Successful endoscopic treatment of superficial esophageal cancer in a patient with esophageal variceal bleeding: A case report

Abstract

BACKGROUND

The coexistence of esophageal variceal bleeding and superficial esophageal cancer (SEC) is relatively rare in clinical practice. Moreover, there have been few reports of SEC overlying esophageal varices (EVs). Herein, we report our successful use of endoscopic submucosal dissection (ESD), esophageal solitary venous dilatation (ESVD), and endoscopic injection sclerotherapy (EIS) to treat a 75-year-old man who was diagnosed with SEC coexisting with esophageal variceal bleeding.

CASE SUMMARY

A 75-year-old man was admitted to the hospital due to black stool for 4 days. The patient had a history of liver cancer, cirrhosis, and portal hypertension. Endoscopic examination revealed esophageal and gastric varicose veins, as well as esophageal carcinoma in situ. We first treated esophageal variceal bleeding by ESVD and EIS. One week later, ESD treatment was done, and the complete resection of early esophageal cancer was successfully completed via endoscopy. There were no postoperative complications, such as bleeding, infection, or perforation.

CONCLUSION

The sequential treatment of ESVD, EIS, and ESD is an effective method for treating EVs with early esophageal cancer.

Key Words: Endoscopic selective varices devascularization, Endoscopic injection sclerotherapy, Endoscopic submucosal dissection, Esophageal variceal bleeding, Superficial esophageal cancer, Case report

Core Tip: Esophageal varices (EVs) with bleeding and superficial esophageal cancer (SEC) are two different diseases. Their coexistence is rare in clinical practice. Endoscopic submucosal dissection (ESD) for SEC with EVs is one of the most challenging endoscopic procedures due to the high risk of bleeding and fibrosis caused by prior treatment. We report on a 75-year-old man with “black stool”. He had a history of cirrhosis and portal hypertension. After esophageal solitary venous dilatation and endoscopic injection sclerotherapy, ESD was successfully performed without significant complications, and the SEC was treated by R0 resection. This method may become the mainstream treatment for EVs with SEC.

INTRODUCTION

Esophageal variceal bleeding and superficial esophageal cancer (SEC) are two different diseases whose coexistence is relatively rare in clinical practice. The Japanese Esophageal Society defines SEC as a tumor limited to the mucosal layer (T1a) and submucosal layer (T1b), regardless of the presence of lymph node or distant organ metastasis[1]. Middle-to-late-stage esophageal cancer is often treated by surgery, radiotherapy, or combination therapy. For SECs staged clinically as cT1N0M0, the traditional treatment option is esophagectomy, but this causes significant surgical trauma. During the last few years, immunotherapy has emerged. Although the antitumor efficacy of immune checkpoint inhibitors is significant, it is also associated with a higher risk of all-grade and grades 3-4 hypertransaminasemia[2-4]. In recent years, endoscopic resection has gradually become the preferred treatment for some SECs due to its safety, effectiveness, and minimal invasiveness, especially its preservation of the esophagus and being more physiologically aligned[5-8]. Esophageal and gastric varices are the most common complications of liver cirrhosis, and endoscopic variceal ligation and endoscopic injection sclerotherapy (EIS) are common treatments for esophageal varices (EVs). However, acute upper gastrointestinal bleeding in patients with esophageal and gastric varices requires emergency hemostasis. The treatment of varicose vein bleeding is often urgent, so doctors have no time to observe the details of the esophageal mucosa carefully. As a result, most cases of esophageal cancer are in the late stage at diagnosis. In addition, the treatment of varicose veins also creates difficulties for SEC, such as adhesions. There have been few reports of SEC with bleeding of EVs. Herein, we report our successful use of endoscopic submucosal dissection (ESD), esophageal solitary venous dilatation (ESVD), and EIS to treat a 75-year-old man who was diagnosed with SEC accompanied by bleeding of EVs.

CASE PRESENTATION

Chief complaints

A 75-year-old man was admitted to the hospital due to black stool for 4 d.

History of present illness

The patient had been diagnosed with liver cirrhosis 6 years earlier and mixed left liver cancer (hepatocellular carcinoma and hepatobiliary cell carcinoma) 3 years earlier.

History of past illness

The patient’s surgical history included surgery for left liver cancer before admission and transcatheter arterial chemoembolization after the operation. The patient was followed up regularly for 3 years. There was no recurrence of the tumor during that period.

Personal and family history

The patient had a history of smoking and drinking but had quit smoking for 6 years. The patient’s family history was unremarkable.

Physical examination

At admission, the vital signs were as follows: Body temperature, 36.3 °C; pulse, 108/min; respiratory rate, 76 per minute; and blood pressure, 102/58 mmHg. The abdomen was distended with prominent abdominal varicose veins. On palpation, the abdomen was firm and tender. Bowel sounds were diminished.

Laboratory examinations

Blood parameters were: Hemoglobin, 102 g/L; platelet count, 99 × 10⁹/L. The fecal occult blood test was positive.

Imaging examinations

Endoscopy revealed three EVs with a diameter of approximately 0.6 cm, with a red color sign, and the patient was diagnosed with LemigfD1Rf1. Narrow-band imaging with magnifying endoscopy (NBI-ME) revealed that a type IIb lesion was located in the inferior region of the esophagus, was pink in color, and could not be stained with iodine (Figure 1A-D).

Figure 1 Endoscopic images. A: Three esophageal varices with a diameter of 0.6 cm; B: IIb-type lesion with a pink color that could not be stained by iodine; C: Irregular blood vessels on narrow-band imaging-magnetic endoscopy (NBI-ME); D: Tatami sign; E: Gum discharged after endoscopic selective variceal debridement and endoscopic injection sclerotherapy; F: Demarcation line and marker; G: Irregular blood vasculature on NBI-ME; H: Postoperative specimen.

FINAL DIAGNOSIS

Bleeding of SEC coexisting with EVs.

TREATMENT

We performed ESVD and EIS to deal with the bleeding of the EVs and performed a biopsy on the lesion, which we considered SEC (Figure 1A-D). The patient was administered an intravenous proton pump inhibitor and somatostatin therapy for 1 wk. Pathology revealed squamous epithelial high-grade intraepithelial neoplasia (in situ carcinoma). After discussion in the department and communication with the patient and his family, the patient agreed to undergo endoscopic therapy and provided informed consent. ESD was used to remove the lesion in the esophagus (Figure 1E-H). The tissue specimen was about 5.0 cm × 4.5 cm in size. During the operation, approximately 100 mL of blood was removed from the patient, and the patient received transfusion therapy and gastrointestinal decompression.

OUTCOME AND FOLLOW-UP

After 7 d of conservative treatment, the patient had no obvious hemorrhage, pain, emesis, or any other clinical symptoms. The final pathological results were as follows (Figure 2): (1) Histological type: 0-IIa + IIb type squamous cell carcinoma with moderate differentiation; (2) Specimen size: 4.2 cm × 1.8 cm; (3) Depth of infiltration: Mucous membrane (MM); (4) Scar and vascular infiltration: (-); (5) Cutting margin: Horizontal (-) and vertical (-); and (6) Immunohistochemical staining: Desmin (smooth muscle +), CD31 (vascular endothelium, +), Ki-67 (30%, +), p53 (80%, +), P63 (+), and CK34βE12 (+).

Figure 2  Pathology revealed 0-IIa + IIb type squamous cell carcinoma with moderate differentiation.

After 3 mo of postoperative follow-up, the wound was repaired well by gastroscopy, and there was no bleeding during the one-year follow-up (Figure 3).

Figure 3 Timeline. ESVD: Esophageal solitary venous dilatation; EIS: Endoscopic injection sclerotherapy; ESD: Endoscopic submucosal dissection.

DISCUSSION

The coexistence of EVs bleeding and SEC is relatively rare in clinical practice, and most cases of esophageal cancer are in the late stage at diagnosis. Therefore, in the process of endoscopy, patients whose esophageal varicose veins are located still need to be carefully scanned. Erosive lesions and protrusive lesions of the esophagus may constitute the early stage of esophageal cancer. The risk of surgical treatment for patients with cirrhosis and esophageal cancer is extremely high. Serious complications, such as anastomotic fistula, chylothorax, and liver function failure, occur frequently[9], result in a very high death rate. In recent years, there have been some case reports of cirrhosis combined with bleeding of EVs in SEC patients, indicating that minimally invasive endoscopic treatments, such as ESD and EMR, are associated with better results with fewer complications[10]. Although the treatment steps may seem clear, many issues still need to be explored. Bleeding and fibrotic adhesions are the most common problems encountered during the ESD procedure[11]. One of the reasons for the observed bleeding may be related to the patient’s concurrent presence of gastric varicose veins, which were not treated properly. For this patient, we used ESVD to treat the gastric varicose veins, resulting in less bleeding during ESD. The liver function status of patients is also worthy of attention. Esophagectomy in patients with cirrhosis has been reported to result in a higher rate of complications and mortality than surgery in patients without cirrhosis[12]. Liver cirrhosis patients with Child-Pugh class A liver function may be more suitable for ESD. Fibrotic adhesions may cause the piecemeal resection, which is thought to be due to the fibrosis caused by EIS[11]. Tahara et al[13] reported that APC may be an option for treating ESCC that is evaluated endoscopically within the mucosa and is difficult to safely treat with ESD. However, APC differs from ESD and surgical esophagectomy because it does not allow histopathological evaluation of ESCC, and careful follow-up is necessary. TIPS may also be effective as an EV treatment that does not affect the ESD in patients with SESCC[14]. ESD can be used to pathologically evaluate the depth of lesions, and it is the first choice for ESCC treatment. There are still many issues that need further attention: What is the best time interval between EIS and ESD? How can the risk of postoperative bleeding be assessed for such patients? Will there be a higher risk of bleeding from recurrent variceal rupture in the ESD resection area? How can esophageal stenosis after ESD combined with varicose veins be treated?

CONCLUSION

Esophageal variceal bleeding is a common complication of liver cirrhosis, but its coexistence with esophageal cancer is relatively rare. Varices are prone to bleeding, and patients with liver cirrhosis have poor coagulation function, making it difficult to tolerate surgical intervention. Therefore, for patients with early-stage esophageal cancer, endoscopic treatment after ESVD and EIS of varicose veins is a feasible method.

ACKNOWLEDGEMENTS

We would like to thank Mr. Zhang Shuo for his support and help with the care of the patient.