Is endoscopic submucosal dissection a first-line treatment for anal squamous cell carcinoma?

Letter to: Outcomes of endoscopic submucosal dissection for treatment of superficial anal squamous cell carcinoma: Multicenter international experience Endosc Int Open 2025; 13(CP): DOI: 10.1055/a-2641-5597 10.1055/a-2641-5597 With a great deal of interest, we read the article entitled “Outcomes of endoscopic submucosal dissection for treatment of superficial anal squamous cell carcinoma: Multicenter international experience” by Fraile-López et al [ 1 ]. The authors presented endoscopic submucosal dissection (ESD) in en bloc resection of anal squamous cell carcinoma (ASCC), evaluating safety and long-term efficacy. We would like to highlight the novel endoscopic approach in local resection of ASCC lesions. First, this minimal invasive resection represents a valuable alternative to surgical resection. Limited circumferential cutting of the lesions resulted in less procedure complications. On the other hand, inclusion of patients without the preexistence of biopsy-confirmed ASCC may avoid unnecessary endoscopic resections. In the study by Fraile-López et al [ 1 ], absence of previous biopsy resulted in resection of low-grade squamous intraepithelial lesions (LSILs), which have relatively low short‑term risk of progressing to cancer and often regress [ 2 ]. As far as the high-grade SILs, ablative treatment (such as electrocautery or laser CO 2 ) is generally preferred over excision because it is less invasive, can often be done in an ambulatory setting, and has already shown effectiveness in preventing cancer progression [ 3 ]. In addition, the discrepancy between the pre-excision biopsy and the final pathology, present in the Fraile-López et al study [ 1 ], can be interpreted as non-proper selection of the biopsy site. The yield and quality of anal biopsies can be improved if and only if high-resolution anoscopy is performed [ 4 ] [ 5 ]. Taking into consideration all the aforementioned facts, it can be assumed that ESD is a valuable tool in treatment of selective patients with ASCC. Further studies are required so as to prove its position as a first-line therapeutical approach. Once again, we would like to thank the authors for sharing their experience. Publication History Received: 25 December 2025 Accepted: 10 February 2026 Article published online: 25 February 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany Bibliographical Record Ioannis D. Gkegkes, Christos Iavazzo, Apostolos P. Stamatiadis. Is endoscopic submucosal dissection a first-line treatment for anal squamous cell carcinoma?. Endosc Int Open 2025; 13: a28114955. DOI: 10.1055/a-2811-4955