Salvage endoscopic resection after definitive chemoradiotherapy for esophageal cancer: a Western experience

Abstract

Background and Aims: Definitive chemoradiotherapy (CRT) is increasingly used as a nonsurgical treatment for esophageal cancer. In Japanese studies, salvage endoscopic resection (ER) has emerged as a promising strategy for local failure after definitive CRT. We aimed to evaluate the safety and efficacy of salvage ER in a Western setting.Methods: Gastroenterologists from Europe and the United States were invited to submit their experience with salvage endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) after definitive CRT. Participating gastroenterologists completed an anonymized database, including patient demographics, clinicopathologic variables, and followup on survival and recurrence.Results: Gastroenterologists from 10 endoscopic units in 6 European countries submitted information on 25 patients. A total of 35 salvage ER procedures were performed, of which 69% were ESD and 31% EMR. Most patients had squamous cell carcinoma (64%) of the middle or lower esophagus (68%) staged as cT2-3 (68%) and cNþ (52%) before definitive CRT. The median time from end of definitive CRT to ER was 22 months (interquartile range, 6-47). The en-bloc resection rate was 92% for ESD and 46% for EMR. During a median of 24 months (interquartile range, 12-59) of follow-up after salvage ER, 52% developed a recurrence (11 locoregional, 2 distant). The 5-year recurrence-free survival, overall survival, and disease-specific survival were 36%, 52%, and 79%, respectively. No major intra-or postprocedural adverse events, such as bleeding or perforation, were reported. Conclusions:In carefully selected esophageal cancer patients, salvage ER is technically feasible after definitive CRT. Further prospective research is recommended to validate the safety and effectivity of salvage ER for the management of local failure. (Gastrointest Endosc 2020;-:1-11.

Patterns of recurrence following definitive chemoradiation for patients with proximal esophageal cancer

“…Particularly in the current era of enhanced surgical procedures in the salvage setting for EC, e.g. endoscopic resections [41], robotassisted minimally invasive esophagectomy [42], and the advantages of high volume expertise centers [43,44].…”

Endoscopic resection as an independent predictive factor of local control in patients with T1bN0M0 esophageal squamous cell carcinoma treated with chemoradiotherapy: a retrospective study

“…In 2003, Hattori et al reported the results of the first EMR performed as a salvage treatment for local recurrence after CRT in Japan [ 19 ]. Consequently, several studies have been conducted to examine the effectiveness and safety of salvage ER after CRT [ 20 – 22 ], it has been regarded as important to detect recurrence after CRT while tumor remains in the superficial layer. In our institution, patients treated with CRT underwent follow-up EGD and CAT scans every 4–6 months during the first 5 years after CRT.…”

Endoluminal resective therapy for residual esophageal neoplasia after definitive chemoradiotherapy: Who are we helping—the patient or the endoscopist?

“…In summary, organ preservation appears desirable after CRT, and this study by Al-Kaabi et al 6 shows that in expert hands endoscopic resection can be a viable alternative, but one has to weigh the consideration of curative margins and concern for locoregional dissemination in the long term against that of the mortality and morbidity from surgery and esophagectomy. Unfortunately, this decision making remains unclear, and patient factors and institutional experience will need to ultimately guide decision making because prospective data are still difficult to collate and are lacking.…”

“…In this cohort, a total of 13 patients (52%) experienced recurrence after salvage ER, of whom 11 (44%) had locoregional recurrence only and 2 had distant disease (8%; Table 3 of Al-Kaabi et al 6 ). The median time of salvage ER to the occurrence of locoregional or distant recurrence was 9.6 months (interquartile range, 4-29; range, 2-48).…”

“…Current literature suggests insufficient accuracy of endoscopic biopsies, EUS, and 18F-fluorodeoxyglucose PET(-CT) as single modalities for detecting residual disease after CRT for EC. 4,5 In this edition of Gastrointestinal Endoscopy, Al-Kaabi et al 6 describe a well-designed retrospective study in a cohort of patients who underwent salvage endoscopic resection (ER) for residual luminal disease after receiving dCRT for EC. This is one of the largest Western experiences showing a variety of high-volume specialist tertiary centers involved in the care of patients with EC.…”