Multimodal approach to early esophageal cancer

Juan M Riganti, Md, Franco F Ciotola, Md, Mauricio G Ramirez, Md, Cecilia Zubieta, Md, Adolfo Badaloni, Md, Fabio Nachman, Md, Alejandro Nieponice, Md, PhD. Esophageal Institute, Favaloro University Hospital

Introduction: Early detection of esophageal cancer is increasing within surveillance programs. Novel endoscopic therapies, such as endoscopic mucosal resection (EMR), submucosal dissection (ESD) or radiofrequency ablation (RFA) have led to a new paradigm of organ preservation in many of these patients. However, surgery should be the first choice when oncological risk is not negligible. Those patients can benefit from minimally invasive procedures. Providing endoscopic and minimally invasive therapies as a single team in a joint effort between the gastroenterologists and surgeons allows the window of opportunity not to be missed. We present our experience using a multimodal approach in a University Hospital setting.

Methods and Procedures: From 2012 – 2015 a total of 28 patients (median age 64,5 years) with early esophageal cancer (t1a,b) or downstaged to complete remission were treated. 16 patients received endoscopic treatment while the remaining 12 underwent surgery using minimally invasive esophagectomy. Patients with endoscopic therapy were treated with EMR (N=11 ),or ESD (N=4 ), and subsequent RFA (N=11 ), when needed. Median follow-up was 21,5 months. Endpoints included R0 resection , number of treatment sessions to achieve R0.

Results: Complete resection R0 was achieved in 16/17 cases (94%) for the endoscopic group and 12/12 cases (100%) in the surgery group. The average number of treatment sessions for endoscopic therapies was 2.25. 5 patients in the surgical group had complications including surgical site infections (n=2), pneumonia (n=2), anastomotic stricture requiring dilation (n=1), and pyloric syndrome (n=1) which required conversion to Roux-Y. The main complications in patients undergoing endoscopic treatment were stricture requiring dilation (n=2) , and bleeding of the resection site (n=1) requiring transfusion. There was no mortality in any of the groups. One patient in the endoscopic group was found to have a recurrence during surveillance and was successfully treated with surgery.

Conclusion: Endoscopic therapies allow organ preservation with equivalent outcomes and less morbidity than surgical treatment under a strict surveillance protocol. Minimally invasive surgery is a safer option when warranted by oncological stage and has less morbidity and mortality rates than open surgery. The balance between endoscopic and surgical resection is still matter of debate and seems to be strongly influenced by the working environment. Embracing all therapies within the same multimodal professional team eliminates the bias of expertise and availability that is usually faced by surgeons or gastroenterologists when working on their own and allows for better outcomes.