of the esophagus. Pathology of the polypoid mass revealed intramuscular adenocarcinoma (stage T1a), and pathology of the nodular mucosa revealed Barrett’s esophagus with high-grade dysplasia all with negative deep margins. Surveillance esophagogastroduodenoscopy with endoscopic ultrasound (EUS) three months later revealed hypoechoic tissue within the submucosa with possible invasion into the muscularis propria (Figure 2). Forceps biopsy revealed esophageal high-grade dysplasia and FNA of the wall thickening revealed atypical cells. Subsequent positron emission tomography-computed tomography showed a fluorodeoxyglucose avid area in the distal esophagus.
Based on the patient’s overall good health and concern for deep invasion, the patient underwent esophagectomy. Gross pathology revealed a white, well-circumscribed mass under the esophageal epithelium. Microscopically, the mass was amorphous material with an extensive foreign body reaction involving submucosa, muscularis propria, and a regional lymph node (Figure 3). While Barrett’s with high- and low-grade dysplasia was present, there was no evidence of residual adenocarcinoma. Discussion: This case introduces a unique histologic and radiologic response to ORISETMgel creating an artifact mimicking recurrent neoplasia. Radiologic findings after injection of ORISETMgel and mucosal resection included wall thickening on EUS and a fluorodeoxyglucose avid area in the distal esophagus on positron emission tomography-computed tomography. Further understanding of the frequency, risk factors, and durability of these changes are necessary to optimize patient management.
Figure 1: Semi-pedunculated polypoid mass prior to endoscopic mucosal resection.
Figure 2: Endoscopic ultrasound demonstrating thickened area of interest in the esophagus.
Figure 3: A hematoxylin and eosin stained slide showing amorphous, hyaline material in a level VII lymph node as well as multinucleated giant cells.
Disclosures: Erin Tsambikos indicated no relevant financial relationships. Eleanor Abreo indicated no relevant financial relationships. William Tierney indicated no relevant financial relationships. Lewis Hassell indicated no relevant financial relationships.