Endoscopic submucosal dissection of recurrent or residual superficial esophageal cancer after chemoradiotherapy

doi:10.1016/j.gie.2007.10.008

Gastrointestinal Endoscopy

Volume 67, Issue 2, February 2008, Pages 355-359

https://doi.org/10.1016/j.gie.2007.10.008 Get rights and content

Background

Treatment of local recurrent or residual superficial esophageal squamous-cell carcinoma (SCC) with conventional EMR often results in a piecemeal resection that requires further intervention.

Objective

The aim of this study was to evaluate the efficacy of endoscopic submucosal dissection (ESD).

Design

A case series.

Patients

Between January 2006 and September 2006, 4 local recurrent or residual superficial esophageal SCCs were treated by ESD.

Interventions

ESD procedures were performed by using a bipolar needle knife and an insulation-tipped knife. After injection of glycerol into the submucosal (sm) layer, a circumferential incision was made, and an sm dissection was performed. All lesions were determined to be intramucosal or sm superficial, without lymph-node metastasis by EUS before treatment.

Main Outcome Measurements

Tumor size, en bloc resection rate, tumor-free lateral margin rates, and complications were recorded.

Results

All 4 ESD cases were successfully resected en bloc, and the tumor-free lateral margin rate was 75% (3/4) by histopathology examination. The mean tumor size of the resected specimens was 35 mm (range, 15-50 mm). There were no complications.

Limitations

The number of ESDs in our series was limited, and there are no long-term follow-up data.

Conclusions

ESD for recurrent or residual superficial esophageal tumors after chemoradiotherapy achieves the goal of an en bloc resection, with a low rate of incomplete treatment without any greater risk than the EMR technique.

Section snippets

Patients and methods

Four patients with esophageal SCC, each of whom had developed a local recurrent or residual tumor (2 recurrent tumors and 2 residual tumors) after CRT, were included in this study, which was conducted between January 2006 and September 2006 at the National Cancer Center Hospital (NCCH) in Tokyo. Three of the ESD cases involved stage I lesions treated by CRT, and the other case was of a stage II lesion. The 4 ESDs were performed from 217 days to 1377 days after the initial CRT.

ESDs by using a

Results

During the study period, 4 patients were treated with ESD. All 4 lesions were eligible for outcome analysis. Clinical characteristics of the patients are presented in Table 1. Each of the 4 ESD cases was successfully resected en bloc, with no complications. The mean (SD) ESD time was 58 ± 42 minutes (range 15-100 minutes), and the mean (SD) size of the resected specimens was 35 ± 15 mm (range 15-50 mm). On histopathologic examination, the lateral and vertical margins were negative in 3 of 4 ESD

Discussion

The ESD technique, by using a B-knife21, 22, 23, 24 and an IT-knife,17, 23, 24 enhanced the en bloc resection rate, thereby increasing the likelihood of curative results for local residual or recurrent tumors. In fact, ESDs with a B-knife and an IT-knife are performed to treat superficial neoplastic lesions, such as gastric and colonic neoplasms, at the NCCH.17, 22, 23, 24 ESD has enabled us to treat recurrent gastric cancers after EMR. As indicated in our previous reports,²⁶ about 5% of such

Acknowledgments

We thank Christopher Dix for editing this manuscript and Paul Fockens, MD, for critically reading the manuscript.

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Cited by (46)

Insulated-tip Knife Tunneling and C-shaped Incision for Esophageal Endoscopic Submucosal Dissection: An Initial Western Experience
2021, Techniques and Innovations in Gastrointestinal Endoscopy
Esophageal endoscopic submucosal dissection (ESD) can be challenging, and technique innovation is needed to make it easier to perform, especially in the West, where experience and procedure volumes are less. The loose esophageal submucosa allows easy entry of the entire ceramic tip of an insulated-tip (IT) knife, allowing the electrocautery blade to dissect the submucosa, while the tip protects the muscle layer. This technique is called IT-knife tunneling and has been described in Japan. We evaluated the safety and feasibility of IT-knife tunneling esophageal ESD in the West.
A prospective, single-center observational study evaluating the outcomes of IT-knife tunneling esophageal ESD from April 2016-December 2019. Lesions with expected fibrosis were excluded. All ESDs were performed by a single expert. Primary aim was to determine safety and feasibility of the technique.
42 patients underwent IT-knife tunneling esophageal ESD. 35 were Barrett's-related neoplasms, three squamous cell cancers, three granular cell tumors, and one submucosal cyst. Mean lesion size was 3.1cm, procedure time 69 min, and resection speed 9.7 mm²/min. No esophageal perforations. One case each with delayed bleeding and significant intraprocedural bleeding. En-bloc, R0, and curative resection rates were 97.6%, 88.1%, and 78.6%, respectively. 7/9 of the non-curative lesions were high-risk lesions in poor surgical candidates. 36 patients are under post-procedure surveillance. Mean follow-up time was 12.1 months with no local/metastatic recurrence.
IT-knife tunneling technique allowed for safe and feasible esophageal ESD of non-fibrotic lesions at our Western center. Further use of this technique in the West is warranted.
Salvage endoscopic submucosal tunneling dissection using an electrosurgical knife for an elderly patient with circumferential residual esophageal squamous cell carcinoma after radiotherapy
2020, VideoGIE
Technical feasibility of endoscopic submucosal dissection for local failure after chemoradiotherapy or radiotherapy for esophageal squamous cell carcinoma
2018, Gastrointestinal Endoscopy
Citation Excerpt :
To date, only a few small-scale reports have described the use of salvage ESD for local failure after CRT.13–15 Saito et al13 reported using salvage ESD to treat 4 patients with local recurrence of esophageal cancer, and successfully achieved en bloc resection in all cases. Koizumi et al14 described 12 cases of salvage ESD for esophageal cancer after CRT and reported procedural success in all cases, with an en bloc resection rate of 91.7% (11/12 cases).
Salvage endoscopic submucosal dissection (ESD) after chemoradiotherapy can be technically difficult as a result of radiation-induced fibrosis. We aimed to evaluate the technical feasibility of ESD for local failure after chemoradiotherapy for esophageal squamous cell carcinoma (ESCC) and for other primary lesions within the irradiation field.
Consecutive patients treated with ESD for superficial ESCC between December 2009 and May 2017 were investigated retrospectively and stratified into group A (33 patients, 35 lesions; local failure at the primary site after chemoradiotherapy), group B (25 patients, 34 lesions; second primary lesions within the irradiation field), and group C (550 patients, 596 lesions; radiotherapy-naïve superficial ESCC). We evaluated procedural success rate, en bloc resection rate, 1-year local relapse-free survival (LRFS) rate, procedure time, and incidence of major adverse events.
The rates of procedural success and en bloc resection, respectively, were significantly lower in group A (89%, 86%) than in groups B (100%, 100%) and C (100%, 98%). The 1-year LRFS rates were 86%, 100%, and 99% in groups A, B, and C, respectively, and significantly lower in group A than in group C. Serious adverse events including perforation were not observed in groups A and B; perforation occurred only in group C (2.8%).
ESD is technically feasible in patients with local failure, especially as initial salvage treatment and as treatment for second primary lesions within the irradiation field.
Salvage endoscopic submucosal dissection for the esophagus-localized recurrence of esophageal squamous cell cancer after definitive chemoradiotherapy
2014, Gastrointestinal Endoscopy
Citation Excerpt :
One might speculate that the difference in the en bloc resection rates may be explained by the recently reported superiority of ESD for the curative treatment of early esophageal SCC compared with EMR.12,13 Saito et al14 previously reported their experience using ESD for the treatment of 2 recurrent and 2 residual superficial esophageal SCC cases after CRT. In their study, SCC was positive at the lateral margin in 1 patient, and submucosal tumor invasion was histopathologically observed in another 2 patients, indicating that curative resection was achieved in only 1 patient (25%).
Endoscopic submucosal dissection: Only for expert endoscopists?
2012, Gastroenterologia y Hepatologia
La disección submucosa endoscópica (DSE) es una técnica terapéutica endoscópica aplicable a las neoplasias digestivas precoces y desarrollada con los objetivos de conseguir una resección radical curativa y una disminución de las intervenciones quirúrgicas innecesarias. Diseñada en los países orientales, se encuentra poco extendida en Occidente.
Aunque la DSE representa un avance terapéutico endoscópico significativo y persigue la curación completa del paciente, ofrece en contrapartida una mayor incidencia de complicaciones (hemorragia, perforación) que obligan a la adquisición de una destreza técnica y experiencia mediante un programa de entrenamiento estructurado y progresivo con el fin de disminuir la morbilidad asociada a esta técnica e incrementar los beneficios potenciales de la misma. Aunque se ha publicado una importante evidencia científica sobre sus aplicaciones y resultados, las publicaciones relacionadas con su enseñanza son escasas y no hay un programa estandarizado de aprendizaje. El autor ha tratado de describir las diversas propuestas de entrenamiento pero también los principios básicos de la técnica, sus indicaciones y los resultados obtenidos, ya que antes del aprendizaje es conveniente disponer de una base teórica de conocimiento que permita guiar al endoscopista durante la aplicación clínica de esta técnica endoscópica. El adiestramiento en una técnica endoscópica no sirve de nada si no se conoce para qué se emplea, en qué situaciones se debe aplicar y qué resultados se debe esperar de ella.
Endoscopic submucosal dissection (ESD) can be applied to early gastrointestinal cancers. This technique was developed to achieve radical curative resection and to reduce unnecessary surgical interventions. ESD was designed in eastern countries and is not widely used in the West.
Although ESD represents a major therapeutic advance in endoscopy and is performed with curative intent, the complication rate (hemorrhage, perforation) is higher than reported in other techniques, requiring from endoscopists the acquirement of technical skill and experience through a structured and progressive training program to reduce the morbidity associated with this technique and increase its potential benefits. Although there is substantial published evidence on the applications and results of ESD, there are few publications on training in this technique and a standardized training program is lacking. The current article aims to describe the various proposals for training, as well as the basic principles of the technique, its indications, and the results obtained, since theoretical knowledge that would guide endoscopists during the clinical application of ESD is advisable before training begins. Training in an endoscopic technique has a little value without knowledge of the technique's aims, the situations in which it should be applied, and the results that can be expected.
State of the art in the endoscopic imaging and ablation of Barrett's esophagus
2011, Digestive and Liver Disease
Citation Excerpt :
However, it is more time-consuming and has a higher rate of bleeding and perforation [72]. Most of the experience in esophageal ESD is in squamous cell carcinomas that are more prevalent in Japan [73–77]. However, there is a growing body of experience with ESD in treating esophageal adenocarcinomas [78,79].
Barrett's esophagus is the result of long-term acid reflux and is a precursor to esophageal adenocarcinoma. Surgical resection of the esophagus has been the mainstay of treatment for high grade dysplasia and early cancer. However, recent advances in the endoscopic imaging and ablation technologies have made esophagectomy avoidable in patients with dysplasia and superficial neoplasia. In this article, we review the most relevant endoscopic imaging technologies, such as chromoendoscopy, narrow band and autofluorescence imaging, and confocal laser endomicroscopy. We also review the various endoscopic ablation technologies, such as endoscopic mucosal resection, photodynamic therapy, radiofrequency ablation, and cryotherapy. Finally, we focus on the studies that evaluate the efficacy of these imaging and ablation technologies in finding and eradicating neoplastic Barrett's esophagus.

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: Presented at 15th United European Gastroenterology Week, October 27-31, 2007, Paris, France (Gastroenterology 2007;39[Suppl]:A224).

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Case studyEndoscopic submucosal dissection of recurrent or residual superficial esophageal cancer after chemoradiotherapy

Background

Objective

Design

Patients

Interventions

Main Outcome Measurements

Results

Limitations

Conclusions

Section snippets

Patients and methods

Results

Discussion

Acknowledgments

Eur J Surg Oncol

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Squamous cell carcinoma in situ at oropharyngeal and hypopharyngeal mucosal sites

Cancer

Appearance of enhanced tissue features in narrow-band endoscopic imaging

J Biomed Opt

Case study
Endoscopic submucosal dissection of recurrent or residual superficial esophageal cancer after chemoradiotherapy