Removing early cancers of the esophagus, stomach and colon
UH Digestive Health Institute- January 2016
John A. Dumot, DO, FASGE
Director, UH Digestive Health Institute; Professor of Medicine, Case Western Reserve University School of Medicine
Amitabh Chak, MD, FASGE
Medical Director, Advanced Technology & Innovation Center, UH Digestive Health Institute; Professor of Medicine, Case Western Reserve University School of Medicine
Esophagus with early squamous cell cancer, shown with high-definition white light
Endoscopic submucosal dissection (ESD) is emerging as a viable option for patients with early cancers of the gastrointestinal tract. ESD techniques were first developed in Japan and then evolved throughout Asia, primarily for early gastric cancers found during endoscopic screening programs. These screenings are similar to use of colonoscopies for colorectal cancer screening in the United States.
Initial circumferential incision
The goal of ESD is to remove lesions or neoplastic growths in one piece (also known as en bloc). These are growths that have clear lateral and deep margins. This can be achieved when the neoplasm is of favorable histology (well or moderately differentiated) and involves only the most superficial layers of the gastrointestinal tract. Deeper invasion or poorly differentiated neoplasms require more traditional surgical approaches, or a combination of radiation and chemotherapy.
This case (Figures 1-5) illustrates endoscopic resection of an early squamous cell esophageal cancer from the mid-esophagus. The patient presented with non-cardiac chest pain, which was thought to be unrelated to this early stage neoplasm. The ESD procedure removed the lesion with clear lateral and deep margins. The resection specimen measured 2.5 x 1.9 x 0.4 cm.
Fresh ESD site with squamous cell cancer removed
After the procedure, the patient was hospitalized for observation due to symptoms of chest pain and exposure of the muscle layer fibers. A CT scan of the chest revealed a small leakage of carbon dioxide, which had been used for insufflation during the procedure. The patient had an otherwise uneventful recovery.
Three-month follow up exam - ESD scar and healing
The endoscopy performed at the three-month follow up showed the lesion to be well healed. PET-CT imaging found no evidence of recurrence at six months.
The patient will undergo surveillance endoscopy every three months for the first year and then yearly exams thereafter. Similar outcomes for patients with early cancers associated with Barrett’s esophagus have also been achieved.
To refer a patient to the UH Digestive Health Institute for ESD in the esophagus, stomach or colon, contact John Dumot, DO, at 216-593-1305 or John.Dumot@UHhospitals.org or Amitabh Chak, MD, at 216-844-3217 or Amitabh.Chak@UHhospitals.org.