Introduction

Endoscopic resection (ER) is widely accepted as the standard treatment for superficial esophageal squamous cell carcinoma (ESCC). In contrast, many old patients, especially 80 years or older, may die as a result of other diseases soon after ER. Therefore, the investigation of clinical outcomes and identification of prognostic factors of patients 80 years or older undergoing ER are clinically important because these findings may inform decision-making regarding the suitability of ER.

Aims & Methods

This study aimed to identify such clinical outcomes and prognostic factors. We retrospectively evaluated the short and long-term outcomes and prognostic factors of 87 patients 80 years or older undergoing ER for ESCC at two cancers between April 2012 and March 2021. We also evaluated the relationships of patient characteristics (sex, age, Eastern Cooperative Oncology Group-performance status; ECOG-PS, American Society of Anesthesiologists physical status; ASA-PS, prognostic nutritional index; PNI, Charlson comorbidity index; CCI) and overall survival rate using the Kaplan-Meier method and a Cox proportional hazards regression model.

Results

The median age of the patients was 82 years, and male was 76 patients (87.4%). The background factors were ECOG-PS 0-1 in 81 patients (93.1%) and a median CCI of 3. As short-term outcomes, 79 patients (90.8%) were curative resections (pT1a-M, V0 and Ly0), 9 patients (10.3%) had adverse events occurred (pneumonia was the most common: 4.6%), and no treatment-related deaths occurred. As long-term outcomes, 34 patients died; however, only two patients died due to ESCC. The 3-year overall survival rates and the 5-year overall survival rates were 81.4% and 71.6%, respectively. CCI≥4 (hazard ratio 4.75, 95% CI: 2.03-11.10) was identified as an independent prognostic factor.

Conclusion

The short-term outcomes were good. In contrast, as the long-term outcomes, the overall survival rates of patients with CCI≥4 were poor. The decision to perform ER for patients with CCI≥4 should be carefully considered because follow-up without ER is possible.

Introduction

Endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) with esophageal varices (EVs) is one of the most challenging endoscopic procedures due to the high risk of bleeding and fibrosis caused by prior treatment of varices. However, due to the small number of such cases, the clinical outcomes of ESD for ESCC with EVs have been reported in only a limited number of cases at single centers^​1-3.

Aims & Methods

We conducted a multicenter, retrospective, cohort study to clarify the safety and efficacy of ESD for ESCC with EVs.Eleven institutions in the Tohoku region of Japan participated in this multicenter, collaborative, retrospective study. We performed endoscopic resection for 3619 patients with esophageal carcinoma at the participating institutions during the period from January 2010 to April 2022. Among those, 30 patients who underwent ESD for ESCC with EVs were recruited for the present study.
Rates of en bloc resection and R0 resection, procedure time and adverse events were evaluated as indicators of the feasibility and safety of ESD. Additional treatment, recurrence and metastasis of the lesions were evaluated as indicators of the long-term efficacy of ESD.

Results

Portal hypertension was caused by cirrhosis, of which alcohol was the most common cause. En bloc resection was achieved in 93.3% and R0 resection in 80.0% of the patients. The median procedure time was 92 minutes. Adverse events included a case of uncontrolled intraoperative bleeding leading to discontinuation of ESD and a case of esophageal stricture due to extensive resection. During the follow-up period of a median for 42 months, a patient with local recurrence and another patient with liver metastasis were observed. One patient died of liver failure after receiving chemoradiotherapy as an additional treatment after ESD. No patient died of ESCC.

Conclusion

This multicenter, retrospective cohort study demonstrated the safety and efficacy of ESD for ESCC with EVs. Further studies are needed to establish appropriate treatment methods for EVs before ESD and additional treatments for patients with insufficient ESD.

References

1. Sawaguchi M, Jin M, Matsuhashi T, et al. The feasibility of endoscopic submucosal dissection for superficial esophageal cancer in patients with cirrhosis (with video). Gastrointest Endosc 2014;79:681-5.
2. Choi YK, Noh JH, Kim DH, et al. Outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms in patients with liver cirrhosis. Clin Endosc 2022;55:381-9.
3. Zhang S, Liu YD, Chai NL, et al. Endoscopic submucosal dissection for early cancers or precancerous lesions of the upper gastrointestinal tract in cirrhotic patients with esophagogastric varices: Ten-year experience from a large tertiary center in China. Gastrointest Endosc 2023 Online ahead of print.

Disclosure

The authors declare that they have no conflicts of interest.

Introduction

Endoscopic submucosal dissection (ESD) has been widely used to treat early esophageal squamous cell carcinoma (ESCC). Literatures reported that the excellent 5-year survival rate of patients with early ESCC treated by ESD can reach more than 95%^1. However the premise of efficacy of ESD is that the esophageal lesions meet the indications of endoscopic therapy. Patients with absolute indications (AI) refer to those with tumor infiltrating into the epithelial layer (M1) or mucosal lamina propria layer (M2) or differentiation type of high grade intraepithelial neoplasia (HGIN), who have lower lymph node metastasis (LNM ) rate than 5.6% and have excellent efficacy and safety of ESD². Patients with relative indications (RI) refer to those with tumor infiltrating into the mucosal muscle layer (M3) or submucosal superficial layer (SM1) but with no clinical evidence of LNM, who have significantly higer risk of LNM, about 8%-53%², and lack high-quality clinical evidence of the efficacy and safety of ESD.
After ESD, if the patients were at high risk of LNM, additional treatment including surgery, radiation or chemotherapy were recommended. However, some elderly patients often presented with multiple underlying ailments, experiencing organ decline that renders them unable to withstand surgical interventions. It's been reported that the overall survival rate of elderly patients with esophageal squamous after surgery is significantly lower than that of non-elderly patients^3-4.There is lack of data reporting on the survival of elderly patients with RI who are at high risk of LNM after ESD.

Aims & Methods

Our target population is elderly patients with relative indications (RI) of endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC). They are limited on the performance of ESD and additional surgery after ESD because of severe complications and high mortality. We aim to investigate the efficacy, safety of ESD and benefits of additional surgery in these patients. We collected data of target population who received ESD in a tertiary hospital from January 2015 to March 2019. We divided them into elderly group (age≥65 years, n=38) and non-elderly group (age＜65 years, n=70).

Results

Two groups had no significant differences in the rates of bleeding (10.5% vs 12.9%, P=0.517), perforation (2.6% vs 2.9%, P=0.938), stenosis (31.6% vs 25.7%, P=0.542), en-bloc resection (94.9% vs 98.6%, P=0.252), R0 resection (61.5% vs 73.2%, P=0.182), recurrence (5.3% vs 2.9%, P=0.088) and metastasis (2.6% vs 2.9%, P=0.938). Kaplan-meier (K-M) analysis showed 5-year progression-free survival rate (5-PFS) ( 88.6% vs 92.4%, P = 0.755) and 5-year overall survival rate (5-OS) ( 96.3% vs 94.9%, P = 0.613) of elderly and non-elderly group. K-M analysis showed 5-OS of patients with and without additional surgery in elderly group (100% vs 94%, P=0.724) and non-elderly group (100% vs 95.8%, P=0.451). COX regression revealed tumor progression (including recurrence and metastasis) affected the survival of target population ( P=0.001, HR=46.562 (4.839, 447.994)) independently. Univariate and multivariate analysis found positive horizontal margin(HM) affected tumor progression (P=0.010, HR=10.751(1.717, 67.334)) independently.

Conclusion

ESD showed excellent efficacy and safety in elderly patients with RI who didn’t benefit significantly from additional surgery.

References

1. Zhang YQ, Chen T, Zhang C, et al. Endoscopic Submucosal Dissection for Superficial Proximal Esophageal Neoplasia is Highly Successful. Ann Surg 2017;266:995–999.
2. Eguchi T, Nakanishi Y, Shimoda T, et al. Histopathological criteria for additional treatment after endoscopic mucosal resection for esophageal cancer: analysis of 464 surgically resected cases. Mod Pathol 2006;19:475–480.
3. Tapias LF, Muniappan A, Wright CD, et al. Short and long-term outcomes after esophagectomy for cancer in elderly patients. The Annals of thoracic surgery 2013;95:1741–1748.
4. Aoyama T, Hara K, Kazama K, et al. The Short- and Long-term Outcomes of Esophagectomy for Esophageal Cancer in Patients Older than 75 Years. Anticancer Res. 2020;40:1087–1093.

Introduction

Oesophageal squamous cell carcinoma (OSCC) necessitates additional therapy such as surgical resection or chemoradiotherapy following non-curative endoscopic resections, considered the gold standard treatment. However, in elderly patients, decisions regarding additional therapy tend to be conservative due to concerns about increased invasiveness and its impact on prognosis.

Aims & Methods

The aim of this study was to investigate the long-term outcomes in elderly patients (aged 75 and above) with OSCC diagnosed pathologically as non-curative following endoscopic resections. A retrospective analysis was conducted on OSCC patients treated with endoscopic resection, evaluating pathology findings and prognosis based on medical records. Non-curative resection was defined as pathology revealing SCC invading the muscularis mucosa (MM) or submucosa (SM). Exclusion criteria included patients with other active malignancy, those with less than 12 months of follow-up, and those pathologically classified as having positive vertical margins (VM1) or margins difficult to evaluate (VMX). T1a-MM OSCC with lymphovascular invasion (LVI) or T1b-SM OSCC often requiring additional therapy were considered as index lesions.

Results

Twenty patients were excluded from the study (other active malignancy: n=16, dropout: n=3, VM1/VMX: n=1). A total of 120 cases were analyzed, with 27 elderly patients and 93 non-elderly patients. The proportion of SM lesions was higher in elderly patients compared to non-elderly patients (44.4% vs. 20.4%, p<0.05). Additional therapy was administered exclusively to the index lesions. There was no significant difference in the rate of additional therapy for index lesions between elderly and non-elderly patients (76.2% [16/21] vs. 63.5% [33/52], p=0.295), although non-elderly patients were more likely to undergo surgery (30.8% [16/52] vs. 3.7% [1/27], p<0.01). The median follow-up periods for elderly and non-elderly patients were 72.6 vs. 78.4 months, respectively, with no significant difference (p=0.11). During follow-up, no metastatic recurrences were observed in elderly patients, with 3 deaths unrelated to OSCC. In non-elderly patients, metastatic recurrences were observed in 8 cases. Among patients with T1a-MM without LVI who did not receive additional therapy (41 cases), 3 experienced metastatic recurrence, and 2 deaths were attributed to OSCC. Two cases (10.5% [2/19]) with additional therapy for T1a-MM and 3 cases (21.4% [3/14]) with T1b-SM had recurrence. Among those who experienced recurrence, 60% (3/5) succumbed to OSCC. In non-elderly patients, 16 deaths occurred, with 6 attributed to OSCC. The 5-year overall survival rates for elderly and non-elderly patients were 100% and 86.1%, respectively (p=0.81), with 5-year disease-specific survival rates of 100% and 93.5%, respectively (p=0.19). The 5-year disease-specific survival rates for elderly and non-elderly patients with index lesions followed by additional therapy were 100% and 90.4%, respectively, with no significant differences (p=0.213).

Conclusion

The long-term outcomes of elderly patients who underwent additional therapy after endoscopic resection for OSCC were comparable to those of non-elderly patients.

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.