Additional radiotherapy following endoscopic submucosal dissection for T1a-MM/T1b-SM esophageal squamous cell carcinoma improves locoregional control

Abstract

Background: Endoscopic submucosal dissection (ESD) can be used as a less invasive treatment option for superficial esophageal cancer involving the muscularis mucosae (T1a-MM) or upper third of the submucosa (T1b-SM1). Additional treatment after ESD is needed to prevent lymph node metastasis. However, the efficacy of radiotherapy following ESD has not been well evaluated. Moreover, the clinical outcomes of patients with large mucosal defects of the esophagus who received radiotherapy after ESD have not been reported. This study aimed to clarify the efficacy of additional radiotherapy following ESD for esophageal squamous cell cancer involving T1a-MM or T1b-SM1.

Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer

“…Analyses of resected specimens of pMM esophageal squamous cell carcinomas from patients who received surgical resection as first‐line treatment, including patients with vascular invasion, revealed concurrent lymph node metastasis in 0–26.7% of cases. In our summary of the main reports, concurrent lymph node metastasis occurred in 29 of 199 patients (14.6%, 95% CI: 10.0–20.3%) . A report of 50 patients with pMM cancer found that the incidence of lymph node metastasis was increased in patients with vascular invasion (invasion negative 4/38 (10.5%) vs. invasion positive patients: 5/12 (41.7%)) …”

“…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 ).…”

“…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.…”

<p>Risk of Recurrence and Metastasis for Patients with T1N0M0 Esophageal Carcinoma Who Achieve Completed Resection via Endoscopic Submucosal Resection: Evidence for the Appropriateness of the Watch and Wait Follow-Up Strategy</p>

“…First, we excluded patients who received additional treatment following ESD. Complementary chemoradiotherapy has been reported to lower the risk of nodal or distal metastasis associated with infiltrative tumors, 23,24 and patients could also benefit from ESD combined with additional treatment 25 . Second, ESD patients were strictly selected according to CT assessments.…”