DISCUSSION
Despite growing evidence towards the use of EMR and other endoscopic
esophagus-preserving techniques for treatment of intramucosal carcinoma,
endoscopic resection as an alternative to esophagectomy is not yet seen
as a consensus treatment (3). Our findings support the use of EMR in the
setting of IMC with invasion to T1sm1 depth or less. We successfully
eradicated IMC in 10/11 (91%) of patients using the EMR technique. This
is similar to described success rates in the literature (15, 16). This
was accomplished in most cases with one or two endoscopy sessions on an
outpatient basis with practically no morbidity; only one patient was
admitted for monitoring for bleeding but no patient actually had
rebleeding or required intervention.
Comparatively, esophagectomy is fraught with significant morbidity.
Two-thirds of patients undergoing esophagectomy had some form of
complication, including two who required reintervention or intensive
care unit stays. Moreover, esophagectomy carries with it all the
disadvantages of a surgical intervention, including post-operative pain,
a decrease in quality of life, and a median hospital stay of over two
weeks.
In the EMR group, one patient failed to have eradication even with an
EMR specimen showing two foci of IMC with margins negative for
malignancy. He was found 8 months later to have persistent disease in
the esophagus and nodal disease, but was not a surgical candidate. In
the esophagectomy group, despite surgical resection, one patient was
found to have recurrent nodal disease a year and a half after
esophagectomy. Both of these patients died of their disease, showing an
estimated similar long-term mortality rate between both groups.
Another patient had successful EMR eradication of IMC with biopsies
showing no persistence of adenocarcinoma but presence of high-grade
dysplasia. He continued to have regular endoscopic treatment with the
goal of removing his high-grade dysplasia but was found 4 years later to
have another adenocarcinoma which was not amenable to endoscopic
treatment. Given the difference in time between the initial IMC and the
recurrence, this patient may have actually had metachronous development
of a new lesion. Nonetheless, he was able to be treated successfully
with a salvage esophagectomy, from which he unfortunately suffered an
anastomotic leak.
EMR also serves as a method for obtaining a larger biopsy, therefore
allowing better determination of depth of invasion (19). Standard
endoscopic biopsies yielding pathology compatible with intramucosal
carcinoma are sometimes unable to detect a nearby invasive component due
to sampling error or lack of depth on the biopsy specimen. Although
excluded from our analysis, two patients were initially found to have
pathology consistent with intramucosal carcinoma and were taken for EMR.
These EMRs showed deeper disease beyond the submucosa with positive
margins confirming a stage greater than T1 and therefore requiring
esophageal resection.
Limitations of our study include the retrospective nature of the data,
which can limit the interpretation of our long-term results. The
relatively small number of patients also allows for potential type II
error but is compatible with the relative rarity of the disease. The
limited number of patients may not capture more rare, but potentially
important, complications such as post-EMR bleeding. There is also a
length-time selection bias inherent to transitioning from esophagectomy
to EMR, with overall in-hospital care changing from 2005 to 2013.
In conclusion, EMR was successful in eradicating IMC in 10/11 patients
with lower morbidity, and similar long-term recurrence and mortality
compared with esophagectomy patients. Patients with IMC may benefit from
EMR as initial therapy by obviating the need for a complex and morbid
operation.