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

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.

Fig. 1 Endoscopic submucosal dissection (ESD) of a hyperplastic polyp with low grade dysplasia located on the posterior wall of the antrum in a 68-year-old man. a White light imaging of the lesion. b Virtual chromoendoscopy with narrow-band imaging. c Resection bed after ESD. d Specimen with large free margins.

Fig. 2 Histology of the initial endoscopic resection in 2013. a Hyperplastic peduncular polyp with low grade dysplasia. b Proliferation of surface foveolar cells, which are elongated and tortuous.

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.

Fig. 3 Endoscopic examination for the recurrence of hyperplasia. a Proximal margin at the level of the angulus on white light imaging. b Proximal margin at the level of the angulus on narrow-band imaging. c Middle view in the antrum. d Retroflexion view in the duodenum, with the lesion extending across the pylorus.

Fig. 4 Recurrence histology. a Diffuse recurrence with both a scarring granulation process and hyperplastic tissue. b Same aspect with low magnification.

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 follow-up appears to be justified in patients who undergo resections of this type.

Endoscopy_UCTN_Code_CPL_1AH_2AZ

• References

• 1 Chung I-K, Lee JH, Lee S-H et al. Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study. Gastrointest Endosc 2009; 69: 1228-1235
• 2 Ahn JY, Son DH, Choi KD et al. Neoplasms arising in large gastric hyperplastic polyps: endoscopic and pathologic features. Gastrointest Endosc 2014; 80: 1005-1013.e2
• 3 Jung E-Y, Choi S-O, Cho KB et al. Successful endoscopic submucosal dissection of a giant polyp in a 21-month-old female. World J Gastroenterol 2014; 20: 323-325
• 4 Joffe N, Goldman H, Antonioli DA. Recurring hyperplastic gastric polyps following subtotal gastrectomy. AJR Am J Roentgenol 1978; 130: 301-305
• 5 Hongo M, Fujimoto K. Gastric Polyps Study Group. Incidence and risk factor of fundic gland polyp and hyperplastic polyp in long-term proton pump inhibitor therapy: a prospective study in Japan. J Gastroenterol 2010; 45: 618-624