Endoscopic resection after downstaging of oesophageal carcinoma by neoadjuvant chemoimmunotherapy: – a new multimodal concept?

Abstract

Oesophageal surgery is the current standard for advanced oesophageal cancer within multimodal protocols involving perioperative chemoimmunotherapy and/or radiotherapy. However, oesophagectomy is afflicted with significant morbidity and mortality so that organ-preserving strategies would be worthwhile to develop. We report a case of advanced oesophageal squamous cell cancer (cT2) treated by neoadjuvant therapy and presumably downstaged to a superficial lesion. Semicircumferential endoscopic full-thickness resection (EFTR) was performed, followed by implantation of a metallic stent. Histology showed residual intramucosal high-grade dysplasia. Three months postoperation, the wound healed well, with no occurrence of oesophageal stenosis. The patient received immunotherapy until 24 months post-EFTR and has been followed for 26 months without the recurrence of the disease. Further studies have to show the oncological success, but also oncological risks associated with such an innovative approach. Radical surgery is the standard treatment for advanced-stage oesophageal cancer without metastases.1 Yet, the radical surgery, which involves extensive resection, is associated with a substantial mortality and a high morbidity rate, significantly impacting the quality of life for patients.2 Existing evidence indicated that the implementation of neoadjuvant chemotherapy and immune checkpoint inhibitors in patients with esophageal squamous cell carcinoma (ESCC) yields a complete pathological response rate ranging from 35.3% to 43.2%,3–5 accompanied by a high major pathological response rate ranging from 44% to 82%.6 The integration of immune checkpoint inhibitors into systemic therapy, in conjunction with radiochemotherapy, has rendered technically unresectable advanced oesophageal cancer surgically resectable lesions in most cases.7 Inspired by this approach, we attempted conversion therapy for patient ineligible for surgery and endoscopic resection. Through neoadjuvant chemotherapy in combination with immune checkpoint inhibitor, the endoscopically unresectable ESCC was converted into endoscopically resectable lesion. Subsequently, by employing EFTR, the oesophageal lesion was successfully removed, achieving oesophagus preservation. A 68-year-old male patient with a history …