Is Endoscopic Submucosal Dissection the Best Treatment for Esophageal Cancer?

Lower proportions of patients with T1am2/m3 or T1b early-stage esophageal squamous cell carcinomas (EESCCs) treated with endoscopic submucosal dissection (ESD) have perioperative adverse events or disease-specific death after a median follow-up time of 21 months, researchers report in the January issue of Clinical Gastroenterology and Hepatology. The authors found no difference in overall survival, cancer recurrence or metastasis in patients with T1a or T1b ESCCs treated with ESD vs esophagectomy.

All-cause mortality analysis of ESD vs esophagectomy.

Esophagectomy has been the standard treatment for early-stage EESCC, but patients who undergo this procedure have high morbidity and mortality. ESD is a less-invasive procedure for treatment of EESCC, and is less limited by lesion size. ESD also delivers adequate specimens for histology examination and is safer than esophagectomy. Overall survival of patients with mucosal (T1a) esophageal adenocarcinomas was reported to be comparable with that of patients treated surgically.

However, ESD is considered risky because EESCCs frequently metastasize to the lymph nodes.

Yiun Zhang et al performed a retrospective study to directly compare outcomes of almost 600 patients with ESCC (274 treated with esophagectomy and 322 with ESD) and found that ESD was safer and more effective than esophagectomy.

Compared with esophagectomy, fewer patients treated with ESD had perioperative adverse events, and disease-specific mortality was lower in patients treated with ESD. There was no difference in overall survival or cancer recurrence in patients treated with ESD vsesophagectomy.

In Kaplan-Meier analysis, all-cause and disease-specific mortality were each lower in patients treated with ESD  (see Figure), although the recurrence or metastasis was higher in patients treated by ESD after about 60 months. However, overall survival estimates for ESD vs esophagectomy at 6 months, and then yearly afterward, showed higher (nonsignificant) survival for patients treated by ESD at all time points.

ESD had a shorter procedure time (median operation time 49 min vs 240 min for esophagectomy) and patients undergoing ESD had shorter hospital stays (median, 3 days) than patients who underwent esophagectomy (median, 11 days). The cost of ESD was also lower than that of esophagectomy (median $2813 vs $10,001).

Zhang et al remind readers that since this was a retrospective study, additional studies are needed to evaluate the benefits and shortcomings of ESD in treating EESCC. A quality-of-life analysis of ESD would also be helpful because this might be one of the biggest advantages of ESD over esophagectomy.

In an editorial that accompanies the article, Ishfaq Bhat and Douglas K. Pleskow point out that the study compared ESD and esophagectomy for T1 esophageal squamous cell cancers, given the higher prevalence in China. Although the pathogenesis of esophageal sqamous cell cancers differs from that of esophageal adenocarcinomas, which are the most common in the United States, we may be able to extrapolate the findings and technical aspects.

Bhat and Pleskow write that the study comes at a time when endoscopic resection, particularly ESD, has become a front-line treatment of early squamous cell esophageal cancers, and that it is unlikely that a prospective randomized study to compare ESD and esophagectomy will be performed any time soon.

Bhat and Pleskow acknowledge that there has been reluctance to perform ESDs in the US, due to different patient pathologies, less robust data for ESD in patients with Barrett’s neoplasia, the relative complexity of the procedure, time constraints, the lack of trained endoscopists, and potential associated risks. However, as more data support the safety and efficacy of ESD, Bhat and Pleskow believe that with proper training, adequate support, reasonable reimbursement, and quality benchmarks, endoscopic submucosal dissection might become the preferred treatment for early esophageal cancers.

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