Introduction

The incidence of oesophageal adenocarcinoma (OAC) has increased worldwide and is associated with high mortality.[1] Surgery is considered the backbone of curative intent treatment for locally advanced disease but is associated with a high procedure-related morbidity and mortality [2-4].

Aims & Methods

We present 3 cases of suspected deep submucosal (T1b sm2-3) or muscular invasive (T2) OAC who had no distant or nodal disease, were unfit for surgery, declined chemoradiotherapy and consented to endoscopic full thickness dissection (EFTD) of their tumour.
Disease staging was with a combination of endoscopic imaging, endoscopic ultrasound and positron emission tomography and computed tomography.
Prior to resection the lesion was delineated and marked using soft coagulation. A submucosal tunnel was dissected (Spray coag. effect 4.2) towards the suspected area of deep invasion. Once invasion was detected a muscularis proparia (MP) incision (EndoCut Q) was made 10mm away (oral-side) until the peri-oesophageal space was reached. To minimise the area of excised MP the submucosal plane was entered distal from the lesion in retroflexion (via a second tunnel) and an incision into the MP was made 10mm caudal to the invasive component. Saline-immersion with use of a water exchange device was used to increase visualisation in the peri-oesophageal space and connect both muscular incisions. The margins of the tunnel and MP were then dissected.
Subsequently a fully covered self-expanding metal stent was placed to cover the entire defect.
On post-operative day (POD) 2 all patients were restarted with fluids. Oral intake was increased over several days to semi-solid. Broad-spectrum antibiotics were started during the procedure and continued for a total of 5 days. Mean time to discharge was POD 5 (range 3–7 days).

Results

In 2 cases the OAC was poorly differentiated with deep submucosal invasion (pT1b sm3). The third case was a moderately differentiated OAC with MP-invasion (pT2). In each case EFTD provided local clearance of tumour. Initial 30-day follow-up showed no evidence of complications. Patients were followed up from the date of resection to present (range 1–16 months) without evidence of local recurrence or metastatic disease.

Conclusion

Three patients with locally advanced OAC who declined alternative treatments underwent successful endoscopic full thickness resection. No evidence of disease recurrence was found on endoscopy, imaging and pathology during follow-up to date. These results suggest local endoscopic therapy should be considered in selected patients with locally advanced OAC, especially if ineligible for conventional treatment.

References

1. Bray, F., et al., Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2024.
2. Obermannova, R., et al., Oesophageal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol, 2022. 33(10): p. 992-1004.
3. Ajani, J.A., et al., Esophageal and Esophagogastric Junction Cancers, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw, 2019. 17(7): p. 855-883.
4. Mota, F.C., et al., Neoadjuvant therapy or upfront surgery? A systematic review and meta-analysis of T2N0 esophageal cancer treatment options. Int J Surg, 2018. 54(Pt A): p. 176-181.