Lifted or not lifted - that is the question!

Flat polyp found in the ascending colon of an elderly patient with anaemia
WHAT DO YOU THINK TO THE LIFT?

■ Good - Attack!

Hmm, you are an optimist here!

■ Borderline - proceed with caution !

Yes, or bail out unless you are sure of what you are doing !

■ Poor - Abort !

There is no shame in bringing this back to the Cancer group to think again!

explanation

 Of course submucosal 'lifting' is not a black & white question!  It's a spectrum as pointed out by Dr Kato some 20 years ago and in his paper (Endoscopy 2001;33:568-73) he included this great 'infographic'. 

By the way, there are two further points to the issue of 'non-lifting'. If you keep injecting below a non-lifting lesion, you will find that it seems to be getting smaller. Of course what is happening is that the edges get pushed over (illustration at the bottom of this page), allowing the lesion to fold in on itself. Don't misinterpret this as a 'reasonable lift'.  Secondly, when you assess if the lesion has lifted, always look behind it. It may seem as if the lesion has lifted well but if you see no submucosal lift behind the lesion, chances are that it's tethered in its centre which stops the submucosal fluid to spread beyond the centre of the lesion.   Click here for an article I have written on the topic! 

Evidently, this lesion is not lifting well in it's centre and I would suggest that you proceed with caution! An ESD resection was required to clear this lesion. As the clear mucosal plane was entirely obliterated in the centre of the lesion (see image on the side), I had some misgivings. However, a previous biopsy had indicated that the lesion was benign and the lower GI MDT had requested an attempt at endoscopic resection before attempting a somewhat hazardous operation (the patient was old, frail and with multiple comorbidities). 

Histology confirmed that the centre was a poorly differentiated cancer which was 'probably completely removed but only with a <100 micron clear deep margin.  As I keep saying, don't expect there to be "entirely good news" after an endoscopic resection of a colonic cancer. 

So what happened?  In spite of the original surgical misgivings the 80 year old patient subsequently underwent a right hemicolectomy which did confirm that the lesion had been completely removed by the earlier ESD. Would a full thickness resection had made any difference?  Of course not! The centre of that cancer would still have been poorly differentiated!!!