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ENDOSCOPIC SUBMUCOSAL DISSECTION FOR ESOPHAGEAL ADENOCARCINOMA AND A NORTH AMERICAN PERSPECTIVE
Philippe Bouchard*, Jonathan Cools-Lartigue, Jonathan Spicer, Carmen L. Mueller, Lorenzo E. Ferri
McGill University, Montreal, QC, Canada
Introduction:
Given the low rate of lymph node metastasis, organ-sparing endoscopic resection of early esophageal cancer is justified. Endoscopic Submucosal Dissection (ESD) has been shown in Asian studies with esophageal squamous cell carcinoma to be superior to Endoscopic Mucosal Resection (EMR) in terms of the ability to resect larger lesions with negative margins. However, there is very limited data on the application of ESD in Western countries and for esophageal adenocarcinoma. We sought to review our experience employing ESD in patients with early esophageal cancer from a North American surgical perspective.
Methods:
A prospectively maintained database (2005-16) on all patients with esophageal cancer at a North American surgical referral center was queried for those undergoing ESD for adenocarcinoma or HGD. Patient demographics, pre-resection tumour characteristics, endoscopic resection technical variables, pathologic results, and short and long term outcomes were recorded. Data presented as Median (IQR).
Results:
Of 650 patients in the database 26 underwent 27 ESDs for adenocarcinoma /HGD between 2012-2016. The median age was 66 (16.5), most were male (78%:21/27). The majority (67%) had pre-treatment EUS and clinical staging was nodular HGD (11%)/cT1a (44%)/cT1b (44%). Procedure time was 86 (50) minutes and 25/27 (93%) were performed en-bloc. Although bleeding was common during the procedure, there were no post-ESD bleeding events requiring re-intervention. Perforation occurred in 2/27 (7%) one of which required operative repair. LOS was 1 (1) day. Final pathology revealed nodular HGD (4/27), pT1a(7/27), pT1b(15/27), pT2(1/27). Complete RO resection was achieved in 18/27(67%). Of the 9 R1 cases, all were deep margin positive and occurred solely in pT1b/pT2 lesions. Salvage laparoscopic esophagectomy was performed in 6 patients for positive deep margins and 1 for multifocal invasive cancer. At follow up of 13.5 (2-30) months recurrent cancer occurred in only 1 patient (1/21 of unresected pts), who was managed successfully with a repeat ESD.
Conclusions:
In this largest single institution North American series to date we have found that although technically challenging, ESD represents a safe and effective treatment of early esophageal adenocarcinoma, even in many T1b lesions. ESD should be more widely adopted as an important tool in the therapeutic armamentarium for the treatment of early esophageal adenocarcinoma in Western countries.
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