Early esophageal squamous cell carcinoma and diverticulum were cured simultaneously by endoscopic submucosal dissection in a patient

Early squamous cell carcinoma (SCC) in esophageal diverticula is rare, with an unclear pathogenesis [1]. Endoscopic septotomy is used to treat patients at high risk for surgical resection of a diverticulum [2], and endoscopic submucosal dissection (ESD) is recommended for selected early esophageal carcinoma [3]. ESD for early cancer in diverticula is challenging for endoscopists, as diverticula have characteristically thin walls and endoscopic treatment carries a higher risk of perforation [1] [4]. Here, we report a case of ESD curing early esophageal SCC in diverticula.

In an 80-year-old man with dysphagia, esophagogastroduodenoscopy (EGD) and biopsy identified a type 0-IIa SCC in an esophageal diverticulum located 28 cm from the incisor ([Fig. 1]). Narrow band imaging and magnification endoscopy showed intraepithelial papillary capillary loops of type B1, suggesting a low risk of submucosal infiltration ([Fig. 2]). ESD was recommended as the preferred treatment. We performed submucosal injection and initial incision of the mucosa outside of the diverticulum to prevent perforation. The submucosal dissection was shallow to further decrease this risk. We lowered the CO₂ volume to avoid overstretching the diverticulum and thinning the diverticulum walls. The entire lesion was resected without complication ([Fig. 3], [Video 1]). A nasojejunal tube was inserted for enteral nutritional support after ESD. The histopathology of the resected specimen showed SCC with mucous muscle infiltration (pT1a-mm) and complete resection. The follow-up EGD (13 and 25 days after ESD) showed that the wound was healing ([Video 1]). The nasojejunal tube was removed 25 days after ESD, and the patient’s dysphagia disappeared when eating. The second and third EGDs (6 months after ESD) showed that the early SCC and diverticulum healed completely ([Fig. 4]).

Fig. 1 A type 0-IIa lesion, observed in an esophageal diverticulum, was confirmed by biopsy to be squamous cell carcinoma.

Fig. 2 Narrow band imaging and magnification endoscopy showed intraepithelial papillary capillary loops of type B1 and a clear margin of the lesion.

Fig. 3 The mucosal defect after endoscopic submucosal dissection showed that no perforation occurred during surgery.

Video 1 Endoscopic submucosal dissection (ESD) for early esophageal squamous cell carcinoma in a diverticulum and follow-up after ESD.

Fig. 4 The follow-up endoscopy showed that the early cancer and diverticulum were simultaneously cured by endoscopic submucosal dissection.

In this rare case, ESD simultaneously cured early esophageal cancer and the diverticulum. The mechanism may be a scar contracture leading to the disappearance of the diverticulum.

Endoscopy_UCTN_Code_TTT_1AO_2AC

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Fu K, Jin P, He Y. et al. A superficial esophageal cancer in an epiphrenic diverticulum treated by endoscopic submucosal dissection. BMC Gastroenterol 2017; 17: 94
• 2 Repici A, Spadaccini M, Belletrutti PJ. et al. Peroral endoscopic septotomy for short-septum Zenkerʼs diverticulum. Endoscopy 2020; 52: 563-568
• 3 Qi ZP, Chen T, Li B. et al. Endoscopic submucosal dissection for early esophageal cancer in elderly patients with relative indications for endoscopic treatment. Endoscopy 2018; 50: 839-845
• 4 Yamaguchi T, Kuwai T, Iio S. et al. Endoscopic submucosal dissection using a stag beetle knife for early esophageal cancer in lower esophageal diverticula. Gastrointest Endosc 2015; 82: 566-567

Publication History

Article published online:
24 February 2023