A comparison of the clinical outcomes of esophagectomy and chemoradiotherapy after noncurative endoscopic submucosal dissection for esophageal squamous cell carcinoma

Abstract

PurposeEndoscopic submucosal dissection (ESD) is widely used to treat esophageal cancer, but some patients require additional treatment due to the possibility of lymph node metastasis. The aim of this study was to elucidate the clinical outcomes of these additional treatments.MethodsThe study included 59 patients who developed superficial esophageal squamous cell carcinoma after noncurative ESD treated between 2005 and 2016, of whom 28 underwent esophagectomy and 31 received chemoradiotherapy (CRT).ResultsThe median follow-up periods were 45 months in the esophagectomy group and 41 months in the CRT group. The overall survival did not differ significantly between the groups (P = 0.46). However, there were no recurrences in the esophagectomy group, and the disease-specific survival rate was significantly higher in this group (P = 0.042). Among the patients at high risk for recurrence due to massive tumor invasion (≥ SM2) with lymphovascular invasion (esophagectomy group, six patients; CRT group, ten patients), none in the esophagectomy group had recurrence, whereas four in the CRT group died of esophageal cancer (P = 0.031).ConclusionThe overall survival did not differ significantly between the groups. However, compared with CRT, esophagectomy provided more favorable disease control for patients with massive tumor invasion (≥ SM2) with lymphovascular invasion.

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.…”

Feasibility of Endoscopic Submucosal Dissection for Early Esophageal Squamous Cell Carcinoma with Relative Indications

“…Some possible reasons include poor physical or mental conditions, substantial economic burden, intolerance to surgery or CRT, and higher rates of comorbidities and adverse events following additional treatment. Koterazawa et al [13] reported that the incidence of anastomotic leakage, pulmonary complications, and recurrent nerve palsy among patients who underwent esophagectomy after ESD was 17.8, 28.5, and 10.7%, respectively. Other studies have indicated that elderly patients (aged 70 years or more) who underwent esophagectomy experienced higher rates of adverse events, operative mortality, and in-hospital mortality, as well as lower 5-year survival rate [14, 15].…”