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en bloc endoscopic submucosal dissection (ESD) for the management of two neighboring, laterally spreading tumors that were small, well-differentiated adenocarcinomas. The precise process and results of this procedure have been previously reported [1]. Both lesions were confined to the lamina propria without lymphovascular involvement (●" Fig. 1) and had clear resection margins. The procedure was considered to be curative in that colonicmucosal cancers do not metastasize to the lymph nodes or distant organs [2,3]. Follow-up studies were performed at 6, 18, and 30 months after the procedure. Only ESD scars without any residual or recurrent lesions were found during each colonoscopy. However, at the last follow-up, computed tomography (CT) and positron emission tomography (PET) showed two newly developed, small perirectal lymph nodes (●" Fig. 2). He underwent surgery, at which no remnants of tumor were observed in the resected colon but metastatic carcinoma was found in the lymph nodes (●" Fig. 3). ESD is now being increasingly usedworldwide for the treatment of colorectal mucosal cancer[4] because en bloc resection of a lesion is possible regardless of lesion size. In the present case, ESD was appropriate treatment for both lesions according to the histologic curative criteria [3], and the lesions appeared to have been successfully treated. However, regional nodal metastases were found without any remnant or recurrent lesions at the resection sites during follow-up studies 30 months after the original procedure. The efficacy of colorectal ESD cannot be completely denied based on the results from the present case; however, every endoscopist should keep in mind that even intramucosal colorectal cancer has some risk of future nodal metastasis. A recent report mentioned the possibility of nodal metastasis in gastric mucosal cancer [5]. Although to date there are no similar reports for colorectal cancer, multimodal evaluations conducted at regular intervals after the procedure seem to be warranted. Nodal metastasis after successful endoscopic submucosal dissection for colorectal mucosal cancer