Endoscopic submucosal dissection of a small rectal submucosal lesion: a rare case of rectal liposarcoma

With the broadening of indications for colonoscopy, colonic subepithelial lesions (SELs) are more frequently detected. Their incidence is about one in 300 colonoscopies. They appear as a small bulging lesion covered with normal mucosa [1]. Liposarcoma is one of the most common soft tissue sarcomas, yet it is an extremely rare disease. Less than 20 colonic liposarcomas have been described [2].

We report here the case of a 65-year-old man referred to our endoscopy unit for endoscopic submucosal dissection (ESD) of a large laterally spreading tumor of the right colon. During the surveillance endoscopy, a 3-mm SEL was found in the middle rectum, which at the time was thought to be a small neuroendocrine tumor. The mucosa covering the SEL was normal ([Fig. 1], [Fig. 2]).

Fig. 1 The subepithelial lesion seen in white light imaging.

Fig. 2 The subepithelial lesion seen in narrow-band imaging.

We decided to perform an ESD to do a complete removal of the suspect lesion on the hypothesis of a small neuroendocrine tumor ([Video 1]). After submucosal injection, a circumferential incision was made ([Fig. 3]). The double-clip traction technique was used to shorten the procedure duration ([Fig. 4]) [3]. Overall the resection lasted 14 minutes. Two clips were placed to avoid delayed bleeding. Histology revealed a complete resection of a 3-mm well differentiated liposarcoma. The patient was referred to a specialized center. Computed tomography (CT) of the chest, abdomen, and pelvis revealed no lymph node or metastasis. The patient will be given no further treatment and will be monitored regularly by CT for the next 5 years.

Video 1 Endoscopic diagnosis and endoscopic submucosal dissection of a small rectal liposarcoma.

Fig. 3 Circumferential incision after submucosal injection.

Fig. 4 The double-clip traction technique.

To our knowledge, this is the first ever case report showing the endoscopic appearance of an early well-differentiated liposarcoma and its complete resection with ESD leading to complete remission. This case emphasizes that ESD is surely the most appropriate technique to remove SELs with R0 margins, as the histological diagnosis may differ a lot between SELs.

Endoscopy_UCTN_Code_CCL_1AD_2AB

Publication History

Article published online:
15 October 2021

• References

• 1 Kim TO. Colorectal subepithelial lesions. Clin Endosc 2015; 48: 302-307
• 2 D’Annibale M, Cosimelli M, Covello R. et al. Liposarcoma of the colon presenting as an endoluminal mass. World J Surg Oncol 2009; 7: 78
• 3 Bordillon P, Pioche M, Wallenhorst T. et al. Double-clip traction for colonic endoscopic submucosal dissection: a multicenter study of 599 consecutive cases (with video). Gastrointest Endosc 2021; 94: 333-343