Salvage endoscopic submucosal dissection with a small-caliber endoscope for recurrent esophageal cancer on distal side of esophageal stricture

Salvage endoscopic submucosal dissection (ESD) is effective for local recurrent esophageal cancer after chemoradiotherapy [1] [2]. However, severe late toxicity, mostly in the form of esophageal strictures and ulcerations, can occur in patients who undergo chemoradiotherapy in the definitive treatment of esophageal cancer [3]. Endoscopic treatment for esophageal neoplasia in patients with esophageal stricture is challenging [4].

A 76-year-old woman with recurrent esophageal cancer after chemoradiotherapy was referred to our department for endoscopic treatment. Endoscopy showed a cervical esophageal stricture due to chemoradiotherapy ([Fig. 1]) and a half-circumferential flat cancer on the distal side of the stricture ([Fig. 2]; [Video 1]). Although balloon dilation was performed, the therapeutic endoscope could not be passed through the stricture. We performed ESD with a small-caliber endoscope (EG-L580NW7; Fujifilm, Tokyo, Japan; diameter 5.8 mm, working channel 2.4 mm). Small-caliber ESD devices such as an endo-knife, clip-line traction device, and hemostatic forceps were used (Souten, Ichigan, and Raicho, respectively; Kaneka Medics, Tokyo, Japan). A distal attachment was used to stabilize the endoscope. Markings, mucosal incision, and submucosal dissection were all performed using the endo-knife ([Fig. 3]). After circumferential mucosal incision, a traction device was applied to obtain a good field of view for dissection. A small-caliber hemostatic forceps was used to arrest bleeding. Finally, the lesion was completely resected en bloc ([Fig. 4]) in 55 minutes without any complications. Histopathology revealed squamous cell carcinoma with slight submucosal invasion and negative horizontal and vertical margins ([Fig. 5]). No other treatment for the recurrent esophageal cancer was performed because the patient refused additional surgical treatment.

Fig. 1 Endoscopy showed circumferential ulceration and stricture in the cervical esophagus that had developed due to chemoradiotherapy.

Fig. 2 Endoscopy showed a half-circumferential flat cancer on the distal side of the esophageal stricture.

Video 1 Endoscopic submucosal dissection with a small-caliber endoscope for recurrent esophageal cancer on the distal side of the esophageal stricture.

Fig. 3 Markings, mucosal incision, and submucosal dissection were all performed using an endo-knife.

Fig. 4 The lesion was completely resected en bloc in 55 minutes without any complications.

Fig. 5 Histopathological examination revealed squamous cell carcinoma with slight submucosal invasion and negative horizontal and vertical margins. Upper: macroscopic view of the resected specimen. Lower: hematoxylin–eosin stain, × 100 magnification.

In conclusion, salvage ESD with a small-caliber endoscope can be a treatment option for recurrent superficial esophageal cancer after chemoradiotherapy where a conventional endoscope cannot be used because of proximal esophageal stricture.

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• References

• 1 Hatogai K, Yano T, Kojima T. et al. Local efficacy and survival outcome of salvage endoscopic therapy for local recurrent lesions after definitive chemoradiotherapy for esophageal cancer. Radiat Oncol 2016; 11: 31
• 2 Saito Y, Takisawa H, Suzuki H. et al. Endoscopic submucosal dissection of recurrent or residual superficial esophageal cancer after chemoradiotherapy. Gastrointest Endosc 2008; 67: 355-359
• 3 Roeder F, Nicolay NH, Nguyen T. et al. Intensity modulated radiotherapy (IMRT) with concurrent chemotherapy as definitive treatment of locally advanced esophageal cancer. Radiat Oncol 2014; 9: 191
• 4 Nishiyama N, Kobara H, Yachida T. et al. Strategy of small-caliber endoscopic submucosal dissection for esophageal neoplasia distal to severe stricture. Endoscopy 2020; 52: E94-E95