Recommendations for

Surveillance and
M a n a g e m e n t o f R e c u r re n t
Esophageal Cancer Following
E n d o s c o p i c Th e r a p i e s
Chigozirim N. Ekeke, MDa,1, Ernest G. Chan, MD, MPHa,1,
Thomas Fabian, MDb, Manuel Villa-Sanchez, MDa,
James D. Luketich, MDc,*

KEYWORDS
 Esophageal malignancy  Minimally invasive esophagectomy
 Endoscopic treatment

KEY POINTS
 Endoscopic therapies for carefully selected, early-stage esophageal cancer can yield
comparable oncologic results when compared with surgery.
 Careful patient selection and endoscopic surveillance are necessary to minimize the risk
of recurrence.
 Multifocal disease occult nodal metastasis, positive margins, and evidence of lymphovascu-
lar invasion are some of the important risks associated with endoscopic resection failure.
 Endoscopic surveillance and follow-up imaging are necessary to detect any sign of recur-
rence or residual disease.
 Clinicians should make therapeutic recommendations based on the data not simply on
their desire to avoid esophagectomy.

INTRODUCTION

The incidence of esophageal cancer has remained relatively stable over the last
20 years. In the United States and western countries, the prevalence of esophageal

a
Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and
the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C800, Pittsburgh, PA
15213, USA; b Department of Surgery, Section of Thoracic Surgery, Albany Medical Center, 43
New Scotland Avenue, MC-50, R-113, Albany, NY 12208, USA; c Department of Cardiothoracic
Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh
Medical Center, 200 Lothrop Street, Suite C816, Pittsburgh, PA 15213, USA
1
These authors contributed equally as co-first authors.
* Corresponding author.
E-mail address: luketichjd@upmc.edu

Surg Clin N Am 101 (2021) 415–426

https://doi.org/10.1016/j.suc.2021.03.004 surgical.theclinics.com
0039-6109/21/ª 2021 Elsevier Inc. All rights reserved.
416 Ekeke et al

adenocarcinoma has surpassed squamous cell carcinoma (SCC). Although many pa-
tients present with advanced disease, with increased access to health care and
endoscopy, more early-stage tumors are being found.1,2
With increased screening of Barrett patients, the percentage of patients diagnosed
with early-stage tumors is 0.5%.3 These patients may be managed either endoscopi-
cally or surgically, and these approaches were discussed in earlier articles. The interest
in localized therapy is important, but it is important to keep in mind that nearly half of all
patients with a new diagnosis of esophageal cancer already has systemic spread. Only
20% of patients is identified with early-stage disease, whereas another 35% to 40% of
patients present with evidence of borderline resectable locoregional disease, that is,
beyond endoscopic resection consideration.4 Multimodal therapy has been shown to
achieve the highest chance of curative success when significant locoregional nodal
involvement exists. Therapeutic options may include chemotherapy alone, combined
chemoradiation, or surgical resection. Despite poor survival at 5 years (19.9%),5 it is
important to identify patients with early-stage esophageal cancer and aggressively treat
the disease and recognize when early endoscopic interventions will or will not work.4 As
surveillance protocols for Barrett disease continue to be refined and access to health
care increases, the authors anticipate a higher number of esophageal neoplasms to
be diagnosed at earlier stages.6
Currently, patients have several therapeutic options depending on the extent of their
disease, comorbidities, and overall performance metrics. Endoscopic intervention has
an acceptable safety profile and minimal risk and has become a widely adopted alter-
native approach for treating premalignant and early, esophageal neoplasms in well-
selected patients. Esophagectomy remains a viable treatment option even for those
with early-stage esophageal cancer and remains the gold standard by which to
compare less-invasive procedures. In some centers, surgical resection remains the
treatment of choice, for example, young and fit patients who may otherwise have a
significant lifetime risk of recurrence if only endoscopic mucosal resection (EMR) is
performed.7 At the authors’ institution, once a stage Ib is diagnosed, they recommend
performing a minimally invasive esophagectomy, given the significant risk of locore-
gional lymph node involvement (15%–27%).7–9 Despite the ongoing developments
in endoscopic intervention, managing locally recurrent disease and the need for
long-term surveillance make minimally invasive esophagectomy (MIE) preferable in
many patients even though they may be candidates for endoscopic therapy. Reported
recurrence rates of esophageal cancer following endoscopic therapies range from 3%
to 32%.10–12
The report by Ells and colleagues7 of a long-term complete remission (CR) rate of
96% over a 57-month follow-up period in patients with early-stage esophageal cancer
treated with endoscopic resection is encouraging. However, it is important to note that
this was a highly selected group of early-stage patients, and of the 1718 patients in this
report that were referred for endoscopic resection, more than 40% were excluded
because of unfavorable criteria, such as deeper invasion beyond a T1a, or other unfa-
vorable criteria. In addition to endoscopic resection, in the favorable group, the major-
ity underwent some form of ablative therapy, such as argon beam coagulation,
radiofrequency ablation (RFA), or phototherapy. Other important details one must
consider before deciding to reject esophagectomy is that these results are from a
highly specialized center with very meticulous follow-up in terms of biopsies, endo-
scopic ultrasound (EUS), and pathologic assessment. This level of expertise is not
widely available.
In the following pages, the authors describe in more detail the treatment of early-
stage esophageal cancer, patterns of recurrent esophageal cancer, surveillance,
 Management of Recurrent Esophageal Cancer 417

and management of recurrent esophageal cancer following endoscopic treatment

options.

INDICATIONS FOR ENDOSCOPIC TREATMENT OF EARLY-STAGE ESOPHAGEAL

CANCER
Intraepithelial Neoplasia (Dysplasia)
In the most recent iteration of the National Comprehensive Cancer Network (NCCN)
Esophageal and Esophagogastric Junction Cancers Guidelines 2020, major changes
include the rebranding of high-grade dysplasia (HGD; previously carcinoma in situ) in
Barrett esophagus as intraepithelial neoplasia or Tis.13 Current recommendations for
treatment of esophageal intraepithelial neoplasia include endoscopic treatment.
Adjunct ablations may be required to ensure adequate treatment of the lesion.

Early-Stage Esophageal Cancer

Based on the American Joint Committee on Cancer 8th Edition Staging System for
esophageal cancer, early-stage esophageal malignancy staged as T1 disease is
defined as a neoplastic lesion of esophageal origin that is limited to the lamina propria,
muscular mucosa, or submucosa.14 Within this T category, the disease is further
differentiated into T1a (tumor invading into the lamina propria or muscularis mucosae)
and T1b (tumor invading the submucosa). This differentiation is important, as it per-
tains to the threshold for endoscopic therapies versus surgery, while considering
risk of disease progression. Angiolymphatic invasion (ALI) is rarely evident (0%–2%
lymph node metastasis in T1a) with mucosal involvement, but submucosal lesions
(T1b) portend to higher risk for ALI and poorly differentiation grade with a risk of lymph
node involving being reported between 13% and 44%.7–9 Along with ALI, poor differ-
entiation grade, the presence of increased depth of invasion, and tumor diameter
greater than 2 cm are risk factors for lymphatic spread. The submucosal layer is
known for its abundant lymphatic channels, which can be a predilection for distant
dissemination. These features are risk factors for failure after endoscopic treatment.
Accurate EUS staging of T1a is 85% sensitivity and 87% specificity, whereas sensi-
tivity and specificity in T1b disease are 86%.15 Computed tomography (CT) and
fluorodeoxyglucose-PET scans have poor sensitivity (50%–57%) for celiac lymph
node metastases, thus are useful primarily for diagnosing distant metastases.15
Currently, endoscopic resection is only recommended for T1a disease and select
cases for T1b disease.16 There is a distinct difference between adenocarcinomas
and squamous carcinoma of the esophagus and their propensity for lymph node
metastasis. Per NCCN guidelines, while patients with T1b adenocarcinoma of the
esophagus can be carefully selected to undergo EMR, patients with T1b squamous
cell of the esophagus should not because of the higher risk of nodal metastasis asso-
ciated with the squamous cell histology.13 Nonetheless, this approach allows for the
potential of curative resection, while assessing pathologic depth of invasion, to accu-
rately determine the true T stage with pathologic confirmation. At the authors’ institu-
tion, they commonly use EMR for T1a disease. Some centers have advocated
endoscopic submucosal dissection (ESD) for deeper or more extensive surface le-
sions, but this is not available in many centers. Multifocal disease, occult nodal metas-
tasis, and evidence of lymphovascular invasion (LVI) are risks associated with
endoscopic therapy failure for early-stage esophageal cancers.17,18 Therefore, the au-
thors recommend a careful and complete work-up with expert pathologic assessment
of the EMR specimen, and the EUS findings before embarking on any endoscopic
resection strategy as the best choice for early-stage esophageal cancers.
418 Ekeke et al

F a c t o r s as s o c ia t e d wit h i nc rea se d f a ilu r e s in p a t i e n t s

undergoing endoscopic tumor therapy
1. Lymphovascular invasion
2. T1b-submucosal involvement
3. Squamous cell carcinoma
4. Deep lesions
5. Piecemeal resection
6. Lesions >2 cm

BENEFITS OF ENDOSCOPIC THERAPIES FOR EARLY-STAGE ESOPHAGEAL CANCER

Endoscopic therapies, such as EMR and ESD, with associated ablative therapies,
such as argon beam, photodynamic therapy, and RFA are associated with less
morbidity in comparison to esophagectomy.19 The decision tree always includes
expert evaluation of the EMR specimen, which provides an extensive tissue sample
for accurate pathologic staging. Therefore, EMR can be used for accurate assessment
and staging as well as therapeutic procedure. Appropriate use of EMR allows for iden-
tification of risk factors as described above. These risk factors for failure in turn assist
the clinician and patient to determine the most appropriate treatment. In addition to
EMR, endoscopic ablative therapies may serve as adjunct tools to endoscopic
removal and treats any residual dysplastic lesions in the presence of Barrett’s esoph-
agus (BE) and early-stage disease. photodynamic therapy (PDT), argon beam laser
coagulation, cryotherapy, and radiofrequency all have been used for ablating residual
dysplastic mucosa after endoscopic resection.19,20
Overall, successful eradiation of T1a malignancy with the use of EMR has been re-
ported to be more than 95%.7,21 Multiple Japanese studies highlighted successful
resection (100%) and 80% cure rate for T1b following utilization of ESD.22,23 The
benefit of reduced morbidity (1%–3%), mortality risk (0%–1%),15 and organ preserva-
tion with the endoscopic approach compares favorably with esophagectomy
(morbidity: 20%–50%, mortality: 2%–5%)24–27 for early-stage disease. Although these
results are overall very impressive, it is important to note that these results can differ
when stratifying by histology. For example, patients with squamous cell histology have
a higher risk of nodal metastasis despite being an early-stage cancer. This finding is
especially highlighted in patients with SCC of the esophagus that has invaded the
muscularis mucosal layers (M3), with reported incidence of nodal metastasis as
high as 11.8%.28

PATTERNS OF RECURRENCE AFTER ENDOSCOPIC TREATMENT

Recurrence rates for endoscopic treatment of early-stage esophageal cancer may be

as high as 21%.29 Manner and colleagues7 retrospectively analyzed endoscopic
remission rates in 66 patients with T1a disease. In their series, 87% (n 5 53) of the pa-
tients achieved CR following endoscopic therapy, but 97% CR was observed in pa-
tients with lesions less than 2 cm. Endoscopic therapy included endoscopic
resection along with use of ablative adjuncts (argon, RFA, and PDT) in areas of residual
Barrett disease. Metachronous lesions were observed in 10 of 53 patients, and 84%
(n 5 51) achieved long-term remission.7 Pech and colleagues30 documented a 22%
 Management of Recurrent Esophageal Cancer 419

rate of recurrent and metachronous lesions following endoscopic resection. A sepa-

rate retrospective study from South Korea identified risk factors for metachronous
recurrence following esophageal ESD in 253 patients with T1a SCC.31 In this study,
the surgeons used Lugol chromoendoscopy before ESD to assess targeted lesion
appearance.31 A univariate and multivariate analyses revealed multiple Lugol-void le-
sions (LVL), margins of the main LVL, and tumor differentiation were risk factors for
metachronous malignancy following endoscopic treatment. Other risk factors for
metachronous lesions following endoscopic treatment include extensive or residual
dysplastic Barrett disease, and multifocal neoplastic lesions.30–33 Furthermore, the
duplication of muscularis mucosa may be indicative of aggressive disease, despite
its intramucosal location. A multi-institutional study evaluated 50 patients with HGD
or T1a disease.34 In this study, 46 patients (92%) showed evidence of esophageal can-
cer that was limited to the muscularis mucosa. ALI and nodal metastasis were evident
in 17% and 10%, respectively, further indicating the challenge in staging superficial
adenocarcinomas.34
Given the multiple risks, careful surveillance after treatment is required. A separate
retrospective analysis assessed the outcomes of patients that underwent EMR
(n 5 23) and esophagectomy (n 5 49) for T1b esophageal adenocarcinoma.35 Within
3 years, 23% of patients (n 5 5) had evidence of local recurrence versus 4.7% (n 5 1),
respectively, and of those, 3 (13%) experienced regional and distal recurrence. Pa-
tients with ALI, tumors greater than 2 cm, and poorly differentiated lesions were at
higher risk of nodal metastasis and increased risk for distant recurrence following
EMR. Furthermore, in patients with low-risk features (no ALI, <2 cm lesion, well to
moderate differentiation), EMR for T1b disease had a higher risk of local recurrence
in comparison to esophagectomy. In the same study, many of these local recurrences
were salvaged with either repeat EMR (n 5 2) or esophagectomy (n 5 1).35 Table 1
provides a brief multistudy summary of the rate of recurrence following endoscopic
resection for early-stage esophageal cancer.

SURVEILLANCE FOR RECURRENCE FOLLOWING ENDOSCOPIC THERAPIES

Presently, NCCN guidelines regarding surveillance after endoscopic therapy fall under
3 groups: patients with completely resected malignancy, persistent Barrett’s or
dysplasia. Recommendations in this group state endoscopic assessment with biopsy
should be performed at or greater than 6 weeks or if there is suspicion for disease
recurrence.13 During endoscopic surveillance, careful attention to detail for mucosal
surface changes is recommended along with multiple biopsies of any visualized

Table 1
Recurrent disease following endoscopic resection

Study Number of Patients Complete Resection (%) Recurrence Rate (%)

Shimizu et al,48 2001 82 100 14.6 at 5 y
Nomura et al,37 2000 51 100 8 at 6 y
Pech et al49 2004 29 92 16.7 at 4 y
Katada et al,50 2005 116 100 20 at 3 y
Fujishiro et al,51 2006 43 100 2.3 at 6 mo
Kim et al,31 2020 253 84 8.3 at 9 y
Nelson et al,32 2018 23 n/a 39 at 3 y

Abbvreviation: n/a, not applicable.

420 Ekeke et al

abnormal appearing mucosa. Furthermore, surgeons and endoscopists should note

any subtle dysplastic mucosal changes, strictures, and any gross changes from pre-
vious endoscopic examination. Beyond that, NCCN guidelines separate tumors into 2
more categories, Tis/T1a or T1b tumors. In Tis/T1a, recommendations are endoscopy
every 3 months for the first year, and endoscopy every 6 months for the second year,
and then annually. No imaging surveillance is recommended in this group.
In T1b, recommendations are EMR-treated patients, endoscopy every 3 months for
first year, endoscopy every 4 to 6 months for the second year, and then annually. Im-
aging may be considered every 12 months for up to 3 years. The NCCN also states
that EUS as part of surveillance endoscopy may be considered as an adjunct to
endoscopy.
At the authors’ institution, their surveillance recommendations are determined by
histopathologic results of the first endoscopic resection. Specifically, patients are
separated into low- and high-risk groups based on T stage, size, and presence of
LVI. The low-risk group includes T 5 Tis or T1a, less than 2 cm and with no evidence
of LVI, versus a second group that includes patients with either T1b or >2 cm, or that
have LVI.
In the first group, the authors believe patients should undergo upper gastrointestinal
endoscopy every 3 months for the first year, every 6 months for the second year, and
then annually indefinitely. Imaging is not recommended as a surveillance tool in these
patients although it may be performed as part of staging. These patients should also
undergo treatment for any other areas of Barrett, and this should coincide with the sur-
veillance endoscopies.
For patients, in the high-risk group whereby risk of failure includes local, regional,
and distant recurrence, surveillance is different. These patients would routinely be
staged before treatment with a PET scan. In some cases, the EMR may precede
the PET scan, and the authors believe it remains an important part of staging patients,
particularly T1b tumors and higher. Serial endoscopy is recommended as described in
the first group of patients, every 3 months for the first year, every 6 months for the sec-
ond year, and then annually indefinitely. The authors also perform a CT every 4 to
6 months for the first 2 years and then annually indefinitely to monitor for any signs
of distant recurrence. No data exist to support surveillance with PET scan. It is consid-
ered unnecessary in T1a tumors. Antidotally, some have argued a limited role of a PET
scan as a single interval scan perhaps 6 to 12 months after treatment for 1B tumors to
rule out regional lymph node recurrence; no evidence at present supports this
approach.

Low-risk tumor s urve illa nce

Esophagoscopy
Every 3 months—1 year
Every 6 months—1 year
Every year– lifetime
High-risk tumor surveillance.
Esophagoscopy
Every 3 months—1 year
Every 4-6 months—1 year
Every year—lifetime
 Management of Recurrent Esophageal Cancer 421

CT scan
Every 3 months—1 year
Every 6 months—1 year
Every year—lifetime

In the event any abnormalities are identified, reevaluation with repeat EMR or EUS
has been found to have a high sensitivity upward of 95% for recurrent disease.36 Im-
aging may be warranted to evaluate these changes; the authors do not routinely add or
recommend EUS in the absence of abnormal findings.

OPTIONS FOR FAILED ENDOSCOPIC TREATMENTS AND THEIR OUTCOMES

Endoscopic Treatment
With proper surveillance, failures will be identified. Recurrences may be local, regional,
or distant. For patients with local recurrence, successful repeat endoscopic therapy
for recurrent has been reported.30,37
Reevaluation of these tumors with EUS or repeat EMR is appropriate. At University
of Pittsburgh Medical Center, recurrent T1a disease in the setting of a patient who is fit
for surgical resection, the authors will recommend esophagectomy for definitive ther-
apy. If the patient is deemed too high risk for surgical resection, they will recommend a
repeat attempt at EMR. Other institutions advocate for repeat EMR despite prior fail-
ures, and this can be a successful approach.
Pech’s series reported an 85% success rate in patients that experienced recurrence
of HGD or intramucosal carcinoma (14.5% recurrence rate) following index endo-
scopic treatment. Techniques to reduce this risk include RFA, ESD, and circumferen-
tial endoscopic resection of high-risk Barrett mucosa and have been introduced to
prevent recurrence after initial malignancy eradication with endoscopic technique.38
Nomuru and colleagues37 conducted a retrospective study (n 5 51) that assessed pa-
tient characteristics and outcomes following endoscopic resection in patients with T1
esophageal malignancy. Three patients underwent treatment for recurrence. Two pa-
tients were treated successfully with repeat EMR, whereas local recurrence arose in
the patient that received only radiation treatment for the initial recurrence.37 Nelson
and colleagues35 reported patients (n 5 5) presenting with local recurrence following
EMR for T1b disease; 2 patients underwent repeat EMR. The remaining patients un-
derwent surgical resection (n 5 1) or radiation (n 5 2).35
Surgical Treatment
Currently, the authors’ institution recommends esophagectomy for patients that present
with index T1b or recurrent esophageal malignancy following failed endoscopic therapy.
Surgical options may include MIE, robotic-assisted esophagectomy, transthoracic (Ivor
Lewis), transhiatal esophagectomy, or 3-incision modified McKeown esophagec-
tomy.39 Resection approaches are dependent on location of the recurrence and sur-
geon preference. Despite the known morbidity and mortality risk of esophagectomy,
the authors’ group has successfully adopted the minimally invasive approach. In their
retrospective study of 1033 patients, the median length of stay in the intensive care
unit and overall length of stay in the hospital was 2 and 8 days, respectively. Thirty-
day operative mortality was less than 2%.40 More than 10% of patients had stage I
esophageal malignancy in the authors’ study. Hunt and colleagues17 reported out-
comes in 15 patients who underwent esophagectomy at a mean time of 13 months after
a mean number of 4.1 failed endotherapies (EMR and RFA). Of these, 15 patients 3
422 Ekeke et al

(20%) were found to have node-positive disease. This finding suggests that either the
patients were inappropriately selected for esophageal preservation or progressed while
undergoing failed EMRs.17 No recurrence was observed at a mean follow-up time of
20 months after esophagectomy. A separate multi-institutional study (7 major centers)
from Molena and colleagues41 reported surgical outcomes of 23 patients with submu-
cosal esophageal adenocarcinoma. These patients underwent esophagectomy at a
median of 2 months after endoscopic resection. Of the patients, 26% (n 5 6) were found
to have positive nodal disease. At a median follow-up time of 37 months, 91% of pa-
tients were alive and had no evidence of residual or recurrent disease. Disease-
specific 5-year survival was reported to be 67% in patients with pathologic-confirmed
nodal disease and 100% in patients with N0 disease at the time of esophagectomy.
Both Molena and Hunt demonstrate the most dreaded of all complications, which is
undertreatment of tumor.17,41 Although data show that some of these patients can be
salvaged with resection, not all will be. Furthermore, these recurrences and then treat-
ment were performed in the setting of academic institutions and clinical studies. It is
likely that outside of that clinical format recurrences will not be identified as early and
lead to even more undertreatment of curable esophageal cancer.
Dickinson and colleagues used an EMR histology-based risk-scoring tool, in a
cohort of 51 patients with clinical T1 esophageal adenocarcinoma. This risk-scoring
tool stratified a patient’s risk of lymph node metastasis based on tumor size, differen-
tiation, depth, and LVI once diagnosed with T1 esophageal adenocarcinoma
(Table 2).42 Based on this risk scoring tool, patients were deemed low predicted
risk of lymph node metastasis (2%) if they scored 0 to 1 points, moderate risk
(3%–6% predicted risk of lymph node metastasis) if they scored between 2 and 4
points, and high risk (7% predicted risk of lymph node metastasis) if they scored
5 or more. Development of this tool found that LVI and tumor size were the strongest
predictors of lymph node involvement in these patients. With this tool, they found that
27% of patients were upstaged after undergoing esophagectomy. Of the 51 patients,
10 patients (19.6%) were found to have nodal involvement, 7 of which were deemed
high risk based on their scoring tool.43
Esophagectomy for acute and nonacute failure of ESD is appropriate and can be suc-
cessful. Wang and colleagues44 describes 32 patients that underwent esophagectomy
after ESD. Indications for esophagectomy following ESD included disease recurrence,
esophageal stricture, or residual tumor at the ESD specimen margin, and perforation.
There was 0% in-hospital mortality 30 days after esophagectomy. Complete resection

Table 2
Tool for predicting lymph node metastasis in patients with T1 esophageal adenocarcinoma

Variable Point Systema

Tumor size Value is dependent on tumor 11 per cm (microscopic disease 5 10)
size per centimeter
Depth T1a 10
T1b 12
Differentiation Well 10
Moderate 13
Poor 13
Lymphovascular Presence of lymphovascular 16
invasion invasion on histology
a
Predictive risk for lymph node metastasis: low risk, 0 to 1 points; moderate risk, 2 to 4 points; high
risk, 5 points.
 Management of Recurrent Esophageal Cancer 423

was achieved in all patients. The recommended period between ESD and elective sur-
gical resection was 30 days to allow for resolution of esophageal edema.44

SUMMARY/FUTURE DIRECTIONS

Endoscopic resection is an accepted approach for treating HGD and node-negative–

early-stage esophageal cancer in select groups of patients. Excellent results with EMR
have been well described, and the 30-day mortality (<1%) is favorable, but with the
advent of centers of excellence performing minimally invasive and robot-assisted
esophagectomy, mortalities of just less than 1% have also been reported; thus, mor-
tality is not the main issue any longer.45,46 Although the authors acknowledge the
morbidity of MIE and the potential for negative quality-of-life impact, several groups,
including the authors’, have reported excellent quality-of-life scores after successful
MIE.47 Despite the high success rate for tumor eradication with EMR, studies still
report a recurrence rate as high as 32%.10–12 Endoscopists and surgeons must
remember these favorable endoscopic resection reports are from very high-volume
centers with excellent endoscopists, high-tech endoscopic ultrasound, and expert pa-
thologists, all of which are not available in most medical centers. In addition, there is
the inherent disadvantage of limited lymph node assessment and inability to remove
involved nodes that are positive in up to 26% of patients.41 Endoscopic experience
and aggressive surgical approach for failed therapy are necessary to successfully
treat early-stage esophageal malignancy. Favorable outcomes following surgical
resection for failed endoscopic therapy have been reported44 but are not ideal. Clini-
cians would be well advised to make therapeutic recommendations based on the data
not simply on their desire to avoid esophagectomy. In discussions with patients, the
shortcomings and challenges of all treatments should be pointed out so that ultimately
the patient is satisfied with their choices.

CLINICS CARE POINTS

 Endoscopic mucosal resection is first-line intervention for accurate and definitive diagnosis
of high-grade dysplasia and T1a esophageal malignancy.
 Postendoscopic surveillance should include repeat endoscopic visualization and possible
adjunct ablative therapy for residual high-grade dysplasia or Barrett disease based on
pathologic assessment of the resected specimen and surrounding random and directed
biopsies.
 Risk factors for recurrent esophageal malignancy following endoscopic treatment include
piecemeal endoscopic mucosal resection, lymphatic invasion, extended segmental Barrett
disease, residual dysplastic Barrett esophagus after remission, no ablative therapy of Barrett
esophagus after resection, multifocal neoplastic lesions, and complete response greater than
10 months.
 Surveillance following endoscopic treatment of early-stage esophageal malignancy should
include repeat esophagogastroduodenoscopy every 3 to 6 months (first 1–2 years), every 6
to 12 months (3–5 years), and annually (>5 years). More favorable biopsies during
surveillance may lessen the number of endoscopies, but as discussed, the presence of
dysplasia and other pathologic features may increase this need.
 Evidence of recurrent disease or residual disease after endoscopic therapy should be treated
with minimally invasive or robotic esophagectomy unless the patient is high risk, in which
repeat endoscopic mucosal resection should be considered (with the possibility of ablation
therapy and addition of chemoradiation for more extensive recurrences).
424 Ekeke et al

DISCLOSURE

The authors have nothing to disclose.

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