Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Gastrointest Endosc. 2022 Aug;96(2):359-367. doi: 10.1016/j.gie.2022.02.014. Epub 2022 Feb 17.
The standard treatment of locally advanced rectal cancer is chemoradiation (CRT) followed by proctectomy and adjuvant chemotherapy. However, there is an emerging role for nonsurgical management after CRT or total neoadjuvant therapy (TNT) consisting of CRT and neoadjuvant chemotherapy. Endoscopic submucosal dissection (ESD) after CRT or TNT for rectal cancer, termed "salvage ESD," may be a viable nonsurgical option for carefully selected patients. We aimed to evaluate the feasibility and safety of salvage ESD.
A retrospective chart review of cases of salvage ESD for locally advanced rectal cancer and standard ESD for rectal tumors without prior CRT from July 2018 to August 2020 at our institution was performed. Clinical factors and imaging, procedural, and pathology results were collected and compared.
Twelve salvage ESD cases were compared with 27 standard ESD cases. Before CRT, 83.3% of lesions in the salvage ESD group were initially clinically staged as T3. The en-bloc resection rates were 92.7% and 91.7% (P = 1.00) and R0 resection rates 66.7% and 75.0% (P = .55) for the standard and salvage groups, respectively. In the salvage ESD group, no adverse events were observed, and 75.0% of the adenocarcinomas in the salvage ESD group had morphologically changed to hyperplasia or adenoma after CRT, with no identifiable lesions greater than T1 tumor depth.
Salvage ESD for locally advanced rectal cancer is technically feasible with low adverse event rates. There may be a diagnostic role in salvage ESD in assessing pathologic response to CRT and a possible therapeutic role in resection of residual lesions with the potential to avoid surgery.
局部晚期直肠癌的标准治疗方法是放化疗（CRT）后行直肠切除术和辅助化疗。然而，CRT 或新辅助放化疗（TNT）后行非手术治疗（包括 CRT 和新辅助化疗）的作用正在不断显现。直肠癌 CRT 或 TNT 后行内镜黏膜下剥离术（ESD），称为“挽救性 ESD”，可能是为精心挑选的患者提供的一种可行的非手术选择。我们旨在评估挽救性 ESD 的可行性和安全性。
对 2018 年 7 月至 2020 年 8 月期间我院局部晚期直肠癌行挽救性 ESD 和无 CRT 前直肠肿瘤行标准 ESD 的病例进行回顾性图表分析。收集并比较了临床因素、影像学、手术过程和病理结果。
比较了 12 例挽救性 ESD 病例和 27 例标准 ESD 病例。在 CRT 前，挽救性 ESD 组 83.3%的病变最初临床分期为 T3。整块切除率分别为 92.7%和 91.7%（P=1.00），R0 切除率分别为 66.7%和 75.0%（P=0.55）。挽救性 ESD 组无不良事件发生，挽救性 ESD 组中 75.0%的腺癌在 CRT 后形态学上转变为增生或腺瘤，无大于 T1 肿瘤深度的可识别病变。
挽救性 ESD 治疗局部晚期直肠癌在技术上是可行的，不良事件发生率低。在评估 CRT 病理反应方面，挽救性 ESD 可能具有诊断作用，在切除可能避免手术的残留病变方面可能具有治疗作用。
