Hybrid endoscopic submucosal dissection and endoscopic full thickness resection for R0 resection of T1 colonic adenocarcinoma. These are our disclosures. Accurate optical diagnosis of malignant colorectal polyps is the key to determine suitable resection strategy. Endoscopic resection of submucosally invasive colorectal adenocarcinoma can be performed for malignant colorectal polyps limited to the superficial submucosa. Endoscopic full thickness resection using the full thickness resection device allows for transmural resection of malignant colorectal polyps. EFTR technique involves the use of a grasping forceps to pull the desired lesion into the cap followed by deployment of preloaded clip and resection using electrocautery. This technique is limited for lesions up to 20 mm due to the width of the cap. In addition, lesions with significant fibrosis or deep submucosal invasion can be challenging to pull into the cap prior to clip deployment due to lack of pliability. This inherent limitation of the technique can be overcome by utilization of endoscopic submucosal dissection initially to make the lesion more pliable thus allowing it to be pulled into the cap and complete end block resection. We report a case of submucosally invasive colorectal adenocarcinoma successfully resected using hybrid ESD EFTR technique. A 72-year-old male with a history of diabetes mellitus, hypertension, coronary artery disease, chronic obstructive pulmonary disease, and chronic kidney disease was referred to our center for management of a large malignant polyp. The polyp revealed a 35 mm lesion classified as PARIS 2A plus 2C in the transverse colon with features concerning for submucosal invasion. Given the optical features were consistent with submucosal invasive cancer, it was decided to perform hybrid ESD EFTR for the lesion. The lesion is marked using the marking probe. Submucosal injection is then performed. Mucosal incision is completed in retroflexion. Partial submucosal dissection is performed using the ESD knife. The full thickness resection device is advanced to the lesion. Grasping forceps is used to grasp the lesion. Grasping forcep is used to pull the lesion into the cap. Intermittent suction is applied to increase tissue purchase. Once the lesion is completely retracted into the cap, the clip is deployed followed by closure of a pre-mounted snare in electrocautery enhanced resection of the lesion. Post resection site with fatty tissue is seen consistent with full thickness resection. No complications are noticed. The resected specimen can be seen here measuring 35 by 30 millimeters with pathology showing adenocarcinoma. The adenocarcinoma was moderately differentiated infiltrating into the outer half of the submucosa with a depth of invasion 1.5 millimeters and low tumor budding. Lateral and deep margins were negative without lymphovascular invasion. However, perineural invasion was observed. There were no adverse events associated with the hybrid ASD-EFTR technique. Patient was referred to surgery given high risk features on pathology. Our case highlights that hybrid ASD-EFTR technique can allow for safe and effective removal of superficially invasive submucosal colon adenocarcinoma for lesions 20 millimeters or greater in size. Circumferential incision and partial dissection make the lesion more pliable to pull into the FTRD cap and ensure complete resection of the lesion.

endoscopic submucosal dissection

endoscopic full thickness resection

colonic adenocarcinoma

R0 resection

tumor budding