Salvage endoscopic submucosal dissection via a continuous irrigation method for locally recurrent esophageal cancer after photodynamic therapy

Photodynamic therapy (PDT) is an established salvage treatment for residual or recurrent esophageal cancer after chemoradiotherapy (CRT), achieving high complete response rates. ^1​ However, subsequent local recurrence remains a clinical challenge, ^2​ and no standard treatment strategy has been established. Because severe post-treatment fibrosis often makes endoscopic resection (ER) technically difficult, more invasive alternatives such as esophagectomy or repeated PDT are frequently selected. ^{3​ ​4​} Endoscopic submucosal dissection (ESD), which enables minimally invasive treatment with esophageal preservation, may therefore offer a valuable therapeutic option; however, reports in this setting remain limited. We previously reported the usefulness of the continuous irrigation method (CIM) for ESD of esophageal squamous cell carcinoma (ESCC) with severe fibrosis after prior ESD. ⁵ Here, we report a case of successful salvage ESD via the CIM for locally recurrent ESCC with severe fibrosis after CRT and PDT ( Video 1​ ). A 73-year-old man underwent CRT for cT1bN0M0 esophageal cancer, followed by local recurrence ( Fig. 1a–c ). After a thorough discussion of the available treatment options, including surgery and ER, the patient opted for PDT ( Fig. 1d ). One year later, a second local recurrence was detected, suspected to be an intramucosal carcinoma ( Fig. 2a–d ), and salvage ESD was planned. Given extensive scarring, severe fibrosis was anticipated, and the CIM was applied. During the mucosal incision, air bubbles impaired visualization; the CIM cleared these and provided stable views ( Fig. 3a–e ). Continuous water pressure facilitated entry into the fibrotic layer and provided buoyancy-induced traction. A tapping technique combined with the CIM and local fluid injections enabled dissection through the fibrosis, yielding en bloc resection ( Figs. 3f–j , 4a–h ). The pathological diagnosis was ESCC in the lamina propria mucosae without lymphovascular invasion ( Fig. 5a and b ). In conclusion, the CIM may be useful for salvage ESD in cases of local recurrence after PDT.

Fig. 1.

Endoscopic images of recurrent lesions after chemoradiotherapy (CRT) and at the time of photodynamic therapy (PDT). ( a ) A white light image. Upper gastrointestinal endoscopy revealed a 20-mm, reddish, flat lesion (type 0-IIb) on the scar after CRT in the middle thoracic esophagus (yellow dotted line). ( b ) A narrowband image. The lesion was visible as a brownish area (yellow dotted line). ( c ) An endoscopic ultrasound (EUS) image. EUS showed a smooth third layer (yellow arrow), suggesting that the lesion was an intramucosal carcinoma. ( d ) An endoscopic view after PDT. A purple discoloration consistent with the ischemic change was observed at the site of laser irradiation.

Fig. 2.

Endoscopic images of the second local recurrence after photodynamic therapy (PDT). ( a ) A white light image. Upper gastrointestinal endoscopy revealed a 20-mm, reddish, flat lesion (type 0-IIb) on the scar after PDT. ( b ) A narrowband image. The lesion was visible as a brownish area. ( c ) A magnified view of the green square in ( b ). The capillary loops exhibited dilatation, tortuosity, caliber changes, and various shapes corresponding to the Japan Esophageal Society classification type B1. ( d ) The lesion was visible as an unstained area upon endoscopic iodine staining (green dotted line).

Fig. 3.

Schema of the steps of lesion resection with underwater endoscopic submucosal dissection using the continuous irrigation method (CIM). ( a ) After marking around the lesion, saline immersion was performed. ( b ) Local fluid injections were administered around the lesion; however, the fibrotic area exhibited poor lifting. ( c ) A mucosal incision was made on the distal side of the lesion. Air bubbles associated with the mucosal incision impaired the endoscopic view. ( d ) By employing the CIM, air bubbles were efficiently blown away, resulting in a consistently clear endoscopic field. ( e ) A complete circumferential incision was made. ( f ) Even during submucosal dissection, the visual field was impaired by bubbles under conventional saline immersion. ( g ) By using the CIM, the air bubbles were cleared, resulting in an improved endoscopic view. ( h ) Submucosal dissection of the fibrotic area was also performed using the CIM. ( i ) Submucosal dissection continued with the CIM. ( j ) En bloc resection was achieved.

Fig. 4.

Schema of the endoscopic view under red dichromatic imaging (RDI). ( a ) A representative endoscopic view during submucosal dissection under RDI. ( b ) Under conventional saline immersion, the visual field becomes obscured by bubbles. ( c ) The continuous irrigation method (CIM) was employed. ( d ) The CIM blew the bubbles away, and the field of view became clear. ( e ) An endoscopic image of the fibrotic area. ( f ) Even during dissection of the fibrotic area, the visual field becomes obscured by bubbles under conventional saline immersion. ( g ) The CIM provides a water pressure effect, generating buoyancy that creates a natural traction effect, thereby facilitating submucosal dissection of the fibrotic areas. ( h ) The visual field was secured using CIM, and the fibrotic area was dissected using a tapping technique with additional fluid injections from the knife tip.

Fig. 5.

Macroscopic and histopathological images of the resected specimen. ( a ) A macroscopic view of the specimen. ( b ) A histopathological image of the specimen. The pathological diagnosis was squamous cell carcinoma in the lamina propria mucosae without lymphovascular invasion. The horizontal margin was considered inconclusive, and the vertical margin was considered negative.

Video 1 Salvage endoscopic submucosal dissection using the continuous irrigation method for a locally recurrent lesion of esophageal cancer after photodynamic therapy.

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