Endoscopic palliative resection of a giant 26-cm esophageal tumor: A case report

BACKGROUND

Esophageal carcinosarcoma, usually presenting as a pedunculated polypoid mass, is a rare malignancy with coexisting sarcomatoid and carcinomatous components. Its imaging and endoscopic characteristics are similar to those of leiomyosarcoma, liposarcoma and so forth. The diagnosis needs histological confirmation. Surgical resection is the traditional therapy. Endoscopic resection is minimally invasive but still controversial. This paper reports the case of a patient with a giant esophageal carsinosarcoma who underwent a palliative endoscopic resection.

CASE SUMMARY

A 55-year-old male patient presented with dysphagia and weight loss for 1 mo. Imaging and endoscopy showed a gray-white, polypoid, stalk-like mass, with a bulky pedicle located in the middle and lower esophagus. The mass almost filled the whole esophageal lumen, but the endoscope could still pass through. Despite the suspicion of a malignancy, repeated biopsies indicated necrosis and inflammation. After multidisciplinary team consultation, an endoscopic resection to diagnose and relieve the obstruction was recommended. The pedicle of the mass was cut off, the bleeding was stopped, and the mass was cut into pieces and pulled out. The mass was 26 cm × 5 cm × 4 cm in size. The final diagnosis was esophageal carcinosarcoma. No postoperative complications occurred. After 1 mo, the patient gained 6 kg and endoscopic reexamination revealed no obstruction. Radical surgery with lymph node dissection was carried out successfully. This lesion was the largest endoscopically resected esophageal carcinosarcoma reported to date.

CONCLUSION

Endoscopic palliative resection can help obtain adequate tissue for diagnosis and relieve obstructions in patients with giant esophageal carcinosarcoma.

Clinical and pathological predictors of failure of endoscopic therapy for Barrett's related high-grade dysplasia and early esophageal adenocarcinoma

BACKGROUND AND AIMS

Multimodal endoscopic treatment for Barrett's esophagus (BE) related high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) is safe and effective. However, there is a paucity of data to predict the response to endoscopic treatment. This study aimed to identify predictors of failure to achieve complete eradication of neoplasia (CE-N) and complete eradication of intestinal metaplasia (CE-IM).

METHODS

We performed a retrospective analysis of prospectively collected data of all HGD/EAC cases treated endoscopically at a tertiary referral center. Only patients with confirmed HGD/EAC from initial endoscopic mucosal resection (EMR) were included. Potential predictive variables including clinical characteristics, endoscopic features, and index histologic parameters of the EMR specimens were evaluated using multivariate Cox regression.

RESULTS

A total of 457 patients were diagnosed with HGD/EAC by initial EMR from January 2008 to January 2019. Of these, 366 patients who underwent subsequent endoscopic treatment with or without RFA were included. Cumulative incidence rates at 3 years for CE-N and CE-IM were 91.4% (95% CI 87.8-94.2%) and 66.8% (95% CI 61.2-72.3%), respectively during a median follow-up period of 35 months. BE segment of 3-10 cm (HR 0.45; 95% CI 0.36-0.57) and > 10 cm (HR 0.25; 95% CI 0.15-0.40) were independent clinical predictors associated with failure to achieve CE-N. With respect to CE-IM, increasing age (HR 0.88; 95% CI 0.78-1.00) was another predictor along with BE segment of 3-10 cm (HR 0.37; 95% CI 0.28-0.49) and > 10 cm (HR 0.15; 95% CI 0.07-0.30). Lymphovascular invasion increased the risk of CE-N and CE-IM failure in EAC cases.

CONCLUSION

Failure to achieve CE-N and CE-IM is associated with long-segment BE and other clinical variables. Patients with these predictors should be considered for a more intensive endoscopic treatment approach at expert centers.

Long-term natural history after endoscopic resection for gastric dysplasia

BACKGROUND AND STUDY AIMS

Natural history after endoscopic resection (ER) for gastric dysplasia is still unclear. The aim of this study was to evaluate the long-term clinical outcomes and risk factors after ER for gastric dysplasia between control and cases with synchronous or metachronous gastric neoplasm.

METHODS

A total of 1090 patients who had undergone ER for gastric dysplasia and been followed up for at least one year from December 2002 to December 2013 were finally analyzed. Risk factors affecting the development of synchronous or metachronous neoplasm (SMN) and long-term clinical outcomes after ER for gastric dysplasia were evaluated.

RESULTS

Synchronous and metachronous neoplasms had developed in 126 (11.6%) and 133 patients (12.2%) during the mean follow-up duration of 63.6 months, respectively. Five-year and 10-year risk of metachronous neoplasm were 9.8% and 27.2%, respectively. Median duration to the development of metachronous neoplasm was 103.1 months. While age (P < 0.001) and mucosal atrophy (P = 0.09) of index cases were associated with the development of synchronous neoplasm, age (P = 0.017), incomplete resection (P = 0.025), and intestinal metaplasia (P = 0.017) of background mucosa of index cases were significantly related to the development of metachronous neoplasm in multivariate analysis. Cumulative incidence of SMN was not significantly different among H. pylori negative, eradicated, and persistent group.

CONCLUSIONS

Age, incomplete ER, and background intestinal metaplasia of index gastric dysplasia were significantly associated with metachronous recurrence. Endoscopic surveillance for metachronous recurrence after ER for gastric dysplasia is mandatory for longer than 10 years.

Endoscopic resection of large (≥ 4 cm) upper gastrointestinal subepithelial tumors originating from the muscularis propria layer: a single-center study of 101 cases (with video)

BACKGROUND AND AIMS

Although endoscopic resection (ER) is already established as a minimally invasive technique for small (< 4.0 cm) upper gastrointestinal subepithelial tumors originating from the muscularis propria layer (MP-SETs), published data of ER for large (≥ 4.0 cm) upper gastrointestinal MP-SETs are extremely rare and limited to case reports. This retrospective study aimed to evaluate the feasibility and safety of ER for large (≥ 4.0 cm) upper gastrointestinal MP-SETs in a large case series.

METHODS

Between June 2012 and December 2018, 101 patients with large (≥ 4 cm) upper gastrointestinal MP-SETs were enrolled in this study. The main outcome measures included complete resection, total complications, and local residual or recurrent tumor.

RESULTS

The rate of complete resection was 86.1%. Thirteen patients (12.9%) experienced complications including gas-related complications (6/101, 5.9%), localized peritonitis (4/101, 4.0%), esophageal/cardiac mucosal laceration (2/101, 2.0%), and delayed bleeding (1/101, 1.0%). These 13 patients recovered after endoscopic and conservative treatment. The independent risk factor for incomplete resection was tumor size (P = 0.005), and the independent risk factors for total complications were tumor size (P = 0.011) and tumor extraluminal growth (P = 0.037). During the median follow-up of 36 months, local residual tumor was detected in 1 patient. No local recurrence occurred in any patient.

CONCLUSIONS

Despite being associated with a relatively low complete resection rate, ER is an alternative therapeutic method for large (≥ 4.0 cm) upper gastrointestinal MP-SETs when performed by an experienced endoscopist. This method is especially valuable for patients who are unwilling to undergo surgery.

Endoscopic resection of large endonasal hemangioma: Case report

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Hemangiomas are common benign vascular tumors of the head and neck region. However, they are not common to arise in the sinonasal mucosa.

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Hemangioms have an average size of one centimeter and have been reported to be as large as 8 cm.

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The endoscopic approach is the usual surgical approach in small size hemangiomas, while an open approach is more common with the larger size.

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Preoperative embolization has been shown to be effective in decreasing tumor size and minimizing bleeding.

Introduction

Hemangiomas are common vascular benign tumors of the head and neck region. However, it is uncommon for them to arise in the paranasal sinus mucosal tissues. Paranasal sinus hemangiomas have nonspecific characteristics clinically and radiologically, even though it has to be considered as a differential diagnosis to avoid the misdiagnosis of sequalae.

Presentation of the case

We present a case of a 37 year-old female diagnosed with a paranasal large size hemangioma treated with functional endoscopic sinus surgery (FESS).

Discussion

The case had a rare anatomical location of the hemangioma, along with a minimally invasive approach for a large size hemangioma. Owing to that fact, it might be challenging to differentiate between paranasal sinus hemangiomas and other benign or malignant pathologies.

Conclusion

While paranasal sinus hemangiomas occur rarely, they have arisen from the paranasal sinus mucosa. They have an average size of 1 cm, and have been reported to be as large as 8 cm, similarly to this case. When larger in size, hemangioma resections are usually approached through open surgery, whereas, in this case, the hemangioma was resected completely by FESS.

Risk of lymph node metastasis in early gastric cancer and indications for endoscopic resection: is it worth applying the east rules to the west?

BACKGROUND

Early gastric cancers are associated with lymph node metastasis (LNM) in 15% of cases. Risk factors for LNM are well established in Eastern countries. Less invasive treatments, such as endoscopic or surgical laparoscopic resection, are well accepted in Eastern countries and a matter of intense debate in the West, were indications for such treatments are still contested The objective of the study is to determine risk factors related to LNM and to validate endoscopic resection indications.

METHODS

The study was a retrospective cohort of 178 patients with early gastric cancer who underwent gastrectomy. Clinical and pathological factors were analyzed. The new rules of ER from JGCA were applied to the studied cohort.

RESULTS

LNM was present in 13.48% of the cases, 3.96% (3/76) in T1a tumors and 20.58% (21/102) in T1b tumors. In univariate analysis ulceration (p = 0.04), differentiation grade (p = 0.04), submucosal invasion (p = 0.001), lymphatic invasion (p < 0.001), and vascular invasion (p < 0.001) were associated with LNM. In multivariate analysis, differentiation grade (p = 0.005) and submucosal invasion (p = 0.005) were independent risk factors. One patient classified in the expanded criteria group and seven from the relative criteria group had LNM. There were no LNM for undifferentiated mucosal lesions without ulceration.

CONCLUSIONS

Undifferentiated tumors and submucosal invasion are risks factors associated with LNM in early gastric cancer in our study. Endoscopic Resection or less invasive and radical surgical treatments are an option to be carefully considered.

Pedunculated esophageal carcinoma endoscopically removed using SB knife Jr with detachable snare after neoadjuvant chemotherapy

An 82-year-old Japanese man with alcoholic liver cirrhosis was referred to our hospital for treatment of advanced esophageal cancer. A protruding tumor was endoscopically observed in the middle thoracic esophagus, and pathological findings of the biopsy specimens revealed a squamous cell carcinoma. The clinical tumor staging was stage II (T3N0M0). The patient received two courses of neoadjuvant chemotherapy with 5-fluorouracil and nedaplatin. After the treatments, computed tomography showed significant reductions in the size of the target tumor. However, radical esophagectomy was not performed because the patient refused major invasive treatments. Instead, endoscopic resection was performed using a combination of polypectomy and endoscopic submucosal resection (ESD). To prevent bleeding during endoscopic treatment, we applied a detachable snare to the base of the tumor and cut the stalk using by an SB knife Jr, without hemorrhage. The pathohistology of the resected specimen was positively showed cancer cells on the margin of the esophageal carcinoma stalk. At 4 weeks after the initial operation, an additional ESD was successfully performed, which pathologically led to radical removal. The patient survived for more than 18 months after beginning the initial treatment. We describe a successful treatment using endoscopic resection after chemotherapy for advanced esophageal cancer with high surgical treatment risks.

Total length of positive resection margins can predict remnant gastric cancer following endoscopic submucosal dissection

BACKGROUND

Prediction of remnant tumor is important in determining subsequent treatment options for gastric cancer patients with positive resection margin (RM) after endoscopic submucosal dissection (ESD).

METHODS

Based on the assumption that pathologic factors, including the length and type of involved RM, could potentially predict residual tumor, we evaluated 451 ESD specimens in patients with early gastric cancer.

RESULTS

Of 408 cases, 37 (9.1 %) showed positive RMs. RM involvement in gastric cancer ESD specimens was associated with extended or beyond ESD criteria, greater tumor size, poor differentiation, submucosal invasion, lymphovascular invasion, and upper third location. Among the 37 positive RM cases, residual tumor was present in seven (18.9 %). The presence of residual tumor was not significantly associated with any clinicopathologic parameters except for tumor size and RM status. The total length of the involved RM was the most significant factor associated with the presence of residual tumor (P < 0.008). A total length cut-off value of 6 mm yielded a sensitivity of 85.7 % and negative predictive value of 94.7 % for predicting remnant tumor at gastrectomy following ESD.

CONCLUSIONS

In conclusion, when the ESD specimen exhibits positive RM, a quantitative assessment of the involved RM should be included in the pathology report, as this can help the clinician predict remnant tumor and determine appropriate future treatment.

Gastro-entero-pancreatic neuroendocrine neoplasia: The rules for non-operative management

Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) with favorable pathological and clinical features may be considered as indolent lesions, and therefore be amenable to conservative management. According to the primary tumor site, different non-aggressive approaches, based on endoscopic resection or simple active surveillance, can be proposed to selected patients fulfilling specific criteria. Tumor size, Ki67 proliferative index and depth of invasion are markers that can be used in order to identify these subjects. Patients with type I gastric NENs <1 cm as well as those with non-ampullary duodenal NENs <1 cm with no associated syndrome can be safely managed by endoscopic resection. On the other hand, an active surveillance approach is preferred over surgery for patients with asymptomatic, non-functioning pancreatic NENs ≤2 cm without dilation of the main pancreatic duct or bile duct. As far as NENs of the appendix are concerned, appendectomy should be considered as curative when a R0 resection has been achieved in the presence of a tumor ≤1.5 cm, graded as G1 and without lymphovascular invasion. Finally, G1 rectal NENs ≤1 cm without invasion of the muscular layer can be safely treated by endoscopic resection. Therefore, surgeons should be aware of the existence of indolent GEP-NENs, in order to avoid unnecessary operations with associated postoperative complications.

Gastric neuroendocrine tumor: A practical literature review

Gastric neuroendocrine tumors are gastric neoplasms originating from enterochromaffin type cells and are inserted in a larger group, named gastroenteropancreatic neuroendocrine tumors. They are considered rare and variable in terms of their clinical, morphological and functional characteristics and may be indolent or aggressive. They are classified into types I, II and III, according to their pathophysiology, behavior and treatment. Their diagnosis occurs, in most cases, incidentally during upper digestive endoscopies, presenting as simple gastric polyps. Most cases (type I and type II) are related to hypergastrinemia, can be multiple and are treated by endoscopic resection, whenever possible. The use of somatostatin analogs for tumor control may be one of the options for therapy, in addition to total or subtotal gastrectomy for selected cases. Adjuvant chemotherapy is only reserved for poorly differentiated neuroendocrine carcinomas. Although rare, gastric neuroendocrine tumors have an increasing incidence over the years, therefore deserving more comprehensive studies on its adequate treatment. The present study reviews and updates management recommendations for gastric neuroendocrine tumors.

Endoscopic resection of tracheal lobular capillary haemangioma with ultrasonically activated device

We reported the case of a 55-year-old man with a large tracheal lobular capillary haemangioma attached to posterior tracheal wall and successfully managed with arterial embolization followed by endoscopic resection using Harmonic™ ACE Plus. Because of the high risk of bleeding, Harmonic™ was used in this case due to its ability to cut and cauterize simultaneously. The instrument jaw repeatedly grasped the attachment point of tumor, and then the cavitation effect, created by the longitudinal vibration of the blade tip, separated it from the posterior tracheal wall, reducing the risk of perforation. Yet, the ultrasonic energy denatured proteins and coagulated the vessels, preventing the bleeding during resection. No complications occurred during and after the procedure. Twelve-month follow-up showed no recurrence.

Outcome of a novel modified endoscopic papillectomy for duodenal major papilla adenoma

Background and aims

In recent years, with the development of endoscopic techniques, endoscopic resection is widely used for duodenal papillary adenomas, but conventional endoscopic resection has a high rate of incomplete resection and recurrence. On this basis, we have employed a novel modified endoscopic papillectomy (ESP). In this study, we evaluated the feasibility and advantages of this ESP for the treatment of duodenal major papilla adenoma.

Methods

A total of 56 patients with duodenal major papilla adenoma confirmed by endoscopic ultrasonography, intraluminal ultrasound and gastroscopic biopsy from October 2007 to June 2017 were collected in the Department of Gastroenterology, Nanjing Drum Tower Hospital. The diameter of the adenoma ranged from 1.41 to 2.02 cm. 16 cases were given the conventional method and 40 cases underwent the modified ESP procedure in which a small incision was made by cutting current when anchoring the snare tip on the distal side of the adenoma.

Results

En bloc resection rate was significantly higher in the modified group (100%, 40/40) than that in the conventional group (81.3%, 13/16; P = 0.02). However, no significance was seen between the modified group and the conventional group in complete resection rate (92.5%, 37/40 vs 93.8%, 15/16; P = 1.00). There was no significant difference in the number and difficulty of postoperative pancreatic and biliary stents placement between the two groups (P = 0.20). Total bleeding occurrence was much lower in the modified group (37.5%, 15/40 vs 87.5%, 14/16; P = 0.001), and no significant differences were found in other short-term complications and the 3, 6, 12 and 24 months recurrences rate between the conventional and modified ESP groups.

Conclusions

The modified ESP improves the treatment outcome of duodenal major papilla adenoma with higher en bloc resection rate and lowering bleeding rate.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07715-0) contains supplementary material, which is available to authorized users.

Technical success, resection status, and procedural complication rate of colonoscopic full-wall resection: a pooled analysis from 7 hospitals of different care levels

Introduction

Endoscopic full-thickness resection (eFTR) using the full-thickness resection device (FTRD®) is a novel minimally invasive procedure that allows the resection of various lesions in the gastrointestinal tract including the colorectum. Real-world data outside of published studies are limited. The aim of this study was a detailed analysis of the outcomes of colonoscopic eFTR in different hospitals from different care levels in correlation with the number of endoscopists performing eFTR.

Material and methods

In this case series, the data of all patients who underwent eFTR between November 2014 and June 2019 (performed by a total of 22 endoscopists) in 7 hospitals were analyzed retrospectively regarding rates of technical success, R0 resection, and procedure-related complications.

Results

Colonoscopic eFTR was performed in 229 patients (64.6% men; average age 69.3 ± 10.3 years) mainly on the basis of the following indication: 69.9% difficult adenomas, 21.0% gastrointestinal adenocarcinomas, and 7.9% subepithelial tumors. The average size of the lesions was 16.3 mm. Technical success rate of eFTR was achieved in 83.8% (binominal confidence interval 78.4–88.4%). Overall, histologically complete resection (R0) was achieved in 77.2% (CI 69.8–83.6%) while histologically proven full-wall excidate was confirmed in 90.0% (CI 85.1–93.7%). Of the resectates obtained (n = 210), 190 were resected en bloc (90.5%). We did not observe a clear improvement of technical success and R0 resection rate over time by the performing endoscopists. Altogether, procedure-related complications were observed in 17.5% (mostly moderate) including 2 cases of acute gangrenous appendicitis requiring operation.

Discussion

In this pooled analysis, eFTR represents a feasible, effective, and safe minimally invasive endoscopic technique.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07772-5) contains supplementary material, which is available to authorized users.

Therapeutic results of proton beam therapy with concurrent chemotherapy for cT1 esophageal cancer and salvage endoscopic therapy for local recurrence

BACKGROUND

Proton beam therapy (PBT) with concurrent chemotherapy is promising for esophageal squamous cell carcinoma (ESCC). The aim of study was to evaluate the outcome of concurrent chemo-proton therapy (CCPT), i.e., PBT with concurrent chemotherapy for cT1 ESCC and the salvage endoscopic therapy for local recurrence.

METHODS

Patients with clinical T1 ESCC who underwent CCPT (60 GyE) between April 2013 and April 2017 at the National Cancer Center Hospital East were investigated. The efficacy of CCPT at the primary site was evaluated via endoscopy; primary complete response (CR) was defined as disappearance of the tumor lesion/ulcer and absence of cancer cells on biopsy. Endoscopic evaluation was performed with the same protocol of conventional chemoradiotherapy. Local recurrence after CCPT was treated with endoscopic resection for cT1a and with esophagectomy or photodynamic therapy for cT1b+.

RESULTS

Of the 44 patients (median age, 70 years) that underwent CCPT, 43 patients (98%) achieved primary CR. Among the 44 patients, the 3-year overall survival rate was 95.2%. Five patients (11%) developed local recurrence without regional lymph node or distant metastasis and received endoscopic resection or photodynamic therapy. All five patients were alive with no recurrence after a median 23 months.

CONCLUSIONS

The results suggest that CCPT is an effective treatment for cT1 ESCC and careful endoscopic follow-up allows preferable local control with salvage endoscopic treatment.

Clinical efficacy of the over-the-scope clip device: A systematic review

BACKGROUND

The over-the-scope clip (OTSC) system has been increasingly utilized as a non-surgical option to endoscopically manage refractory gastrointestinal (GI) hemorrhage, perforations/luminal defects and fistulas. Limited data exist evaluating the efficacy and safety of OTSC.

AIM

To determine the clinical success and adverse event (AE) rates of OTSC across all GI indications.

METHODS

A PubMed search was conducted for eligible articles describing the application of the OTSC system for any indication in the GI tract. Any article or case series reporting data for less than 5 total patients was excluded. The primary outcome was the rate of clinical success. Secondary outcomes included: Technical success rate, OTSC-related AE rate and requirement for surgical intervention despite-OTSC placement. Pooled rates (per-indication and overall) were calculated as the number of patients with the event of interest divided by the total number of patients.

RESULTS

A total of 85 articles met our inclusion criteria (n = 3025 patients). OTSC was successfully deployed in 94.4% of patients (n = 2856/3025). The overall rate of clinical success (all indications) was 78.4% (n = 2371/3025). Per-indication clinical success rates were as follows: (1) 86.0% (1120/1303) for GI hemorrhage; (2) 85.3% (399/468) for perforation; (3) 55.8% (347/622) for fistulae; (4) 72.6% (284/391) for anastomotic leaks; (5) 92.8% (205/221) for defect closure following endoscopic resection (e.g., following endoscopic mucosal resection or endoscopic submucosal dissection); and (6) 80.0% (16/20) for stent fixation. AE’s related to the deployment of OTSC were only reported in 64 of 85 studies (n = 1942 patients), with an overall AE rate of 2.1% (n = 40/1942). Salvage surgical intervention was required in 4.7% of patients (n = 143/3025).

CONCLUSION

This systematic review demonstrates that the OTSC system is a safe and effective endoscopic therapy to manage GI hemorrhage, perforations, anastomotic leaks, defects created by endoscopic resections and for stent fixation. Clinical success in fistula management appears limited. Further studies, including randomized controlled trials comparing OTSC with conventional and/or surgical therapies, are needed to determine which indication(s) are the most effective for its use.

Barrett's Esophagus Management in the Elderly: Principles and Best Practice

PURPOSE OF REVIEW

Endoscopic screening and surveillance for Barrett's esophagus (BE) as well as treatment of dysplastic BE is well established. A significant proportion of BE patients are older (geriatric age group, > 65 years age). There is relatively little information or recommendations in the literature with regards to evaluation and management of geriatric BE patients. The purpose of this review is to outline specific caveats and best practice recommendations to help manage the geriatric BE patient.

RECENT FINDINGS

In this review, we have attempted to summarize the latest evidence and guideline-based recommendations for evaluation and treatment of BE and early esophageal neoplasia, with a special focus on the challenges and considerations involved when caring for the geriatric BE patient. Concepts related to sedation, endoscopy, risk-benefit assessment, and other unique issues pertaining to the older BE patient are discussed. Expert recommendations are provided wherever possible. This review highlights the importance of recognizing the unique aspects of evaluating and managing the geriatric BE patient. Practical recommendations are discussed which will help the provider individualize and optimize care for their geriatric BE patient.

Multiple gastrointestinal metastasis after endoscopic submucosal dissection for poorly differentiated gastric adenocarcinoma

A 76-year-old man had a diagnosis of double primary cancers consisting of poorly differentiated esophageal squamous cell carcinoma (ESCC) invading the submucosa and poorly differentiated gastric adenocarcinoma (GAC) invading the submucosa. The clinical stage of both ESCC and GAC was T1N0M0 stage I. The tumor diameter of ESCC and GAC was 20 mm and 25 mm, respectively. We performed chemoradiotherapy for ESCC. Chemotherapy consisted of nedaplatin in an intravenous dose of 90 mg/m² on day 1 and 5-fluorouracil in an intravenous dose of 800 mg/m² on days 1-5, repeated every 4 weeks for two cycles. Radiotherapy consisted of 50.4 Gy in 28 fractions for ESCC. GAC was down-staged after chemoradiotherapy for ESCC and was treated by endoscopic submucosal dissection (ESD). The tumor was histopathologically confirmed to be down-staged to intramucosal cancer with a diameter of 18 mm and no evidence of lymphovascular invasion and ulceration. Multiple metastasis occurred in the stomach, the small intestine and the colorectum after ESD. ESD is not a curative treatment even if chemotherapy is effective for poorly differentiated GAC invading the submucosa. Multiple gastrointestinal metastasis may be a unique recurrence pattern after ESD for such a lesion.

Effectiveness of salvage radiotherapy for superficial esophageal Cancer after non-curative endoscopic resection

BACKGROUND

Endoscopic resection is widely used as an effective treatment for superficial esophageal cancer. However, the risk of lymph node metastasis increases in cases of muscularis mucosae or deeper invasion, for which additional treatment such as radiotherapy or surgery is required. Accordingly, the current study investigated the efficacy and toxicity of salvage radiotherapy after non-curative endoscopic resection as an organ preservation strategy.

METHODS

We retrospectively reviewed 37 esophageal cancer patients who received salvage radiotherapy after non-curative endoscopic resection. The pathological invasion depths were the muscularis mucosae, submucosal layer, and muscularis propria in 14, 22, and one patient, respectively. All patients received external beam radiotherapy. Among them, eight received intraluminal brachytherapy following external beam radiotherapy. Elective nodal irradiation was administered to all patients. Twenty-five patients received concurrent platinum and fluorouracil-based chemotherapy.

RESULTS

The median follow-up time was 74 months (range: 3-212). The 5-year progression-free survival and overall survival rates were 64 and 78%, respectively. No local or regional lymph node recurrence was observed. The causes of death included esophageal cancer in one patient, metachronous esophageal cancer in one patient, other malignancies in eight patients, and other causes in six patients. Late cardiac toxicities ≥ grade 3 were observed in six patients, one of whom died of arrhythmia.

CONCLUSIONS

Salvage radiotherapy after non-curative esophageal endoscopic resection is an effective treatment as an organ preservation strategy. Although muscularis mucosae and submucosal cancer have a high risk of lymph node metastasis, our results suggest that elective nodal irradiation contributes to reduced regional node metastases.

Recurrence with malignancy after endoscopic resection of large colon polyps with high-grade dysplasia: incidence and risk factors

BACKGROUND

In the West, piecemeal endoscopic resection remains the primary treatment for large colon polyps (LCP), as most recurrences are believed to be benign and resectable with follow-up endoscopy. However, invasive malignancy at the site of prior piecemeal endoscopic mucosal resection has been reported in the Asian literature. This study aims to identify the incidence of and the risk factors for local recurrence with malignancy after endoscopic resection of LCP with high-grade dysplasia (HGD).

METHODS

In this retrospective cohort study, we identified patients undergoing complete endoscopic resection of LCPs (≥ 20 mm) with HGD at the Cleveland Clinic between January 2000 and December 2016. Demographic, endoscopic, and pathologic data were collected. All subsequent endoscopic and pathology reports were reviewed to identify recurrence. The cumulative incidence of malignancy at the polypectomy site was determined and univariate analysis was performed to assess risk factors.

RESULTS

A total of 254 LCPs with HGD were resected in 229 patients. Mean polyp size was 29.2 mm. There were 138 lesions resected in piecemeal fashion and 116 en-bloc. After a median follow-up of 28.7 months for the entire cohort, local recurrence with malignancy was diagnosed in six cases. Median time to malignancy diagnosis was 28.5 months. All malignant cases occurred after piecemeal resection and none after en-bloc resection (HR 11.4; 95% CI 0.48-273).

CONCLUSION

Malignancy after endoscopic resection of LCPs with HGD is uncommon and may be associated with piecemeal resection. When possible, en-bloc resection should be the goal for the management of LCPs.

[Retrospective investigation of patients receiving additional surgery after endoscopic non-curative resection for early colorectal cancer]

Objective: To investigate the clinical application of additional surgery after non-curative endoscopic resection for early colorectal cancer. Methods: A retrospectively descriptive cohort study was conducted. Inclusion criteria: (1) pathologically confirmed primary colorectal adenocarcinoma;(2) receiving additional surgery after endoscopic resection; (3) semi-elective operation. Exclusion criteria: familial adenomatous polyposis, appendiceal neoplasms, anal canal neoplasms, neuroendocrine tumors, and surgery because of perforation or bleeding after endoscopic resection. Indications of additional surgery: (1) pathologically positive lateral or basal resection margin; (2) submucosal invasion depth ≥ 1000 μm; (3) lymphovascular invasion; (4) poorly differentiated, undifferentiated or mucinous adenocarcinoma; (5) more than grade G2 in tumor budding; (6) incomplete resection or piecemeal specimen with margin impossible to evaluate; (7) patient's consent due to undetermined pathology. According to the above criteria, clinical data of 92 patients at the Colorectal Surgery Department, the First Affiliated Hospital of Nanjing Medical University between January 2013 and December 2018 were collected. Demographic data, pathological examinations, operative methods and outcomes were analyzed. Results: There were 61 (66.3%) male and 31 female (33.7%) patients with an average age of (58.2±10.7) years. The average BMI was (23.8±3.5) kg/m(2). The lesions located in the right-sided colon, left-sided colon and rectum in 19, 37 and 36 patients respectively. Sixteen patients received endoscopic snare resection, 45 received endoscopic mucosal resection and 31 received endoscopic submucosal dissection. Reasons for additional surgery included endoscopic specimen with pathologically positive margin (n=22, 23.9%), submucosal invasion depth ≥ 1000 μm (n=9, 9.8%), lymphovascular invasion (n=4, 4.3%), poorly differentiated, undifferentiated or mucinous adenocarcinoma (n=5, 5.4%), piecemeal resection (n=13, 14.1%), undetermined pathology (n=52, 56.5%). The median duration from endoscopic resection to additional surgery was 16 days. Thirty-four patients (37.0%) received preoperative endoscopic localization with carbon nanoparticles suspension injection and 5 (5.4%) were marked with titanium clip. Seventy-four patients (80.4%) received laparoscopic surgery, 17 (18.5%) received open surgery, while 1 patient (1.1%) was converted to open surgery due to missing titanium clip. Three patients (3.3%) were treated with transanal excision, 2 (2.2%) with bowel resection, and 87 (94.6%) with radical excision. After additional surgery, histopathological examination of surgical specimens revealed the presence of residual tumor in 5 patients (5.4%), lymph node metastasis in 8 (8.7%), lymphovascular invasion in 1 (1.1%) and tumor deposit in 1 (1.1%). Twelve patients (13.0%) developed postoperative complications, including 4 mid-low rectal cancer patients (4.3%) with anastomostic leakage or bleeding. After surgery, according to the TNM staging system, 83 patients (90.2%) were classified as TNM stage 0-I, 9 (9.8%) as TNM stage II-IV. One patient of stage IV with liver metastasis underwent concomitant hepatectomy. One patient of stage II received regular follow-up after operation. Seven cases of stage III and 1 of stage IV received postoperative chemotherapy. Eighty-five patients (92.4%) were followed up with a median time of 12.8 (IQR: 8.1, 24.3) months. No recurrence or metastasis was observed. Conclusions: Surgery is an effective salvage measure for non-curative endoscopic resection of early colorectal cancer. Since surgery may have complications, indications of the additional surgery should be considered carefully. Preoperative endoscopic localization should be performed in order to ensure the safety and efficacy of surgery.

Analysis of factors associated with local recurrence after endoscopic resection of gastric epithelial dysplasia: a retrospective study

Background

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are widely used techniques for the treatment of gastric epithelial dysplasia. Previous studies have compared the clinical outcome of endoscopic resection for early gastric cancer, but few studies have focused on gastric dysplasia alone. This study aimed to evaluate the long-term prognosis following endoscopic procedures for gastric epithelial dysplasia, investigate differences in local recurrence rates according to the treatment modality, and identify risk factors associated with local recurrence.

Methods

In this retrospective study, local recurrence rates and risk factors associated with local recurrence were compared between 599 patients who underwent EMR and 306 who underwent ESD for gastric epithelial dysplasia from January 2011 to December 2015.

Results

The en bloc resection rate (32.2% vs. 100%, p < 0.001) and complete resection rate (94.8% vs. 99.0%, p = 0.003) were significantly lower in the EMR group than in the ESD group. The local recurrence rate was significantly lower in the ESD group (1.3%) than in the EMR group (4.2%; p = 0.026). There was a significantly increased risk of local recurrence, regardless of lesion location or histologic grade, in patients with lesions > 2 cm (p = 0.002) or red in color (p = 0.03). The ESD group had a significantly lower local recurrence rate, with a higher complete resection rate, than that in the EMR group (p < 0.05). In the case of recurrence after endoscopic resection, most of the recurred lesions were removed through additional endoscopic procedures; there was no difference between the two groups (p = 0.153).

Conclusions

The complete resection rate was significantly higher, and the local recurrence rate was significantly lower, in patients with gastric epithelial dysplasia treated with ESD. Therefore, ESD should be considered the preferred treatment in patients with lesions > 2 cm or showing redness due to an increased risk of local recurrence and EMR may be possible for low-grade dysplasia that is less than 2 cm without surface changes such as redness, depression and nodularity.