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In the present case, a 56\u2010year\u2010old woman with no family history of colon cancer underwent surveillance colonoscopy in which a metachronous flat adenoma was detected following an interval of 23 years after a colectomy and 20 years subsequent to treatment for uterine cancer. A second metachronous flat lesion histopathologically determined to be a submucosal (sm) deep invasive cancer with lymphovascular involvement was detected 12 months later. This second metachronous lesion was suspected of having developed rapidly in the rectal remnant accounting for its sm deep invasion. The findings of this case suggest colonoscopy surveillance guidelines proposed for individuals at high risk should be evaluatedbased on cancer history and an analysis of possible mismatch repair gene mutations. In addition, the first metachronous lesion was located directly on the suture line of the anastomosis. Endoscopic submucosal dissection (<jats:styled-content style=\"fixed-case\">ESD<\/jats:styled-content>) was indicated despite severe fibrosis into the sm layer. This case also demonstrates the successful use of improved <jats:styled-content style=\"fixed-case\">ESD<\/jats:styled-content> instruments, sm injection agents and technique refinements in the treatment of a technically difficult lesion with a high risk of complications.<\/jats:p>","DOI":"10.1111\/den.12094","type":"journal-article","created":{"date-parts":[[2013,4,26]],"date-time":"2013-04-26T01:12:22Z","timestamp":1366938742000},"page":"46-51","source":"Crossref","is-referenced-by-count":4,"title":["Metachronous adenoma on ileorectal anastomosis suture line and submucosal deep invasive cancer suspected of rapid growth in rectal remnant following long\u2010term interval after curative surgery for advanced colon cancer"],"prefix":"10.1111","volume":"25","author":[{"given":"Toshio","family":"Uraoka","sequence":"first","affiliation":[{"name":"Division of Research and Development for Minimally Invasive Treatment Cancer Center School of Medicine Keio University  Tokyo Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Joichiro","family":"Horii","sequence":"additional","affiliation":[{"name":"Division of Research and Development for Minimally Invasive Treatment Cancer Center School of Medicine Keio University  Tokyo Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Osamu","family":"Goto","sequence":"additional","affiliation":[{"name":"Division of Research and Development for Minimally Invasive Treatment Cancer Center School of Medicine Keio University  Tokyo Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Masayuki","family":"Shimoda","sequence":"additional","affiliation":[{"name":"Department of Pathology School of Medicine Keio University  Tokyo Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Naohisa","family":"Yahagi","sequence":"additional","affiliation":[{"name":"Division of Research and Development for Minimally Invasive Treatment Cancer Center School of Medicine Keio University  Tokyo Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2013,4,25]]},"reference":[{"key":"e_1_2_5_2_1","doi-asserted-by":"publisher","DOI":"10.3322\/canjclin.55.2.74"},{"key":"e_1_2_5_3_1","doi-asserted-by":"publisher","DOI":"10.1002\/1097-0142(19810915)48:6<1492::AID-CNCR2820480636>3.0.CO;2-K"},{"key":"e_1_2_5_4_1","doi-asserted-by":"publisher","DOI":"10.1007\/BF02236257"},{"key":"e_1_2_5_5_1","unstructured":"National Comprehensive Cancer Network.NCCN clinical practice guideline.http:\/\/www.nccn.org\/professionals\/physician_gls\/f_guidelines.asp"},{"issue":"5","key":"e_1_2_5_6_1","first-page":"v70\u20107","article-title":"Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow\u2010up","volume":"21","author":"Labianca R","year":"2010","journal-title":"Ann. 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