Organ Preservation after Endoscopic Resection of Early Esophageal Cancer with a High Risk of Lymph Node Involvement

Abstract

Background: Esophagectomy is recommended after endoscopic resection of an early esophageal cancer when pejorative histoprognostic criteria indicate a high risk of lymph node involvement. Our aim was to analyze the clinical outcomes of a non-surgical, organ preserving management in this clinical setting. Patients and Methods: This retrospective study was performed in two tertiary centers from 2015 to 2020. Patients were included if they had histologically complete resection of an early esophageal cancer, with poor differentiation, lymphovascular invasion or deep submucosal invasion. Endoscopic resection was followed by chemoradiotherapy or follow-up in case of surgical contraindications or patient refusal. Outcome measures were disease-free survival (DFS), overall survival (OS), cancer specific survival (CSS) and toxicity of chemoradiotherapy. Results: Forty-one patients (36 with squamous cell carcinoma and 5 with adenocarcinomas) were included. The estimated high risk of lymph node involvement was based on poor differentiation (10/41; 24%), lympho-vascular invasion (11/41; 27%), muscularis mucosa invasion or deep sub-mucosal invasion (38/41; 93%). Thirteen patients (13/41; 32%) were closely monitored, and 28 (28/41; 68%) were treated by chemoradiotherapy or radiotherapy alone. In the close follow-up group, DFS, OS and CSS were 92%, 92% and 100%, respectively vs. 75%, 79% and 96%, respectively in the chemoradiotherapy group at the end of the follow-up. Serious adverse events related to chemoradiotherapy occurred in 10% of the patients. There were no treatment-related deaths. Conclusions: Our study shows that close follow-up may be an alternative to systematic esophagectomy after endoscopic resection of early esophageal cancer with a predicted high risk of lymph node involvement.

Efficacy of Organ Preservation Strategy by Adjuvant Chemoradiotherapy after Non-Curative Endoscopic Resection for Superficial SCC: A Multicenter Western Study

“…This study confirms the findings of previous studies [13][14][15][16]19]. ER combined with CRT is an organ preservation strategy for tumors with pejorative histoprognostic criteria and high risk of lymph node involvement [22]. The organ preservation strategy of combined ER and adjuvant treatment can be an alternative to esophagectomy with a similar diseasefree survival rate [17].…”

cT1N0M0 Esophageal Squamous Cell Carcinoma Invades the Muscularis Mucosa or Submucosa: Comparison of the Results of Endoscopic Submucosal Dissection and Esophagectomy

“…When the detectable LN/distant metastasis could not be confidently attributed to a primary cancer, we attributed the metastasis to ESCC. In this case, esophagectomy might not prevent late tumor recurrences in this study [ 29 ].…”

“…First, most patients who follow this strategy can keep their esophagus intact. Organ-preserved therapy improves not only morbidity and mortality but also the quality of life [ 29 ]. The risk of subclinical LN for cT1bN0M0 ESCC patients is 20–27%, indicating that some patients do not require adjuvant therapy after ESD [ 10 , 30 ].…”

“…The risk of subclinical LN for cT1bN0M0 ESCC patients is 20–27%, indicating that some patients do not require adjuvant therapy after ESD [ 10 , 30 ]. Dermine et al reported that close follow-ups may be an alternative to esophagectomy after ESD of early esophageal cancer with a predicted high risk of subclinical LN [ 29 ]. Second, compared with esophagectomy, ESD is a safer treatment, as it is characterized by shorter operation time, lower incidence and severity of complications, and shorter hospital stays [ 25 , 27 ].…”