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Salvage endoscopic submucosal dissection with a small-caliber endoscope for recurrent esophageal cancer on distal side of esophageal stricture
Salvage endoscopic submucosal dissection (ESD) is effective for local recurrent esophageal cancer after chemoradiotherapy  . However, severe late toxicity, mostly in the form of esophageal strictures and ulcerations, can occur in patients who undergo chemoradiotherapy in the definitive treatment of esophageal cancer . Endoscopic treatment for esophageal neoplasia in patients with esophageal stricture is challenging .
A 76-year-old woman with recurrent esophageal cancer after chemoradiotherapy was referred to our department for endoscopic treatment. Endoscopy showed a cervical esophageal stricture due to chemoradiotherapy ([Fig. 1]) and a half-circumferential flat cancer on the distal side of the stricture ([Fig. 2]; [Video 1]). Although balloon dilation was performed, the therapeutic endoscope could not be passed through the stricture. We performed ESD with a small-caliber endoscope (EG-L580NW7; Fujifilm, Tokyo, Japan; diameter 5.8 mm, working channel 2.4 mm). Small-caliber ESD devices such as an endo-knife, clip-line traction device, and hemostatic forceps were used (Souten, Ichigan, and Raicho, respectively; Kaneka Medics, Tokyo, Japan). A distal attachment was used to stabilize the endoscope. Markings, mucosal incision, and submucosal dissection were all performed using the endo-knife ([Fig. 3]). After circumferential mucosal incision, a traction device was applied to obtain a good field of view for dissection. A small-caliber hemostatic forceps was used to arrest bleeding. Finally, the lesion was completely resected en bloc ([Fig. 4]) in 55 minutes without any complications. Histopathology revealed squamous cell carcinoma with slight submucosal invasion and negative horizontal and vertical margins ([Fig. 5]). No other treatment for the recurrent esophageal cancer was performed because the patient refused additional surgical treatment.
Video 1 Endoscopic submucosal dissection with a small-caliber endoscope for recurrent esophageal cancer on the distal side of the esophageal stricture.
In conclusion, salvage ESD with a small-caliber endoscope can be a treatment option for recurrent superficial esophageal cancer after chemoradiotherapy where a conventional endoscope cannot be used because of proximal esophageal stricture.
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19 November 2020 (online)
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