Intralesional steroid injection to prevent stricture after endoscopic submucosal dissection for esophageal cancer: a controlled prospective study Authors N. Hanaoka 1 , R. Ishihara 1 , Y. Takeuchi 1 , N. Uedo 1 , K. Higashino 1 , T. Ohta 1 , H. Kanzaki 1 , M. Hanafusa 1 , K. Nagai 1 , F. Matsui 1 , H. Iishi 1 , M. Tatsuta 1 , Y. Ito 2 Institutions 1 Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan 2 Department of Cancer Epidemiology and Prevention Center for Cancer Control and Statistics, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan submitted 12. January 2012 accepted after revision 15. June 2012 Bibliography DOI http://dx.doi.org/ 10.1055/s-0032-1310107 Published online: 28.8.2012 Endoscopy 2012; 44: 1007– 1011 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author Noboru Hanaoka, MD Department of Gastrointestinal Oncology Osaka Medical Center for Cancer and Cardiovascular Diseases 1-3-3 Nakamichi Higashinari-ku Osaka 537-8511 Japan Fax: +81-66-9814067 hanaoka-no@mc.pref.osaka.jp Original article 1007 Introduction ! Esophageal cancer is the eighth most common cancer in the world and is considered to be an ag- gressive tumor that often presents at an advanced stage. Historically it has poor survival rates [1]. Endoscopic submucosal dissection (ESD) was de- veloped in Japan and has been performed on many patients with early-stage esophageal cancer and a low risk of lymph node metastases because it is minimally invasive and offers excellent re- sults [2, 3]. Subsequently the indications for endo- scopic resection have gradually been extended to include larger lesions that were previously treat- ed by chemoradiotherapy or surgery. Stricture is a major complication after ESD. Multi- variate analysis has shown that a mucosal defect of more than three-quarters of the circumference is a reliable predictor of stricture [4 – 6]. The fre- quency of stricture after ESD for esophageal can- cer with a high-risk, more than three-quarter cir- cumferential mucosal defect is 70 % – 90 % [5, 7, 8]. Post-ESD stricture substantially decreases the pa- tients’ quality of life and requires multiple endo- scopic balloon dilation (EBD) sessions. Preventive EBD has been the treatment of choice to prevent stricture; however, even after six ses- sions of preventive EBD, stricture is a frequent complication [8]. Recently, the efficacy of prophy- lactic oral prednisolone in the prevention of post- ESD stricture was described [9]. Although this method reduced the stricture rate, the cumulative dose of prednisolone was approximately 1000 mg and exposure to such a high prednisolone dose raises concerns regarding adverse effects. Hashimoto et al. first described the efficacy of in- tralesional triamcinolone injection [7]. The cumu- lative steroid dose is much lower with locally in- jected triamcinolone than with oral prednisolone. However, three additional endoscopic procedures for steroid injections after ESD were mandatory with their method, which resulted in additional cost and patient inconvenience. Hanaoka N et al. Intralesional steroid injection to prevent esophageal stricture after ESD … Endoscopy 2012; 44: 1007–1011 Background and study aims: The frequency of stricture after endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma with a mucosal defect involving more than three-quarters of the circumference is 70 % – 90 %. Stricture decreases quality of life and requires multiple endoscopic balloon dilation (EBD) ses- sions. We investigated the efficacy and safety of a single session of intralesional steroid injections to prevent post-ESD stricture. Patients and methods: We conducted a prospec- tive study on 30 patients with esophageal squa- mous cell carcinoma treated by ESD, who had a more than three-quarter but less than whole cir- cumferential defect. A single session of intrale- sional steroid injections was undertaken immedi- ately after ESD. Esophagogastroduodenoscopy was performed whenever patients reported dys- phagia and 2 months after ESD in patients with- out dysphagia. Results were compared with a his- torical control group of 29 patients who under- went ESD without intralesional steroid injection. The primary endpoint was the post-ESD stricture rate. Secondary endpoints were the number of EBD sessions and the complication rate. Results: Compared with the historical control group, the study group had a significantly lower stricture rate (10 %, 3 /30 patients vs. 66 %, 19 /29 patients; P <0.0001) and a lower number of EBD sessions (median 0, range 0 – 2 vs. median 2, range 0 – 15; P < 0.0001). The study group had a complication rate of 7% (2 /30 patients), compris- ing a submucosal tear in one patient and bleeding in another, which were not a direct result of EBD. Conclusions: A single session of intralesional ster- oid injections showed promising results for the prevention of stricture after ESD for esophageal cancer. Downloaded by: Noriya Uedo. Copyrighted material.