Outcomes of Endoscopic

Submucosal Dissection of
Pathologically Staged T1b
Esophageal Cancer
Gastrointestinal Endoscopy
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 The authors evaluated outcomes in 66 patients with pathologically
staged T1b esophageal adenocarcinoma or squamous cell carcinoma
who underwent resection via endoscopic submucosal dissection
(ESD). Overall, 17 patients underwent immediate surgery after ESD for
incomplete resection, and 49 went on to undergo surveillance. R0
resection was achieved in 54.5% (n = 36) of the patients. Among
patients who went on to undergo surveillance, approximately 20% (n =
10) had curative resection and approximately 80% (n = 39) had
noncurative resection. Among the 39 patients with noncurative ESD,
25.6% (n = 10) experienced recurrence.

 Patients with noncurative ESD for T1b esophageal cancer have high
rates of recurrence and need close surveillance. Staging ESD should
be considered in patients with T1b esophageal cancer to improve the
accuracy of staging.

–  S. Kusuma Pokala, MD
 Gastroenterology
Written by

 
  

Seiichiro Abe MD, PhD, FJGES, FASGE 

Written by

Yutaka Saito MD, PhD, FJGES, FASGE, FACG

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment

option, which allows for en-bloc resection regardless of tumor size and
location.1 ESD is currently performed not only for curative intent but also for
tumor staging.

This multicenter retrospective study aimed to investigate the outcomes for

ESD of pathologically staged T1b esophageal cancer and provided valuable
input to real clinical practice. First, endoscopic ultrasound (EUS) is an
unreliable tool for tumor staging of superficial esophageal adenocarcinoma
and squamous cell carcinoma. ESD is a promising staging modality to provide
histological depth of invasion and lymphovascular invasion, which is
undetectable preoperatively. In this study, 92.4% of en bloc resection was
achieved and it is high enough in line with a Japanese multicenter
study.2 However, there is some room to improve the R0 resection rate. The
authors suggested using a traction device to dissect a deeper dissection
plane.

The low accuracy of EUS staging is consistent with the recommendation from
Japanese guidelines.3 The low R0 resection rate could be explained by
inappropriate preoperative assessment or owing to the high number of
difficult-to-diagnose Barrett's cancers. A strict preoperative evaluation and
clinical indications for staging ESD regarding lesion size and macroscopic
morphology will help achieve a better R0 resection rate, especially for Barret
cancer treatment. A clinical trial should be conducted to determine whether
EUS is effective for optimal patient selection to assure negative deep margin
rather than depth diagnosis. Also, the data on high recurrence rate in patients
with R1 resection suggest appropriate informed consent and adjuvant
treatment selection, particularly for nonsurgical candidates.

Further investigation of staging ESD for clinically as well as pathologically

staged T1b esophageal cancer will lead the treatment algorithm for elderly
patients and patients with comorbidities.

References

1. Saito Y, Abe S, Inoue H, et al. How to Perform a High-Quality Endoscopic

Submucosal Dissection. Gastroenterology. 2021;161(2):405-
410. https://www.gastrojournal.org/article/S0016-5085(21)03073-0/fulltext

2. Abe S, Ishihara R, Takahashi H, et al. Long-term outcomes of endoscopic

resection and metachronous cancer after endoscopic resection for
adenocarcinoma of the esophagogastric junction in Japan. Gastrointest
Endosc. 2019;89(6):1120-1128. https://www.giejournal.org/article/S0016-
5107(18)33361-3/fulltext

3. Ishihara R, Arima M, Iizuka T, et al. Endoscopic submucosal

dissection/endoscopic mucosal resection guidelines for esophageal cancer.
Dig Endosc. 2020;32(4):452-
493. https://onlinelibrary.wiley.com/doi/10.1111/den.13654

Abstract
This abstract is available on the publisher's site.

Access this abstract now    Full Text Available for ClinicalKey Subscribers 

BACKGROUND AND AIMS

The outcomes of endoscopic submucosal dissection (ESD) for T1b
esophageal cancer (EC) and its recurrence rates remain unclear in the West.
Using a multicenter cohort, we evaluated technical outcomes and recurrence
rates of ESD in the treatment of pathologically staged T1b EC.

METHODS
We included patients who underwent ESD of T1b EC at 7 academic tertiary
referral centers in the United States (n = 6) and Brazil (n = 1). We analyzed
demographic, procedural, and histopathologic characteristics and follow-up
data. Time-to-event analysis was performed to evaluate recurrence rates.

RESULTS
Sixty-six patients with pathologically staged T1b EC after ESD were included
in the study. A preprocedure staging EUS was available in 54 patients and
was Tis/T1a in 27 patients (50%) and T1b in 27 patients (50%). En-bloc
resection rate was 92.4% (61/66) and R0 resection rate was 54.5% (36/66).
Forty-nine of 66 patients (74.2%) did not undergo surgery immediately after
resection and went on to surveillance. Ten patients had ESD resection within
the curative criteria, and no recurrences were seen in a 13-month (range, 3-
18.5) follow-up period in these patients. Ten of 39 patients (25.6%) with
noncurative resections had residual/recurrent disease. Of the 10 patients with
noncurative resection, local recurrence alone was seen in 5 patients (12.8%)
and metastatic recurrence in 5 patients (12.8%). On univariate analysis, R1
resection had a higher risk of recurrent disease (hazard ratio, 6.25; 95%
confidence interval, 1.29-30.36; P = .023).

CONCLUSIONS
EUS staging of T1b EC has poor accuracy, and a staging ESD should be
considered in these patients. ESD R0 resection rates were low in T1b EC,
and R1 resection was associated with recurrent disease. Patients with
noncurative ESD resection of T1b EC who cannot undergo surgery should be
surveyed closely, because recurrent disease was seen in 25% of these
patients.