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Ishihara. Mini-invasive Surg 2021;5:36 https://dx.doi.org/10.20517/2574-1225.2021.72 Page 7 of 9

recommended for these patients.

FUTURE PERSPECTIVES
Widespread use of ESD
ESD has higher en bloc resection rate and R0 resection rate than EMR. However, piecemeal EMR is still
conducted in some areas. Widespread use of ESD is desired by overcoming its technical difficulties.

Best treatment for circumferential lesions
ESD is a minimally invasive treatment with high curative potential in patients with esophageal cancer.
However, circumferential endoscopic resection can result in intractable stenosis, considerably reducing the
patient’s quality of life. Chemoradiotherapy is another option for circumferential lesions. A literature search
failed to find any previous studies that described the specific survival rates of patients with circumferential
lesions. Survival analyses and comparative studies of ESD and chemoradiotherapy for circumferential
lesions are therefore required to determine the best treatment for circumferential lesions.

Curability assessment for (p)MM cancer
Assessing the curability of (p)MM cancer without vascular invasion is an issue in clinical practice. Previous
studies examining the incidence of metastasis following endoscopic resection were conducted
retrospectively, did not make it clear if the pathological evaluations were performed using immunostaining,
and lacked thorough and long-term follow-up observations. Future prospective studies are anticipated to
evaluate the metastasis rates in patients with (p)MM cancer based on detailed histological evaluations and
intensive follow-up.

Indication of additional treatment after ESD
The indications for additional treatment are mainly determined based on the risk of metastasis and the
patient’s condition. Considering our aging society, additional treatment may not be indicated even in
patients with a substantial risk of metastasis. However, detailed stratification of metastasis risk based on
histologic findings is currently not possible, and further studies are needed to develop factors to determine
detailed individual risks of metastasis.

Conclusion
An accurate preoperative diagnosis, appropriate indication, and adequate curability assessment based on the
pathological diagnosis of resected specimens are important for effective ESD.

DECLARATIONS
Acknowledgments
I thank Susan Furness, PhD from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.

Authors’ contributions
The author contributed solely to the article.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.