Response.

Abstract

We thank Drs Luo and Zhang1Luo W. Zhang T. The clinical outcomes of endoscopic submucosal dissection for superficial circumferential esophageal squamous cell carcinoma may be not as ideal as expected.Gastrointest Endosc. 2023; 98: 138Google Scholar for their comments on our article.2Minamide T. Kawata N. Maeda Y. et al.Clinical outcomes of endoscopic submucosal dissection for superficial circumferential esophageal squamous cell carcinoma.Gastrointest Endosc. 2023; 97: 232-240.e4Google Scholar This cohort study examined the clinical outcomes of endoscopic submucosal dissection (ESD) in 52 patients with circumferential esophageal squamous cell carcinoma (cESCC). Our results showed that ESD is a minimally invasive treatment with high rates of curability and esophageal preservation, except for the drawback of a risk of esophageal stricture. As Drs Luo and Zhang1Luo W. Zhang T. The clinical outcomes of endoscopic submucosal dissection for superficial circumferential esophageal squamous cell carcinoma may be not as ideal as expected.Gastrointest Endosc. 2023; 98: 138Google Scholar noted, although the en bloc resection rate was 100%, the R0 resection rate was lower (69.2%) than that reported previously.3Yoshida M. Takizawa K. Suzuki S. et al.Conventional versus traction-assisted endoscopic submucosal dissection for gastric neoplasms: a multicenter, randomized controlled trial (with video).Gastrointest Endosc. 2018; 87: 1231-1240Google Scholar,4Yeh J.H. Huang R.Y. Lee C.T. et al.Long-term outcomes of endoscopic submucosal dissection and comparison to surgery for superficial esophageal squamous cancer: a systematic review and meta-analysis.Therap Adv Gastroenterol. 2020; 131756284820964316Google Scholar We attribute this to the high frequency of positive/indeterminate vertical margins (VM1/VMx) resulting from pT1b lesions and intralesional damage and of positive/indeterminate horizontal margins (HM1/HMx) resulting from intentional resection near the lesion margins to reduce the risk of esophageal stricture, as mentioned in a previously proposed strategy.5Kuwabara H. Abe S. Nonaka S. et al.Clinical feasibility of endoscopic submucosal dissection with minimum lateral margin of superficial esophageal squamous cell carcinoma.Endosc Int Open. 2019; 7: E396-E402Google Scholar Given that no local recurrence was observed in these patients, the impact of positive/nonassessable (R1/Rx) resection on long-term prognosis might be limited, but the technical difficulty should be kept in mind, given the high frequency of intralesional damage and long procedure time. With regard to the long-term outcomes of ESD for cESCC (4-year overall survival, 86.2%; disease-specific survival, 95.5%), we believe that they are not inferior to those reported in a recent meta-analysis.4Yeh J.H. Huang R.Y. Lee C.T. et al.Long-term outcomes of endoscopic submucosal dissection and comparison to surgery for superficial esophageal squamous cancer: a systematic review and meta-analysis.Therap Adv Gastroenterol. 2020; 131756284820964316Google Scholar Importantly, for cESCC, unlike noncircumferential ESCC, the technical difficulty and concerns about esophageal stricture weigh heavily on the decision between surgery and chemoradiotherapy, although it is an early-stage cancer without lymph node metastasis. From this perspective, ESD may well deserve consideration as a treatment option. This was a retrospective single-center study and was undeniably subject to selection bias. However, we believe that the findings are important and can be used as reference when treatment decisions are made for patients with cESCC. Nevertheless, future prospective comparative studies of ESD, surgery, and chemoradiotherapy are needed to gain further insight into accurate treatment selection for this patient population. All authors disclosed no financial relationships.