Introduction Risk of lymph node metastases depends on good or bad prognostic features of submucosally (SM) invasive cancer specimen following endoscopic resection (ER). Invasion limited to SM1 level, lack of lymphovascular invasion and well differentiated grade are good prognostic features and may indicate that radical resection is not required following ER. However, depth of SM invasion can be very difficult to assess in ER specimens and hence a “safe” strategy would be to offer radical surgery to all patients with SM invasive disease, irrespective of other features. This is the policy we follow. We aimed to evaluate the outcome of these cancers in an ER population.
Methods All Upper Gastrointestinal ER procedures for the period 2005–2011 were recorded on a prospective database. All procedures were carried out by a single skilled endoscopist. Demographic data, histology, procedure success, long-term outcome and complications were assessed. Careful endoscopic assessment using chromoendoscopy, plus CT/EUS where appropriate, were performed prior to attempted endoscopic resection and afterwards if indicated.
Results Cancer with submucosal invasion was detected in 26 of 123 (21.1%) cases of oesophagogastric neoplasia. 22 patients were male and the mean age was 75.2 years (range 54–84 years). Submucosal invasion was present in 16 of 74 (21.6%) lesions arising in Barrett's oesophagus, 4 of 7 (57.1%) oesophageal squamous lesions and 6 of 39 (15.3%) gastric lesions. All patients were discussed at a multidisciplinary meeting and those patients who were fit were offered radical surgery or chemoradiotherapy. Six patients who were offered radical surgery opted for conservative management with endoscopic follow-up. 14 patients proceeded to radical surgery; six of these had no residual cancer in surgical specimen and eight had residual cancer present. 11 of the 14 are currently in disease free survival, two died of recurrence and one died of post-operative complications. Two patients received radical chemoradiotherapy; one is in disease free survival, the other died of advanced adenocarcinoma. One patient received radical radiotherapy and remains free of recurrence. Nine patients received conservative/endoscopic management; of these seven had disease free survival, two died of metastatic adenocarcinoma. Mean follow-up was 32 months.
Conclusion Our results show that submucosal invasion is found in a significant proportion of patients undergoing upper gastrointestinal ER. Management of SM invasive cancer following ER remains challenging and our series shows a wide variation in management outcomes. Further research to guide the optimum management of this group of patients is required.
Competing interests None declared.
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