Introduction
Endoscopic submucosal dissection (ESD) is the preferred treatment for superficial esophageal squamous cell carcinoma (ESCC). However, curative resection is not always achievable for all patients1. Currently, the curability criteria was inconsistent among different societies2-3 and may be overly stringent for suggesting additional treatments4, which causes dilemmas in clinical decision-making and potential overtreatments in some low-risk cases.
Aims & Methods
The research aim was to develop and validate a risk scoring system to assess curability after ESD for superficial ESCC. This study was based on a nationwide cohort, the China Early Esophageal Cancer Cohort, and all patients were follow-up at least for 3 years. Patients with superficial ESCC undergoing ESD were included, and those with positive horizontal margin, adjuvant chemoradiotherapy, and metachronous esophegeal cance after ESD were excluded. The primary outcome was noncurative resection, defined as either (1) pathological confirmation of residual tumor or lymph node metastasis (LNM) after additional surgery, or (2) identification of local recurrence, LNM, or distant metastasis during follow-up. Data from South and North China were used to develop and validate the scoring system, respectively. Logistic regression analysis was used for model construction, and Kaplan-Meier survival estimates, the C-statistic, and decision curve analysis were employed for performance evaluation.
Results
A total of 1,273 patients with superficial ESCC were included, with 995 for model development and 278 for validation. Multivariable analysis identified 6 independent risk factors for noncurative resection: tumor size ≥30 mm, submucosa invasion, positive vertical margin, lymphatic invasion, vascular invasion, and poor differentiation. For the risk scoring system (ESCC-eCura), lymphatic invasion was assigned as 2 points, and others were assigned as 1 point. In the development cohort, the non-curative resection rates of the low- (≤1 point), intermediate- (2 to 3 points), and high-risk (≥4 points) groups was 4.5%, 16.3%, and 75.0%, respectively. The ESCC-eCura demonstrated a C-statistic of 0.75 (95% condifence interval [CI], 0.69 - 0.81). In the validation cohort, the C-statistic was 0.84 (95% CI, 0.73-0.95), and intermediate- or high-risk groups were significant predictors for subsequent recurrence (hazard ratio [HR] for intermediate-risk group 14.35, 95% CI 4.01-51.35, P<0.001; HR for high-risk group 28.16, 95% CI 4.90-161.83, P<0.001; all compared with the low-risk group). Decision curve analysis also showed acceptable clinical benefits and utility.
Total points
| Patients (n=995)
| Noncurative resection (n=76)
| Noncurative resection rate (%)
|
0
| 372 | 11 | 3.0 |
| 1 | 436 | 25 | 5.7 |
| 2 | 133 | 14 | 10.5 |
| 3 | 38 | 14 | 36.8 |
| 4 | 11 | 7 | 63.6 |
| 5 | 2 | 2 | 100.0 |
| 6 | 3 | 3 | 100.0 |
Low-risk group, ≤1 point; intermediate-risk group, 2 to 3 points; high-risk group, ≥4 points.
|
Table 1. Distribution of the ESCC-eCura risk scores and rates of non-curative resection in the development cohort.
Conclusion
This ESCC-eCura scoring system can predict non-curative resection after ESD for superficial ESCC, which offers a practical tool for individualized management. Additiomal treatments should be recommended for patients in ESCC-eCura intermediate- or high-risk groups, while follow-up may be acceptable for the low-risk group.
References
1.Jiang, H., et al., Risk and Pathological Factors of Recurrence after Endoscopic Resection for Superficial Esophageal Squamous Cell Carcinoma: A Systematic Review and Meta-analysis. Gastrointest Endosc, 2024.
2. Kitagawa, Y., et al., Esophageal cancer practice guidelines 2022 edited by the Japan esophageal society: part 1. Esophagus, 2023. 20(3): p. 343-372.
3. Pimentel-Nunes, P., et al., Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy, 2022. 54(6): p. 591-622.
4.Liu, Z., et al., Additional Esophagectomy Following Noncurative Endoscopic Resection for Early Esophageal Squamous Cell Carcinoma: A Multicenter Retrospective Study. Ann Surg Oncol, 2021. 28(12): p. 7149-7159.
Disclosure
Nothing to disclose.