Combined assessment of clinical and pathological prognostic factors for deciding treatment strategies for esophageal squamous cell carcinoma invading into the muscularis mucosa or submucosa after endoscopic submucosal dissection

Long-Term Prognostic Factors for Patients Aged 80 and Older With Superficial Esophageal Squamous Cell Carcinoma Undergoing Endoscopic Submucosal Dissection

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is an acceptable treatment for superficial esophageal squamous cell carcinoma (ESCC) even in elderly patients. However, studies on the prognostic factors in very elderly patients are limited. Therefore, we aimed to explore the prognostic factors affecting overall survival (OS) in patients aged ≥ 80 with superficial ESCC who underwent ESD.

METHODS

This study included 155 patients aged ≥ 80 who underwent ESD for superficial ESCC. Clinicopathological findings and long-term outcomes were examined. The prognostic nutritional index (PNI) and geriatric nutritional index (GNRI) were used to assess pre-treatment nutritional status.

RESULTS

Twenty-nine patients (18.7%) were aged ≥ 85. Thirty-five (22.6%) and 61 (39.4%) patients had a GNRI < 92 and PNI < 45, respectively. Metastatic relapse was observed in five cases, four (80%) of which resulted in death due to the primary disease. The median OS of all patients was 86 months. Although factors specifically associated with disease-specific survival were not identified, GNRI, PNI, comorbidity, and physical status were associated with OS. In multivariate analysis, age ≥ 85 years (p = 0.03), GNRI (p < 0.01), and PNI (p < 0.01) remained factors associated with OS. Patients aged ≥ 85 with either GNRI ≥ 92 or PNI ≥ 45 had a median OS of 106 months, whereas those aged ≥ 85 with GNRI < 92 had a median OS of 12 months.

CONCLUSIONS

GNRI and PNI are important indicators for assessing the suitability of ESD in elderly patients aged ≥ 80. These indices can help predict OS and guide clinical decision-making for this patient population.

Esophagectomy Versus Endoscopic Resection with Adjuvant Therapy for T1b/T2 Esophageal Cancer: A Systematic Review and Meta-Analysis

Esophageal cancer is the seventh most common cause of cancer-related death worldwide [...].

Risk and pathologic factors of recurrence after endoscopic resection for superficial esophageal squamous cell carcinoma: a systematic review and meta-analysis

BACKGROUND AND AIMS

The risk and pathologic factors of recurrence after endoscopic resection (ER) for superficial esophageal squamous cell carcinoma (ESCC) are inconsistent across studies. We evaluated this in a systematic review and meta-analysis.

METHODS

The data of recurrence in such patients were extracted from all studies. Risk ratios (RRs) were combined using random-effects meta-analysis to assess pooled recurrence rate and pathologic risk factors. Relapse-free survival was combined using the Kaplan-Meier method to estimate the relationship between various pathologic factors and recurrence time.

RESULTS

We identified 26 studies, with a total of 5100 patients and 321 with recurrences (pooled rate, 6.2%). The risk of recurrence was significantly higher in positive vertical margin (RR, 4.51; 95% confidence interval [CI], 2.16-9.44), positive horizontal margin (RR, 2.54; 95% CI, 1.57-4.13), lymphovascular invasion (LVI) (RR, 2.33; 95% CI, 1.75-3.11; P < .001), lymphatic invasion (LI) (RR, 2.24; 95% CI, 1.24-4.06), and tumor invading submucosa of ≤200 μm (SM1) (RR, 1.71; 95% CI, 1.32-2.21, compared to muscularis mucosa). Patients with LI (hazard ratio, 2.47; 95% CI, 1.24-4.90; P = .02) and LVI (HR, 2.36; 95% CI, 2.22-4.59; P = .0006) tended to have earlier recurrence after ER.

CONCLUSIONS

The recurrence rate of superficial esophageal squamous cell carcinoma after ER is acceptable. Patients with positive margins, LVI, LI, and SM1 need to pay significant attention to the risk of recurrence. LI and VI should be evaluated separately. (PROSPERO CRD42023406309.).

Risk factors and pattern of metastatic recurrence after endoscopic resection with additional treatment for esophageal cancer

Although esophageal cancers invading the muscularis mucosa (pT1a-MM) or submucosa (pT1b-SM) after endoscopic resection (ER) are associated with a risk of lymph node metastasis, details of metastatic recurrence after additional treatment remain unknown. We aimed to identify the risk factors for metastatic recurrence and recurrence patterns in patients receiving additional treatment after ER for esophageal cancer. Between 2006 and 2017, patients with pT1a-MM/pT1b-SM esophageal cancer who underwent ER with additional treatment (esophagectomy, chemoradiotherapy [CRT], and radiation therapy) at 21 institutions in Japan were enrolled. We evaluated the risk factors for metastatic recurrence after ER with additional treatment. Subsequently, the rate and pattern (locoregional or distant) of metastatic recurrence were investigated for each additional treatment. Of the 220 patients who received additional treatment, 57, 125, and 38 underwent esophagectomy, CRT, and radiation therapy, respectively. In the multivariate analysis, lymphatic invasion was the sole risk factor for metastatic recurrence after additional treatment (hazard ratio, 3.50; P = 0.029). Although the risk of metastatic recurrence with additional esophagectomy was similar to that with CRT (hazard ratio, 1.01; P = 0.986), the rate of locoregional recurrence tended to be higher with additional esophagectomy (80.0% (4/5) vs. 36.4% (4/11)), leading to a better prognosis in patients with metastatic recurrence after additional esophagectomy than CRT (survival rate, 80.0% (4/5) vs. 9.1% (1/11)). Patients with lymphatic invasion have a high risk of metastatic recurrence after ER with additional treatment for pT1a-MM/pT1b-SM esophageal cancer. Additional esophagectomy may result in a better prognosis after metastatic recurrence.

Management of Superficial Esophageal Squamous Cell Carcinoma and Early Gastric Cancer following Non-Curative Endoscopic Resection

According to the European and Japanese guidelines, additional treatment is recommended for cases of superficial esophageal squamous cell carcinoma (ESCC) and early gastric cancer (EGC) that do not meet the curability criteria for endoscopic resection (ER), i.e., non-curative ER, owing to the risk of lymph node metastasis (LNM). However, the rates of LNM in such cases were relatively low (e.g., 8% for EGC). Several recent advances have been made in this field. First, pathological risk stratification for metastatic recurrence following non-curative ER without additional treatment was developed for both superficial ESCC and EGC. Second, the pattern of metastatic recurrence and prognosis after recurrence following non-curative ER without additional treatment was found to be considerably different between superficial ESCC and EGC. Third, a combination of ER and selective chemoradiotherapy was developed as a minimally invasive treatment method for clinical T1b-SM ESCC. These findings may help clinicians decide the treatment strategy for patients following non-curative ER; however, for optimal therapeutic decision-making in such patients, it is also important to predict the prognosis other than SESCC or EGC and impaired quality of life. Thus, a novel algorithm that considers these factors, as well as metastatic recurrence, should be developed.