Endoscopic treatment of esophageal mucosal carcinomas: indications and outcomes

Abstract

The indications for endoscopic mucosal resection (EMR) and treatment outcomes are discussed for 402 patients (336 men and 66 women with 527 lesions) who had squamous-cell carcinoma of superficial type and with no lymph-node metastasis (N0) on clinical evaluation. The patients were followed-up for at least 2 years after EMR, conducted between January 1988 and December 2004. They were classified according to the depth of tumor invasion as follows: m1 cancer in 179 patients, m2 in 137, m3 in 61, and sm1 in 25. The number of lesions treated at the initial session of EMR was one in 317 patients (79%) and multiple lesions in 85 (21%). For the resection technique, a two-channel scope method was used in 318 patients (79%) and the cap method in 84 (21%). In patients with m3 or sm1 cancers, additional treatments included follow-up observations in 62 patients (72%) (m3 in 52 and sm1 in 10), chemoradiotherapy or radiotherapy in 17 (20%) (m3 in 7 and sm1 in 10), chemotherapy in 3 (3%) (m3 in 2 and sm1 in 1), and surgery in 4 (5%) (sm1 in 4). With regard to complications, only 5 patients (1.2%) with difficult-to-control bleeding were considered to have bleeding; a hemostatic clip was used in 1, a Sengstaken-Blakemore tube insertion in 1, and repeated argon plasma coagulation (APC) in 3. Of the 402 patients undergoing EMR, 1 (0.2%) had perforation. Despite no evidence of esophageal perforation, mediastinal emphysema occurred in 10 patients (2.3%) who underwent piecemeal resection because of large lesions. Of the 34 patients with mucosal defects occupying more than three quarters of the circumference of the esophagus, 29 (85%) had esophageal strictures. Local recurrence was found in 19 (5.4%) of the 349 patients in whom esophageal mucosal cancer was clinically considered to be completely resected and treatment completed. All patients with local recurrence had undergone piecemeal resection. Of the 402 patients who underwent EMR, 71 (18%) had a total of 111 metachronous esophageal cancers. Among the 71 patients with metachronous esophageal cancers, EMR was performed in 67 patients (107 lesions); 104 lesions were mucosal cancers and 3 were submucosal cancers (1 sm1 cancer and 2 sm2 cancers). Regarding prognosis: (1) m1 and m2 cancer: Of the 316 patients who underwent EMR for m1 or m2 cancer, 12 (4%) had local recurrence. There were 39 deaths (12%). Two patients refused further treatment after EMR, and finally died of advanced esophageal cancer. (2) m3 and sm1 cancer: Local recurrence was found in 7 (11%) of 61 patients with m3 cancer. Lymph-node metastasis was found in 2 patients (3%) and bone metastasis was found in 1. There were 17 deaths (28%); 3 patients died of recurring esophageal cancer. Lymph-node metastasis was found in 3 (12%) of 25 patients with sm1 cancer. There were 7 deaths (28%); no patient died of esophageal cancer.