Giant atypical hyperplastic lesions on Barrett’s esophagus and at the esophagogastric junction resected by endoscopic submucosal dissection

Barrett’s esophagus (BE) neoplasms are usually flat or slightly depressed and should be treated by endoscopic resection when lesions are visible, according to European Society of Gastrointestinal Endoscopy (ESGE) guidelines [1].

We report here an unusual case of several villous semipedunculated [2] lesions all located along a C10M10 BE and at the esophagogastric junction (EGJ) ([Video 1]).

Video 1 Endoscopic appearance of giant hyperplastic lesions at the esophagogastric junction and at the middle part of Barrett’s esophagus area.

Macroscopically, the largest lesion ([Fig. 1]) was an exophytic villous polyp with abundant mucus secretion that had developed on the EGJ. There was no depressed area and the pit pattern was type IV regular pattern [3]. Previous biopsy samples showed low grade dysplasia, and computed tomography (CT) scan and endoscopic ultrasound (EUS) evaluation did not reveal lymph node metastasis or muscle invasion.

Fig. 1 Giant hyperplastic lesion at the esophagogastric junction (1st polyp): a, b endoscopic appearance; c resected specimen; d pathology findings.

Endoscopic submucosal dissection (ESD) was proposed and achieved en bloc R0 resection of a 14 × 6-cm specimen. After expert pathology discussion, the final diagnosis was hyperplastic foveolar polyp of size 10 × 5 cm that had developed upon a cardial mucosa, with no sign of intestinal metaplasia nor of dysplasia. Complementary examinations were carried out, and revealed diffuse marking of the lesion with anti-MUC6 antibodies, pointing to pyloric adenoma. However, pyloric adenomas usually present RAS or GNAS mutations but none of these could be identified. Follow-up endoscopy did not show any recurrence at the ESD site.

The second largest lesion was located in the middle of the BE and had a similar pedunculated hyperplastic aspect. A second ESD procedure was performed ([Fig. 2]) without adverse events, allowing an en bloc R0 resection of a 7 × 5-cm area. Pathological examination revealed low grade dysplasia on BE mucosa.

Fig. 2 The low grade dysplasia lesion on the Barrett’s esophagus (2nd polyp): a, b endoscopic appearance; c resected specimen; d pathology findings.

This combination of different lesions with both a hyperplastic lesion of the EGJ and pedunculated low grade dysplasia is not usual, especially considering the large size of the lesions [4]. Aggravated mucosal injury due to gastroesophageal reflux disease could be responsible. ESD is an option for removing those large lesions en bloc and with margins.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AH

• References

• 1 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
• 2 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: S3-43
• 3 Kudo S, Tamura S, Nakajima T. et al. Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc 1996; 44: 8-14
• 4 Abraham SC, Singh VK, Yardley JH. et al. Hyperplastic polyps of the esophagus and esophagogastric junction: histologic and clinicopathologic findings. Am J Surg Pathol 2001; 25: 1180-1187