Endoscopic Mucosal Resection (EMR) and Photodynamaic Therapy (PDT) As Curative Salvage Treatments for Local Failure After Definitive Chemoradiotherapy (CRT) for Esophageal Cancer (EC)

Abstract

Background: Although definitive CRT for EC shows a high response rate, local failure without distant metastasis is up to 40% or more. Salvage esophagectomy is considered to be only curative treatment option, however, it is relevant to high morbidity and mortality rate. We have previously published short-term results of salvage EMR and PDT. (Hattori S, et al. GIE 2003,58, Yano T, et al. GIE 2005, 62). Aim: The aim of this retrospective analysis is to up date these results with further follow up periods and evaluate the efficacy and safety. Patients and Methods: CRT consists of more than 50.4 Gy of external beam irradiation and concurrent with chemotherapy (cisplatin + 5-fluorouracil (5FU) or nedapratin + 5FU). The indication of salvage EMR or PDT were as follows; 1) clinically defined N0M0 by computed tomography and endoscopic ultrasound (EUS) after CRT, 2) patients' refusal of salvage esophagectomy 3) written informed consent. EMR or PDT was performed up to the following findings: 1) If the cancerous lesion was limited within mucosal layer without ulceration, we select salvage EMR, 2) if the lesion had ulceration or invaded into the submucosal layer or estimated as uT2 by EUS, we select salvage PDT. EMR was performed with strip-biopsy methods. PDT proceeded with injection of Photofrin and irradiation with excimer dye laser. Results: From Feb. 1998 to Feb. 2005, a total of 67 patients with EC were underwent endoscopic salvage treatment for local failure definitive CRT. (EMR 30 / PDT 37) [Salvage EMR]Median age was 63 y-o (range, 47-70) Baseline clinical stage before CRT was as follows: T1/2/3/4 in 15/2/12/1, N0/1 in 18/12 and stage I/II/III in 13/9/8 patients. 21 patients could achieve complete resection. Major complication was perforation with one patient. There was no treatment-related death (TRD) with EMR. With a median follow up period of 39 months after salvage EMR, 3 year overall survival (OS) rate was 64.4%. [Salvage PDT]Median age was 64.5 y-o (range, 50-75) Baseline clinical stage before CRT was as follows: T1/2/3/4 in 3/4/21/2, N0/1 in 13/24 and clinical stage I/II/III/IV in 2/11/21/2 patients. Before PDT, 20 patients were assessed having uT1 lesion and remaining were uT2. 22 patients were achieved complete response (CR rate; 59.5%, uT1: 15/20; 75%, uT2:7/17; 41.2%). Major complication was 4 perforations and 20 esophageal stenosis. A patient was died with perforation 2 months after PDT. With a median follow up period of 28 months after salvage PDT, 2 year OS rate was 53.1%. Conclusion: Salvage EMR and PDT could be promising curative intent treatment option for local failure after definitive CRT for EC with low rate of morbidity and mortality.