Characterization of Novel Injectable Lifting Agents Used in Colonic Polyp Removal

Abstract

Colon polypectomy can require an injection of a submucosal lifting agent to fully visualize and completely remove the polyp. To the best of our knowledge, this is the largest morphologic series on the novel lifting agents Eleview and Orise. The study consisted of 1 polypectomy and 8 colon resections from 9 patients: 6 women, 3 men (mean age=64 y); Orise=6, Eleview=3; the median time interval between injection and resection=16 weeks. Pathologic diagnoses of the polyps included tubular adenoma (n=4), tubulovillous adenoma (n=4), and sessile serrated adenoma/polyp (n=1). We report that a histologically processed Orise aliquot from the manufacturer showed similar histology to that seen in the specimens from patients with confirmed Orise injection. The morphology of the agents in the patient specimens changed with time status postinjection: immediate resection of the lifting agent showed basophilic, amorphous, and bubbly-extracellular material with prominent hemorrhage, and resection ∼3 months after lifting agent injection showed prominent hyalinized, pink-amorphous ribbons and globules with a foreign body giant cell reaction and fibrosis. The epicenter of the lifting agents was in the submucosa, and the agents were neither refractile nor polarizable. Because of the morphologic overlap with amyloid, 5 cases were stained with Congo Red, and all cases were negative. In conclusion, awareness of the morphology of these new lifting agents is important for accurate diagnosis and to avoid the diagnostic pitfall of amyloid. These lesions can be definitively distinguished from amyloid by their nonreactivity on a Congo Red and familiarity with their characteristic clinicopathologic presentation.

New Kids on the Block

“…Eleview and ORISE are recently introduced synthetic lifting agents. They are injected into the submucosa during an endoscopic procedure to fully visualize and resect flat or sessile lesions 5,[33][34][35][36] (Figure 4, A and B). They are most commonly seen in the resection of sessile colonic polyps, but can also be used for removal of sessile lesions in the esophagus, stomach, and small bowel ( Table 1).…”

“…34 Compared with the more traditional agents composed of saline and methylene blue, these new submucosal lifting agents are more expensive, but they offer the advantage of immediate availability without requiring media preparation during the procedure. 5,34,[36][37][38] Compared with the more traditional agents, studies have shown that these newer submucosal lifting agents are equally safe, are more effective, require fewer repeat injections, and have a decreased procedure duration because they maintain the submucosal fluid cushion for a longer period of time. 33,37,38 Histopathologic Examination ORISE and Eleview have a similar histologic appearance.…”

“…33,37,38 Histopathologic Examination ORISE and Eleview have a similar histologic appearance. 5,35,36 These agents are best seen in the submucosa, and the morphology changes with time. Immediately after injection, the agent has a similar appearance to acellular mucin on H&E and manifests as extracellular pale, bluegray, amorphous, and variably bubbly to finely granular material ( Figure 4, C and D).…”

“…Resection 2 to 3 months after lifting agent injection grossly presents as a white-tan, firm submucosal mass. Histologic sections show prominent amorphous, pink hyaline-like material with a foreign body giant cell reaction and fibrosis, also referred to as lifting agent granuloma 5,35,36,39 (Table 2; Figure 4, E and F). The hyalinized ribbons and globules seen in the older lesions are thought to represent degrading lifting agent or a tissue reaction to the degrading agent.…”

“…W ith increasing endoscopy and the increasing development and use of iatrogenic agents, pathologists encounter a mounting number of retrieved gastrointestinal (GI) specimens with characteristic foreign materials. [1][2][3][4][5][6][7][8][9] As detailed in this review, some agents are critical to recognize because of their association with significant background mucosal injury, such as yttrium 90 ( 90 Y) microsphereassociated radiation 1,10,11 or sodium polystyrene sulfonateor sevelamer-associated mucosal ulcers, ischemia, and pseudotumors. 8,[12][13][14][15][16][17][18][19][20][21][22] Other foreign materials are inconsequential, such as pharmaceutical fillers or bile acid sequestrants (BASs), but awareness of their typical histologic appearance is important to prevent misdiagnosis and triggering of unnecessary additional studies.…”