Endoscopic resection of esophageal squamous cell carcinoma: Current indications and treatment outcomes

Abstract

Endoscopic resection (ER) is an alternate minimally invasive treatment for superficial esophageal squamous cell carcinoma (SESCC). We aimed to review the clinical indications and treatment outcomes of ER for SESCC. Endoscopic mucosal resection is relatively easy and efficient for SESCC ≤ 15 mm. In contrast, endoscopic submucosal dissection (ESD) is recommended to achieve en bloc resection for lesions >15 mm, in view of the accurate pathological evaluation. The Japan Gastroenterological Endoscopy Society guidelines recommend ER for non‐circumferential cT1a‐EP/LPM (epithelium/lamina propria mucosae), cT1a‐MM/T1b‐SM1 (muscularis mucosa/superficial submucosa ≤ 200μm) SESCC, and whole‐circumferential T1a‐EP/LPM SESCC ≤ 50 mm (upon implementing preventive measures for stenosis), considering the risk‐benefit balance of ER. It defines pT1a‐EP/LPM without lymphovascular invasion as a curative endoscopic resection. The guidelines recommend additional esophagectomy or chemoradiotherapy for pT1b SESCC or any SESCC, with lymphovascular invasion. However, there is no recommendation for or against the administration of additional treatments for pT1a‐MM without lymphovascular invasion, owing to limited evidence. Researchers have reported on high en bloc and R0 resection rates of ESD, and a randomized controlled trial demonstrated that clip‐line traction‐assisted ESD could significantly reduce the ESD procedural time. Moreover, steroid treatment has been developed to prevent post‐ESD esophageal strictures. There have been reports on favorable long‐term outcomes of ESD. However, most of them are retrospective studies. Further robust data in prospective trials are warranted to achieve a definitive evidence of ESD, which will be beneficial to patients with SESCC.

Endoscopic diagnosis and management of superficial esophageal squamous cell carcinoma

“…However, due to the risk of linfonodal metastasis, they are considered relative indications. Lesions with endoscopic features of deep submucosa invasion (more than 200 μm or ≥SM2) are associated with a risk of lymph node metastasis at a frequency of about 50% and should be treated similarly to advanced carcinomas 24 - 27 .…”

“…On the contrary, in patients with muscularis mucosa (M3) or superficial submucosa (SM1) and positive vascular invasion, an additional treatment (surgical or chemoradiotherapy) is required. Also, for lesions showing deep submucosal invasion, regardless of lymphovascular metastasis, additional esophagectomy or chemoradiotherapy is necessary 27 . The selection between surgery and chemoradiotherapy should be made after assessing the patient's clinical condition ( Figure 19 ).…”

Assessment of predictive factors associated with the technical difficulty of endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma: Japanese multicenter retrospective study

“…Esophageal cancer is the most common esophageal neoplasm and has the seventh highest incidence and sixth highest mortality rate worldwide, with an estimated 604,100 new cases and 544,076 deaths in 2020 1 . Endoscopic resection (ER) is a minimally invasive procedure for the treatment of superficial esophageal cancer 2–4 . Endoscopic mucosal resection resulted in piecemeal resection for large lesions and was associated with a high rate of local recurrence 2,5,6 .…”

“…1 Endoscopic resection (ER) is a minimally invasive procedure for the treatment of superficial esophageal cancer. [2][3][4] Endoscopic mucosal resection resulted in piecemeal resection for large lesions and was associated with a high rate of local recurrence. 2,5,6 Endoscopic submucosal dissection (ESD) allows en bloc resection of lesions, regardless of size or macroscopic type; it was covered by insurance in Japan in 2008.…”