Superficial Esophageal Cancer Completely Cured With Radiotherapy Alone: A Case Report

Article information

Korean J Helicobacter Up Gastrointest Res. 2025;25(4):389-393

Publication date (electronic) : 2025 December 4

doi : https://doi.org/10.7704/kjhugr.2025.0059

Hyung Jin Bae, Younghee Choe, Byung-Wook Kim

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Corresponding author Younghee Choe, MD Division of Gastroenterology and Hepatology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 56 Dongsu-ro, Bupyeong-gu, Incheon 21431, Korea E-mail: ychoe@catholic.ac.kr

Received 2025 August 19; Revised 2025 October 24; Accepted 2025 November 7.

Abstract

INTRODUCTION

In Korea, esophagogastroduodenoscopy (EGD) is a national health screening program for people over 40 years of age, and the number of cases of esophageal cancer being discovered early is gradually increasing [1,2]. Esophageal cancer confined to the mucosa or submucosal layer is called superficial esophageal cancer, and most cases are squamous cell carcinomas, primarily involving the middle esophagus [3].

According to domestic esophageal cancer treatment guidelines, endoscopic resection is the preferred treatment for superficial esophageal squamous cell carcinoma without obvious submucosal invasion or distant or lymph node metastasis [4-6].

However, surgical resection of esophageal cancer carries a high risk of complications and a decreased quality of life after surgery [3,7]. Endoscopic resection has recently endoscopic ultrasound for staging suggested submucosal invasion become more popular, but in cases of large lesions, it can lead to complications such as strictures at the surgical site. If a lesion invades more than 75% of the lumen, the risk of stricture at the surgical site after endoscopic resection increases, which is known to be a relative contraindication to endoscopic resection. Therefore, depending on the patient’s condition, preoperative radiotherapy may be administered to reduce the lesion size before endoscopic resection, or chemoradiotherapy may be attempted [8,9]. However, radiotherapy alone is rarely used as a definitive treatment for superficial esophageal cancer.

This case report describes a patient with superficial esophageal squamous cell carcinoma who was planned for endoscopic resection after radiotherapy and achieved complete remission with radiotherapy alone.

CASE REPORT

A 57-year-old female patient underwent EGD at a primary care clinic one week before her presentation for health screening purposes. The patient was referred for further evaluation due to nodular mucosal changes in the esophageal mucosa discovered on EGD.

At the time of presentation, her vital signs were stable, and her physical examination was unremarkable. The patient had undergone a mastectomy and radiotherapy for breast cancer in 2007 and 2011, and a total thyroidectomy for thyroid cancer. She had no history of alcohol consumption and quit smoking approximately 20 years ago. Aside from mild heartburn, she had no other symptoms.

A repeat EGD was performed at our hospital, revealing nodular changes in the esophageal mucosa 30–35 cm from the upper incisor (Fig. 1A). After applying Lugol’s solution, a pink sign was observed, and a biopsy was performed on the lesion (Fig. 1B). The biopsy results confirmed moderately differentiated squamous cell carcinoma. Endoscopic ultrasound for staging did not reveal submucosal invasion (Fig. 1C), and abdominal, pelvic, and chest CT scans showed no evidence of lymph node or other organ metastasis.

Fig. 1.

Initial esophagogastroduodenoscopy findings. A: Mucosal nodularity was observed in the mid-esophagus. B: A pink sign was noted following the application of Lugol’s solution. C: Submucosal invasion is not suspected on endoscopic ultrasound.

However, the lesion occupied more than 75% of the esophageal lumen, raising the risk of postoperative stricture during endoscopic resection. To develop a more appropriate treatment plan, a multidisciplinary meeting was held involving medical oncology, thoracic surgery, and radiation oncology. The treatment plan consisted of neoadjuvant radiotherapy to reduce the lesion size, followed by endoscopic submucosal dissection (Fig. 2). The patient received 45–50 Gy of radiotherapy targeting the mid-lower esophagus over five weeks and completed treatment without any further complications other than mild generalized weakness.

Fig. 2.

Neoadjuvant radiotherapy planning before endoscopic resection. The patient was scheduled to receive neoadjuvant radiotherapy at a dose of 45–50 Gy over 5 weeks. A: Coronal view. B: Sagittal view.

A follow-up EGD performed one week after completion of radiotherapy revealed no pre-existing esophageal cancer lesions, and no lesions were observed after application of Lugol’s solution (Fig. 3A). A biopsy was performed on the area corresponding to the original lesion. Still, it was “negative for malignancy.” A follow-up EGD performed three months after completion of radiotherapy showed no evidence of pre-treatment lesions. A biopsy was performed on a lesion that did not stain after application of Lugol’s solution. Still, no malignancy was found (Fig. 3B). There were no specific findings in the EGD, and chest CT performed one year after the end of radiotherapy, so it was determined that the superficial esophageal squamous cell carcinoma was in complete remission with radiotherapy alone (Fig. 3C). Since then, the patient was followed annually through EGD and chest CT. There were no signs of recurrence as of 5 years after the end of treatment (Fig. 3D).

Fig. 3.

Follow-up endoscopic findings after radiotherapy. A: 1 week post-radiotherapy. B: 3 months post-radiotherapy. C: 1 year post-radiotherapy. D: 5 years post-radiotherapy.

DISCUSSION

This case report describes the treatment of a patient with superficial esophageal squamous cell carcinoma occupying more than three-quarters of the esophageal lumen, who presented for endoscopic resection. To prevent the risk of esophageal stricture, the patient was given neoadjuvant radiotherapy before the planned endoscopic resection. The patient subsequently achieved pathological complete remission and is currently undergoing follow-up without endoscopic resection.

Endoscopic resection is recommended as the initial treatment for superficial esophageal squamous cell carcinoma that has invaded only the lamina propria. When the tumor invades the muscularis mucosa, either endoscopic resection or surgical resection is recommended as the initial treatment [10]. How-ever, in actual clinical practice, endoscopic resection and surgical resection are sometimes difficult depending on the patient’s comorbidities and the location and extent of the cancer, and radiotherapy or chemoradiotherapy is often considered as an alternative treatment [11-13].

In this case, we initially planned to perform neoadjuvant radiotherapy to reduce the size of a superficial esophageal squamous cell carcinoma that surrounded more than 75% of the esophageal lumen, a condition known to carry a high risk of esophageal stricture following endoscopic resection. However, a complete cure of esophageal cancer was observed with radiotherapy alone, and the potential of radiotherapy as a curative treatment was investigated.

A Japanese study that evaluated the response and survival rates of 20 patients with superficial esophageal cancer who received definitive radiotherapy or chemoradiotherapy reported a 5-year disease-specific survival rate of 100% [9]. Six patients had local recurrence, and two had metachronous recurrence. Seven of them underwent salvage endoscopic submucosal dissection, one underwent argon plasma coagulation treatment, and 12 required no additional treatment.

Similarly, a study of 24 patients with superficial thoracic esophageal cancer (T1a/T1b) in Korea demonstrated that definitive extended-field radiotherapy achieved a 3-year local control rate of 89.7%, was safe in patients who were inoperable or endoscopically unsuitable and could achieve long-term disease control [8]. Another retrospective study of 20 patients with cT1aN0M0 esophageal cancer who were not suitable for endoscopic resection or surgery showed that all patients had a complete response to definitive radiotherapy or chemoradiotherapy. The 5-year disease-specific survival rate was 100%, demonstrating its potential as an organ-preserving treatment [9].

While definitive radiotherapy offers the advantage of organ preservation, its most significant limitation is the relatively high risk of local and metachronous recurrence. However, recurrence can be effectively managed through salvage endoscopic therapy. Therefore, long-term endoscopic surveillance is essential for patients receiving radiotherapy alone. Another limitation of radiotherapy is that in rare cases, the lesion size remains unchanged, ultimately necessitating surgical treatment.

This case from our institution supports the idea that radiotherapy or chemoradiotherapy can be considered a viable alternative for the initial definitive treatment of superficial esophageal squamous cell carcinoma in patients for whom endoscopic or surgical resection is not suitable. Furthermore, a treatment strategy of using radiotherapy alone, followed by regular endoscopic surveillance to determine the need for salvage therapy, may be appropriate. Based on this experience, the authors now administer neoadjuvant radiotherapy to patients with superficial esophageal cancer that occupies more than 75% of the esophageal circumference.

In studies concerning radiotherapy for superficial esophageal cancer, potential complications such as dysphagia and retrosternal pain due to radiation esophagitis may occur, but more serious adverse effects are uncommon. To prevent these complications, it is recommended to keep the cumulative average dose to the esophagus below 34 Gy and limit the treatment area to 60 Gy or less [14].

The authors report on this case to highlight their experience with radiotherapy as a potential definitive treatment for patients with superficial esophageal squamous cell carcinoma for whom endoscopic or surgical resection is not a viable option.

Article information Continued