Efficacy and Safety of Endoscopic Resection Followed by Chemoradiotherapy for Superficial Esophageal Squamous Cell Carcinoma: A Retrospective Study

Abstract

Objectives:The reported 1- and 3-year overall survival rates after esophagectomy for stage I superficial esophageal squamous cell carcinoma (SESCC) are 95–97% and 86%, and those after definitive chemoradiotherapy (CRT) are 98% and 89%, respectively. This study was performed to elucidate the efficacy and safety of another treatment option for SESCC: endoscopic resection (ER) followed by CRT.Methods:We retrospectively reviewed the overall survival, recurrence, and grade ≥3 adverse events of consecutive patients who refused esophagectomy and underwent ER followed by CRT for SESCC from 1 January 2006 to 31 December 2012.Results:In total, 66 patients with SESCC underwent ER followed by CRT during the study period, and complete follow-up data were available for all patients. The median age was 67 (range, 45–82) years, and the median observation period was 51 (range, 7–103) months. Local and metastatic recurrences occurred in 2 (3%) and 6 (9%) patients, respectively, and 17 (26%) patients died. The 1-, 3-, and 5-year overall survival rates were 98%, 87%, and 75%, respectively. One of the 23 patients with mucosal cancer and 5 of 43 with submucosal cancer developed metastatic recurrences (P=0.65). Five of the 61 patients with negative vertical resection margin and 1 of 5 with positive vertical resection margin developed metastatic recurrences (P=0.39). None of the 30 patients without lymphovascular involvement developed metastatic recurrences; however, 6 of 36 patients with lymphovascular involvement developed metastatic recurrences (P=0.0098). Grade ≥3 adverse events occurred in 21 (32%) patients and all adverse events were associated with CRT, hematological adverse events in 13 (20%), and non-hematological adverse events in 9 (14%).Conclusions:ER followed by CRT provides survival comparable with that of esophagectomy or definitive CRT and has a low local recurrence rate. A particularly favorable outcome is expected for cancers without lymphovascular involvement.

Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer

“…The metastasis rates for each group were 12/216 (5.6%, 95% CI: 2.9–9.5%) in the follow‐up observation group (six reports; Table ), 0/6 in the additional surgical resection group (three reports; 0%, 95% CI: 0–46.0%), and 1/17 in the additional chemoradiotherapy group (six reports; 5.9%, 95% CI: 0.2–28.7%) (Table ).…”

“…Furthermore, after contacting the authors, we also tabulated the data for the follow‐up observation, additional surgical resection, and additional chemoradiotherapy groups for patients with pMM cancer with vascular invasion and pVM0 esophageal squamous cell carcinoma following ER. Metastasis occurred in 3/14 patients (21.4%, 95% CI: 4.7–50.8%) in the follow‐up observation group (four reports), 1/20 patients in the additional surgical resection group (four reports; 5.0%, 95% CI: 0.1–24.9%), and 7/45 patients in the additional chemoradiotherapy group (six reports; 15.6%, 95% CI: 6.5–29.5%) (Table ).…”

“…Metastasis among patients with pSM1/SM2 cancer without vascular invasion occurred in 8/54 patients in the follow‐up observation group (six reports; 14.8%, 95% CI: 6.6–27.1%), 1/17 patients in the additional surgical resection group (six reports: 5.9%, 95% CI: 0.2–28.7%), and 9/121 patients in the additional chemoradiotherapy group (11 reports 7.4%, 95% CI: 3.5–13.7%) …”

“…The rates of treatment‐related death following surgical resection were 0–2.0% in four case‐series studies and 1.3% in a non‐RCT (1.3%, 95% CI: 0.7–2.2%). Delayed adverse events of additional chemoradiotherapy were tabulated from eight case‐series studies and one single‐arm prospective trial, with radiation pneumonitis grade ≥3 in 1.0% (3/302) of patients, grade 3 thromboembolism in 0.3% (1/302) of patients, and myocardial infarction grade ≥3 in 1.3% (4/302) of patients. A total of four treatment‐related deaths (4/302: 1.3%, 95% CI: 0.4–3.4%) were reported, comprising pneumonitis in one, sudden death in one, and myocardial infarction in two patients.…”

Failure patterns after adjuvant chemoradiotherapy following endoscopic resection for superficial esophageal squamous cell carcinoma

“…The combination of ER and adjuvant CRT has emerged as a new strategy for treating SESCC, as ER plus adjuvant CRT can provide a lower incidence of residual tumors or local recurrence than definitive CRT. Furthermore, pre‐CRT ER may help predict the risk of metastasis and guide subsequent treatment . In our institution, ER has been widely performed for both T1b and T1a SESCC, and adjuvant CRT with elective nodal irradiation (ENI) has been performed to reduce the risk of locoregional recurrence when the pathological examination reveals high‐risk metastatic features, such as T1b DOI or the presence of lymphovascular invasion (LVI) .…”