SAN FRANCISCO – Endoscopic resection may help tailor management for clinically node–negative superficial squamous cell carcinoma of the esophagus, new data from Japan suggest.
Dr. Toshiro Iizuka
A retrospective study of 83 patients who underwent endoscopic resection and had subsequent treatment because of the depth of invasion of their cancer found a 5-year survival rate of 76% when it was followed by chemoradiation and 100% when it was followed by surgery.
The most common complication of the endoscopic resection was stenosis, noted in 11% of cases overall, lead investigator Dr. Toshiro Iizuka, a gastroenterologist at Toranomon Hospital in Tokyo, reported at a meeting on gastrointestinal cancers sponsored by the American Society of Clinical Oncology.
"Endoscopic therapy plus additional treatment for M3 to SM2 superficial carcinoma of the esophagus did not entail the development of any serious complications. Thus, such combined treatment was safe and feasible," Dr. Iizuka commented. "The long-term follow-up results were fairly gratifying."
"Surgical resection has been considered as a standard treatment in cases of superficial esophageal cancer with potential lymph node metastasis," he noted, but up to two-thirds of patients experience serious complications.
"The frequency of lymph node metastases in superficial squamous cell carcinoma of the esophagus ... depends on the depth of invasion," said Dr. Iizuka. "Accordingly, a therapeutic strategy has become feasible whereby endoscopic submucosal dissection aimed at local control is undertaken first, followed by considering additional treatment based on the results of the histological examination."
The patients studied all had T1 tumors and clinically node–negative (cN0) status as determined by endoscopy, endoscopic ultrasound, computed tomography, and positron emission tomography.
They underwent endoscopic resection, either endoscopic mucosal resection (EMR) before March 2005 or endoscopic submucosal dissection (ESD) thereafter.
Histologic evaluation of the endoscopically resected lesions showed that 140 patients had pathologic M3, SM1, or SM2 tumors, and they therefore received additional treatment. Patients found to have pathologic M1 or M2 tumors were followed.
Dr. Iizuka focused on results for 27 patients who underwent subsequent surgical resection and 56 who underwent subsequent chemoradiation, with the choice between these two options left to patients after discussion of the pros and cons of each in their case.
Overall, these patients had a mean age of about 63 years, and 87% were men. Tumors were roughly equally located in the upper, middle, and lower esophagus; the mean size was 42 mm in the surgery group and 26 mm in the chemoradiation group. The majority of endoscopic resections were ESD.
In the surgery group, patients more often had a three-field lymph node dissection (59%) than a two-field one (41%). In the chemoradiation group, the majority of patients received 40-45 Gy of radiation (86%) and low-dose 5-fluorouracil and cisplatin chemotherapy (57%).
Results for all 140 patients who underwent endoscopic resection showed a resection rate of 81% and an R0 resection rate of 72%. Overall, 15% of patients had a complication from the procedure, with stenosis, at 11%, being the most common.
The main complications of surgery were anastomotic stenosis (seen in 15% of patients) and recurrent nerve palsy (7%). Also, 7% of patients were found to have residual cancer and 4% were found to have lymph node metastases. The main serious complication of chemoradiation was grade-3 leukopenia (14%). There were no treatment-related deaths or grade-4 adverse events.
The median duration of follow-up was 42.5 months in the surgery group and 33 months in the chemoradiation group.
None of the patients had a local recurrence. The actuarial 5-year rates of relapse-free survival were 100% and 88%, respectively; the actuarial 5-year rates of overall survival were 100% and 76%, respectively.
"Endoscopic therapy with subsequent additional treatment is considered to be valid and ... [achieved] good local control and selection of the treatment based on the precise diagnosis," asserted Dr. Iizuka.
"To overcome ... [the study’s] shortcomings, a prospective multicenter trial is ongoing in the Japan Clinical Oncology Group," he concluded. "We will have to await the results of this trial."
Dr. Iizuka reported that he had no relevant conflicts of interest.