Endoscopic Submucosal Dissection for Esophageal Adenocarcinoma: A North American Perspective

Esophageal Endoscopic Submucosal Dissection in Older Patients Is Safe and Feasible: A Retrospective Single-Center Cohort Study in the United States

BACKGROUND

Endoscopic submucosal dissection (ESD) is a well-established method for treating early esophageal carcinomas. However, data on the safety and efficacy of esophageal ESD in older patients in the United States are limited.

METHODS

This retrospective study investigated the outcomes of esophageal ESD in patients aged ≥80 years and included those who underwent esophageal ESD between June 2018 and April 2023 at a single center in the United States. Patients were divided into two age groups for comparison: ≥80 and <80 years. Treatment outcomes and complications were evaluated and compared between these groups.

RESULTS

A total of 53 cases of esophageal ESD for malignant neoplasms were included, with 12 patients in the ≥80 years age group. No significant differences were observed in the patients' background and characteristics, except for a prior history of interventions (p = 0.04). The en bloc resection rate was 100% in both groups. The R0 resection rate was lower in the ≥80 years age group (75% vs. 88%). There were no complications requiring additional intervention in the ≥80 years age group, such as post-ESD bleeding, perforation, mediastinal emphysema, or pneumonia.

CONCLUSIONS

Esophageal ESD may be a safe and feasible procedure for treating esophageal carcinomas in older patients.

Risk factors of postoperative stricture after endoscopic submucosal dissection for superficial esophageal neoplasms: A meta-analysis

BACKGROUND

As larger-sized superficial esophageal neoplasms became candidates for endoscopic submucosal dissection (ESD), post-ESD esophageal stricture has inevitably developed into a significant complication during long-term follow-up.

METHOD

The PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, as well as China National Knowledge Infrastructure, the Wanfang Database, and the Chinese Biomedical Literature Database, were searched to identify all the appropriate studies published from January 2000 through October 2019. For risk factor assessment between postoperative stricture and control groups, pooled odds ratios (OR) and weighted mean differences (WMD) estimation was done. All meta-analytical procedures were conducted by using Stata version 15.1 software.

RESULTS

The results showed that 11 studies with 2248 patients (284 structure cases and 1964 controls) were eligible for this meta-analysis. Statistical results indicated 6 substantial risk factors: lesion characteristics involving the upper third of the esophagus (OR 1.51, [1.02-2.25]), macroscopic type of IIa/IIc (OR 2.76, [1.55-4.92]), tumor depth of invasion above m1 (OR 7.47, [3.31-16.86]), and m2 (OR 12.67, [4.00-40.10]), longitudinal length (WMD 13.75 mm, [7.76-19.74]), circumferential diameter (WMD 10.87 mm, [8.13-13.60]), and circumferential range >3/4 (OR 38.17, [9.94-146.52]). Each additional 10% of the circumferential range increased the risk of stricture by 149% (OR 9282.46, [978.14-88089.35]).

CONCLUSIONS

Six risk factors were assessed to have a key role in the elevated risk levels of post-ESD esophageal stricture. The results can help doctors identify patients with increased risk and thus can guide management of the adequate period of surveillance after ESD and take available approaches of stricture prevention.

Short-term clinical outcomes of non-curative endoscopic submucosal dissection for early esophageal adenocarcinoma

OBJECTIVES

Few Western studies highlighted the outcomes of endoscopic submucosal dissection (ESD) for early esophageal adenocarcinoma (EAC). Data regarding the outcomes of noncurative ESDs remains scarce. In this study, we share our experience with ESD for early EAC with a focus on noncurative ESDs.

METHODS

A retrospective single-center analysis of consecutive patients who underwent ESD for early EAC from August 2015 through February 2020. Primary outcomes included the clinical outcomes of noncurative ESDs along with overall en bloc, R0 and curative resection rates. Secondary outcomes included comparing results between T1a and T1b tumors.

RESULTS

Final group included 23 T1a and 17 T1b EAC patients. Patients' median Charlson comorbidity index was five. En bloc resection rate was (97.5%). Compared to the T1b group, the T1a group had a statistically significantly higher R0 (78.3 vs. 41.2%; P = 0.0235), curative (73.9 vs. 11.8%; P = 0.0001) and accumulative endoscopic curative resection rates (82.6 vs. 23.5%; P = 0.0003). A study flowchart is presented in (Fig. 1). Out of the 21 noncurative ESDs, 10 patients (47.6%) underwent R0 esophagectomy, 6 patients (28.6%) are undergoing surveillance endoscopies without additional therapy, 3 patients (14.3%) underwent repeat curative ESD and 1 patient (4.76%) is receiving chemotherapy with surveillance endoscopy. Over median endoscopic follow-up of 22.5 months (IQR, 14.25-30.75), 2 out of 10 patients with noncurative ESDs had recurrent disease.

CONCLUSIONS

ESD achieved a higher curative resection rate in T1a EAC when compared to T1b. Despite a lower curative resection rate in T1b EAC, certain patients might benefit from a conservative multimodal therapy.

Long-term outcomes of endoscopic mucosal resection for early-stage esophageal adenocarcinoma

BACKGROUND

With growing application of endoscopic therapy for early-stage esophageal cancer, we sought to review our experience of endoscopic mucosal resections (EMRs). The aim of our study was to understand the natural course of these patients, especially with positive margins.

METHODS

A prospectively maintained database of all patients undergoing endoscopic therapies at Georgetown University Hospital for esophageal cancer was used for the analysis between 2010 and 2020.

RESULTS

Of 80 patients in the EMR database, 35 were performed as index cases for esophageal adenocarcinoma. Majority (74.3%) had a pre-treatment ultrasound confirming absence of regional adenopathy. There were no post-EMR bleeding or perforation events requiring re-intervention. Complete R0 resection was achieved in 22/35 (62.9%) after initial EMR. Thirteen patients had positive margins. Of these 13 patients, only 7 patients underwent repeat endoscopic resection, 2 underwent subsequent esophagectomy, 2 received definitive radiation given poor surgical candidacy, and 2 were lost to follow-up. Overall and 5-year survival of all patients undergoing EMR was 67.9 months and 85%, respectively. Subset analysis of the 13 patients with R1 resection demonstrated an overall survival of 49.2 months and 60% 5-year survival vs overall survival of 78.9 months and 93% 5-year survival for R0 resection. At a median follow-up of 60.5 months, cancer recurrence occurred in 3 patients. All of them were successfully managed with repeat EMR.

CONCLUSIONS

Endoscopic resections represent a safe and effective treatment for early-stage esophageal cancer. Patients with high-risk features should be counseled to undergo an esophagectomy if they are operable candidates.

Outcomes of endoscopic submucosal dissection for early esophageal and gastric cardia adenocarcinomas

OBJECTIVES

Adenocarcinomas of the esophagus and of the gastric cardia are regarded as a same clinical entity in oncology. For endoscopic resection however, endoscopic mucosal resection is recommended for esophageal adenocarcinoma, while endoscopic submucosal dissection (ESD) is advocated for gastric adenocarcinomas. Our aim was to compare the outcomes of ESD in both types of esophagogastric junction adenocarcinomas.

METHODS

Between March 2015 and December 2019, we included all patients who underwent an ESD for early adenocarcinoma of the esophagogastric junction at a French tertiary referral center. Esophageal and gastric cardia adenocarcinomas were compared in terms of clinical, procedural and histological outcomes.

RESULTS

57 esophageal and 19 gastric cardia adenocarcinomas were included in the analysis, for a total of 76 patients. The median (IQR) size of the resections was 40 (40-57.5) and 50 (35-55)mm, p=0.96, respectively. En bloc resection was achieved in 100% and 89% for adenocarcinomas of the esophagus and the gastric cardia, p=0.06. Late adverse events occurred in 14% and 5.3%, respectively, p=0.44, with no severe adverse event. Curative resection rates were 67% and 63% for adenocarcinomas of the esophagus and the gastric cardia, respectively, p=0.89.

CONCLUSION

ESD is a safe treatment for T1 adenocarcinomas of the esophagogastric junction, curative in two thirds of the patients, in tumors arising from the esophagus or from the stomach. ESD should be considered for the routine resection of esophageal adenocarcinomas.

Cohort profile: a nationwide population-based retrospective assessment of oesophageal cancer in the Finnish National Esophago-Gastric Cancer Cohort (FINEGO)

PURPOSE

The Finnish National Esophago-Gastric Cancer Cohort (FINEGO) was established to combine the available registry data with detailed patient information to form a comprehensive, retrospective, population-based research platform of surgically treated oesophageal and gastric cancer in Finland. This cohort profile describes the 2045 surgically treated patients with oesophageal cancer included in the FINEGO cohort.

PARTICIPANTS

Registry data were collected from the National Cancer, Patient, Education and Death Registries from 1 January 1987 to 31 December 2016. All patients over 18 years of age, who had either curative surgery, palliative surgery or salvage surgery for primary cancer in the oesophagus are included in this study.

FINDINGS TO DATE

2045 patients had surgery for oesophageal cancer in the selected time period. 67.2% were man, and the majority had only minor comorbidities. The proportions of adenocarcinomas and squamous cell carcinomas were 43.1% and 44.4%, respectively, and 12.5% had other or missing histology. Only about 23% of patients received neoadjuvant therapy. Oesophagectomy was the treatment of choice and most patients were treated at low-volume centres, but median annual hospital volume increased over time. Median overall survival was 23 months, 5-year survival for all patients in the cohort was 32.9% and cancer-specific survival was 36.5%.

FUTURE PLANS

Even though Finland only has a population of 5.5 million, surgery for oesophageal carcinoma has not been centralised and therefore previously reported results have mostly been small, single-centre cohorts. Because of FINEGO, we now have a population-based, unselected cohort of surgically treated patients, enabling research on national trends over time regarding oesophageal cancer, including patient characteristics, tumour histology, stage and neoadjuvant treatment, surgical techniques, hospital volumes and patient mortality. Data collection is ongoing, and the cohort will be expanded to include more detailed data from patient records and national biobanks.