Endoscopic Submucosal Dissection Versus Esophagectomy For Poorly Differentiated Superficial Esophageal Squamous Cell Carcinoma: A Cohort Study

Objectives:The purpose of this study is to compare the efficacy and prognosis of endoscopic submucosal dissection(ESD)with esophagectomy for poorly differentiated superficial esophageal cancer and to assess the risk factors associated with postoperative survival to help guide patients with poorly differentiated superficial esophageal cancer to the most beneficial treatment modality in clinical practice.Methods:A retrospective cohort of patients with poorly differentiated superficial esophageal cancer treated with ESD or esophagectomy at the Department of Gastroenterology and Department of Thoracic Surgery of the First Affiliated Hospital of Naval Medical University between the period of January 2011 and January 2021 was established,and those patients with postoperative pathological confirmed diagnosis of poorly differentiated cancer were selected for inclusion in the study,and their clinicopathological data were collected,The differences in efficacy and prognosis between the ESD group and the surgical group were compared by statistical methods,and the risk factors affecting the prognosis of patients with superficial poorly differentiated esophageal squamous carcinoma were analyzed.Results:1.Patients in the ESD group were older(66.6±7.4 vs.63.4±6.4 P=0.003),The median diameter of the lesions was significantly larger(3.4 cm vs.2.0 cm,P < 0.001);there were more pericyclic lesions,and the surgical group had a higher rate of lymphovascular invasion(19.8% vs.3.2% P < 0.001),and there were significant differences in tumor gross morphology and depth of infiltration distribution between the two groups.Those with additional radiotherapy after operation were significantly higher in the surgical group than in the ESD group(P=0.031).The duration of operation,postoperative hospital days,hospital costs,and serious complications were better in the ESD group than in the surgical group.The differences in OS(P= 0.587),DSS(P=0.172),and RFS(P=0.111)between the ESD and surgical groups were not statistically significant.cox regression analysis,treatment approach was not associated with OS,DSS,and RFS.Lymphatic vascular invasion was an independent risk factor for OS and DSS,and failure to undergo postoperative radiotherapy was an independent risk factor for RFS.2.After propensity scoring match,the two groups were matched to produce 50 pairs of patients.Lesion diameter,surgery-related parameters and survival outcomes were consistent with those before matching,and the independent risk factor affecting OS was the combination of other malignancies;however,the combination of other malignancies was not a risk factor affecting DSS,and gender and failure to administer chemoradiotherapy were risk factors affecting RFS.3.We conducted a subgroup analysis of patients again according to the depth of invasion,In M1-M3 and SM1-SM3 patients,there were no significant differences between the ESD group and the surgical group in terms of margins,R0 resection rate(100%),and additional postoperative surgery or radiochemotherapy.In the M1-M3 subgroup,there were no significant differences between the ESD group and the surgical group in terms of margins,R0 resection rate(100%),and additional postoperative surgery or radiochemotherapy.For the subgroup with an invasion depth of SM1-SM3,the R0 resection rate was significantly lower in the ESD group than in the surgical group,and those who had additional postoperative surgery were significantly higher in the ESD group than in the surgical group.For survival,there was no significant difference between the two treatment modalities in both subgroups.Conclusion:1.There was no significant difference in overall survival,disease-specific survival and recurrence-free survival between the ESD group and the surgical group,and the ESD group was preferred to the surgical group in terms of early adverse events,operative time,postoperative hospital days and hospital costs.2.For patients with intra-mucosal poorly differentiated esophageal cancer,there was no statistical difference between the ESD group and the surgical group in postoperative Radiochemotherapy and various prognostic indicators when R0 resection was achieved;therefore,patients with intra-mucosal poorly differentiated superficial esophageal cancer treated with ESD can be monitored closely after R0 resection is achieved.3.For poorly differentiated squamous carcinoma with invasion of the submucosa after ESD treatment,additional surgery or radiotherapy should be aggressively performed even if R0 is resected.