What is the correct action?
This is the scar following the piecemeal removal of a sigmoid polyp some 6 months ago. It was a 15mm tubular adenoma harbouring high-grade dysplasia. Samples from the EMR scar has showed 'distorted glands' only.
WHAT WOULD BE THE CORRECT FOLLOW UP?
a) organise an immediate follow-up
WTF ! This not a normal scar! You absolutely need to organise more samples, and perhaps a CT !!!
b) organise a follow-up in 6 months time
Would have been a mistake !
c) organise a follow-up in 12 months time
Would have been a big mistake!!!
d) organise a follow-up in 3 years time
May have cost the patient his life!!!
The first EMR was piecemeal and histology could of course not confirm that the resection had been complete. Indeed the 'index histology' reads oddly mentioning "frequent mitotic figures" and "back to back glands". To a gastroenterologist these words does not sound particularly alarming.
However, the pathologist was trying to say "this looks like cancer but I can't actually make that diagnosis" !!! Indeed this doesn't look like a normal EMR scar! The whole area is indurated as if there is an infiltrative process below the mucosa. Histology was reassuring mentioning some distorted crypts only.
Sadly, the endoscopist was content with the reassuring repeat histology and did not reflect on the worrying endoscopic appearances. He did NOT organise a second round of post-EMR samples and the patient returned 2 years later with an advanced cancer.
The take home messages from this sad story?