Evaluation of endoscopic mucosal resection for superficial esophageal carcinoma

Abstract

Esophageal superficial carcinoma safely can be resected surgically or endoscopically. We evaluated indications for endoscopic mucosal resection (EMR) and optimal treatment modality for superficial carcinoma of the esophagus based on clinical and pathologic analyses. Between January 1, 1984, and September 30, 1999, 113 patients with superficial cancer of the esophagus underwent surgical or endoscopic resection (n = 33 patients, 36 lesions). The two-channel method, esophageal EMR-tube method or EMR cap-fitted panendoscope was used. Mucosal and submucosal cancers were classified to be epithelial layer (m1), proper mucosal layer (m2), muscularis mucosae (m3), upper third of the submucosal level (sm1), middle third of the submucosal layer (sm2), or the lower third of the submucosal level (sm3) cancers, according to criteria of the Japanese Society for Esophageal Disease. Absolute indication for EMR was restricted to m1 or m2 cancers, and relative indications for EMR included m3 or sm1 lesions. In our department, indications for EMR were not related to size or circumference of lesions. Lymph vessel invasion and lymph node metastasis markedly increased in lesions that infiltrated the lamina muscularis mucosa (m3). All lesions resected with use of EMR were 0-II (flat), and the depth of invasion in 10 0-IIa or 0-IIb lesions was m1 or m2. Twenty-one 0-IIc lesions were distributed widely from m1 to sm1. All 0-IIa+IIc lesions were m3 or sm1. Preoperative diagnosis accurately was established preoperatively in 61% of patients. Complications related to EMR were detected in 21% of patients and included perforation, stenosis, and hemorrhage. Ten patients also received radiotherapy, chemotherapy, or esophagectomy with lymph node dissection after use of EMR. No such combination therapy was administered in six patients with m3 lesions, but without lymph vessel invasion. All patients treated with use of EMR, including patients with m3 cancer who did not receive additional treatment, are living without recurrence. Local resection with use of EMR could be regarded to be the preferred treatment of superficial esophageal cancers limited to the lamina propria mucosae. Endoscopic mucosal resection also could be regarded to be the preferred treatment of m3 cancer without lymph vessel invasion. Use of additional therapy, such as radiotherapy, allows the use of EMR for m3 cancer with lymph vessel invasion or sm1 cancers.