Treatment Of Superficial Esophageal Cancer Research Articles

Advances in The Application of Regenerative Medicine in Prevention of Post-endoscopic Submucosal Dissection for Esophageal Stenosis.

Endoscopic submucosal dissection (ESD) is a curative treatment for superficial esophageal cancer with distinct advantages. However, esophageal stenosis after ESD remains a tough problem, especially after large circumferential proportion of esophageal mucosa is removed, which limits the wide use of ESD, especially in circumferential lesions. In this scenario, preventive procedures are highly recommended against post-ESD esophageal stenosis. However, the efficacy and safety of traditional prophylactic methods (steroids, metal and biodegradable stents, balloon dilation, radial incision, etc.) are not satisfactory and novel strategies need to be developed. Regenerative medicine has been showing enormous potential in the reconstruction of organs including the esophagus. In this review, we aimed to describe the current status of regenerative medicine in prevention of post-ESD esophageal stenosis. Cell injection, cell sheet transplantation, and extracellular matrix implantation have been proved effective. However, numerous obstacles still exist and further studies are necessary.

Treatment of Superficial Esophageal Cancer: An Update

Superficial esophageal squamous cell carcinoma (SESCC) is an esophageal squamous cell carcinoma confined to the mucosa or superficial submucosa. Recent Korean Guidelines recommend an endoscopic resection as the first-line treatment for SESCC without a distant or lymph node metastasis (LNM) after excluding those with an obvious submucosal invasion. Before endoscopic treatment of SESCC, Lugol chromoendoscopy or image-enhanced endoscopy is recommended to define the extent of the lesion, and endoscopic ultrasound is recommended to determine the T stage. The tumor size, macroscopic type of tumor, pathologic differentiation, depth of tumor, and lymphovascular invasion (LVI) are risk factors of LNM in SESCC. No additional treatment is necessary after an en bloc complete resection of SESCC invading no more than the lamina propria without LVI. Although the risk of LNM in a SESCC invading into muscularis mucosa without LVI is low, a close follow-up is recommended without additional treatment. On the other hand, additional treatment is recommended in the case of a tumor with submucosal invasion or an LVI positive or positive vertical resection margin. Adjuvant therapy includes esophagectomy or chemoradiotherapy (CRT), but it is unclear which treatment is better. The 5-year overall survival rates were reportedly 90-100% for esophagectomy and 75-85% for CRT. Nevertheless, patients with high-risk features including poorly differentiated histology, LVI positive, perineural invasion positive, T1b-SM2/T1b-SM3 cancer, and vertical resection margin positive need to be treated with an additional esophagectomy. Elderly patients, those with a physical condition and co-morbidities, and those with LNM or cancer-specific mortality require additional treatment after a non-curative endoscopic resection of SESCC.

Long-Term Clinical Outcome and Safety Analysis of Superficial Esophageal Cancer Patients Receiving Definite or Adjuvant/Salvage Radiotherapy

<h3>Purpose/Objective(s)</h3> The role of definite concurrent chemoradiation (CCRT) or adjuvant/ salvage radiation therapy (RT) in the treatment of superficial esophageal cancer remains uncertain. We hypothesize that definite or adjuvant/salvage RT/CCRT was an alternative treatment for superficial esophageal cancer, especially for those who are ineligible for endoscopic resection (ER) or those with T1b tumor or receiving non-curative endoscopic resection. We aim to investigate the long-term clinical outcome and safety of superficial esophageal cancer patients receiving definite or adjuvant/salvage radiotherapy. <h3>Materials/Methods</h3> 48 patients with clinical T1N0M0 esophageal squamous cell carcinoma from 2011 to 2019 were included. 33 patients received RT (n = 9)/CCRT (n = 24). 15 patients received ER+RT (n = 8)/CCRT (n = 7). In ER+RT/CCRT group, median dose of 50.40 Gy and 59.36 Gy were delivered to regional lymph nodes and primary tumor with recurrence or tumor bed with positive margin, respectively. In RT/CCRT group, median dose of 50.40 Gy and 59.36 Gy were delivered to regional lymph nodes and primary tumor, respectively. 31 patients (64.5%) received concurrent chemotherapy. The Kaplan–Meier curves were used to calculate actuarial rates of 1-, 3-, and 5-year local recurrence-free survival (LRFS) and overall survival (OS). <h3>Results</h3> The median follow-up time was 38.5 months. The OS at 1-, 3-, and 5-year was 95.8%, 90.9% and 90.9%, respectively. The LRFS at 1-, 3-, and 5-year was 97.9%, 95.2% and 95.2%, respectively. The 5-year LRFS and OS in ER + RT/CCRT group were 100.0% and 100.0%, respectively. 5-year LRFS and OS in RT/CCRT group was 92.7% and 86.3%, respectively. Local recurrence occurred in 2 patients (4.2%) within the radiation field in the RT/CCRT group. No salvage therapy was delivered to these 2 patients and their median OS was 27.2 months and 13.0 months, respectively. No distant metastasis or regional recurrence were observed in all 48 patients. The cause of death included local recurrence in 2 patients and infectious pneumonia in 2 patients. The most frequent early toxicity was esophagitis. Grade 1-2 esophagitis in 13 (86.6%) and 29 (87.8%) patients in the ER+RT/CCRT and RT/CCRT group, respectively. Grade 3 in 1 (6.6%) and in 1 (3.0%) patient in the ER+RT/CCRT and RT/CCRT group, respectively. The most frequent late toxicity was esophageal stricture. Grade 1-2 occurred in 12 (80%) and 32 (96.9%) patients in the ER+RT/CCRT and RT/CCRT group, respectively. Grade 3 esophageal stricture occurred in 3 (20%) patients and 1 (3.0%) patient in the ER+RT/CCRT and RT/CCRT group, respectively. No patients experienced grade 4 toxicity and there was no treatment-related death. <h3>Conclusion</h3> Our long-term results of definite or adjuvant/salvage radiotherapy for patients with superficial esophageal cancer showed favorable outcomes and acceptable toxicities. Radiotherapy was an alternative treatment for superficial esophageal cancer.

Clinical Outcome of Additional Esophagectomy After Endoscopic Treatment for Superficial Esophageal Cancer

Endoscopic treatment is one of the options for superficial esophageal cancer, but additional therapy such as esophagectomy or chemoradiotherapy (CRT) is sometimes needed due to noncurative resection. However, the outcome of additional therapy after endoscopic treatment has not been fully evaluated. In 160 patients with superficial esophageal cancer, including 37 patients who underwent esophagectomy and 123 patients who underwent CRT after noncurative endoscopic resection, outcomes were investigated. The CRT group included more elderly patients than the surgery group, although there were no significant differences in tumor depth or lymphovascular invasion between the two groups. Overall survival was significantly better in the surgery group than in the CRT group (5-year overall survival: 94.3% vs. 79.9%; p = 0.039). Two (5.4%) patients in the surgery group who developed lymph node recurrence achieved complete response by chemotherapy or CRT, and 9 of 16 patients (13.0%) in the CRT group who developed recurrence underwent salvage esophagectomy or lymphadenectomy. As a result, the 5-year cause-specific survival was 100% in the surgery group and 92.8% in the CRT group. SM2 invasion (≥ SM2) was significantly associated with recurrence after CRT, while lymphatic invasion was associated with lymph node metastasis in the surgery group. Endoscopic treatment combined with esophagectomy or CRT can be a curative treatment option in patients with superficial esophageal cancer. However, esophagectomy rather than CRT should be recommended for patients with massive submucosal tumor invasion due to the risk of recurrence after CRT.

Impact of Time to Endoscopic Resection on Outcomes for Stage I Esophageal Adenocarcinoma

BackgroundEndoscopic resection (ER) is the preferred treatment for superficial esophageal cancer; however, a safe time frame for performing ER has not been established. This study evaluated the period in which ER can be performed for patients with stage I esophageal adenocarcinoma without compromising outcomes. MethodsThe 2004-2015 National Cancer Database was used to identify patients with cT1 N0 M0 esophageal adenocarcinoma who underwent upfront ER. The primary outcome was overall survival, which was evaluated using Kaplan-Meier and multivariable Cox proportional hazards methods. The secondary outcome was rate of margin-positive resection, which was evaluated using a multivariable logistic regression. ResultsA total of 983 patients met study criteria. The median time from diagnosis to ER was 34 days (interquartile range, 5-70 days). Patients in the highest quartile of time to ER were more likely to be treated at a high-volume center and at a center different from that of diagnosis compared with those in the lowest quartile. Increasing time to ER was not independently associated with survival (adjusted hazard ratio per 10 days, 1.02; 95% confidence interval, 0.98-1.05; P = .32) or margin-positive resection (odds ratio per 10 days 1.01; 95% confidence interval, 0.96-1.06; P = .60). ConclusionsIn this National Cancer Database analysis, increasing time to endoscopic resection, up to 180 days from diagnosis, was not associated with worsened survival or increased odds of margin-positive resection in patients with cT1 N0 M0 esophageal adenocarcinoma. Given these findings, patients may be afforded time to be seen in specialty centers without risk of tumor progression.

Utilization Trends and Volume-outcomes Relationship of Endoscopic Resection for Early Stage Esophageal Cancer.

We describe utilization trends and center volume-outcomes relationship of ER of early stage esophageal cancer using a large hospitalbased registry. ER is increasingly accepted as the preferred treatment for early stage esophageal cancer, however its utilization and the center volume-outcomes relationship in the United States is unknown. The National Cancer Database was used to identify patients with cT1N0M0 esophageal cancer treated with ER or esophagectomy between 2004 and 2015. Relative frequencies were plotted over time. Restricted cubic splines and maximally selected rank statistics were used to identify an inflection point of center volume and survival. A total of 1136 patients underwent ER and 2829 patients underwent esophagectomy during the study period. Overall utilization of ER, and relative use compared to esophagectomy, increased throughout the study period. Median annualized center ER volume was 1.9 cases per year (interquartile range 0.5-5.8). Multivariable Cox regression showed increasing annualized center volume by 1 case per year was associated with improved survival. Postoperative 30- or 90-day mortality, 30-day readmission, and pathologic T upstaging rates were similar irrespective of center volume. Utilization of ER compared to esophagectomy for stage I esophageal cancer has increased over the past decade, though many individual centers perform fewer than 1 case annually. increasing annualized center volume by one procedure per year was associated with improved survival. increased volume beyond this was not associated with survival benefit. Referral to higher volume centers for treatment of superficial esophageal cancer should be considered.

Effectiveness of salvage radiotherapy for superficial esophageal Cancer after non-curative endoscopic resection

BackgroundEndoscopic resection is widely used as an effective treatment for superficial esophageal cancer. However, the risk of lymph node metastasis increases in cases of muscularis mucosae or deeper invasion, for which additional treatment such as radiotherapy or surgery is required. Accordingly, the current study investigated the efficacy and toxicity of salvage radiotherapy after non-curative endoscopic resection as an organ preservation strategy.MethodsWe retrospectively reviewed 37 esophageal cancer patients who received salvage radiotherapy after non-curative endoscopic resection. The pathological invasion depths were the muscularis mucosae, submucosal layer, and muscularis propria in 14, 22, and one patient, respectively. All patients received external beam radiotherapy. Among them, eight received intraluminal brachytherapy following external beam radiotherapy. Elective nodal irradiation was administered to all patients. Twenty-five patients received concurrent platinum and fluorouracil-based chemotherapy.ResultsThe median follow-up time was 74 months (range: 3–212). The 5-year progression-free survival and overall survival rates were 64 and 78%, respectively. No local or regional lymph node recurrence was observed. The causes of death included esophageal cancer in one patient, metachronous esophageal cancer in one patient, other malignancies in eight patients, and other causes in six patients. Late cardiac toxicities ≥ grade 3 were observed in six patients, one of whom died of arrhythmia.ConclusionsSalvage radiotherapy after non-curative esophageal endoscopic resection is an effective treatment as an organ preservation strategy. Although muscularis mucosae and submucosal cancer have a high risk of lymph node metastasis, our results suggest that elective nodal irradiation contributes to reduced regional node metastases.

Clinical outcomes of endoscopic submucosal tunnel dissection compared with conventional endoscopic submucosal dissection for superficial esophageal cancer: a systematic review and meta-analysis.

Endoscopic submucosal dissection (ESD) is the standard treatment for superficial esophageal cancer. However, it has limitations in case of large superficial esophageal squamous cell neoplasms (SESCNs), in which submucosal injection cannot attain satisfactory lifting effects. Thus, endoscopic submucosal tunnel dissection (ESTD) was introduced as a new treatment for SESCNs presenting satisfying results. Many studies have tried to verify the efficacy of ESTD, yet no meta-analysis has been published until now. We searched the databases of PubMed, Cochrane Library, Web of Science, SinoMed, Wanfang, and CNKI dating up to February 1, 2019. Studies comparing the clinical outcomes of ESTD and ESD for superficial esophageal cancers were enrolled. The Newcastle-Ottawa Quality Assessment Scale was used to evaluate the quality of these studies. Eight articles were included that involved a total of 625 superficial esophageal cancer patients. Our analysis revealed that ESTD is superior to ESD as it has higher en bloc resection rate, shorter operation time, and lower recurrence rate 1 year after operation. The R0 resection rate and postoperative adverse event rate of ESTD group is comparable with ESD group. Our study implicates that ESTD is a potentially superior treatment to ESD for superficial esophageal cancer.

Outcomes of endoscopic submucosal dissection for superficial esophageal cancer in an elderly population: a retrospective single center cohort study.

Background and study aims Endoscopic submucosal dissection (ESD) is increasingly being used to treat superficial esophageal cancer in the elderly. However, data on clinical outcomes in this age group are limited. The aim of this study was to evaluate the safety and efficacy of ESD in treatment of superficial esophageal cancer and its effect on long-term outcome in the elderly. Patients and methods In total, 664 consecutive patients with a histological diagnosis of squamous cell carcinoma or high-grade intraepithelial neoplasia who underwent ESD between April 2008 and March 2016 at our institution were enrolled. Clinical outcomes and prognostic factors were compared retrospectively between those aged 75 years or older (n = 162) and those aged younger than 75 years (n = 502). Results There was no significant difference in post-ESD bleeding (0 vs. 0.8 %, P = 0.27) and perforation rates (1.8 vs. 1.2 %, P = 0.47) between the two age groups; however, stricture rate was higher in younger patients than in elderly patients (20.8 % vs 11 %; P = 0.036). There was no significant difference in the rate of locoregional recurrence between the two groups. Overall survival was significantly different between the two groups, but cause-specific survival was similar. Conclusion These findings confirm the efficacy of ESD for superficial esophageal cancer in selected elderly patients (75 years or older) who were fit for the treatment because they can achieve similar long-term survival to younger patients.

Argon Plasma Coagulation Treatment for superficial esophageal cancer: A Case Report

Argon Plasma Coagulation Treatment for superficial esophageal cancer: A Case Report

Endoscopic submucosal dissection followed by chemoradiotherapy for superficial esophageal cancer: choice of new approach

BackgroundThe standard treatment for superficial esophageal cancer (SEC) involving muscularis mucosal (T1a-MM) or submucosal (T1b) invasion has been the surgical resection of the esophagus. However, esophagectomy with extended lymph node dissection is highly invasive. Recent reports have shown that endoscopic submucosal dissection (ESD) followed by chemoradiotherapy (CRT) has promising results and might become a new therapeutic approach. This retrospective study aimed to elucidate the efficacy and safety of this new treatment.MethodsPatients with clinical stage T1b tumor without apparent metastasis treated with ESD followed by CRT from 2014 to 2017 (the CRT group) were included. The outcomes on disease-free survival (DFS) of this group were compared with those of consecutive patients in a historical control group who underwent ESD followed by esophagectomy (the esophagectomy group) between 2008 and 2015.ResultsOf 32 patients analyzed, 16 were in the CRT group and 16 with similar stage cancer were in the esophagectomy group. Radiotherapy was completed in all patients, and the incidence of grade ≥ 3 nonhematologic adverse events was 6%. The 2-year overall survival rates were 100%, and locoregional control was achieved in all patients in the CRT group, and the 2-year DFS rates were 88 and 100% for the CRT and esophagectomy groups, respectively, without significant differences.ConclusionsOur data confirmed our new approach as being safe and effective for locoregional control and may provide a nonsurgical treatment option for patients with clinical stage T1b tumors.

Predictors of technical difficulty during endoscopic submucosal dissection of superficial esophageal cancer

Endoscopic submucosal dissection (ESD) is the standard treatment for superficial esophageal cancer (SEC); however, it is sometimes technically difficult. Our aim was to identify the predictors of technical difficulty during ESD for SEC. We reviewed the records of patients who underwent ESD for superficial esophageal squamous cell carcinomas at a tertiary cancer center between April 2008 and March 2016. Patients undergoing ESD after esophagectomy or for residual/recurrent lesions were excluded. Preoperative factors such as tumor subsite, localization, preoperative size, macroscopic type, endoscopic depth of invasion, and treatment for synchronous multiple SECs or previous history of radiation therapy were analyzed. Logistic regression analysis was performed to identify the predictors of technical difficulty, defined as (1) long procedure time (≥ 120min), (2) adverse events (perforation, pneumomediastinum), or (3) incomplete resection (piecemeal resection, positive or indeterminate vertical margin). A total of 679 lesions in 511 patients were analyzed. Difficultly was experienced in 60 cases. The procedure time was > 120min in 43 (6.3%) patients, adverse events occurred in 16 (2.8%), and incomplete resection occurred in 17 (2.5%). Multivariate logistic regression revealed that tumors in the left esophageal wall (OR 2.15; 95% CI 1.17-3.91; p = 0.014) and those encompassing ≥ 1/2 its circumference (OR 5.06; 95% CI 2.40-11.34; p < 0.001) were independently associated with difficulty. Tumors in the left esophageal wall and tumors measuring > 1/2 of the esophageal circumference are predictors of difficult esophageal ESD. These results may contribute to better patient selection according to each endoscopist's skill.

Salvage Radiation Therapy with Elective Nodal Irradiation for Superficial Esophageal Cancer after Incomplete Endoscopic Resection

Endoscopic resection (ER) is widely used as an effective treatment for superficial esophageal cancer. However, the risk of lymph node metastasis increases in case of muscularis mucosae or deeper invasion, and additional treatment such as radiotherapy (RT) or surgery is required in those cases. The aim of this study is to investigate the efficacy and toxicity of salvage RT after incomplete ER as an organ preservation strategy. We retrospectively reviewed 37 esophageal cancer patients received salvage RT after incomplete ER at one institution between 2000 and 2014. There were 34 males and 3 females, and the median age was 67 (range: 53-85). All patients had squamous cell carcinoma. Pathological invasion depth was muscularis mucosae/submucosal layer/muscularis propria in 14/22/1 patients, respectively. The circumference of tumor was less than three quarters in 25 patients, more than three quarters in 4 patients, entire in 4 patients and unknown in 4 patients. All patients received external beam radiotherapy (EBRT). Among them, 8 patients received intraluminal brachytherapy (IBT) following EBRT. Elective nodal irradiation (ENI) was administered in all patients. Median EBRT dose was 60 Gy/30 fractions (range: 50.4-66Gy). IBT was administered to a total dose of 10 Gy/4 fractions. Twenty-five patients received concurrent platinum and 5FU-based chemotherapy. The Kaplan–Meier method was used to generate actual survival curves. Fisher’s exact test was used for statistical comparisons. Median follow-up time was 56 months (range: 3-212 months) for all patients. The 5-year progression free survival and overall survival rates were 61% and 75%, respectively. Local recurrence and regional lymph node recurrence was not observed. Distant metastasis was observed in 2 patients (5%). Metachronous esophageal cancer was observed in 6 patients (16%) and 4 patients were salvaged by ER. The 5-year incidence rates of metachronous tumor were 15%. Double cancer after RT was observed in 15 patients (41%). The causes of death were attributed to esophageal cancer in 1 patient, metachronous esophageal cancer in 1 patient, other malignancies in 8 patients, and other causes in 6 patients. Although grade 2 esophageal stenosis was observed in 7 patients (19%), and significantly high in patients with tumor circumference more than 3/4 (p<0.001). Grade 3 or worth stenosis was not observed. Late cardiac toxicities ≥ grade 3 was observed in 6 patients (pericardial effusion in 2, ischemic heart disease in 1 and arrhythmia in 3 patients) and one patient died of arrhythmia. Salvage radiotherapy after incomplete esophageal ER is effective treatment as an organ preservation strategy. Although muscularis mucosae and submucosal cancer have a high risk of lymph node metastasis, our results suggest that ENI contribute to reduce regional node metastases. Early detection of metachronous esophageal cancer and other malignancies is important for survivors.

PS02.029: USEFULNESS OF TRIAMCINOLONE INJECTION TO PREVENT STRICTURE AFTER CIRCUMFERENTIAL ESOPHAGEAL ESD

Abstract Background ESD is a standard treatment for superficial esophageal cancer in Japan. Stricture is one of important complication of esophageal ESD, and it makes quality of life of the patient worse. Usefulness of Triamcinolone (TA) injection to prevent stricture after semi-circumferential ESD has been reported. However, usefulness of TA injection after circumferential esophageal ESD is still unclear. Methods The aim of this study is to clarify the usefulness of triamcinolone injection to prevent stricture after circumferential ESD. A total of forty-nine patients treated by circumferential esophageal ESD from 2004 to 2017 in Saku Central Hospital Advanced Care Center were enrolled to this retrospective study. Fifty mg TA was injected into submucosal layer just after ESD, and TA injection was repeated in two-weeks interval by the ESD ulcer healed. When the length of circumferential ESD was 50mm or longer, 100 mg Triamcinolone was injected just after ESD, and 50mg TA injection was repeated in two-weeks interval. Fifteen mm endoscopic balloon dilatation (EBD) was performed when the scope couldn’t pass the ESD ulcer. The primary endpoint was the number of balloon dilatation. The secondary endpoints were duration from ESD to ulcer healing, complications and the difference between Barrett's esophageal adenocarcinoma (EAC) and squamous cell carcinoma (SCC). Results 1. Median number of EBD in Non-TA and TA group were 15 (13–33) and 3 (0–23), respectively (P &lt; 0.01) 2. Median duration from ESD to ulcer healing were 6 (3–23) and 4 (1–24) months. respectively. (P = 0.47) 3. Complications: Perforation rate due to EBD was 6.3% (1/16) and 3.0%(1/33). Both patients were treated by conservative therapy. 4. Difference between EAC and SCC: There were nine EAC and forty SCC patients in TA group. The number of EBD were 5.3 (5–11) and 5.4 (3 -11), respectively. Duration of ulcer healing were 10 (4–14) and 6.5 (1–24), respectively. There was no significant difference between two groups. Conclusion Triamcinolone injection is safe and effective treatment to prevent stricture after circumferential ESD, not only for SCC but also for EAC. Disclosure All authors have declared no conflicts of interest.

PS02.094: EVALUATION OF ADDITIONAL TREATMENT AFTER NON-CURATIVE ENDOSCOPIC SUBMUCOSAL RESECTION FOR ESOPHAGEAL CANCER

Abstract Background Recently, endoscopic submucosal dissection (ESD) has been used as a less invasive treatment for superficial esophageal cancer. Additional treatment is often required after non-curative resection to prevent local recurrence and lymph node metastasis. Here, we present the outcomes of various additional treatments for patients with superficial esophageal cancer who underwent ESD. Methods Between 2006 and 2017, we performed ESD in 179 patients (210 lesions) with superficial esophageal cancer and 44 cases resulted in the non-curative resection diagnosed by the pathological examination. Among them, 29 patients received additional treatment, whereas 15 patients with no additional treatment were followed up. Additional treatment included esophagectomy (8 patients), chemoradiotherapy (15 patients), ablation using argon plasma coagulation (4 patients), and chemotherapy alone (2 patients). We examined the clinicopathological characteristics and prognosis of patients in the additional esophagectomy group (S group) and chemoradiotherapy group (CRT group). Results Twenty-three patients with pT1a-MM, pT1b, lymphatic invasion, venous invasion, and positive resection margins (both horizontal and vertical) were divided into two treatment groups. Clinicopathological characteristics of patients in the S and CRT groups were not significantly different. Pathological findings after additional esophagectomy showed one residual tumor and one lymph node metastasis. There were no recurrences in the two groups. There was no statistically significant difference in the 5-year overall survival rate between the S group (87.5%) and the CRT group (93.3%). One patient from the S group died due to respiratory pneumonia, and one patient died due to radiation pneumonia. However, five out of the 15 (33.3%) patients who were followed up with no additional treatment developed recurrence. The 5-year overall survival rate was 40.4%, which was not significantly different from that in the additional treatment group. However, the 5-year relapse-free survival rate (30%) was significantly different from that in the additional treatment group (P &gt; 0.05). Conclusion Additional treatment is essential after non-curative endoscopic submucosal resection for esophageal cancer. Additional esophagectomy and chemoradiotherapy were both safe and effective in this cohort. Disclosure All authors have declared no conflicts of interest.

Diagnosis and treatment of superficial esophageal cancer.

Endoscopy allows for the screening, early diagnosis, treatment and follow up of superficial esophageal cancer. Endoscopic submucosal dissection has become the gold standard for the resection of superficial squamous cell neoplasia. Combinations of endoscopic mucosal resection and radiofrequency ablation are the mainstay of the management of Barrett’s associated neoplasia. However, protruded, non-lifting or large lesions may be better managed by endoscopic submucosal dissection. Novel ablation tools, such as argon plasma coagulation with submucosal lifting and cryoablation balloons, are being developed for the treatment of residual Barrett’s esophagus, since iatrogenic strictures still hamper the development of extensive circumferential resections in the esophagus. Optimal surveillance modalities after endoscopic resection are still to be determined. The assessment of the risk of lymph-node metastases, as well as of the need for additional treatments based on qualitative and quantitative histological criteria, balanced to the patient’s condition, requires a dedicated multidisciplinary team decision process. The need for trained endoscopists, expert pathologists and surgeons, and specialized multidisciplinary meetings underlines the role of expert centers in the management of superficial esophageal cancer.

Single Locoregional Triamcinolone Injection Immediately After Esophageal Endoscopic Submucosal Dissection Prevents Stricture Formation.

Objectives:Although endoscopic submucosal dissection (ESD) is an efficient treatment for superficial esophageal cancer, it is associated with stricture formation after wide-circumference resection that leads to a low quality of life. Although locoregional steroid injections prevent stricture formation, a randomized comparative study did not report any advantages associated with steroid injection. We evaluated the prophylactic efficacy of a single locoregional triamcinolone injection for stricture formation after esophageal ESD.Methods:This was a retrospective matched case-control study using propensity score matching (PSM). Between April 2006 and July 2015, a total of 602 patients with superficial esophageal neoplasia underwent ESD. Among them, 189 patients with mucosal defects that spanned more than 2/3 of the esophageal circumference were included. After exclusion, 150 patients were enrolled. Triamcinolone acetonide (80 mg) was injected into the residual submucosal layer of the resected region immediately after ESD. PSM was performed to reduce the effects of selection bias for steroid injection. The primary outcome was the incidence of stricture formation. The secondary outcome was the number of balloon dilatation procedures required to resolve the stricture formation.Results:Thirty-seven patients, with and without triamcinolone injection each, were matched after PSM. The incidence of stricture formation decreased from 45.9% (17/37) without triamcinolone injection to 18.9% (7/37) with triamcinolone injection (p=0.016). After matching, the mean number of balloon dilatation procedures required also decreased from 2.8±4.6 to 0.6±1.5 times (P<0.01).Conclusions:A single locoregional triamcinolone injection efficiently prevented stricture formation after esophageal ESD.

Tu1225 Single Locoregional Triamcinolone Injection Immediately After ESD for Superficial Esophageal Cancer Prevents Stricture Formation: A Propensity Score Matching Analysis

Although endoscopic submucosal dissection (ESD) is an efficient treatment for superficial esophageal cancer, stricture formation after wide-circumference resection leads to low quality of life. Locoregional steroid injection reportedly prevents stricture formation. However, a randomized comparative study could not show the advantage of steroid injection, while another comparative study without randomization had selection bias, particularly in circumference. We evaluated the prophylactic efficacy of single locoregional triamcinolone injection for stricture formation after ESD for superficial esophageal cancer using propensity score matching (PSM).

Locoregional steroid injection prevents stricture formation after endoscopic submucosal dissection for esophageal cancer: a propensity score matching analysis

Although endoscopic submucosal dissection (ESD) has become accepted for the treatment of superficial esophageal cancer, the incidence of stricture formation caused by ESD for widespread lesions is high and leads to a low quality of life. A few studies reported that locoregional steroid injections are useful for the prevention of such stricture formation compared with historical controls. We evaluated the efficacy of prophylactic locoregional steroid injections for stricture formation caused by ESD using quasi-randomized analysis. This matched case-control study included 461 superficial esophageal cancers from 305 patients who underwent ESD between 2006 and 2013. We used two methods of locoregional steroid injection to prevent stricture formation after ESD. A propensity score matching analysis was performed to reduce the effects of a selection bias for steroid injections and other potential confounding factors. In addition, generalized estimating equations were used to analyze repeated measures data. We compared the incidence of stricture formation with or without steroid injections. Forty-two lesions were treated with locoregional steroid injection (dexamethasone/triamcinolone, 23/19) after ESD and esophageal stricture formation occurred in 36 lesions. Fifty-six lesions treated with or without steroid injections were matched after propensity score matching. Locoregional steroid injection reduced the incidence of stricture formation to 10.7% (3/28) of patients compared with 35.7% (10/28) in the control group (odds ratio 4.63, 95% confidence interval 1.11-19.25, p = 0.035). Locoregional steroid injections could be efficient for the prevention of stricture formation after ESD for superficial esophageal cancer.

Early esophageal cancer in Europe: endoscopic treatment by endoscopic submucosal dissection.

Endoscopic resection is the standard treatment for superficial esophageal cancer. Data on early adenocarcinoma (EAC) are widely restricted to endoscopic mucosal resection (EMR), whereas large studies have been published on endoscopic submucosal dissection (ESD) for early squamous cell carcinoma (ESCC). ESD has potential advantages regarding en bloc and R0 resection rates, which have been demonstrated for ESCC. However, studies have failed to confirm these advantages in EAC. The aim of this study was to investigate the efficacy of ESD in early esophageal cancer. A total of 111 early esophageal cancers (87 EACs and 24 ESCCs) were resected by ESD at a German tertiary referral center. A total of 60 EACs were resected within Barrett's segments ≤ M3. Resection rates, complications, and follow-up data were recorded prospectively. En bloc resection rates were 95.4 % for EAC and 100 % for ESCC (P = 0.575), and R0 resection rates were 83.9 % and 91.7 %, respectively (P = 0.515). The R0 resection rate was higher in Barrett's ≤ M3 vs. > M3 (90 % vs. 70.4 %; P = 0.029). The curative resection rate was 72.4 % for EAC vs. 45.8 % for ESCC (P = 0.026). Endoluminal recurrence was observed in 2.4 % of EACs (8 % in Barrett's > M3, 0 % in Barrett's ≤ M3), and 0 % of ESCCs. Complications included strictures (11.7 %) and bleedings (0.9 %), but no perforation. Disease-specific survival was 97.7 % (EAC) and 95.8 % (ESCC), and overall survival was 96.6 % (EAC) and 66.7 % (ESCC) over a mean follow-up period of 24.3 months and 38.0 months, respectively. ESD was shown to be a safe resection method, achieving high R0 resection rates in both EAC and ESCC. Recurrence rates were low. To improve R0 resection within long Barrett's segments, diagnosis of the lateral extension of the lesion needs to be improved.