H. Lee Moffitt Cancer Center and Research Institute kansas city, MO, United States
Deepan Panneerselvam, MBBS, Thabuna Sivaprakasam, MBBS, Jose Pimiento, MD, Mark Friedman, MD, Luis Pena, MD, Aamir Dam, MD H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
Introduction: Endoscopic resection (ER) is the preferred treatment of superficial (T1a) esophageal cancer (EAC), while esophagectomy remains the mainstay of treatment for tumors with submucosal invasion (T1b). However, prognostic data directing the management of early T1a EAC based on histologic grade is lacking. Here we report a case of the management of a poorly differentiated T1a EAC.
Case Description/Methods: A 44-year-old male with a h/o Barrett’s esophagus (BE) was referred for ER of a “4 mm esophageal nodule”. Our expert GI pathologist confirmed the diagnosis of intramucosal adenocarcinoma (IMAC). Repeat EGD showed long segment BE (C3-M4) and a 2 cm lesion (Paris classification 0-IIc) in the lower esophagus. EUS suggested confinement to the mucosa and no pathological lymphadenopathy. The patient was referred for endoscopic submucosal dissection and underwent successful en-bloc resection. The final pathology revealed poorly differentiated IMAC (1.5 cm x 0.2cm), invading the muscularis mucosa with negative margins and no submucosal or lymphovascular (LV) invasion. PET/CT revealed no nodal or distant metastasis.
Due to lack of data on poorly differentiated T1a EAC, counselling the patient on the exact risk of nodal metastasis was limited. Given his younger age, we recommended therapeutic options including close surveillance, chemoradiation or esophagectomy. The patient ultimately decided on surgery and underwent Robotic Assisted Ivor-Lewis esophagectomy. Pathology revealed no residual malignancy at the primary site, but 2 out of 36 lymph nodes were positive for disease. He was started on adjuvant chemotherapy and had treatment delays due to poor tolerance. His most recent imaging at 12 months post-op revealed no recurrence.
Discussion: Historically, esophagectomy was preferred for localized EAC. Due to surgical morbidity, management has largely shifted towards ER for T1a EAC. There is also emerging data for ER in T1b lesions without high risk features (poor differentiation, LV invasion, deep submucosal invasion). In this unique scenario, the patient initially underwent curative ER for the smaller T1a lesion(< 2 cm), that revealed nodal spread only upon final pathologic analysis after esophagectomy. Although rate of nodal metastasis for T1a EAC is low(< 2%), it is unknown for those with high risk features, specifically with a poorly differentiated tumor. More prospective data is needed on the long-term prognosis of patients with T1a EAC who undergo ER to guide management strategies.
Figure: A- Endoscopic image of a 2cm lesion with central depression(Paris Classification 0-IIc) in the lower thoracic esophagus. B- Endoscopic ultrasound showing invasion into muscularis mucosa, no submucosal invasion and no pathological lymphadenopathy.
Deepan Panneerselvam indicated no relevant financial relationships.
Thabuna Sivaprakasam indicated no relevant financial relationships.
Jose Pimiento indicated no relevant financial relationships.
Mark Friedman indicated no relevant financial relationships.
Luis Pena indicated no relevant financial relationships.
Aamir Dam indicated no relevant financial relationships.
Deepan Panneerselvam, MBBS, Thabuna Sivaprakasam, MBBS, Jose Pimiento, MD, Mark Friedman, MD, Luis Pena, MD, Aamir Dam, MD. P1396 - Management of Poorly Differentiated Early Superficial Esophageal Cancer: A Case Report, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.