ESD for Oesophageal SCC: Absolute vs outside criteria resection and outcomes

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Aims Endoscopic submucosal dissection (ESD) can yield an endoscopic cure for oesophageal squamous high-grade dysplasia (HGD) and early squamous cell carcinoma (ESCC). Its role in the West remains unclear, as absence of screening programs lead to detection of lesions that may be considered resectable but fall outside ‘absolute criteria’ as per Japanese guidelines. Thus, we sought to determine the endoscopic curability and long-term outcomes of ESD for HGD and ESCC in a large single-centre Australian cohort. Methods A prospective observational cohort study was performed over 92 months until April 2024. The primary outcomes were enbloc, R0 and curative resection rates. Secondary outcomes included disease recurrence, adverse events and survival. Results 75 patients underwent oesophageal ESD for squamous HGD or SCC (mean age 72.9±8.2 years; 47 (62.7%) female). Median lesion size was 40 mm (IQR 20-60 mm). Technical success and enbloc resection were achieved in all 75 (100%). Overall R0 excision was achieved in 61 (81.3%), and curative resection in 35 (46.7%). The median hospital length of stay was 1 day (IQR 1-3). 39 (52%) met ‘absolute criteria (AC)’, with the remaining 36 (48%) ‘outside criteria (OC)’. AC lesions were more likely to under an R0 excision (n=36, 92.3% vs. n=25; 69.4%; P=0.011), and be endoscopically cured (n=28, 71.8% vs. 7; 19.4%, P<0.001). Of the 40 (53.3%) non-curative resections, 16 (35%) underwent additional therapy. The remainder entered endoscopic surveillance after MDT discussion due to advanced age and comorbidities. At a median follow up of 26 months (IQR 9-50 months), recurrence occurred in 9/75 patients (12%) and 10/75 (13.3%) patients died, of which 6/10 deaths (60%) were related to SCC. No deaths occurred in the AC group. 5-year OS was significantly higher in curative resections than non-curative resections (100% vs 58.5%, P=0.002). Similarly, 5-year DSS was significantly higher in curative resections (100% vs 80.1%, P=0.017). Charlson comorbidity index was the only significant independent risk factor for OS (HR, 3.66; 95% CI, 1.39-9.59; P=0.008). Conclusions In a Western setting, ESD for squamous HGD and ESCC is safe. A curative resection yields excellent long-term outcomes with 5-year OS and DSS of 100%. Furthermore, almost 20% of OC patients were cured, avoiding surgery and adjuvant therapy. In non-curative resections, primarily represented by the OC group, ESD conferred over 80% 5-year DSS. Thus, ESD also serves as a valid palliative treatment option for the frail and elderly with advanced disease, who fall outside ‘absolute criteria’, and who are otherwise unsuitable candidates for esophagectomy or adjuvant therapy. Publication History Article published online: 27 March 2025 © 2025. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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