Introduction
Esophageal squamous cell carcinoma (ESCC) is an aggressive malignancy often detected through surveillance esophagogastroduodenoscopy (EGD). Despite regular screening, some cases still progress to advanced stages, including invasion into the muscularis mucosa (pT1a-MM) or deeper layers. The detection of interval ESCC during surveillance presents a clinical challenge, as these lesions can impact long-term prognosis.
Aims & Methods
This study aimed to investigate the characteristic endoscopic features and prognosis of post-EGD ESCC (PEESCC), defined as ESCC that progressed to pT1a-MM or deeper within two years of a prior surveillance EGD that did not identify neoplasia or carcinoma. We retrospectively analyzed 225 superficial ESCC lesions from 215 patients treated with endoscopic submucosal dissection (ESD) at the Hiroshima University Hospital between April 2010 and March 2023. Among them, 29 lesions in 28 patients were classified as the post-EGD ESCC (PEESCC) group, defined as cases where EGD performed 24 months before diagnosis did not detect neoplasia or carcinoma. The remaining 196 lesions in 188 patients were the control group. Subsequently, endoscopic findings [the presence of multiple Lugol-voiding lesions (LVLs), cancer location, circumferential involvement, direction, tumor size, macroscopic type, submucosal tumor (SMT)-like elevation, tumor color, intrapapillary capillary loop (IPCL), and clinical depth of invasion] and prognosis were compared. For accurate endoscopic findings and prognostic evaluation, patients with concurrent pT2 or deeper ESCC, those who had undergone treatment for pT2 or deeper ESCC, and those with a history of esophagectomy were excluded.
Results
In the PEESCC group, the proportions of cases with the presence of multiple-LVLs (69.0% vs. 39.3%, p < 0.01), cervical esophageal lesions (17.2% vs. 3.1%, p < 0.01), lesions localized between the 11 o’clock and 1 o’clock positions (20.7% vs. 7.7%, p = 0.037), and SMT-like marginal elevations (20.7% vs. 7.7%, p = 0.037) were significantly higher, whereas the proportion of red-colored lesions (24.5% vs. 44.9%, p = 0.027) was significantly lower compared to the control group. Additionally, the tumor size in the PEESCC group was significantly smaller than that in the control group (21.6±12.3 mm vs. 34.0±18.3 mm, p<0.01). From the multivariate analysis using the stepwise method, the presence of multiple-LVLs (OR=3.2, 95%CI:1.3-8.5, p<0.01), cervical esophageal lesions (OR=9.9, 95%CI:2.2-45.6, p<0.01), small tumor diameter(≦30mm)(OR=3.3, 95%CI:1.2-10.6, p=0.017), and SMT-like elevation (OR=3.8, 95%CI:1.1-12.0, p=0.034) were significanty identified as characteristic endoscopic findings of PEESCC. No statistically significant findings were detected in the multivariate analysis of patients without ESD history. But in the multivariate analysis limited to non-CRT cases to exclude the influence of CRT, the presence of multiple-LVLs (OR=6.5, 95%CI:2.1-23.4, p<0.01), cervical esophageal lesions (OR=15.7, 95%CI:3.1-86.8, p<0.01), tumor circumferential involvement: <1/3(OR=8.5, 95%CI:1.6-46.1, p=0.013), and SMT-like marginal elevation(OR=6.5, 95%CI:0.8-9.8, p=0.015) were identified as independent risk factors for PEESCC.The PEESCC group had a lower 5-year disease-specific survival (93.1% vs. 98.5%, p=0.039) and recurrence-free survival (69.0% vs. 83.7%, p=0.0245).
Conclusion
PEESCC lesions are associated with distinct endoscopic features and poor prognosis than non-PEESCC lesions.