Uno K, Koike T, Kusaka G, Takahashi Y, Ara N, Shimosegawa T
Dis Esophagus. 2017 Jun 1;30(6):1-8. doi: 10.1093/dote/dox005.
Development of endoscopic submucosal dissection (ESD) improves the en bloc resection rate of superficial esophageal squamous cell carcinoma (SESCC). Although the background mucosa after ESD remains malignant potential, esophageal (sub)circumferential ESD, in cases where the mucosal defect is greater than three-fourths of the circumference, might induce refractory stricture, and it may disturb early detection of the recurrence. Therefore, we aimed to elucidate whether the patients treated by (sub)circumferential ESD for SESCC may remain at risk of metachronous recurrence. In a single-center retrospective study, we collected data from 154 consecutive patients who were treated with curative ESD for SESCC from 2002 to 2013 and followed by surveillance for longer than 12 months. Metachronous recurrence was defined as histologically proven SESCC at other site of the ESD scar or abnormal nodal swelling was detected later than 12 months after ESD. The primary endpoint was to identify the risk of metachronous recurrence using multivariate analyses. The secondary endpoint was to investigate difference in clinical pathological features between patients with and without the recurrence. The overall rate of metachronous recurrence was 14.9% during 40.5 median months after the initial ESD. 24.1% and 9.0% of overall metachronous recurrence were observed in patients treated with (sub)circumferential ESD and non-subcircumferential ESD, respectively, despite no significant difference in their observation duration. After the application of a stepwise regression model that included all variants, a Cox proportional hazards regression model identified (sub)circumferential ESD as the only risk for the recurrence (hazard ratio (HR): 1.48, 95% confidence intervals (CI): 1.04-2.08, P = 0.028). The cumulative recurrence rate revealed a significant difference between patients treated by (sub)circumferential ESD and those by nonsubcircumferential ESD (HR: 3.094, 95% CI: 1.33-7.52, P = 0.009), despite no significant difference in their cause-specific survival. Additionally, the session numbers of the follow-up endoscopy until the detection of metachronous recurrence after the non-subcircumferential ESD were significantly less than those after the (sub)circumferential ESD (7.8 ± 1.8 vs. 15.2 ± 1.5 P = 0. 005), despite no significant difference in their cancer-free duration. In conclusion, we demonstrated that patients treated by curative (sub)circumferential ESD for SESCC might be high risk for metachronous recurrence. Therefore, we should establish a risk-stratified surveillance program after (sub)circumferential ESD and preventive strategies for post-ESD stricture.
内镜黏膜下剥离术（ESD）的发展提高了浅表食管鳞状细胞癌（SESCC）的整块切除率。尽管ESD术后的背景黏膜仍具有恶性潜能，但在食管（亚）环周ESD中，当黏膜缺损大于周长的四分之三时，可能会导致难治性狭窄，并可能干扰复发的早期检测。因此，我们旨在阐明接受SESCC（亚）环周ESD治疗的患者是否仍有发生异时性复发的风险。在一项单中心回顾性研究中，我们收集了2002年至2013年连续154例接受SESCC根治性ESD治疗并随访超过12个月患者的数据。异时性复发定义为ESD瘢痕其他部位经组织学证实的SESCC或ESD后12个月后检测到异常淋巴结肿大。主要终点是通过多变量分析确定异时性复发的风险。次要终点是调查复发患者和未复发患者临床病理特征的差异。在初次ESD后的40.5个月中位随访期内，异时性复发的总发生率为14.9%。接受（亚）环周ESD和非环周ESD治疗的患者中，异时性复发的总体发生率分别为24.1%和9.0%，尽管它们的观察期无显著差异。在应用包含所有变量的逐步回归模型后，Cox比例风险回归模型确定（亚）环周ESD是复发的唯一风险因素（风险比（HR）：1.48，95%置信区间（CI）：1.04 - 2.08，P = 0.028）。累积复发率显示，接受（亚）环周ESD治疗的患者与接受非环周ESD治疗的患者之间存在显著差异（HR：3.094，95% CI：1.33 - 7.52，P = 0.009），尽管它们的特定病因生存率无显著差异。此外，非环周ESD后直至检测到异时性复发的随访内镜检查次数显著少于（亚）环周ESD后（7.8 ± 1.8对15.2 ± 1.5，P = 0.005），尽管它们的无癌持续时间无显著差异。总之，我们证明了接受SESCC根治性（亚）环周ESD治疗的患者可能具有较高的异时性复发风险。因此，我们应在（亚）环周ESD后建立风险分层监测计划以及ESD后狭窄的预防策略。
