Endoscopic submucosal dissection for early esophageal cancer in elderly patients with relative indications for endoscopic treatment
submitted 09 July 2017
accepted after revision 30 January 2018
16 March 2018 (eFirst)
Background According to the Japanese Esophageal Society (JES) guidelines, early esophageal squamous cell carcinoma (SCC) involving the muscularis mucosae (M3) or upper submucosal (SM1) layers are relative indications for endoscopic submucosal dissection (ESD). Additional esophagectomy or chemoradiotherapy is recommended for patients with relative indications after evaluation. However, elderly patients (≥ 60 years) with relative indications in China often refuse additional treatment because of the debilitating side effects. The aim of this study was to evaluate the long-term outcomes of elderly patients with relative indications who did not undergo additional treatment after ESD.
Methods Data from elderly patients with relative indications who underwent ESD for early esophageal SCC between January 2008 and December 2013 were reviewed retrospectively. Stricture and recurrence, and 5-year progression-free survival (PFS) and overall survival rates were compared with patients with absolute indications for ESD.
Results 158 elderly patients were included and analyzed (89 in the absolute indications group and 69 in the relative indications group). The baseline characteristics were balanced between the two groups. During 56 months (range 1 – 108) of follow-up, the postoperative stricture rates were similar in the absolute and relative indications groups (21.3 % vs. 31.9 %; P = 0.13). The hazard ratio (HR) for PFS in the absolute vs. the relative indications groups was 1.025 (95 % confidence interval [CI] 0.36 – 2.95; P = 0.96). The 5-year PFS rates were 90.5 % (95 %CI 83.44 – 97.56) and 90.8 % (95 %CI 83.74 – 97.86) for the absolute and relative indications groups, respectively. The HR for overall survival in the absolute vs. the relative indications groups was 0.564 (95 %CI 0.13 – 2.52; P = 0.45). The 5-year overall survival rates were 96.6 % (95 %CI 92.88 – 100) and 95.6 % (95 %CI 90.70 – 100) for the absolute and relative indications groups, respectively.
Conclusions Based on this study, regular follow-up without additional treatment may be considered as another choice for elderly patients with early esophageal SCC and relative indications after ESD.
* These authors contributed equally to this paper.
- 1 Chen W, Zheng R, Baade PD. et al. Cancer statistics in China, 2015. CA Cancer J Clin 2016; 66: 115-132
- 2 Briez N, Piessen G, Bonnetain F. et al. Open versus laparoscopically-assisted oesophagectomy for cancer: a multicentre randomised controlled phase III trial – the MIRO trial. BMC Cancer 2011; 11: 310
- 3 Allum WH, Bonavina L, Cassivi SD. et al. Surgical treatments for esophageal cancers. Ann N Y Acad Sci 2014; 1325: 242-268
- 4 Luo LN, He LJ, Gao XY. et al. Evaluation of preoperative staging for esophageal squamous cell carcinoma. World J Gastroenterol 2016; 22: 6683-6689
- 5 Mannath J, Ragunath K. Role of endoscopy in early oesophageal cancer. Nat Rev Gastroenterol Hepatol 2016; 13: 720-730
- 6 Kuwano H, Nishimura Y, Oyama T. et al. Guidelines for diagnosis and treatment of carcinoma of the esophagus April 2012 edited by the Japan Esophageal Society. Esophagus 2015; 12: 1-30
- 7 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2015; 47: 829-854
- 8 Jiang D, Li X, Wang H. et al. A retrospective study of endoscopic resection for 368 patients with early esophageal squamous cell carcinoma or precancerous lesions. Surg Endosc 2017; 31: 2122-2130
- 9 Jing W, Guo H, Kong L. et al. Clinical outcomes of elderly patients (70 years) with resectable esophageal squamous cell carcinoma who underwent esophagectomy or chemoradiotherapy: a retrospective analysis from a single cancer institute. Medicine (Baltimore) 2016; 95: e5630
- 10 Shi Q, Ju H, Yao LQ. et al. Risk factors for postoperative stricture after endoscopic submucosal dissection for superficial esophageal carcinoma. Endoscopy 2014; 46: 640-644
- 11 Li ZS, Li Q. [The latest 2010 WHO classification of tumors of digestive system]. Zhonghua Bing Li Xue Za Zhi 2011; 40: 351-354
- 12 Bollschweiler E, Baldus SE, Schroder W. et al. High rate of lymph-node metastasis in submucosal esophageal squamous-cell carcinomas and adenocarcinomas. Endoscopy 2006; 38: 149-156
- 13 Eguchi T, Nakanishi Y, Shimoda T. et al. Histopathological criteria for additional treatment after endoscopic mucosal resection for esophageal cancer: analysis of 464 surgically resected cases. Mod Pathol 2006; 19: 475-480
- 14 Morita M, Egashira A, Yoshida R. et al. Esophagectomy in patients 80 years of age and older with carcinoma of the thoracic esophagus. J Gastroenterol 2008; 43: 345-351
- 15 Cijs TM, Verhoef C, Steyerberg EW. et al. Outcome of esophagectomy for cancer in elderly patients. Ann Thorac Surg 2010; 90: 900-907
- 16 Jing W, Zhu H, Guo H. et al. Feasibility of elective nodal irradiation (ENI) and involved field irradiation (IFI) in radiotherapy for the elderly patients (aged ≥70 years) with esophageal squamous cell cancer: a retrospective analysis from a single institute. PLoS One 2015; 10: e143007
- 17 Libanio D, Pimentel-Nunes P, Dinis-Ribeiro M. Complications of endoscopic resection techniques for upper GI tract lesions. Best Pract Res Clin Gastroenterol 2016; 30: 735-748
- 18 Song BG, Min YW, Lee JH. et al. Efficacy and safety of endoscopic submucosal dissection in elderly patients with esophageal squamous cell carcinoma. Surg Endosc 2017; 31: 3905-3911
- 19 DeVault KR. Presbyesophagus: a reappraisal. Curr Gastroenterol Rep 2002; 4: 193-199
- 20 Sato H, Inoue H, Kobayashi Y. et al. Control of severe strictures after circumferential endoscopic submucosal dissection for esophageal carcinoma: oral steroid therapy with balloon dilation or balloon dilation alone. Gastrointest Endosc 2013; 78: 250-257
- 21 Ratone JP, Bories E, Caillol F. et al. Oral steroid prophylaxis is effective in preventing esophageal strictures after large endoscopic resection. Ann Gastroenterol 2017; 30: 62-66
- 22 Kadota T, Yano T, Kato T. et al. Prophylactic steroid administration for strictures after endoscopic resection of large superficial esophageal squamous cell carcinoma. Endosc Int Open 2016; 4: E1267-E1274
- 23 Ono S, Fujishiro M, Niimi K. et al. Predictors of postoperative stricture after esophageal endoscopic submucosal dissection for superficial squamous cell neoplasms. Endoscopy 2009; 41: 661-665
- 24 Takahashi H, Arimura Y, Okahara S. et al. Risk of perforation during dilation for esophageal strictures after endoscopic resection in patients with early squamous cell carcinoma. Endoscopy 2011; 43: 184-189
- 25 Hanaoka N, Ishihara R, Takeuchi Y. et al. Intralesional steroid injection to prevent stricture after endoscopic submucosal dissection for esophageal cancer: a controlled prospective study. Endoscopy 2012; 44: 1007-1011
- 26 Jin XF, Gai W, Chai TH. et al. Comparison of endoscopic resection and minimally invasive esophagectomy in patients with early esophageal cancer. J Clin Gastroenterol 2017; 51: 223-227
- 27 Tsujii Y, Nishida T, Nishiyama O. et al. Clinical outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms: a multicenter retrospective cohort study. Endoscopy 2015; 47: 775-783
- 28 Nakagawa K, Koike T, Iijima K. et al. Comparison of the long-term outcomes of endoscopic resection for superficial squamous cell carcinoma and adenocarcinoma of the esophagus in Japan. Am J Gastroenterol 2014; 109: 348-356
- 29 Yamashina T, Ishihara R, Nagai K. et al. Long-term outcome and metastatic risk after endoscopic resection of superficial esophageal squamous cell carcinoma. Am J Gastroenterol 2013; 108: 544-551
- 30 Araki K, Ohno S, Egashira A. et al. Pathologic features of superficial esophageal squamous cell carcinoma with lymph node and distal metastasis. Cancer 2002; 94: 570-575
- 31 Dubecz A, Kern M, Solymosi N. et al. Predictors of lymph node metastasis in surgically resected T1 esophageal cancer. Ann Thorac Surg 2015; 99: 1879-1886