Clinical feasibility of endoscopic submucosal dissection with minimum lateral margin of superficial esophageal squamous cell carcinoma

Abstract

Background Esophageal stricture following endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell cancer (SESCC) has been associated with wide mucosal defects greater than three-quarters of the luminal circumference. Some patients developed dysphagia and required repeated endoscopic balloon dilation even after steroid therapy. As iodine staining clearly visualized the margin of SESCC, we made a longitudinal mucosal incision close to the margin of the lesion to avoid a mucosal defect involving over three-quarters of the luminal circumference for large lesions. This retrospective study aimed to clarify the clinical feasibility of ESD with minimum lateral margin of SESCC.

Patients and methods Between 2005 and 2013, 94 patients with 94 initial SESCCs had lesions greater than half of the luminal circumference. Of those, 70 patients with 70 SESCCs had achieved endoscopic clearance for the initial SESCC. In this study, endoscopic clearance was defined as en bloc resection of SESCC histologically confined to the mucosa without lymphovascular invasion and with a free deep margin regardless of the lateral margin. This study evaluated the short- and long-term outcomes in patients undergoing endoscopic clearance.

Results In total, 61.4 % (43/70) of the patients had mucosal defects involving over three-quarters of the luminal circumference and 38.5 % (27/70) had a positive or indeterminate lateral margin. However, there was no local or nodal recurrence during the median follow-up period of 3.8 years; the 3-year overall survival rate was 98.5 % and the 3-year disease-free survival rate was 100 %.

Conclusion Using our institutions’ strategy, ESD for SESCCs with minimum lateral margins was oncologically acceptable; this approach could reduce the known risk factor of post-ESD stricture.

• References

• 1 Shimizu Y, Takahashi M, Yoshida T. et al. Endoscopic resection is the criterion standard of treatment for patients with early squamous cell neoplasia of the esophagus. Gastrointest Endosc 2012; 76: 464-465
• 2 Inoue H, Tani M, Nagai K. et al. Treatment of esophageal and gastric tumors. Endoscopy 1999; 31: 47-55
• 3 di Pietro M, Canto MI, Fitzgerald RC. Endoscopic management of early adenocarcinoma and squamous cell carcinoma of the esophagus: Screening, diagnosis, and therapy. Gastroenterology 2018; 154: 421-436
• 4 Katada C, Muto M, Momma K. et al. Clinical outcome after endoscopic mucosal resection for esophageal squamous cell carcinoma invading the muscularis mucosae – a multicenter retrospective cohort study. Endoscopy 2007; 39: 779-783
• 5 Katada C, Muto M, Manabe T. et al. Local recurrence of squamous-cell carcinoma of the esophagus after EMR. Gastrointest Endosc 2005; 61: 219-225
• 6 Ishihara R, Iishi H, Takeuchi Y. et al. Local recurrence of large squamous-cell carcinoma of the esophagus after endoscopic resection. Gastrointest Endosc 2007; 67: 799-804
• 7 Ishihara R, Iishi H, Uedo N. et al. Comparison of EMR and endoscopic submucosal dissection for en bloc resection of early esophageal cancers in Japan. Gastrointest Endosc 2008; 68: 1066-1072
• 8 Ono S, Fujishiro M, Niimi K. et al. Long-term outcomes of endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms. Gastrointest Endosc 2009; 70: 860-866
• 9 Takahashi H, Arimura Y, Masao H. et al. Endoscopic submucosal dissection is superior to conventional endoscopic resection as a curative treatment for early squamous cell carcinoma of the esophagus (with video). Gastrointest Endosc 2010; 72: 255-264
• 10 Mizuta H, Nishimori I, Kuratani Y. et al. Predictive factors for esophageal stenosis after endoscopic submucosal dissection for superficial esophageal cancer. Dis Esophagus 2009; 22: 626-631
• 11 Ono S, Fujishiro M, Niimi K. et al. Predictors of postoperative stricture after esophageal endoscopic submucosal dissection for superficial squamous cell neoplasms. Endoscopy 2009; 41: 661-665
• 12 Katada C, Muto M, Manabe T. et al. Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions. Gastrointest Endosc 2003; 57: 165-169
• 13 Shi Q, Ju H, Yao L-Q. et al. Risk factors for postoperative stricture after endoscopic submucosal dissection for superficial esophageal carcinoma. Endoscopy 2014; 46: 640-644
• 14 Yamaguchi N, Isomoto H, Nakayama T. et al. Usefulness of oral prednisolone in the treatment of esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma. Gastrointest Endosc 2011; 73: 1115-1121
• 15 Hashimoto S, Kobayashi M, Takeuchi M. et al. The efficacy of endoscopic triamcinolone injection for the prevention of esophageal stricture after endoscopic submucosal dissection. Gastrointest Endosc 2011; 74: 1389-1393
• 16 Hanaoka N, Ishihara R, Takeuchi Y. et al. Intralesional steroid injection to prevent stricture after endoscopic submucosal dissection for esophageal cancer: a controlled prospective study. Endoscopy 2012; 44: 1007-1011
• 17 Hanaoka N, Ishihara R, Uedo N. et al. Refractory strictures despite steroid injection after esophageal endoscopic resection. Endosc Int Open 2016; 4: E354-359
• 18 Bhatt A, Abe S, Kumaravel A. et al. Indications and techniques for endoscopic submucosal dissection. Am J Gastroenterol 2015; 110: 784-791
• 19 Shiozaki H, Tahara H, Kobayashi K. et al. Endoscopic screening of early esophageal cancer with the Lugol dye method in patients with head and neck cancers. Cancer 1990; 66: 2068-2071
• 20 Kuwano H, Nishimura Y, Oyama T. et al. Guidelines for Diagnosis and Treatment of Carcinoma of the Esophagus April 2012 edited by the Japan Esophageal Society. Esophagus 2015; 12: 1-30
• 21 Ohata K, Fu K, Sakai E. et al. Esophageal endoscopic submucosal dissection assisted by an overtube with a traction forceps: An animal study. Gastroenterol Res Pract 2016; 2016: 3186168
• 22 Ezoe Y, Muto M, Horimatsu T. et al. Efficacy of preventive endoscopic balloon dilation for esophageal stricture after endoscopic resection. J Clin Gastroenterol 2011; 45: 222-227
• 23 Japan Esophageal Society. Japanese Classification of Esophageal Cancer, 11th Edition: part I. Esophagus 2017; 14: 1-36
• 24 Japan Esophageal Society. Japanese Classification of Esophageal Cancer, 11th Edition: part II and III. Esophagus 2017; 14: 37-65
• 25 Katada C, Yokoyama T, Yano T. et al. Alcohol consumption and multiple dysplastic lesions increase risk of squamous cell carcinoma in the esophagus, head, and neck. Gastroenterology 2016; 151: 860-867
• 26 Kanda Y. Investigation of the freely available easy-to-use software “EZR” for medical statistics. Bone Marrow Transplant 2013; 48: 452-458
• 27 Ban S, Toyonaga A, Harada H. et al. Iodine staining for early endoscopic detection of esophageal cancer in alcoholics. Endoscopy 1998; 30: 253-257
• 28 Abe S, Iyer PG, Oda I. et al. Approaches for stricture prevention after esophageal endoscopic resection. Gastrointest Endosc 2017; 86: 779-791
• 29 Matsuda Y, Kataoka N, Yamaguchi T. et al. Delayed esophageal perforation occurring with endoscopic submucosal dissection: A report of two cases. World J Gastrointest Surg 2015; 7: 123-127
• 30 Ishida T, Morita Y, Hoshi N. et al. Disseminated nocardiosis during systemic steroid therapy for the prevention of esophageal stricture after endoscopic submucosal dissection. Dig Endosc 2015; 27: 388-391
• 31 Kadota T, Yano T, Kato T. et al. Prophylactic steroid administration for strictures after endoscopic resection of large superficial esophageal squamous cell carcinoma. Endosc Int Open 2016; 4: E1267-E1274
• 32 Nagami Y, Ominami M, Shiba M. et al. The five-year survival rate after endoscopic submucosal dissection for superficial esophageal squamous cell neoplasia. Dig Liver Dis 2017; 49: 427-433
• 33 Makazu M, Sakamoto T, So E. et al. Relationship between indeterminate or positive lateral margin and local recurrence after endoscopic resection of colorectal polyps. Endosc Int Open 2015; 3: 252-257
• 34 Matsuda K, Watanabe H, Kuwabara S. et al. Esophageal submucosal tumor (SMT)-like carcinoma [Japanese with English abstract]. Stomach Intestine 1997; 32: 671-689