Justin T Huntington, MD, Jon P Walker, MD, Michael P Meara, MD, Jeffrey W Hazey, MD, Scott Melvin, MD, Kyle A Perry, MD. The Ohio State University Wexner Medical Center.
BACKGROUND: Endoscopic management represents a less invasive approach with decreased morbidity compared to esophagectomy for the treatment of early esophageal cancers. Endoscopic mucosal resection (EMR) has emerged as a preferred method for staging and treatment of esophageal nodules. We report our initial experience with EMR for management of early esophageal cancer.
METHODS: A retrospective review was conducted for all patients undergoing EMR for esophageal nodules between 2008 and 2013. Patients with pathologic confirmation of carcinoma were included in this study. The primary outcome measure was need for esophagectomy based on tumor stage or disease progression. Secondary outcomes included complete eradication of adenocarcinoma, recurrence or persistence of cancer, and complications resulting from endoscopic treatment. Patients were followed for a median follow up interval of 11 months following EMR. Data are presented as incidence (%) or median (range) as appropriate.
RESULTS: During the study period, 84 patients underwent EMR for treatment of nodular disease, and 24 met the inclusion criteria for this study. Grossly margin negative endoscopic resection was achieved in all cases. Ten patients (42%) had evidence of submucosal invasion in the EMR specimen and were recommended to undergo esophagectomy. Seven of these were identified at their initial endoscopy, and 3 arose following radiofrequency ablation of dysplastic Barrett’s esophagus. Patients with margin negative EMR (n=10, 42%) or positive radial margins without evidence of submucosal invasion (n=4, 16%) underwent continued endoscopic surveillance and treatment. Five patients underwent multiple EMRs due to positive radial margin (n=1) or recurrent nodular disease (n=4). One showed no evidence of persistent disease, 3 had dysplastic Barrett’s esophagus, and 1 nodule contained recurrent intramucosal cancer. Ten patients (72%) underwent subsequent radiofrequency ablation of Barrett’s esophagus. Thirteen patients (93%) with intramucosal cancer have been successfully managed with ongoing endoscopic surveillance and treatment with a median follow up of 11 months. One patient underwent esophagectomy due to recurrent IMC despite margin negative EMR in the setting of long-segment multifocal high-grade dysplasia. Overall, successful endoscopic management of esophageal nodules containing esophageal cancer was achieved in 13 (54%) patients. Esophagectomy was recommended to 11 patients during the study period, and 9 agreed to proceed with surgery. Complete surgical resection was achieved in each case, and one patient was found to have lymph node metastasis. There were no esophageal perforations in this series, and one patient (4%) developed an esophageal stricture following EMR and radiofrequency ablation that was successfully managed with endoscopic dilation.
CONCLUSIONS: Curative treatment of early esophageal cancer can be achieved with EMR and thus avoid esophagectomy in a significant proportion of patients. Endoscopic management may be successfully utilized in the setting of complete resection, or radial margin involvement without evidence of submucosal invasion. Close endoscopic follow up is of paramount importance, because recurrent disease may occur following EMR with a negative resection margin. Long-term follow up studies are needed to accurately assess the recurrence rate following endoscopic management of IMC.
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