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Colorectal Tumor

Among various diseases, the most frequent diseases of the large intestine involve polyps and cancer.

Polyps are classified into tumorous polyp, inflammatory polyp and hyperplastic polyp. Tumorous polyp carries the risk of malignant transformation, and is therapeutically important.

The concept that cancer is derived from tumorous polyp has generally been accepted. However, recent studies have shown that cancer develops directly from the normal mucosa not in a few cases other than those related to malignant transformation of tumorous polyp.

Not only polyp but also cancer is asymptomatic in most cases. Endoscopy should be performed not only in patients positive for occult blood in stool but also in patients negative for occult blood in stool, if there is a family history of colorectal tumor.

When tumor is detected by endoscopy, endoscopic resection is aggressively performed at our clinic, although there are various criteria. Figures 1 to 4 serially show the process of resecting a flat tumorous lesion. We call the process "Strip Biopsy".

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Figure1
The overall figure of the lesion was unclear due to the flat morphology.

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Figure2
Scattered specific dye facilitated examining the features of this lesion.

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Figure3
Solution was infused into the general area to elevate the entire lesion.

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Figure4
The lesion was held with a snare forceps, and resected using an electrocautery.
black arrowFmucosa after resection
white arrowFresected lesion

flat-depressed early colon cancer about 10mm
Figure5

Early colorectal cancer or adenoma has been considered mostly to be of the elevated type, and superficial types, particularly the flat-depressed type, have been regarded as rarity. Therefore, endoscopic treatment has been limited to polypectomy. However, thanks to the efforts of Dr. Shinei Kudo et al. of the Division of Gastroenterology, Akita Red Cross Hospital, flat-depressed type early cancers have come to be detected frequently on close examination of the colon by total colonoscopy. This has made strip biopsy necessary for the diagnosis and treatment.

Since most of flat-depressed type cancers exceeding 10mm in diameter reach the submucosa, they are not indications of strip biopsy, and few of them can be resected as intramucosal cancers. Therefore, flat-depressed type cancers should be regarded as indications of strip biopsy when they are 10mm or smaller.

The figure5 shows flat-depressed early colon cancer about 10mm in diameter. The lesion had a borderline size between an indication and no indication of strip biopsy, but we performed endoscopic resection after through consultation with the patient. The lesion turned out to be an intramucosal cancer, and we, for the time being,consider that complete cure could be achieved by endoscopic resection. However, for the above reasons, immediate open surgery instead of endoscopic resection is recommended for flat-depressed type cancers of this or greater size.