**4. Discussion**

Curative surgery has been considered the standard treatment for squamous cell carcinoma of the esophagus with submucosal invasion (T1b) because of the possibility of lymph node metastasis6)7)8). Although chemoradiotherapy (CRT) has been performed recently for T1bN0 cancer, it is controversial whether CRT has the same therapeutic effect as surgery, and a randomized controlled trial of surgery versus CRT is still ongoing.

EMR has become widely employed for esophageal early carcinoma1)2) at a large number of institutions10). ESD has been adopted for the treatment of early esophageal cancer as a

**Mod.SCC,pSM1, ly3, v0, INFc→CRT(ND+5FU, 66Gy)**  Fig. 5. Though pathological finding showed moderate. SCC, pSM1, ly3, v0, chemoradiotherapy

Recurrence was diagnosed in three patients. Medistinal lymph node recurrence occurred in a man with moderately differentiated SCC (sm1, ly (-)) treated by EMR alone and cervical lymph node recurrence was detected in 1 woman with moderately differentiated SCC (sm2, ly (+)) treated by EMR alone. Both cervical lymph node recurrence and intramural metastasis were detected in 1 man with moderately differentiated SCC (sm1, ly (+)) treated

There was 1 death from the primary disease and 10 patients died of other diseases. The

Curative surgery has been considered the standard treatment for squamous cell carcinoma of the esophagus with submucosal invasion (T1b) because of the possibility of lymph node metastasis6)7)8). Although chemoradiotherapy (CRT) has been performed recently for T1bN0 cancer, it is controversial whether CRT has the same therapeutic effect as surgery, and a

EMR has become widely employed for esophageal early carcinoma1)2) at a large number of institutions10). ESD has been adopted for the treatment of early esophageal cancer as a

by EMR + chemoradiotherapy (Fig. 4-6). Local recurrence did not occur.

randomized controlled trial of surgery versus CRT is still ongoing.

Fig. 4. 0-IIa+IIc lesion was seen in middle esophagus. EMR was performed

was treated

**4. Discussion** 

overall survival rate was 69% (Fig. 7).

Fig. 6. After 6 month later, intrmural metastasia and cervical lymph node were detected. The patient died from the primary disease

method of excising extensive lesions en bloc. Endoscopic resection was previously considered to be curative for tumors limited to the proper mucosal layer9). Although the indications of EMR/ESD have been extended to tumors with invasion of the muscularis mucosae and submucosal tumors with a comparatively low rate of lymph node metastasis in recent years11)-13), these procedures are not indicated for tumors invading deeply into the submucosal layer.

Fig. 7. Over all survival

**Part 3** 

**The Stomach and Duodenum** 

One advantage of EMR/ESD is that histopathological examination is possible, which allows us to identify the patients who do not need chemotherapy or radiotherapy. EMR/ESD seemed to be effective because there was no local recurrence and residual tumor. There were many high risk patients in our series, so deaths from other causes were frequent. Thus, a randomized controlled trial will be needed to evaluate the correct survival rate. There were also cases of cervical and mediastinal lymph node recurrence in our series. These lymph nodes are removed by esophagectomy with 3-field dissection, so recurrences would have been avoided if esophagectomy had been performed in such patients. Accordingly, EMR/ESD needs to be selected carefully.

#### **5. References**

