Primary Treatment of T1aN0 Esophageal Cancer: Selection of Patients for Endoscopic Dissection and Endoscopic Resection

Key Takeaways:

• Endoscopic resection via either endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is the preferred first-line treatment option for superficial (T1a) esophageal cancer

• ESD is preferred for larger lesions (>1.5 cm), whereas EMR is preferred for smaller ones, as well as combined with ablation for Barrett’s esophagus–related neoplasia

• Both EMR and ESD should be performed by highly trained physicians in high-volume esophageal centers

This transcript has been edited for clarity.

So with advancement in endoscopic technique, the first-line treatment for superficial cancers—or the T1a cancers—is, generally, endoscopic resection. These lesions are superficial enough that [they] are confined to the mucosa, and they have very little to no risk of lymph node involvement, or lymph node metastasis. 

Generally, there are two methods for performing the endoscopic resection. One is endoscopic mucosal resection, which is called EMR. And the other one is endoscopic submucosal dissection, which is called ESD. Again, the decision to employ either one of these modalities is generally based upon the size of the lesion, the likelihood of the depth of the lesion, and also the local expertise. Again, both of these modalities require significant training and are better done in high-volume centers. 

So now, I'll talk about the first technique, which is endoscopic mucosal resection. EMR is a technique which involves the "lift and excise," or "cut and scoop," technique. It's basically snaring that dysplastic lesion. It's relatively quick and simple. And it basically can help guide therapy based on the grade of differentiation and also the depth of involvement. It can be curative in a very low-risk superficial lesion—very [low] complication rates. And it's generally good for lesions that are smaller, generally less than 1.5 cm—very low perforation rate, and it's safe. 

However, if the lesion is larger, sometimes [it has] to be resected in a piecemeal fashion. And if this is done, this may compromise that lateral margin and that good histopathologic evaluation for a curative resection. Basically, you may lose that R0 resection opportunity. Recurrence rates can be slightly higher with this modality. But generally, that's been recorded in patients who have had a piecemeal resection, if there is a Barrett segment that is longer, or patients [who] had no ablation done after resection. 

The other technique is called endoscopic submucosal dissection. This is, basically, dissection of the lesion at the level of the submucosa. This is a really good en-bloc resection of the lesion, which provides both the lateral, as well as the deep, margin for histopathologic evaluation. This was initially introduced in Japan because of a high risk of gastric cancer there. And this technique provided a nonsurgical approach to be able to cure and remove these tumors. It's slowly being adapted in the Western world for treatment of gastric cancer, as well as esophageal cancers, as well as colorectal lesions. 

The recurrence rates [with ESD] are much lower because, obviously, the lesion is completely removed in [a] whole, and the curative rate is pretty high. The problem that comes with this technique or modality is that the stricture rate can be higher, of course. With a larger tissue being removed, there is more scar tissue formation, which can require serial dilations. Perforation rates can be slightly higher, which can be treated endoscopically. This technique also requires more time and a much steeper learning curve. 

So in summary, EMR is better for lesions that are smaller than 1.5 cm. It is safer. It's quicker, with lesser complications. But I do want to emphasize that EMR plus ablation is still the gold standard for Barrett's esophagus–related neoplasia. ESD, on the other hand, is better for lesions greater than 1.5 cm. It does provide better cure rates, with lower recurrences; however, the complications may be slightly higher and the learning curve steeper.