Chapter 6

Indication for Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection in the Esophagus

Helmut Messmann, MD; Alanna Ebigbo, MD; and Andreas Probst, MD

Introduction

The widespread use of endoscopy has resulted in the increased detection of early neoplasia in the gastrointestinal tract. This situation is ideal for curative endoscopic treatment because the risk of lymph node metastases is almost null for early lesions. The treatment of choice is endoscopic resection, which procures a specimen for precise histopathologic diagnosis. Ablation therapy, either thermal (ie, radiofrequency ablation, argon plasma coagulation, cryotherapy) or nonthermal (photodynamic therapy), are alternative treatment options when endoscopic resection is technically not feasible or surgery is contraindicated.

Ablation techniques can also serve as adjunctive treatment in Barrett-associated neoplasia if the visible lesion is endoscopically resected yet the remaining Barrett’s segment has to be treated. Endoscopic resection in the gastrointestinal tract is often curative if the target lesion is limited to the mucosa and en bloc resection is achieved. When a lesion is resected in piecemeal fashion, the risk for local recurrence increases up to 30% and is by definition noncurative. Select esophageal lesions involving the submucosa may also be resected endoscopically, which will be elaborated on later in this chapter.

Endoscopic submucosal dissection (ESD) is a resection technique that allows en bloc resection of lesions independent of size. However, the technique has a steep learning curve, can be time consuming, and has a learning phase associated with higher complication rates such as perforation.

Nonetheless, ESD has gained more acceptance in Western countries because various studies have shown its superiority over endoscopic mucosal resection (EMR) especially regarding the en bloc resection as well as recurrence rates.¹ Complications with ESD, such as perforation, have decreased over time and most of these can be successfully managed endoscopically given the availability of novel and effective closure devices.² Finally, procedure time has also decreased over the years with the introduction of newer ESD devices and accessories, all of which have helped improve efficiency and safety.

Lesions with a Paris type 0-I and 0-III morphology often have submucosal invasion (SMI) and may not be ideal for endoscopic resection, whereas lesions with Paris classifications 0-IIa, 0-IIb, and 0-IIc are likely confined to the mucosa and may be amenable to endoscopic therapy. According to the Japan Esophageal Society guidelines for treatment of esophageal cancer,3 the absolute indication for endoscopic resection is defined as flat lesions (Paris 0-II), with M1 to M2 invasion, and circumferential extent of ≤ 2/3, while the relative indication includes M3 to SM1 lesions and where resection would leave a mucosal defect of circumferential extent ≥ 3/4.

Using ESD, the indication for size can be expanded. Lesions larger than 3 cm or occupying the entire circumference of the esophagus, provided that the lesion is restricted to the mucosa, can be treated. Several series^4–7 reported en bloc resection rates of 83% to 100%, complete resection rates of 78% to 100%, and local recurrence rates of 0% to 2.6%.

The risk of lymph node metastasis of M3 or SM1 lesions without lymphovascular invasion has been reported to be as low as 4.7%.⁸ Moreover, several studies have shown higher morbidity with surgery than endoscopic resection. Therefore, for poor surgical candidates with multiple comorbidities or those unwilling to undergo esophagectomy, ESD should be considered as an appropriate alternative for M3 or SM1 well-differentiated lesions without lymphatic or vessel infiltration.^9–11 The size of the lesion is the main criterion for choosing between EMR and ESD excision. En bloc R0 resection is mandatory for SCC removal to provide a better disease-free survival rate in a cancer with a high risk of lymph node metastasis, the risk of which can be assessed only on a single, intact pathological specimen; otherwise, important histological features may be missed. EMR may not provide en bloc resection (and R0 excision) in large lesions, with recurrence rates ranging from 9% to 23% following piecemeal excision.⁴ Ishihara et al⁵ considered cap-assisted EMR to be a good alternative for small lesions because they reported no difference concerning local recurrence, R0 resection, and en bloc resection for lesions < 15 mm, while results were significantly better with ESD for lesions between 15 and 20 mm. However, in a meta-analysis, Cao and colleagues¹ showed that even for lesions < 10 mm local recurrence was lower with ESD (Figure 6-1).

Therefore, based on the available data, the European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend that EMR be considered in lesions smaller than 10 mm if en bloc resection can be ensured. However, ESD remains the first option, particularly for larger lesions, mainly to provide an en bloc resection with accurate pathology staging and to avoid missing important histological features.¹²

In summary, the ESGE recommends that an en bloc R0 resection of a superficial lesion with histology no more advanced than M2 SCC, with no lymphovascular invasion, can be considered curative. Additionally, an en bloc R0 resection of a well-differentiated M3/SM1 tumor (≤ 200 μm) without lymphovascular invasion has a low risk of lymph node metastases and is curative in the majority of cases. The risk of further therapy should be balanced, in a multidisciplinary discussion, against the risk of lymph node metastasis. In the case of an SM2 or more advanced tumor (> 200 μm), a poorly differentiated tumor, lymphovascular invasion, or positive deep margins, further treatment is recommended (chemoradiotherapy and/or surgery) depending on the patient’s status. If the horizontal margin is positive and no other high-risk criteria are met, endoscopic surveillance/retreatment is an option.

Related posts:

Introduction and History of Endoscopic Resection Techniques Per-Oral Endoscopic Myotomy Devices and Accessories for Endoscopic Submucosal Dissection Endoscopic Submucosal Dissection Technique in the Esophagus Full-Thickness Endoscopic and Combined Laparoscopic-Endoscopic Techniques Endoscopic Submucosal Dissection Technique to Conquer Difficult Cases

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