Successful endoscopic submucosal dissection of duodenal cancer

This is the first report of complete resection of early duodenal cancer using endoscopic submucosal dissection (ESD) monotherapy.

A 66-year-old Japanese man visited the hospital in order to undergo screening for cancer on June 2004. Endoscopic examination of the upper digestive tract revealed a faintly marked, red, depressed (0-IIc) lesion, 3.5 × 3.0 mm in diameter, on the posterior wall of the duodenal cap ([Fig. 1]). The biopsy specimen obtained from the lesion revealed a well-differentiated tubular adenocarcinoma ([Fig. 2]). No metastasis to any other organ was found. A barium X-ray study showed there was no notable duodenal transformation. In addition, the lesion showed the lifting sign after submucosal saline injection [1] [2]. This lesion was diagnosed as a mucosal duodenal cancer. ESD was selected for this patient after histological confirmation of the diagnosis. A cylindrical transparent hood was attached to the endoscope to maintain a satisfactory view during the procedure.

Fig. 1 An endoscopic examination of the upper digestive tract revealed a faintly marked, red, depressed (0-IIc) lesion, 3.5 × 3.0 mm in diameter, on the posterior wall of the duodenal cap.

Fig. 2 The biopsy specimen obtained from the lesion revealed a well-differentiated tubular adenocarcinoma (H & E, original magnification × 40).

ESD was carried out primarily using the flex knife (KD-630L; Olympus) and hook knife (KD-620LR; Olympus) as described previously by Kodashima and Rösch [3] [4] ([Fig. 3]). Bleeding during the procedure was managed by the administration of thrombin and by snare coagulation. Some hemoclips were also used to prevent perforation ([Fig. 4]). No recurrence has been found in more than 3 years since ESD ([Fig. 5]). In this patient, the successful outcome depended on two points: (i) the use of hemoclips on the scar after resection, and (ii) the attachment of a cylindrical transparent hood to the endoscope, which together made the ESD easier and safer.

Fig. 3 The lesion was completely resected with a safe lateral and vertical margin.

Fig. 4 After the resection the scar was closed by hemoclips to prevent perforation.

Fig. 5 No recurrence has been observed in more than 3 years since the ESD was carried out.

ESD might be one of the most effective and useful techniques for the treatment of early duodenal cancer in the future.

Endoscopy_UCTN_Code_TTT_1AO_2AG

References

• 1 Han K S, Sohn D K, Choi D H. et al . Prolongation of the period between biopsy and EMR can influence the nonlifting sign in endoscopically resectable colorectal cancers.  Gastrointest Endosc. 2008;  67 97-102
• 2 Kobayashi N, Saito Y, Sano Y. et al . Determining the treatment strategy for colorectal neoplastic lesions: endoscopic assessment or the non-lifting sign for diagnosing invasion depth?.  Endoscopy. 2007;  39 701-705
• 3 Kodashima S, Fujishiro M, Yahagi N. et al . Endoscopic submucosal dissection using flexknife.  J Clin Gastroenterol. 2006;  40 378-384
• 4 Rösch T, Sarbia M, Schumacher B. et al . Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series.  Endoscopy. 2004;  36 788-801