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ORIGINAL ARTICLE
Year : 2018  |  Volume : 14  |  Issue : 1  |  Page : 52-56

Clinical efficacy of endoscopic submucosal dissection in the treatment of early esophageal cancer and precancerous lesions


Department of Gastroenterology, Zhengzhou University People's Hospital, Zhengzhou, Henan 450003, P.R. China

Date of Web Publication8-Mar-2018

Correspondence Address:
Shuangyin Han
Department of Gastroenterology, Zhengzhou University People's Hospital, No.7 Weiwu Road, Zhengzhou, Henan 450003
P.R. China
Dr. Yanrui Zhang
Department of Gastroenterology, Zhengzhou University People's Hospital, No.7 Weiwu Road, Zhengzhou, Henan 450003
P.R. China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_805_17

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 > Abstract 

Objective: The objective of this study was to evaluate the clinical value of endoscopic submucosal dissection (ESD) in the treatment of early esophageal cancer and precancerous lesions.
Materials and Methods: We retrospectively analyzed 58 patients who suffered from early esophageal and precancerous lesions and received ESD in the First Affiliated Hospital of Zhengzhou University from February 2012 to January 2016. The clinical efficacy and safety of ESD in treating the early esophageal cancer and precancerous lesions was evaluated by analyzing the operation successful rate, postoperative pathology, complications, and follow-up data of patients who received ESD.
Results: For the 58 patients, ESD was successfully completed in 56 cases with a success rate of 96.6%, whereas ESD was unsuccessful in 2 cases. Invasive lesions were observed in the esophageal muscular layer of 1 patient. Consequently, surgery was terminated and this patient was transferred to thoracotomy surgical intervention involving radical resection of esophageal cancer. Esophageal perforation was observed during the annular incision of the esophageal mucosa in another patient with early-stage cancer. This perforation was occluded with an endoscopic titanium clip and surgery was terminated. Intraoperative blood loss in 56 patients was ranged from 10 to 90 mL with an average of 28.3 ± 17.2 mL. The diameter of ESD resection lesion was varied from 2 to 6.0 cm with an average of 3.4 ± 1.1 cm. For the 56 patients, enbloc resection was performed in 50 patients, with an enbloc resection rate of 89.3%. Complete lesion resection was performed in 49 patients, with a complete resection rate of 87.5%. For all patients, 36 manifested with severe atypical hyperplasia confirmed by postoperative pathology, 11 showed moderate atypical hyperplasia, 2 showed carcinoma insitu, and 7 presented with esophageal squamous cell carcinoma. In these 7 patients, 6 patients whose lesions limited to their mucosa were in the early stage of cancer while 1 patient with esophageal cancer involving the incisal edge, and the submucosal layer was subjected to additional surgical treatment. In addition, 1 patient experienced postoperative delayed hemorrhage (1.79%), 6 patients suffered from fever (10.71%), 33 patients reported substernal burning pain (58.93%) that mostly lasted 1–2 days before spontaneous remission, 1 patient was observed intraoperative perforation (1.79%), and 3 patients showed postoperative esophageal stenosis (5.36%), received multiple balloon dilatations, and consumed fluids afterward. Follow-up visits were facilitated for 49 patients for more than 1 year, and their median follow-up time was 36 months. Of these patients, recurrence was observed in 3 patients, with a recurrence rate of 6.1% (3/49). Of these 3 patients, 2 received surgical treatment and 1 underwent another endoscopic lesion resection. No patient died of esophageal cancer during follow-up.
Conclusion: ESD was safe and reliable for the treatment of early esophageal cancer and precancerous lesions, and its recurrence and complication rates were low. Complete pathological information could be obtained after operation, which could be applied to assess patients' condition accurately.

Keywords: Clinical efficacy, endoscopic submucosal dissection, esophageal cancer, precancerous lesions, safety


How to cite this article:
Wu Y, Zhang H, Zhou B, Han S, Zhang Y. Clinical efficacy of endoscopic submucosal dissection in the treatment of early esophageal cancer and precancerous lesions. J Can Res Ther 2018;14:52-6

How to cite this URL:
Wu Y, Zhang H, Zhou B, Han S, Zhang Y. Clinical efficacy of endoscopic submucosal dissection in the treatment of early esophageal cancer and precancerous lesions. J Can Res Ther [serial online] 2018 [cited 2019 Nov 13];14:52-6. Available from: http://www.cancerjournal.net/text.asp?2018/14/1/52/226765


 > Introduction Top


Esophageal cancer is one of the most common upper gastrointestinal cancers. Epidemiological studies have shown that approximately 300 thousand patients died of esophageal cancer every year worldwide.[1] In China, the incidence of esophageal cancer was high, and the number of annual deaths was approximately 150,000, which accounted for 50% of global deaths attributed to esophageal cancer.[2],[3] The prognosis of advanced esophageal cancer was poor, and the 5-year survival rate of patients undergoing radical surgery was low.[4] The postoperative prognosis of patients with early esophageal cancer was better, with a 5-year survival rate of ≥90%.[5] However, most early esophageal cancer or precancerous lesions showed no clinical symptoms or untypical symptoms, which could not be easily detected. At present, regular follow-up was recommended for most patients with esophageal cancer and precancerous lesions, and surgical treatment was recommended for patients with confirmed cancer. Nevertheless, the compliance of patients undergoing long-term follow-up visits was poor, which has led to a considerable psychological burden to these patients. At present, the endoscopic submucosal dissection (ESD) was recommended in the treatment of early esophageal cancer and precancerous lesions by doctors.[6] Esophageal precancerous lesions could be completely resected with ESD, as well as providing reliable pathological staging after surgery. The risk of esophageal cancer development could be reduced after the removal of precancerous lesions.[7]


 > Materials and Methods Top


Patients

We retrospectively analyzed 58 patients who suffered from early esophageal and precancerous lesions and underwent ESD in the Zhengzhou University People's Hospital from February 2012 to January 2016. These patients were confirmed as early esophageal cancer or precancerous lesions after they were endoscopically and pathologically diagnosed. Of the 58 patients, 36 were male and 22 were female, and their average age was 56.8 ± 11.2 years. The average lesion diameter was 2–3 cm determined with endoscopic iodine staining or narrow-band imaging (NBI). Before surgery, these patients received routine endoscopic iodine staining and bioptic pathology that verified the presence of early esophageal cancer or precancerous lesions. The depth of invasion was determined through endoscopic ultrasonography, and extracorporeal infiltration and lymph node metastasis were excluded with computed tomography examination.

Equipment

The following instruments were applied in this study: Olympus GIF-H260Z/Olympus GIF-Q260-J endoscope and endoscopic ultrasound system; Olympus UM-2R and UM-3R ultrasonic probes with respective frequencies of 12 and 20 MHz; and endoscopic light source that could be converted into NBI.

Operation method

The esophagus was stained with 3% iodine solution to obtain a clear lesion boundary. An annular electric coagulation marker was then drawn with a group of dots 0.3–0.5 cm away from the edge of the lesion with an argon plasma coagulation (APC) argon probe to mark the resection range. Afterward, 5 mL of hyaluronic acid was mixed with 100 mL of saline, 3 mL of indigo, and 1 mL of adrenaline, and the mixture solution was injected into multiple sites in the submucosa of the lesion. The lesion was lifted with repeated injection during dissection. The mucosa to the submucosal layer was cut with a hook knife along the outer edge of the marker, and the lesion was gradually resected along the lesion edge with an electric knife (IT knife) equipped with an insulated ceramic ball on its top. When the esophageal width of lesions was more than one-thirds of the perimeter, it could be resected through a combination of tunneling and ESD. In some cases, endoscopic mucosal resection (EMR) could be performed to remove the remaining lesions before complete removal of lesions. To minimize intraoperative bleeding after the lesions were resected, APC or heat coagulation biopsy forceps were applied for coagulation hemostasis. The bleeding was also directly blocked with metal blood vessel clips. After the lesions were completely resected, the potential bleeding sites could be coagulated with hot biopsy forceps. After the operation was accomplished, a gastric tube was placed under the endoscope to drain gastric juice when the amount of bleeding was observed.

Statistical analysis

The measurement data were demonstrated as ± s and the enumeration data were expressed with a relative number. The statistical analysis was performed with SPSS 19.0 software (SPSS, Inc., Chicago, IL, USA).


 > Results Top


Of the 58 patients, ESD was successfully completed in 56, with a success rate of 96.6%, whereas ESD was unsuccessfully performed in 2. Invasive lesions were observed in the esophageal muscular layer of one patient. Consequently, surgery was terminated, and this patient was transferred to surgical intervention involving radical surgery of esophageal cancer. Esophageal perforation was observed during the annular incision of the esophageal mucosa of another patient with early-stage cancer. This perforation was occluded with an endoscopic titanium clip, and surgery was terminated. Intraoperative blood loss in 56 patients was ranged from 10 to 90 mL, with an average of 28.3 ± 17.2 mL. The diameter of ESD resection lesion was varied from 2.0 to 6.0 cm, with an average of 3.4 ± 1.1 cm. Of the 56 patients, 50 received en bloc resection, with an en bloc resection rate of 89.3% and 49 suffered from complete lesion resection, with a complete resection rate of 87.5%. During the operation, 12 cases were observed with satellite lesions, and all of them were resected, of which 8 cases were resected en bloc with the main lesion, and satellite lesions were treated in the other 4 cases, respectively [Table 1].
Table 1: The general characteristics and treatment outcomes of the included 56 cases

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Pathology diagnosis

Of the total number of patients, 36 manifested with severe atypical hyperplasia confirmed by postoperative pathology, 11 showed moderate atypical hyperplasia, 2 showed carcinoma in situ, and 7 presented with esophageal squamous cell carcinoma. Of these seven patients, six patients whose lesions were limited to their mucosa were in the early stage of cancer while one patient whose esophageal cancer involving the incisal edge and the submucosal layer was subjected to additional surgical treatment [Figure 1].
Figure 1: The pathology type distribution of the 56 cases

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Complications

One patient experienced postoperative delayed hemorrhage (1.79%), 6 patients suffered from fever (10.71%), 33 patients reported substernal burning pain (58.93%) that mostly lasted for 1–2 days before spontaneous remission, intraoperative perforation was observed in 1 patient (1.79%), and 3 patients showed postoperative esophageal stenosis (5.36%), received multiple balloon dilatations, and consumed fluids afterward [Table 2].
Table 2: The complication of the included 56 patients who received endoscopic submucosal dissection

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Follow-up outcomes

The patients were instructed to return for endoscopy, together with mucosal iodine staining and biopsy, after 1, 3, 6, and 12 months of the surgery and once a year thereafter. The follow-up visits of 49 patients were completed for more than 1 year, and the median follow-up time was 36 months. Of these patients, 3 experienced recurrence, with a recurrence rate of 6.1% (3/49). Of the three patients, two received surgical treatment and one was subjected to another endoscopic lesion resection. No patient died of esophageal cancer during follow-up.

Typical cases

Case 1

A 65-year-old male patient was admitted for endoscopy due to abdominal discomfort. During endoscopy, the mucosa in the middle of the esophagus was rough and was unstained after iodine staining. ESD was conducted after the scope of the lesion was determined, and the lesion with a size of 1.5 cm × 1.0 cm was resected completely [Figure 2].
Figure 2: (a) Mucosa in the middle of the esophagus was rough and unstained; (b) submucosal layer was cut with a hook knife; (c and d) the lesion was gradually resected along the lesion edge; (e) tumor size was 1.5 cm × 1.0 cm; (f) Moderate dysplasia

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Case 2

A 60-year-old male patient manifested with high-grade intraepithelial neoplasia and focal carcinoma in situ in the middle of the esophagus after preoperative pathological examination. During endoscopy, the mucosa in the middle of the esophagus was unstained after iodine staining was conducted [Figure 3]a, and the mucosa of the lesion was rough and uplifted under NBI [Figure 3]b. The mucosa to the submucosal layer was cut with a hook knife along the outer edge of the marker [Figure 3]c, and the lesion was gradually resected along the lesion edge with an electric knife (IT knife) equipped with an insulated ceramic ball on its top. The submucosal muscular layer was exposed after the lesion mucosa was completely resected [Figure 3]d. The lesion was approximately 3.0 cm × 4.0 cm [Figure 3]e, and the postoperative pathological observation was carcinoma in situ [Figure 3]f.
Figure 3: (a) Mucosa in the middle of the esophagus was unstained after iodine staining was conducted; (b) mucosa of the lesion was rough and uplifted under NBI. (c) mucosa to the submucosal layer was cut with a hook knife along the outer edge of the marker; (d) the submucosal muscular layer was exposed after the lesion mucosa was completely resected; (e) the lesion was approximately 3.0 cm× 4.0 cm; (f) pathological examination showed carcinoma in situ

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Case 3

A 72-year-old male patient was admitted for endoscopy because of repeated abdominal discomfort for several years. Preoperative pathological examination indicated high-grade intraepithelial neoplasia in the esophageal mucosa. During surgery, the middle portion of the esophagus was pale and rough [Figure 4]a, the lesions were clearly observed through NBI, the surrounding mucosae were rough [Figure 4]b, and the lesions could not be stained after iodine staining [Figure 4]c. The mucosa was cut along the outer edge of the marker with a hook knife [Figure 4]d to remove the lesions completely [Figure 4]e. Postoperative pathological examination revealed high-grade intraepithelial neoplasia in the esophageal mucosa [Figure 4]f.
Figure 4: (a) The esophagus was pale and rough; (b) the lesions were clearly through NBI; (c) the lesions could not be stained after iodine staining; (d and e) the mucosa was cut along the outer edge of the marker with a hookknife to resect the lesions completely; (f) Postoperative pathological examination revealed high-grade intraepithelial neoplasia

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 > Discussion Top


Early esophageal cancer affected the esophageal submucosa without involving muscle tissues. This type of cancer was classified into mucosal carcinoma, submucosal carcinoma, and carcinoma in situ, which were equivalent to Grades 0 and l in the TNM classification. For mucosal carcinoma, most patients did not experience lymph node metastasis and vascular invasion, which could be applied as an indication of mucosal resection because it could be radically treated through local techniques. Lymph node metastasis occurred in a small number of patients with Grade 3 mucosal cancer. Given that patients with esophageal cancer were generally older, surgeries would lead to considerable trauma, slow recovery, and an increased risk of death. For Grade 3 mucosal carcinoma and submucosal cancer, a surgical plan could be selected based on endoscopic ultrasonography and endoscopic results, which could be applied as relative indications for endoscopic resection.

In previous procedures, esophageal gastric anastomosis was performed for all patients with esophageal cancer, but this technique has also lead to surgical trauma and an anastomotic fistula risk.[8] The risk of death was high for elderly patients with anastomotic fistula.[9],[10] With the development of endoscopic diagnosis technology and the general application of endoscopic ultrasound, endoscopic treatment of early esophageal cancer has become current trend. Endoscopic surgeries, such as EMR and ESD, provided a minimally invasive platform for early esophageal cancer resection.[11],[12],[13] EMR resection was clinically applied for esophageal lesions with a diameter of <2 cm, whereas ESD was recommended for lesions with a diameter of greater than 2 cm.[14] In this study, the average diameter of lesions was 2–3 cm after endoscopic iodine staining or NBI, and all the patients were treated with ESD. Of the 58 patients who received ESD, 56 were successfully treated while 2 were transferred to surgical intervention due to perforation and lesion invasion of the submucosal base. Of the 56 successful cases of ESD, 50 experienced less intraoperative blood loss and had en bloc resection, with an en bloc resection rate of 89.3% and 49 received complete lesion resection with a complete resection rate of 87.5%. These results suggested that ESD was safe and reliable for the treatment of early esophageal cancer and precancerous lesions. The relevant indicators of ESD efficacy were en bloc resection, complete resection, and curative resection rates. The en bloc and complete resection rates of ESD were 90%–100% and 87.9%–97.4%, respectively.[15],[16],[17] In our study, the respective en bloc and complete resection rates were 89.3% and 87.5%, which were slightly lower than those of reported in previous studies. It was possibly because of the heterogeneity of patient selection and the technical expertise of surgeons. Our study also found that the main postoperative complications were substernal burning pain, which exhibited an incidence rate of 58.93% and lasted for 1–2 days before spontaneous remission and postoperative esophageal stenosis, which yielded an incidence rate of 5.36%. In the three patients with postoperative esophageal stenosis, a large range of lesions, which was accounted for more than one-half of the perimeter of the esophagus, was resected. In patients with postoperative esophageal stenosis, the clinical symptoms caused by stenosis could be significantly alleviated with early esophageal balloon dilatation.


 > Conclusion Top


ESD of esophageal cancer and precancerous lesions was characterized by a high resection rate, a low recurrence rate, and a few complications. It can be applied to provide accurate pathological information and treat early esophageal cancer and precancerous lesions. This surgical procedure may be beneficial for elderly patients because of its clinical efficacy and reduced trauma.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

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