Salvage ESD: endoscopic submucosal dissection in rectal neoplasia after total neoadjuvant therapy

The standard treatment of locally advanced rectal neoplasia relies on neoadjuvant chemoradiation followed by surgery [1]. However, organ-preserving strategies seem promising, with endoscopic submucosal dissection (ESD) reporting en bloc and R0 resection rates of 93 and 67%, respectively, and rare adverse events or need for surgery [2].

We present an 84-year-old male diagnosed with stage IIa (T3N0M0) 60 mm neoplasia localized in the middle and low rectum. He was submitted to total neoadjuvant therapy (TNT) with capecitabine and radiation, and his reevaluation magnetic resonance demonstrated a favorable response, with significant but not complete tumoral reduction. Endoscopically, a friable 50 mm granular mixed laterally spreading tumor remained, involving half of the circumference, with small nodules and necrotic areas, but no evident aspects of invasive cancer. The patient refused surgery and was, therefore, proposed for local excision.

After elevation and mucosotomy, ESD was successfully performed, with the aids of tunneling and patient mobilization, to surpass the intense central fibrosis inherent to TNT. Histologically, the excision piece showed an en bloc completely resected tubulovillous adenoma with low-grade dysplasia. There were no immediate or late complications, and a 6-month follow-up showed no tumoral evidence.

With this work, we intend to focus not only on the ESD technical difficulties after TNT, but also in the curative possibility of ESD after TNT in patients with high surgical risk or refusing surgery.

 

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Conflicts of Interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Leung G., Nishimura M., Hingorani N., Lin I.H., Weiser M.R., Garcia-Aguilar J.. et al. Technical feasibility of salvage endoscopic submucosal dissection after chemoradiation for locally advanced rectal adenocarcinoma. Gastrointestinal Endoscopy 2022; 96 (2): 359-367
• 2 Glynne-Jones R., Wyrwicz L., Tiret E., Brown G., Rödel C.D., Cervantes A., Arnold D.. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology 2017; 28: iv22-iv40

Publication History

Article published online:
27 March 2025