Oesophagectomy within 30 days after noncurative endoscopic resection for oesophageal cancer: are we able to follow this 'golden' interval?

Abstract

Endoscopic mucosal resection (EMR) is considered the first-line treatment for early-stage intramucosal lesion pT1a (m1-3) and carefully selected pT1b (sm1) non-circumferential oesophageal carcinomas [1]. This endoscopic treatment strategy has great advantages compared to surgical oesophageal resection, with a reduced invasiveness, decreasing morbidity and mortality rates and allowing the organ preservation with subsequent improvement in patients’ quality of life. Moreover, recent data demonstrated that EMR has equivalent long-term outcomes when compared to both oesophagectomy for intramucosal tumour (m1-3) or limited to the invasion of few microns of the muscularis mucosa with favourable histopathological factors (sm1), with an acceptable low risk of positive lymph node (LN) occurring in <5% of cases [2]. However, there are many circumstances in which EMR has to be deemed as noncurative, leading to consider radical oesophagectomy because of the high risk of recurrence or LN metastases. These circumstances are: tumour size >2 cm, invasion >sm1, excavated or polypoid lesion, circumferential lesion, positive lateral and/or vertical margin, poorly differentiated tumour, evidence of lymphovascular or perineural invasion and suspicion of positive LN [3]. If oesophagectomy is the recommended treatment option for noncurative EMR, the question that remains unclear is the optimal interval between the 2 procedures regarding the surgical risk if the delay is too short due to post-resection inflammation, and the risk of a pathological upstaging if the delay is too long due to local disease progression.