ENDOSCOPIC SUBMUCOSAL DISSECTION OF A SUSPICIOUS ESOPHAGEAL LESION

A 80-year-old woman, hospitalized for atrial fibrillation and cardiac decompensation, presented anemia and melena during her stay. An esogastroduodenoscopy revealed a 2 × 2 cm Paris type 0-IIa+IIc neoplastic lesion at 30 to 32 cm from the incisors. The IPCL pattern analysis with NBI and near focus revealed V-3 type suggesting the presence of submucosal infiltration. The biopsy revealed a poorly differentiated squamous cell carcinoma. Endoscopic ultrasound disclosed a 15 mm mucosal lesion with extension in the submucosa (uT1N0Mx). There was no distant metastasis on work-up (thoracic and abdominal CT scan, bronchoscopy and PET CT).

Due to the advanced age of the patient and her comorbidities, we decided in multidisciplinary oncologic meeting to perform a staging endoscopic submucosal dissection. The therapeutic alternative would be a major surgery in a patient with cardiac decompensation. An en-bloc endoscopic complete resection was performed using a Dual knife (Olympus, Japan) and glycerol solution. The procedure was well tolerated without any secondary symptoms nor stricture and patient was discharged on day 3. Surprisingly, the pathological analysis revealed a large-cell neuroendocrine carcinoma with no lympho-vascular involvement nor perineural invasion. Lateral margins were free but vertical resection margin revealed some tumoral cells. The Ki67 index was 95%. The pathological classification according to the TNM classification was pT1bNx.

The multidisciplinary oncologic meeting had suggested an adjuvant treatment by radiochemotherapy which was refused by the patient. Therefore, surveillance was performed with esogastroduodenoscopy and thoracoabdominal CT scan. The 3-months follow-up showed no recurrence.

Conclusion:

ESD is the technique of choice for en-bloc resection of > 15 mm esophageal superficial carcinoma to obtain a good pathological analysis. Staging ESD is an option in aged and comorbid patients before choosing the right therapeutic approach. Esophagus large-cell neuroendocrine carcinomas are uncommon. Due to the lack of data, no treatment strategies have yet been established for esophageal neuroendocrine carcinomas.