Patients with Lynch syndrome have an increased risk of developing colorectal neoplasia, but evidence regarding the role of endoscopic submucosal dissection (ESD) in this setting, compared with surgery, is limited. This study aims to evaluate the efficacy and safety of ESD for superficial colorectal neoplasia in patients with Lynch syndrome.

A single-center case series was conducted including all Lynch syndrome patients who underwent ESD for superficial colorectal neoplasia between November 2020 and October 2025. Clinical and lesion characteristics, procedural outcomes, complications, histology, and post-ESD management were analyzed.

Twelve patients were included, nine of whom had a prior history of extra-colonic malignancy. Mean lesion size was 34 mm (range 20–60 mm). Lesions were located in the rectum (17%), sigmoid colon (33%), descending colon (8%), transverse colon (8%), hepatic flexure (17%) and ascending colon (17%). Morphology of lesions was assessed using Paris classification: there were 5 (42%) sessile polyps, 3 (25%) flat elevated lesions, 3 (25%) flat elevated lesions with central depression and 1 (8%) flat elevated lesion with raised nodule. Pit pattern of lesions was assessed using Kudo’s classification and was IIIs in 5 (42%) lesions, IIIL in 2 (17%) lesions, IV in 1 (8%) lesion, Vi in 3 (25%) lesions and Vn in 1 (8%) lesion. En bloc resection was achieved in 10 patients (83%), while two procedures (17%) were discontinued due to technical difficulty and suspected deep invasion. Adenocarcinoma was identified in four cases, two with submucosal invasion >2 mm, two with lymphovascular invasion and one with both. Overall, five patients (42%) achieved curative resection; six (50%) were referred for surgery and one (8%) to oncologist for evidence of diffuse abdominal lymphadenopathy on staging CT. No perforation or clinically significant bleeding occurred. At 1-year follow-up, no local recurrence was observed among patients who underwent curative ESD.

In patients with Lynch syndrome, ESD appears to be an effective and safe therapeutic option for selected cases of superficial colorectal cancer. The considerable rate of non-curative resections due to unfavorable histological features highlights the need for thorough endoscopic assessment before resection and supports ESD as the preferred technique. Further studies with larger cohorts are warranted to define the optimal role of ESD in this high-risk population.