Endoscopic management and follow-up of patients with a submucosal esophageal adenocarcinoma

Abstract

Introduction: The risk of lymph node metastases (LNM) in submucosal esophageal adenocarcinoma (EAC) patients is subject to debate. These patients might be treated endoscopically if the risk of LNM appears to be low.

Objective: The objective of this article is to evaluate the outcome of patients who underwent an endoscopic resection (ER) and subsequent endoscopic follow-up for a submucosal EAC.

Methods: All patients who underwent ER for submucosal EAC between January 2012 and August 2016 and were subsequently managed with endoscopic follow-up were retrospectively identified. Primary outcome was the number of patients diagnosed with LNM; secondary outcomes included intraluminal recurrences.

Results: Thirty-five patients (median age 68 years) were included: 17 low-risk (submucosal invasion <500 microns, G1-G2, no lymphovascular invasion (LVI)), and 18 high-risk (submucosal invasion >500 microns, and/or G3-G4, and/or LVI, and/or a tumor-positive deep resection margin (R1)) EACs. After a median follow-up of 23 (IQR 15-43) months, in which patients underwent a median of six (IQR 4-8) endoscopies and a median of four (IQR 2-8) endoscopic ultrasound procedures, none of the included patients were diagnosed with LNM. Five (14%) patients developed a local intraluminal recurrence a median of 18 (IQR 11-21) months after baseline ER that were treated endoscopically.

Conclusions: In 35 patients with a submucosal EAC, no LNM were found during a median follow-up of 23 months. Endoscopic therapy may be an alternative for surgery in selected patients with a submucosal EAC.

Keywords: Esophageal adenocarcinoma; T1b EAC; early neoplasia; endoscopic treatment; lymph node metastases.

Figure 1.

Flow diagram of inclusion and main outcomes. cT1bN0: clinical T1bN0: CRT: chemoradiotherapy; EAC: esophageal adenocarcinoma; ER: endoscopic resection; IQR: interquartile range; LNM: lymph node metastases.

Figure 2.

Endoscopic images of a 59-year-old patient with local recurrence during follow-up after removal of a submucosal esophageal adenocarcinoma. (a) and (b) A C3M4 Barrett’s esophagus with a T1sm1 esophageal adenocarcinoma that was removed with endoscopic resection. (c) and (d) The residual Barrett’s mucosa was removed by radiofrequency ablation. (e) and (f) After 21 months of follow-up, recurrence of a T1sm1 esophageal adenocarcinoma was found. (g) The lesion was removed by endoscopic submucosal dissection. (h) and (i) During the next follow-up endoscopy, the resection scar was seen without signs of residual or recurrent neoplasia.