Endoscopic Therapy for Esophageal Squamous High-Grade Dysplasia and Early Squamous Cell Carcinoma: A North American Experience

Abstract

Introduction: Squamous cell cancer (SCC) represents the predominant histological subtype of esophageal cancer worldwide. Endoscopic mucosal resection (EMR) and ablative therapies, such as radiofrequency ablation (RFA) and photodynamic therapy (PDT), have become established treatments for early stage SCC in high-incidence regions. According to national guidelines, endoscopic therapy is the preferred treatment approach for high-grade dysplasia (HGD) and early stage SCC and adenocarcinoma; however, data supporting endoscopic therapy for SCC in low-incidence countries are limited. We report the experience with endoscopic treatment for this cancer subtype at a North American comprehensive cancer center. Methods: We performed a retrospective search of the institutional electronic medical record to identify cases of esophageal squamous HGD or early stage esophageal SCC between 1998 and 2017 that were managed endoscopically by EMR, RFA, PDT and/or argon plasma coagulation (APC). Demographic data, disease characteristics, and clinical outcomes were collected. Results: Twenty patients (11 Tis, 6 T1a, 3 T1b) were included in this study, with a median age of 73 years (IQR 65.5-77.9). There were 14 (70.0%) female patients in our series. Fifteen patients (75.0%) achieved an initial complete remission of dysplasia at a median of 95 days (IQR 78.5-265.0). The complete remission rates for Tis, T1a, and T1b lesions were 81.8%, 83.3% and 33.3%, respectively. Patients required a mean of 1.9 (range 1-4) endoscopic procedures to achieve remission. Five patients (25.0%) required further therapy, including esophagectomy (n=1), intraluminal brachytherapy (n=1), chemoradiation (n=1), or were lost to follow up (n=2). Eleven (73.3%) out of the fifteen patients, who achieved initial remission, remained disease-free at a median follow-up of 79.8 months (IQR 45.2-132.0). Four patients (26.6%) had disease recurrence requiring further endoscopic therapy (n=2) or chemoradiation (n=1), while one patient with low-grade dysplasia recurrence chose to undergo surveillance. Five of sixteen patients treated with EMR (31.3%) and two of eight patients treated with RFA (25.0%) developed minor complications. There were no severe complications.Table: Table. Demographic and Tumor CharacteristicsTable: Table. Treatment and OutcomesConclusion: This study describes a North American experience with squamous HGD and T1 SCC treated endoscopically. This study demonstrates that endoscopic therapy is highly effective and durable in eradicating squamous HGD and T1 SCC of the esophagus.