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Rubenstein JH, Sawas T, Wani S, Eluri S, Singh S, Chandar AK, Perumpail RB, Inadomi JM, Thrift AP, Piscoya A, Sultan S, Singh S, Katzka D, Davitkov P. AGA Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett's Esophagus and Related Neoplasia. Gastroenterology 2024; 166:1020-1055. [PMID: 38763697 PMCID: PMC11345740 DOI: 10.1053/j.gastro.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
BACKGROUND & AIMS Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Endoscopic eradication therapy (EET) can be effective in eradicating BE and related neoplasia and has greater risk of harms and resource use than surveillance endoscopy. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for the use of EET in BE and related neoplasia. METHODS The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients, conducted an evidence review, and used the Evidence-to-Decision Framework to develop recommendations regarding the use of EET in patients with BE under the following scenarios: presence of (1) high-grade dysplasia, (2) low-grade dysplasia, (3) no dysplasia, and (4) choice of stepwise endoscopic mucosal resection (EMR) or focal EMR plus ablation, and (5) endoscopic submucosal dissection vs EMR. Clinical recommendations were based on the balance between desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS The panel agreed on 5 recommendations for the use of EET in BE and related neoplasia. Based on the available evidence, the panel made a strong recommendation in favor of EET in patients with BE high-grade dysplasia and conditional recommendation against EET in BE without dysplasia. The panel made a conditional recommendation in favor of EET in BE low-grade dysplasia; patients with BE low-grade dysplasia who place a higher value on the potential harms and lower value on the benefits (which are uncertain) regarding reduction of esophageal cancer mortality could reasonably select surveillance endoscopy. In patients with visible lesions, a conditional recommendation was made in favor of focal EMR plus ablation over stepwise EMR. In patients with visible neoplastic lesions undergoing resection, the use of either endoscopic mucosal resection or endoscopic submucosal dissection was suggested based on lesion characteristics. CONCLUSIONS This document provides a comprehensive outline of the indications for EET in the management of BE and related neoplasia. Guidance is also provided regarding the considerations surrounding implementation of EET. Providers should engage in shared decision making based on patient preferences. Limitations and gaps in the evidence are highlighted to guide future research opportunities.
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Affiliation(s)
- Joel H Rubenstein
- Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Cancer Control and Population Sciences Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Tarek Sawas
- Division of Digestive and Liver Disease, University of Texas Southwestern, Dallas, Texas
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Swathi Eluri
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida
| | - Shailendra Singh
- Division of Gastroenterology, West Virginia University, Morgantown, West Virginia; Advanced Center for Endoscopy, West Virginia University Medicine, Morgantown, West Virginia
| | - Apoorva K Chandar
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - John M Inadomi
- Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota; Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - David Katzka
- Division of Gastroenterology and Hepatology, Columbia University, New York, New York
| | - Perica Davitkov
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Division of Gastroenterology, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio
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Dunn JM, Reyhani A, Santaolalla A, Zylstra J, Gimson E, Pennington M, Baker C, Kelly M, Van Hemelrijck M, Lagergren J, Zeki SS, Gossage JA, Davies AR. Transition from esophagectomy to endoscopic therapy for early esophageal cancer. Dis Esophagus 2022; 35:6321381. [PMID: 34260693 DOI: 10.1093/dote/doab047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/24/2021] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND To assess the outcomes of patients with early esophageal cancer and high-grade dysplasia comparing esophagectomy, the historical treatment of choice, to endoscopic eradication therapy (EET). METHODS Retrospective cohort study of consecutive patients with early esophageal cancer/high-grade dysplasia, treated between 2000 and 2018 at a tertiary center. Primary outcomes were all-cause and disease-specific mortality assessed by multivariable Cox regression and a propensity score matching sub analysis, providing hazard ratios (HR) with 95% confidence intervals (CI) adjusted for age, tumor grade (G1/2 vs. G3), tumor stage, and lymphovascular invasion. Secondary outcomes included complications, hospital stay, and overall costs. RESULTS Among 269 patients, 133 underwent esophagectomy and 136 received EET. Adjusted survival analysis showed no difference between groups regarding all-cause mortality (HR 1.85, 95% CI 0.73, 4.72) and disease-specific mortality (HR 1.10, 95% CI 0.26, 4.65). In-hospital and 30-day mortality was 0% in both groups. The surgical group had a significantly higher rate of complications (Clavien-Dindo ≥3 26.3% vs. endoscopic therapy 0.74%), longer in-patient stay (median 14 vs. 0 days endoscopic therapy) and higher hospital costs(£16 360 vs. £8786 per patient). CONCLUSION This series of patients treated during a transition period from surgery to EET, demonstrates a primary endoscopic approach does not compromise oncological outcomes with the benefit of fewer complications, shorter hospital stays, and lower costs compared to surgery. It should be available as the gold standard treatment for patients with early esophageal cancer. Those with adverse prognostic features may still benefit from esophagectomy.
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Affiliation(s)
- Jason M Dunn
- Gastroenterology, Guy's and St.Thomas' Esophago-Gastric Centre, London, UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Arasteh Reyhani
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Aida Santaolalla
- Gastroenterology Unit,Translational Oncology & Urology Research(TOUR). King's College London, London UK
| | - Janine Zylstra
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK
| | - Eliza Gimson
- Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Mark Pennington
- Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Cara Baker
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK
| | - Mark Kelly
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK
| | - Mieke Van Hemelrijck
- Gastroenterology Unit,Translational Oncology & Urology Research(TOUR). King's College London, London UK
| | - Jesper Lagergren
- Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Sebastian S Zeki
- Gastroenterology, Guy's and St.Thomas' Esophago-Gastric Centre, London, UK
| | - James A Gossage
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Andrew R Davies
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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3
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Zheng H, Kang N, Huang Y, Zhao Y, Zhang R. Endoscopic resection versus esophagectomy for early esophageal cancer: a meta-analysis. Transl Cancer Res 2022; 10:2653-2662. [PMID: 35116578 PMCID: PMC8798594 DOI: 10.21037/tcr-21-182] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/14/2021] [Indexed: 12/26/2022]
Abstract
Background Esophagectomy is the standard treatment for early-stage esophageal cancer but is associated with high morbidity and mortality. Thus, endoscopic resection is increasingly used as an alternative option. However, the literature is inconsistent regarding the efficacy of these treatments. This meta-analysis aimed to compare the efficacy and safety of these two treatments. Methods A systematic electronic search of PubMed, EMBASE, and the Cochrane Library was performed for studies comparing endoscopic resection and surgery for early-stage esophageal cancer. The overall survival, tumor recurrence, major adverse events, procedure-related mortality, and R0 resection rates were investigated. Forest plots were constructed based on the random-effects model. Results We found 15 studies involving 2,467 and 2,264 patients who underwent endoscopic resection and surgery, respectively. The meta-analysis showed that patients undergoing endoscopic resection had significantly fewer major adverse events (relative risk, 0.46; 95% confidence interval, 0.33–0.64) and a lower procedure-related mortality rate (relative risk, 0.27; 95% confidence interval, 0.10–0.73) than those undergoing surgery. The number of postprocedural stricture events did not significantly differ between the two treatments (relative risk, 0.89; 95% confidence interval, 0.53–1.49). Endoscopic resection was associated with higher recurrence rates (relative risk, 1.69; 95% confidence interval, 0.99–2.89) and lower R0 resection rates (relative risk, 0.92; 95% confidence interval, 0.86–0.98) than surgery. There may be some advantage conferred by esophagectomy in the long-term survival outcomes (hazard ratio, 1.21; 95% confidence interval, 1.02–1.43). Discussion Endoscopic resection is a minimally invasive and safe treatment for early-stage esophageal cancer. However, esophagectomy may be associated with better long-term survival.
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Affiliation(s)
- Hao Zheng
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ningning Kang
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yunlong Huang
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yuan Zhao
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Renquan Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Badgery H, Read M, Winter NN, Taylor ACF, Hii MW. The role of esophagectomy in the management of Barrett's esophagus with high-grade dysplasia. Ann N Y Acad Sci 2020; 1481:72-89. [PMID: 32812261 DOI: 10.1111/nyas.14439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/12/2020] [Accepted: 06/24/2020] [Indexed: 12/19/2022]
Abstract
Barrett's esophagus (BE) with high-grade dysplasia (HGD) has previously been a routine indication for esophagectomy. Recent advances in endoscopic therapy have resulted in a shift away from surgery. Current international guidelines recommend endoscopic therapy for BE with HGD irrespective of recurrence or progression of dysplasia. Current guidelines do not address the ongoing role of esophagectomy as an adjunct in the setting of failed endoscopic therapy. This review examines the role of esophagectomy as an adjunct to endoscopy in the management of patients with BE and HGD, with a specific focus on patients with persistent, progressive, or recurrent disease, disease resistant to endoscopic therapy, in patients with concomitant esophageal pathology, and in those patients in whom lifelong surveillance may not be possible or desired.
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Affiliation(s)
- Henry Badgery
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Matthew Read
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Nicole N Winter
- Department of Upper Gastrointestinal Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Andrew C F Taylor
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, the University of Melbourne, Melbourne, Victoria, Australia
| | - Michael W Hii
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
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5
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Workload, Recurrence, Quality of Life and Long-term Efficacy of Endoscopic Therapy for High-grade Dysplasia and Intramucosal Esophageal Adenocarcinoma. Ann Surg 2020; 271:701-708. [PMID: 30247330 DOI: 10.1097/sla.0000000000003038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To review the workload, type and frequency of recurrence, long-term quality of life (QOL), and late oncologic outcomes with endoscopic therapy. BACKGROUND The short-term oncologic efficacy of endoscopic resection (ER) and ablation for patients with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC) is well-established in the literature. METHODS A retrospective chart review was performed of the initial 40 patients who had endoscopic therapy from 2001 to 2010 at 1 center by 1 physician. RESULTS Initial pathology was HGD in 22 and IMC in 18 patients, but 9 patients (41%) with HGD progressed to invasive cancer during endotherapy. The median follow-up was 82 months. Four patients had an esophagectomy, and in the remaining 36 patients, 70 ERs and 111 ablations were performed. The median number of endoscopic sessions was 4 in patients with short segment compared with 7 in patients with long-segment Barrett's. Complete resolution of intestinal metaplasia (CRIM) was achieved in 30 patients (83%) at a median of 21 months. In 18 patients (60%), CRIM was maintained, whereas 12 patients developed recurrence at a median of 14 months. Additional endotherapy (n = 11) led to CRIM again in 10 patients (83%). There were no cancer deaths when CRIM was achieved. Overall survival with endotherapy was 73% at 5 years and 67% at 10 years. Quality of life (QOL) was below population means in 4 of 8 areas, but alimentary satisfaction was good after endotherapy. CONCLUSIONS Endotherapy is successful in most patients, but multiple sessions are usually required and disease progression can occur. Once CRIM is achieved, recurrence is common and mandates continued endoscopic follow-up. QOL is impaired with endotherapy, but alimentary satisfaction and oncologic outcomes support esophageal preservation with endotherapy for patients with HGD or IMC.
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6
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Bennett C, Green S, DeCaestecker J, Almond M, Barr H, Bhandari P, Ragunath K, Singh R, Jankowski J. Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus. Cochrane Database Syst Rev 2020; 5:CD007334. [PMID: 32442322 PMCID: PMC7390331 DOI: 10.1002/14651858.cd007334.pub5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy). OBJECTIVES We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)). SEARCH METHODS We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012. SELECTION CRITERIA Types of studies: RCTs comparing endotherapies with surgery in the treatment of high-grade dysplasia or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately. TYPES OF PARTICIPANTS patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus. Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent. DATA COLLECTION AND ANALYSIS Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9. MAIN RESULTS We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies. AUTHORS' CONCLUSIONS This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.
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Affiliation(s)
- Cathy Bennett
- Centre for Innovative Research Across the Life Course (CIRAL), Coventry University, Coventry, UK
| | - Susi Green
- Gastroenterology, Portsmouth Hospitals Trust, Cosham, UK
| | | | - Max Almond
- Department of Oesphogastric Surgery, Gloucestershire Royal Hospital, Gloucester, UK
| | - Hugh Barr
- Surgery, Gloucester Royal Hospital, Gloucester, UK
| | - Pradeep Bhandari
- Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Krish Ragunath
- Wolfson Digestive Diseases Centre, Queens Medical Centre, Nottingham University NHS Trust, Nottingham, UK
| | - Rajvinder Singh
- Gastroenterology, The Lyell McEwin Hospital, Elizabeth Vale, Australia
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Management of Early-Stage Esophageal Adenocarcinoma by Endoscopic Spray Cryotherapy in the Setting of Portal Hypertension With Varices. ACG Case Rep J 2020; 7:e00309. [PMID: 32309502 PMCID: PMC7145164 DOI: 10.14309/crj.0000000000000309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 11/18/2019] [Indexed: 11/25/2022] Open
Abstract
The use of endoscopic spray cryotherapy to manage pathological conditions of the esophagus has become increasingly common. This mucosal ablation technique is believed to carry a lower risk of bleeding than other modalities. A 71-year-old woman and a 64-year-old man with portal hypertension and varices were diagnosed with invasive esophageal adenocarcinoma during routine variceal surveillance. Staging by endoscopic ultrasound and computed tomography was uT1N0M0 in both patients. They each underwent mucosal ablation using liquid nitrogen cryosprays with no adverse events. Both cancers completely resolved with 2 treatments, and neither patient has shown recurrence of neoplasia during follow-up observations for up to 2 years.
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8
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Abstract
Traditionally, early esophageal cancer (i.e., cancer limited to the mucosa or superficial submucosa) was managed surgically; the gastroenterologist's role was primarily to diagnose the tumor. Over the last decade, advances in endoscopic imaging, ablation, and resection techniques have resulted in a paradigm shift-diagnosis, staging, treatment, and surveillance are within the endoscopist's domain. Yet, there are few reviews that provide a focused, evidence-based approach to early esophageal cancer, and highlight areas of controversy for practicing gastroenterologists. In this manuscript, we will discuss the following: (1) utility of novel endoscopic technologies to identify high-grade dysplasia and early esophageal cancer, (2) role of endoscopic resection and imaging to stage early esophageal cancer, (3) endoscopic therapies for early esophageal cancer, and (4) indications for surgical and multidisciplinary management.
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9
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Zhang Y, Ding H, Chen T, Zhang X, Chen WF, Li Q, Yao L, Korrapati P, Jin XJ, Zhang YX, Xu MD, Zhou PH. Outcomes of Endoscopic Submucosal Dissection vs Esophagectomy for T1 Esophageal Squamous Cell Carcinoma in a Real-World Cohort. Clin Gastroenterol Hepatol 2019; 17:73-81.e3. [PMID: 29704682 DOI: 10.1016/j.cgh.2018.04.038] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/12/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophagectomy is the standard treatment for early-stage esophageal squamous cell carcinoma (EESCC), but patients who undergo this procedure have high morbidity and mortality. Endoscopic submucosal dissection (ESD) is a less-invasive procedure for treatment of EESCC, but is considered risky because this tumor frequently metastasizes to the lymph nodes. We aimed to directly compare outcomes of patients with EESCC treated with ESD vs esophagectomy. METHODS We performed a retrospective cohort study of patients with T1a-m2/m3, or T1b EESCCs who underwent ESD (n = 322) or esophagectomy (n = 274) from October 1, 2011 through September 31, 2016 at Zhongshan Hospital in Shanghai, China. The primary outcome was all-cause mortality at the end of follow up (minimum of 6 months). Secondary outcomes included operation time, hospital stay, cost, perioperative mortalities/severe non-fatal adverse events, requirement for adjuvant therapies, and disease-specific mortality and cancer recurrence or metastasis at the end of the follow up period. RESULTS Patients who underwent ESD were older (mean 63.5 years vs 62.3 years for patients receiving esophagectomy; P = .006) and a greater proportion was male (80.1% vs 70.4%; P = .006) and had a T1a tumor (74.5% vs 27%; P = .001). A lower proportion of patients who underwent ESD had perioperative mortality (0.3% vs 1.5% of patients receiving esophagectomy; P = .186) and non-fatal severe adverse events (15.2% vs 27.7%; P = .001)-specifically lower proportions of esophageal fistula (0.3% of patients receiving ESD vs 16.4% for patients receiving esophagectomy; P = .001) and pulmonary complications (0.3% vs 3.6%; P = .004). After a median follow-up time of 21 months (range, 6-73 months), there were no significant differences between treatments in all-cause mortality (7.4% for ESD vs 10.9%; P = .209) or rate of cancer recurrence or metastasis (9.1% for ESD vs 8.9%; P = .948). Disease-specific mortality was lower among patients who received ESD (3.4%) vs patients who patients who received esophagectomy (7.4%) (P = .049). In Cox regression analysis, depth of tumor invasion was the only factor associated with all-cause mortality (T1a-m3 or deeper vs T1a-m2: hazard ration, 3.54; P = .04). CONCLUSION In a retrospective study of patients with T1am2/m3 or T1b EESCCs treated with ESD (n = 322) or esophagectomy (n = 274), we found lower proportions of patients receiving ESD to have perioperative adverse events or disease specific mortality after a median follow up time of 21 months. We found no difference in overall survival or cancer recurrence or metastasis in patients with T1a or T1b ESCCs treated with ESD vs esophagectomy.
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Affiliation(s)
- Yiun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Han Ding
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoen Zhang
- Department of Internal Medicine, Mount Sinai St. Luke's-West Hospital Center, New York, New York
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Quanin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Praneet Korrapati
- Department of Gastroenterology, Mount Sinai Beth Israel Hospital, New York, New York
| | - Xue-Juan Jin
- Center of Evidence-Based Medicine, Fudan University, Shanghai, China
| | - Yong-Xing Zhang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
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10
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Yuan B, Liu L, Huang H, Li D, Shen Y, Wu B, Liu J, Yang M, Wang Z, Lu H, Liu Y, Liao L, Wang F. Comparison of the short-term and long-term outcomes of surgical treatment versus endoscopic treatment for early esophageal squamous cell neoplasia larger than 2 cm: a retrospective study. Surg Endosc 2018; 33:2304-2312. [DOI: 10.1007/s00464-018-6524-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/11/2018] [Indexed: 12/23/2022]
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11
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Feczko AF, Louie BE. Endoscopic Resection in the Esophagus. Thorac Surg Clin 2018; 28:481-497. [PMID: 30268294 DOI: 10.1016/j.thorsurg.2018.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The article is a review of the principles behind endoscopic resection of esophageal dysplasia and early cancers. The techniques of endoscopic mucosal resection and endoscopic submucosal dissection are reviewed, and the supporting literature compared. Endoscopic resection is compared with esophagectomy for the management of these lesions and current areas of controversy with regard to T1b lesions and gastroesophageal reflux following resection are addressed.
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Affiliation(s)
- Andrew F Feczko
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Avenue, Seattle, WA 98104, USA
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Avenue, Seattle, WA 98104, USA.
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12
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Chilukuri P, Gromski MA, Johnson CS, Ceppa DKP, Kesler KA, Birdas TJ, Rieger KM, Fatima H, Kessler WR, Rex DK, Al-Haddad M, DeWitt JM. Impact of the development of an endoscopic eradication program for Barrett's esophagus with high grade dysplasia or early adenocarcinoma on the frequency of surgery. Endosc Int Open 2018; 6:E1085-E1092. [PMID: 30211296 PMCID: PMC6133650 DOI: 10.1055/a-0640-3030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/12/2018] [Indexed: 11/20/2022] Open
Abstract
Background and aims The impact of the advent of an institutional endoscopic eradication therapy (EET) program on surgical practice for Barrett's esophagus (BE)-associated high grade dysplasia (HGD) or suspected T1a esophageal adenocarcinoma (EAC) is unknown. The aims of this study are to evaluate the different endoscopic modalities used during development of our EET program and factors associated with the use of EET or surgery for these patients after its development. Methods Patients who underwent primary endoscopic or surgical treatment for BE-HGD or early EAC at our hospital between January 1992 and December 2014 were retrospectively identified. They were categorized by their initial modality of treatment during the first year, and the impact over time for choice of therapy was assessed by multivariable logistic regression. Results We identified 386 patients and 80 patients who underwent EET and surgery, respectively. EET included single modality therapy in 254 (66 %) patients and multimodal therapy in 132 (34 %) patients. Multivariable logistic regression showed that, for each subsequent study year, EET was more likely to be performed in patients who were older ( P = 0.0009), with shorter BE lengths ( P < 0.0001), and with a pretreatment diagnosis of HGD ( P = 0.0054) compared to surgical patients. The diagnosis of EAC did not increase the utilization of EET compared to surgery as time progressed ( P = 0.8165). Conclusion The introduction of an EET program at our hospital increased the odds of utilizing EET versus surgery over time for initial treatment of patients who were older, had shorter BE lengths or the diagnosis of BE-HGD, but not in patients with EAC.
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Affiliation(s)
- Prianka Chilukuri
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark A. Gromski
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Duy Khanh P. Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenneth A. Kesler
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas J. Birdas
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Karen M. Rieger
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hala Fatima
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - William R. Kessler
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Douglas K. Rex
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John M. DeWitt
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA,Corresponding author John M. DeWitt, MD Indiana University School of Medicine550 University BlvdSuite 4100IndianapolisIN 46202-5250USA+1-317-948-8144
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13
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Plum PS, Hölscher AH, Pacheco Godoy K, Schmidt H, Berlth F, Chon SH, Alakus H, Bollschweiler E. Prognosis of patients with superficial T1 esophageal cancer who underwent endoscopic resection before esophagectomy—A propensity score-matched comparison. Surg Endosc 2018. [DOI: 10.1007/s00464-018-6139-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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14
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McLaren PJ, Dolan JP. Surgical Treatment of High-Grade Dysplasia and Early Esophageal Cancer. World J Surg 2018; 41:1712-1718. [PMID: 28258451 DOI: 10.1007/s00268-017-3958-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The treatment of early-stage esophageal cancer and high-grade dysplasia of the esophagus has changed significantly in recent years. Many early tumors that were traditionally treated with esophagectomy can now be resected with endoscopic therapy alone. These new endoscopic modalities can offer similar survival outcomes without the associated morbidity of a major operation. However, a number of these cases may still require surgical intervention as the best treatment option. METHODS The current scientific literature, national and international guidelines were reviewed for recommendations regarding optimal treatment of early esophageal malignancy. RESULTS The primary advantage of surgery over endoscopic treatment lies in the reduced risk of recurrence as well as the ability to assess harvested lymph nodes for regional disease. We recommend that esophageal tumors that have invaded into the submucosa (T1b) or beyond should be treated with an esophagectomy. In addition, dysplastic lesions and cancers that demonstrate poorly differentiated pathology or lymphovascular or perineural invasion should be surgically resected. Finally, large tumors, multifocal lesions, tumors within a long segment of Barrett's esophagus, tumors adjacent to a hiatal hernia, tumors that cannot be resected enbloc with endoscopic techniques should also be treated with an esophagectomy. CONCLUSIONS When performed at high-volume centers in experienced hands, esophagectomy can have consistently good outcomes for high-grade dysplasia and early esophageal cancers, and should be considered as a treatment option.
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Affiliation(s)
- Patrick J McLaren
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd., Portland, OR, 97239, USA
| | - James P Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd., Portland, OR, 97239, USA.
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15
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Dolan JP, McLaren PJ, Diggs BS, Schipper PH, Tieu BH, Sheppard BC, Gilbert EW, Conroy MA, Hunter JG. Evolution in the Treatment of Esophageal Disease at a Single Academic Institution: 2004-2013. J Laparoendosc Adv Surg Tech A 2017; 27:915-923. [PMID: 28486000 DOI: 10.1089/lap.2017.0069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Management of benign and malignant esophageal disease has changed rapidly over the past decade. The aim of this study was to analyze evolution in surgical management of esophageal disease at a single academic medical center during this period. MATERIALS AND METHODS We reviewed a retrospective cohort of patients who underwent esophagectomy between 2004 and 2013. Patient, institutional, treatment, and outcomes variables were reviewed. RESULTS 317 patients were analyzed. Median age was 63.5 years; 80% were male. Average inhospital mortality rate was 3.8%. Operative indications changed significantly from 2004 to 2013, with more operations performed for invasive malignancy (77% vs. 95%) and fewer for high-grade dysplasia (12% vs. 3%, P = .008). In 2004, Ivor Lewis esophagectomy was the most common surgical technique, but the three-field technique was the operation of choice in 2013. A minimally invasive approach was used in 19% of cases in 2004 and 100% of cases in 2013 (P < .001). Anastomotic leak ranged from 0% to 21% with no significant difference over the study period (P = .18). Median lymph node harvest increased from seven to 18 nodes from 2004 to 2013 (P = .001). Hospital length of stay decreased from 15 to 8 days (P = .001). In 2013, 79% of patients were discharged to home, compared to 73% in 2004 (P = .04). DISCUSSION Over the last decade, our treatment of esophageal disease has evolved from a predominantly open Ivor Lewis to a minimally invasive three-field approach. Operations for malignancy have also increased dramatically. Postoperative complications and mortality were not significantly changed, but were consistently low during the latter years of the study.
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Affiliation(s)
- James P Dolan
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Patrick J McLaren
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Brian S Diggs
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Paul H Schipper
- 2 Division of Cardiothoracic Surgery, Section of General Thoracic Surgery, Department of Surgery, Oregon Health & Science University , Portland, Oregon
| | - Brandon H Tieu
- 2 Division of Cardiothoracic Surgery, Section of General Thoracic Surgery, Department of Surgery, Oregon Health & Science University , Portland, Oregon
| | - Brett C Sheppard
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Erin W Gilbert
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Molly A Conroy
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - John G Hunter
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
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Bustamante FAC, Hourneaux DE Moura EG, Bernardo W, Sallum RAA, Ide E, Baba E. SURGERY VERSUS ENDOSCOPIC THERAPIES FOR EARLY CANCER AND HIGH-GRADE DYSPLASIA IN THE ESOPHAGUS: a systematic review. ARQUIVOS DE GASTROENTEROLOGIA 2017; 53:10-9. [PMID: 27281499 DOI: 10.1590/s0004-28032016000100004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/19/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Esophageal cancer occurs as a local disease in 22% of cases, and a minority of this disease is limited to the mucosa or submucosa (early lesions). Endoscopic mucosal resection, endoscopic submucosal dissection, photodynamic therapy, laser therapy, and argon plasma coagulation have emerged as alternatives to surgical resection for early lesions. OBJECTIVE The aim of this systematic review is to identify studies that statistically compare survival, disease-free survival, morbidity and mortality associated with the procedure, and mortality associated with cancer in the endoscopic versus surgical therapies. DATA SOURCES A systematic review using MEDLINE, COCHRANE, EMBASE, EBSCO, LILACS, Library University of Sao Paulo, BVS, and SCOPE. STUDY SELECTION Randomized controlled trial, controlled clinical trial, clinical trial, and cohort study. CRITERIA - Studies that statistically compare survival, disease-free survival, morbidity and mortality associated with the procedure, and mortality associated with cancer in patients who underwent endoscopic and surgical therapy for early lesions of esophageal cancer. DATA EXTRACTION Independent extraction of the articles by two authors using predefined data fields, including study quality indicators. LIMITATION Only retrosprospective cohort studies comparing the endoscopic and surgical therapies were recovered. RESULTS The survival rates after 3 and 5 years were different and exhibited superiority with the surgical therapies over time. Endoscopy is superior in the control of mortality related to cancer with a high rate of disease recurrence. With regard to the comorbidity and the mortality associated with the procedure, endoscopy is superior. CONCLUSION There is no evidence from clinical trials. In this systematic review, surgical therapies showed superiority for survival, and endoscopic therapies showed superiority in the control of mortality related to cancer with a high rate of disease recurrence; also, for the comorbidity and the mortality associated with the procedure, endoscopy is superior. Prospective, controlled trials with large sample sizes are necessary to confirm the results of the current analysis.
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Affiliation(s)
- Fabio Alberto Castillo Bustamante
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| | - Eduardo Guimarães Hourneaux DE Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| | - Wanderley Bernardo
- Projeto Diretrizes, Associação Médica Brasileira, São Paulo, SP, Brasil, Associação Médica Brasileira, São Paulo SP , Brasil
| | - Rubens Antonio Aissar Sallum
- Divisão de Cirurgia Esofágica, Departamento de Gastroenterologia, Hospital das Clinicas Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Departamento de Gastroenterologia, Hospital das Clinicas, Universidade de São Paulo, São Paulo SP , Brazil
| | - Edson Ide
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| | - Elisa Baba
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
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McLaren PJ, Dolan JP. Esophagectomy as a Treatment Consideration for Early-Stage Esophageal Cancer and High-Grade Dysplasia. J Laparoendosc Adv Surg Tech A 2016; 26:757-762. [DOI: 10.1089/lap.2016.29010.pjm] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Patrick J. McLaren
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - James P. Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
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18
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Emerging Concepts for the Endoscopic Management of Superficial Esophageal Adenocarcinoma. J Gastrointest Surg 2016; 20:851-60. [PMID: 26691147 DOI: 10.1007/s11605-015-3056-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 12/07/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Endoscopic therapy has revolutionized the treatment of Barrett's esophagus with high-grade dysplasia (HGD) or intramucosal adenocarcinoma by allowing preservation of the esophagus in many patients who would previously have had an esophagectomy. This paradigm shift initially occurred at high-volume centers in North America and Europe but now is becoming mainstream therapy. There is a lack of uniform guidelines and algorithms for the management of these patients. Our aim was to review important concepts and pitfalls in the endoscopic management of superficial esophageal adenocarcinoma. METHODS A small group colloquium consisting of gastroenterologists, surgeons, and pathologists reviewed published data and discussed personal and institutional experiences with endotherapy for HGD and superficial esophageal adenocarcinoma. RESULTS The group reviewed data and provided recommendations and management algorithms for seven areas pertaining to endoscopic therapy for Barrett's HGD and superficial adenocarcinoma: (1) patient selection and evaluation; (2) imaging and biopsy techniques; (3) devices; (4) indications for resection versus ablation; (5) ER specimen handling, processing, and pathologic evaluation; (6) patient care and follow-up after endoscopic therapy; and (7) complications of endoscopic therapy and treatment options. CONCLUSIONS Endoscopic therapy is preferred over esophagectomy for most patients with HGD or intramucosal adenocarcinoma, and may be applicable to select patients with submucosal tumors. Clear guidelines and management algorithms will aid physicians and centers embarking on endoscopic therapy and enable a standardized approach to the management of these patients that is applicable internationally.
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Chadwick G, Riley S, Hardwick RH, Crosby T, Hoare J, Hanna G, Greenaway K, Varagunam M, Cromwell DA, Groene O. Population-based cohort study of the management and survival of patients with early-stage oesophageal adenocarcinoma in England. Br J Surg 2016; 103:544-52. [PMID: 26865114 DOI: 10.1002/bjs.10116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/12/2015] [Accepted: 12/21/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Until recently, oesophagectomy was the treatment of choice for early oesophageal cancer. Endoscopic treatment has been introduced relatively recently. This observational national database study aimed to describe how endoscopic therapy has been introduced in England and to examine the safety of this approach. METHODS A population-based cohort study was undertaken of patients diagnosed with oesophageal adenocarcinoma between October 2007 and June 2009 using three linked national databases. Patients with early-stage disease (T1 tumours with no evidence of spread) were identified, along with the primary treatment modality where treatment intent was curative. Short-term outcomes after treatment and 5-year survival were evaluated. RESULTS Of 5192 patients diagnosed with oesophageal adenocarcinoma, 306 (5·9 per cent) were considered to have early-stage disease before any treatment, of whom 239 (79·9 per cent of 299 patients with data on treatment intent) were managed with curative intent. Of 175 patients who had an oesophagectomy, 114 (65·1 (95 per cent c.i. 57·6 to 72·7) per cent) survived for 5 years. Among these, 47 (30·3 per cent of 155 patients with tissue results available) had their disease upstaged after pathological staging; this occurred more often in patients who did not have staging endoscopic ultrasonography before surgery. Of 41 patients who had an endoscopic resection, 27 (66 (95 per cent c.i. 49 to 80) per cent) survived for 5 years. Repeat endoscopic therapy was required by 23 (56 per cent) of these 41 patients. CONCLUSION Between 2007 and 2009, oesophagectomy remained the initial treatment of choice (73·2 per cent) among patients with early-stage oesophageal cancer treated with curative intent; one in five patients were managed endoscopically, and this treatment was more common in elderly patients. Although the groups had different patient characteristics, 5-year survival rates were similar.
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Affiliation(s)
- G Chadwick
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Gastroenterology, St Mary's Hospital, London, UK
| | - S Riley
- Department of Gastroenterology, Northern General Hospital, Sheffield, UK
| | - R H Hardwick
- Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - T Crosby
- Velindre Cancer Centre, Cardiff, UK
| | - J Hoare
- Department of Gastroenterology, St Mary's Hospital, London, UK
| | - G Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
| | - K Greenaway
- Health and Social Care Information Centre, Leeds, UK
| | - M Varagunam
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - D A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - O Groene
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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20
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Early Esophageal Cancer Specific Survival Is Unaffected by Anatomical Location of Tumor: A Population-Based Study. Can J Gastroenterol Hepatol 2016; 2016:6132640. [PMID: 27559535 PMCID: PMC4983357 DOI: 10.1155/2016/6132640] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/15/2016] [Accepted: 06/29/2016] [Indexed: 12/31/2022] Open
Abstract
Background. Approximately one-fifth of all esophageal cancer cases are defined as early esophageal cancer (EEC). Although endoscopic therapy (ET) has been shown to be equally effective as esophagectomy (EST) in patients with EEC, there is little information comparing the survival outcomes of the two therapies based on anatomical location. Methods. A population-based study was conducted and the data was obtained from Surveillance, Epidemiology, and End Results program. Patients with EEC (i.e., stages Tis and T1a) and treated with either ET or EST were analyzed to compare EEC-related survival for three different locations of tumor. Results. The overall EEC-specific 1-year and 5-year mean (±SE) survival rates were 11.66 ± 0.05 and 52.80 ± 0.58 months, respectively. Tumors located in lower third had better 5-year survival compared to those located in middle third (83.50% versus 73.10%, p < 0.01). However, when adjusted for age, race, gender, marital status, grade, stage of tumor, histological type, and treatment modality, there was no significant difference. Conclusion. The EEC-specific 1-year or 5-year adjusted survival did not differ by anatomic location of the tumor. Therefore, ET might serve as a minimally invasive yet effective alternative to EST to treat EEC.
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21
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Boys JA, Worrell SG, Chandrasoma P, Vallone JG, Maru DM, Zhang L, Blackmon SH, Dickinson KJ, Dunst CM, Hofstetter WL, Lada MJ, Louie BE, Molena D, Watson TJ, DeMeester SR. Can the Risk of Lymph Node Metastases Be Gauged in Endoscopically Resected Submucosal Esophageal Adenocarcinomas? A Multi-Center Study. J Gastrointest Surg 2016; 20:6-12; discussion 12. [PMID: 26408330 DOI: 10.1007/s11605-015-2950-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/14/2015] [Indexed: 02/07/2023]
Abstract
Endoscopic resection (ER) allows for local therapy of superficial esophageal cancers. Factors reported to be associated with an increased risk of lymph node metastases in patients with adenocarcinoma are poor differentiation, lymphovascular invasion (LVI), and submucosal invasion >500 μ. The aim of this study was to determine whether depth of invasion and tumor characteristics in an ER specimen can be used to gauge the risk of lymph node metastases in patients with superficial esophageal adenocarcinoma. Patients from seven US centers that had ER of an adenocarcinoma followed by an esophagectomy were identified. The ER pathology slides were rereviewed by three experienced GI pathologists for depth of invasion, presence of LVI, and tumor differentiation. The findings from the ER specimen were correlated with the presence and number of lymph node metastases in the final esophagectomy specimen. There were 19 T1a and 23 T1b tumors. A median of 24 nodes were resected per patient. None of the T1a tumors had involved lymph nodes despite the presence of LVI in 5% and poor differentiation in 21% of patients. In contrast, 26% of T1b tumors had involved nodes. None of the four patients with submucosal invasion ≤500 μ, no LVI, and no poor differentiation had involved nodes. However, with an increasing number of risk factors, the likelihood of involved lymph nodes increased, reaching 50% when all three factors were present. Endoscopic therapy appears appropriate for intramucosal tumors and may be an option for low-risk T1b tumors. Esophagectomy is preferred for patients with submucosal invasion and one or more risk factors.
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Affiliation(s)
- Joshua A Boys
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | - Stephanie G Worrell
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | - Parakrama Chandrasoma
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John G Vallone
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Dipen M Maru
- Department of Pathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Lizhi Zhang
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Wayne L Hofstetter
- Department of Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Michael J Lada
- Department of Surgery, University of Rochester, New York, NY, USA
| | - Brian E Louie
- Department of Surgery, Swedish Cancer Institute, Seattle, WA, USA
| | - Daniela Molena
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Thomas J Watson
- Department of Surgery, University of Rochester, New York, NY, USA
| | - Steven R DeMeester
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA.
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22
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Schmidt HM, Mohiuddin K, Bodnar AM, El Lakis M, Kaplan S, Irani S, Gan I, Ross A, Low DE. Multidisciplinary treatment of T1a adenocarcinoma in Barrett's esophagus: contemporary comparison of endoscopic and surgical treatment in physiologically fit patients. Surg Endosc 2015; 30:3391-401. [PMID: 26541725 DOI: 10.1007/s00464-015-4621-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 10/09/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Previous reports comparing endoscopic therapy (ET) and surgical therapy (ST) have predominantly assessed patients with high-grade dysplasia. The study aim was to compare ET to ST in physiologically fit patients with cT1a adenocarcinoma (EAC). METHODS Review of two prospective databases yielded 100 patients presenting with clinical cT1a EAC between 2000 and 2013. Only physiologically fit patients who were candidates for either treatment were analyzed. RESULTS Presenting patient characteristics were similar between ET (n = 36) and ST groups (n = 49). Surgical patients were less likely to be staged with EMR (43 vs 100 %) and were associated with mass lesions >1 cm at EGD (p = 0.01), multifocal EAC (p = 0.03), and positive margins for EAC on EMR (p < 0.05). On multivariate analysis, only multifocal HGD was an independent factor for surgery. Following esophagectomy, R0 resection rates for Barrett's esophagus and cancer were 100 %. Incidence of surgery decreased over the study period from 85 to 25 %. All ET patients had EMR, and 28 patients underwent additional ablative therapies for Barrett's esophagus. Following ET, eradication rates of EAC, dysplasia, and BE were 92, 81, and 53 %, respectively. Morbidity rates were comparable between groups (ST 51 % vs ET 39 %, p = 0.31). In-hospital mortality rate was zero in each group. Recurrence rates in ST and ET group were 2 and 11 % (p = 0.08). In the ET group, two patients with endoluminal cancer recurrence after complete eradication underwent esophagectomy. Age-adjusted overall survival was comparable. CONCLUSION In high-volume esophageal centers, ST and ET provide equally safe and effective treatment for cT1a EAC in medically fit patients. While the results of this study provide a historical perspective and clearly demonstrate an evolution toward ET over time, the appropriate treatment modality is best selected in a multidisciplinary fashion with EMR providing the most accurate staging. In endoscopically treated patients, indefinite endoscopic follow-up required, however, standardized long-term follow-up protocols are needed.
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Affiliation(s)
- Henner M Schmidt
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Kamran Mohiuddin
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Artur M Bodnar
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Mustapha El Lakis
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Stephen Kaplan
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Shayan Irani
- Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Ian Gan
- Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andrew Ross
- Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Donald E Low
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA.
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Whiteman DC, Appleyard M, Bahin FF, Bobryshev YV, Bourke MJ, Brown I, Chung A, Clouston A, Dickins E, Emery J, Eslick GD, Gordon LG, Grimpen F, Hebbard G, Holliday L, Hourigan LF, Kendall BJ, Lee EY, Levert-Mignon A, Lord RV, Lord SJ, Maule D, Moss A, Norton I, Olver I, Pavey D, Raftopoulos S, Rajendra S, Schoeman M, Singh R, Sitas F, Smithers BM, Taylor AC, Thomas ML, Thomson I, To H, von Dincklage J, Vuletich C, Watson DI, Yusoff IF. Australian clinical practice guidelines for the diagnosis and management of Barrett's esophagus and early esophageal adenocarcinoma. J Gastroenterol Hepatol 2015; 30:804-20. [PMID: 25612140 DOI: 10.1111/jgh.12913] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2014] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE as most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE. Moreover, there have been recent advances in knowledge and practice about the management of BE and early EAC. To aid clinical decision making in this rapidly moving field, Cancer Council Australia convened an expert working party to identify pertinent clinical questions. The questions covered a wide range of topics including endoscopic and histological definitions of BE and early EAC; prevalence, incidence, natural history, and risk factors for BE; and methods for managing BE and early EAC. The latter considered modification of lifestyle factors; screening and surveillance strategies; and medical, endoscopic, and surgical interventions. To answer each question, the working party systematically reviewed the literature and developed a set of recommendations through consensus. Evidence underpinning each recommendation was rated according to quality and applicability.
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Affiliation(s)
- David C Whiteman
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
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24
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Abstract
Esophagectomy has been the traditional therapy for high-grade dysplasia and intramucosal cancer. Though surgery can completely resect the cancer and the affected lymph nodes, it carries significant morbidity and mortality (often exceeds 2%). New developments in endoscopy have provided less-invasive therapies that can also be used to stage tissue invasion of cancer; they include esophageal mucosal resection (EMR) and endoscopic submucosal dissection. Additional endoscopic therapies include photodynamic therapy, radiofrequency ablation (RFA) and argon plasma coagulation. Combining EMR that targets the cancer and RFA that targets the surrounding Barrett's esophagus offers an alternative to the operative approach when there is no lymph node metastasis. Arguments for surgical esophagectomy include concern for missed lymph node metastasis and incomplete endoscopic resection. Based on EMR's high neoplasia eradication rate and its fewer and more manageable complications, EMR, especially when combined with RFA, appears to be a viable alternative to surgery in early submucosal cancers, that is, sm1.
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Affiliation(s)
- Ioana Smith
- Division of Gastroenterology, University of Alabama, Birmingham, AL, USA
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25
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Balalis GL, Thompson SK. Sentinel lymph node biopsy in esophageal cancer: an essential step towards individualized care. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2014; 8:2. [PMID: 24829610 PMCID: PMC4019891 DOI: 10.1186/1750-1164-8-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 04/29/2014] [Indexed: 12/23/2022]
Abstract
Lymph node status is the most important prognostic factor in esophageal cancer. Through improved detection of lymph node metastases, using the sentinel lymph node concept, accurate staging and more tailored therapy may be achieved. This review article outlines two principle ways in which the sentinel lymph node concept could dramatically influence current standard of care for patients with esophageal cancer. We discuss three limitations to universal acceptance of the technique, and propose next steps for increasing enthusiasm amongst physicians and surgeons including the development of a universal tracer, and improved contrast agents with novel dual-modality 'visibility'.
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Affiliation(s)
- George L Balalis
- Department of Surgery, Level 5, Eleanor Harrald Building, Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia
| | - Sarah K Thompson
- Department of Surgery, Level 5, Eleanor Harrald Building, Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia
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26
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Wu J, Pan YM, Wang TT, Gao DJ, Hu B. Endotherapy versus surgery for early neoplasia in Barrett's esophagus: a meta-analysis. Gastrointest Endosc 2014; 79:233-241.e2. [PMID: 24079410 DOI: 10.1016/j.gie.2013.08.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 08/04/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Esophagectomy is the conventional treatment for Barrett's esophagus with high-grade dysplasia and intramucosal cancer. Endotherapy is an alternative treatment. OBJECTIVE To compare the efficacy and safety of these 2 treatments. DESIGN PubMed, Web of Science, EMBASE, Cochrane Library and momentous meeting abstracts were searched. Studies comparing endotherapy with esophagectomy were included in the meta-analysis. Pooling was conducted in a random-effects model. SETTING Tertiary-care facility. PATIENTS Seven studies involving 870 patients were included. INTERVENTION Endotherapy and esophagectomy. MAIN OUTCOME MEASUREMENTS Neoplasia remission rate, neoplasia recurrence rate, overall survival rate, neoplasia-related death, and major adverse events. RESULTS Meta-analysis showed that there was no significant difference between endotherapy and esophagectomy in the neoplasia remission rate (relative risk [RR] 0.96; 95% CI, 0.91-1.01); overall survival rate at 1 year (RR 0.99; 95% CI, 0.94-1.03), 3 years (RR 1.03; 95% CI, 0.96-1.10), and 5 years (RR 1.00; 95% CI, 0.93-1.06); and neoplasia-related mortality (risk difference [RD] 0; 95% CI, -0.02 to 0.01). Endotherapy was associated with a higher neoplasia recurrence rate (RR 9.50; 95% CI, 3.26-27.75) and fewer major adverse events (RR 0.38; 95% CI, 0.20-0.73). LIMITATIONS Relatively small number of retrospective studies available, different types of endoscopic treatments were used. CONCLUSION Endotherapy and esophagectomy show similar efficacy except in the neoplasia recurrence rate, which is higher after endotherapy. Prospective, randomized, controlled trials are needed to confirm these results.
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Affiliation(s)
- Jun Wu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China
| | - Ya-min Pan
- Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China
| | - Tian-tian Wang
- Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China
| | - Dao-jian Gao
- Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China
| | - Bing Hu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China
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27
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Abstract
The management of Barrett's oesophagus and associated neoplasia has evolved considerably in recent years. Modern endoscopic strategies including endoscopic resection and mucosal ablation can eradicate dysplastic Barrett's and prevent progression to invasive oesophageal cancer. However, several aspects of Barrett's management remain controversial including the stage in the disease process at which to intervene, and the choice of endoscopic or surgical therapy. A review of articles pertaining to the management of Barrett's oesophagus with or without associated neoplasia, was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Medline, Embase and Cochrane databases were searched to identify literature relevant to eight pre-defined areas of clinical controversy. The following search terms were used: Barrett's oesophagus; dysplasia; intramucosal carcinoma; endotherapy; endoscopic resection; ablation; oesophagectomy. A significant body of evidence exists to support early endoscopic therapy for high-grade dysplasia (HGD). Although not supported by randomised controlled trial evidence, endoscopic therapy is now favoured ahead of oesophagectomy for most patients with HGD. Focal intramucosal (T1a) carcinomas can be managed effectively using endoscopic and surgical therapy, however surgery should be considered the first line therapy where there is submucosal invasion (T1b). Treatment of low grade dysplasia is not supported at present due to widespread over-reporting of the disease. The role of surveillance endoscopy in non-dysplastic Barrett's remains controversial.
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28
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Ngamruengphong S, Wolfsen HC, Wallace MB. Survival of patients with superficial esophageal adenocarcinoma after endoscopic treatment vs surgery. Clin Gastroenterol Hepatol 2013; 11:1424-1429.e2; quiz e81. [PMID: 23735443 PMCID: PMC3889479 DOI: 10.1016/j.cgh.2013.05.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 04/23/2013] [Accepted: 05/01/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Endoscopic therapy can improve long-term outcomes of patients with superficial esophageal adenocarcinoma (EAC), producing fewer complications than esophagectomy. However, there have been few population-based studies to compare long-term outcomes of patients who received these treatments. We used a large national cancer database to evaluate the outcomes of patients with superficial EAC who underwent endoscopic therapy or surgery. METHODS We used the Surveillance Epidemiology and End Results database to identify 1618 patients with Tis or T1 N0M0 EAC from 1998-2009. Patients were grouped on the basis of whether they received endoscopic therapy (n = 306) or surgery (n = 1312). Multivariate logistic regression was performed to identify factors associated with endoscopic therapy. We collected survival data through the end of 2009; overall survival and esophageal cancer-specific survival were compared after controlling for relevant covariates. RESULTS The use of endoscopic therapy increased progressively from 3% in 1998 to 29% in 2009. Factors associated with use of endoscopic therapy included age older than 65 years, diagnosis in 2006-2009 vs 1998-2001, and the absence of submucosal invasion. Overall survival after 5 years was higher in the surgery group than in the endoscopic therapy group (70% vs 58%, respectively). After adjusting for patient and tumor factors, patients treated by endoscopy had similar overall survival times (hazard ratio, 1.21; 95% confidence interval, 0.92-1.58) and esophageal cancer-specific survival times (hazard ratio, 0.74; 95% confidence interval, 0.49-1.11). CONCLUSION In a population-based analysis, the use of endoscopic therapy for superficial EAC tended to increase from 1998-2009. Long-term survival of patients with EAC did not appear to differ between those who received endoscopic therapy and those treated with surgery.
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29
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Allende D, Dumot J, Yerian L. Esophageal squamous cell carcinoma arising after endoscopic ablation therapy of Barrett's esophagus with high-grade dysplasia. Report of a case. Dis Esophagus 2013; 26:314-8. [PMID: 23009180 DOI: 10.1111/j.1442-2050.2012.01411.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with Barrett's esophagus are at risk for dysplasia and esophageal adenocarcinoma. Although surgery was the mainstay treatment for Barrett's dysplasia and cancer, patients with high-grade dysplasia and early cancers now have several nonsurgical treatment options. Most of the endoscopic therapies are relatively safe but do carry a risk for complications. Treatment failure with progression of the disease is the most severe complication, especially among patients with low surgical risk. Cryoablation has been used with promising results in both high-grade dysplasia and early esophageal cancer. A patient with a well-documented history of Barrett's esophagus with high-grade dysplasia that underwent multiple sessions of photodynamic therapy and salvage cryoablation for residual high-grade dysplasia was presented. The patient was diagnosed with squamous cell carcinoma of the distal esophagus approximately 1 year after cryoablation. This is the first complete report of squamous cell carcinoma occurring after endoscopic ablation for Barrett's neoplasia. Careful follow up is necessary in any endoscopic ablation program due to the risk of recurrent neoplasia.
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Affiliation(s)
- D Allende
- Pathology and Laboratory Medicine Department, Cleveland Clinic Florida, Weston, FL 33331, USA.
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30
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Endoscopic management of Barrett's esophagus: advances in endoscopic techniques. Dig Dis Sci 2012; 57:3055-64. [PMID: 22760590 DOI: 10.1007/s10620-012-2279-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 06/05/2012] [Indexed: 12/13/2022]
Abstract
Barrett's esophagus (BE) is a well-known premalignant condition that can be associated with the development of dysplasia and adenocarcinoma. In the past, esophagectomy was the standard treatment for patients with BE with high grade dysplasia (HGD) and early cancer (EC). However, esophagectomy is not necessarily the only treatment response to HGD and EC anymore. Over the past decade, a number of endoscopic therapies have been developed for management of BE. These include endoscopic mucosal resection, thermal ablation techniques that use laser irradiation, multipolar electrocoagulation, argon plasma coagulation, photodynamic therapy, and the recently developed cryotherapy and radiofrequency ablation.
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31
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Li Z, Rice TW, Liu X, Goldblum JR, Williams SJ, Rybicki LA, Murthy SC, Mason DP, Raymond DP, Blackstone EH. Intramucosal esophageal adenocarcinoma: primum non nocere. J Thorac Cardiovasc Surg 2012; 145:1519-24, 1524.e1-3. [PMID: 23158254 DOI: 10.1016/j.jtcvs.2012.10.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 10/16/2012] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Intramucosal esophageal cancer treatment is evolving. Less-invasive therapies have emerged, necessitating review of safety, effectiveness, and determinants of long-term outcome after esophagectomy to clarify the role of this traditional, maximally invasive, and potentially harmful therapy. METHODS From January 1983 to January 2011, 164 patients underwent esophagectomy alone for intramucosal adenocarcinoma. Cancers were subdivided by depth of invasion: lamina propria 50 (30%) and muscularis mucosa 114 (70%; inner 42 [26%], middle 16 [10%], and outer 56 [34%]). We assessed complications and esophagectomy-related mortality (safety) and cancer recurrence (effectiveness), and identified determinants of long-term outcomes. RESULTS Barrett esophagus (P = .005), larger cancers (P < .001), worse histologic grade (P < .001), lymphovascular invasion (P < .001), and overstaging (P = .02) were associated with deeper cancers. One patient had regional lymph node metastases (0.6%). Seventy-five patients (46%) had complications. Seven of 9 deaths within 6 months were esophagectomy related, 6 from respiratory failure. Seven patients had recurrence, all within 4 years. Five-, 10-, and 15-year survivals were 82%, 69%, and 60%, respectively, which were similar to those of a matched general population. Determinants of late mortality were older age (P = .004), poorer lung function (P < .0001), longer cancer (P = .04), postoperative pneumonia (P = .06), cancer recurrence (P < .0001), and second cancers (P < .0001). CONCLUSIONS Survival after esophagectomy for intramucosal adenocarcinoma is excellent, determined more by patient than cancer characteristics. Patient selection and respiratory function are crucial to minimize harm. Considering the outcome of emerging therapies, esophagectomy should be reserved for patients with a long intramucosal adenocarcinoma or those in whom endoscopic therapies fail or are inappropriate.
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Affiliation(s)
- Zhigang Li
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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32
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Fovos A, Jarral O, Panagiotopoulos N, Podas T, Mikhail S, Zacharakis E. Does endoscopic treatment for early oesophageal cancers give equivalent oncological outcomes as compared with oesophagectomy? Best evidence topic (BET). Int J Surg 2012; 10:415-20. [PMID: 22771501 DOI: 10.1016/j.ijsu.2012.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 05/27/2012] [Accepted: 06/21/2012] [Indexed: 11/16/2022]
Abstract
A best evidence topic was written according to a structured protocol. The question addressed was whether endoscopic mucosal resection (EMR) for early oesophageal cancer gives equivalent oncological outcomes as compared to oesophagectomy. A total of 340 papers were found using the reported searches of which 7 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Oesophagectomy with lymph node dissection for early oesophageal cancer is the standard to which every other treatment modality is compared to. However, the associated mortality and morbidity rates highlight the need for the development of effective, less invasive procedures. The evidence from the present review supports the use of EMR in this context as a first line treatment in T1a (mucosal) oesophageal cancer. The trade-off is a higher recurrence rate which can be dealt with successfully using a tight follow-up schedule and retreatment. The higher rates of lymph node involvement in T1b (submucosal) cancers preclude the use of endoscopic treatment in this setting except for patients unfit for surgery.
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Affiliation(s)
- Athanasios Fovos
- Department of Gastroenterology, Hammersmith Hospital, Imperial College London, United Kingdom
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33
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High-grade dysplasia and intramucosal adenocarcinoma in Barrett's esophagus: the role of endoscopic eradication therapy. Curr Opin Gastroenterol 2012; 28:354-61. [PMID: 22450896 PMCID: PMC4389732 DOI: 10.1097/mog.0b013e328352b78a] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Endoscopic eradication therapy is considered a well tolerated and effective alternative to esophagectomy for a select patient population with high-grade Barrett's esophagus and intramucosal adenocarcinoma. This review highlights the available eradication techniques (resection and ablation) with emphasis on factors that influence the choice of therapy. RECENT FINDINGS Long-term follow-up of patients treated with endoscopic eradication therapies demonstrates high rates of complete remission of dysplasia and intestinal metaplasia with overall survival comparable to patients treated surgically. Cohort studies also report that recurrence following successful ablation occurs in a significant proportion of patients, making careful surveillance an indispensable component following successful endoscopic therapy. Endoscopic eradication therapy is also effective for the treatment of recurrent dysplasia and intestinal metaplasia. Ablative therapies may lead to buried metaplasia in a small proportion of patients. The long-term clinical implications of buried metaplasia are unclear. SUMMARY Patients undergoing endoscopic eradication therapy should be enrolled in a comprehensive surveillance and staging program that offers both resection and ablative techniques. Complete remission of dysplasia and intestinal metaplasia can be achieved in the vast majority of patients undergoing endoscopic therapy. Surveillance should continue after treatment with close monitoring for recurrent dysplasia.
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34
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Endoskopische und chirurgische Resektion des Mukosaadenokarzinoms bei Barrett-Ösophagus. Chirurg 2012; 83:72-4. [DOI: 10.1007/s00104-011-2256-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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35
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Green S, Bhandari P, DeCaestecker J, Barr H, Ragunath K, Jankowski J, Singh R, Longcroft-Wheaton G, Bennett C. Endoscopic therapies for the prevention and treatment of early esophageal neoplasia. Expert Rev Gastroenterol Hepatol 2011; 5:731-43. [PMID: 22017700 DOI: 10.1586/egh.11.80] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Esophageal cancers have traditionally been diagnosed late and prognosis has been dire. For many years the only real treatment option was esophagectomy with substantial morbidity and mortality. This situation has now changed dramatically. Improvements have been achieved in surgical outcomes and there is an array of new effective treatment options now available, particularly for the increasing proportion diagnosed with early-stage disease. Minimally invasive endoscopic therapies can now prevent, cure or palliate esophageal cancers. This article aims to investigate the role and evidence base for these new therapeutic options.
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Affiliation(s)
- Susi Green
- St Mark's Hospital, Northwick Park, Watford Road, Harrow, Middlesex, HA1 3UJ, UK.
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36
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Gray NA, Odze RD, Jon Spechler S. Buried metaplasia after endoscopic ablation of Barrett's esophagus: a systematic review. Am J Gastroenterol 2011; 106:1899-908; quiz 1909. [PMID: 21826111 PMCID: PMC3254259 DOI: 10.1038/ajg.2011.255] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Endoscopic ablation of Barrett's esophagus can bury metaplastic glands under a layer of neosquamous epithelium. To explore the frequency and importance of buried metaplasia, we have conducted a systematic review of reports on endoscopic ablation. METHODS We performed computerized and manual searches for articles on the results of photodynamic therapy (PDT) and radiofrequency ablation (RFA) for Barrett's esophagus. We extracted information on the number of patients treated, biopsy protocol, biopsy depth, and frequency of buried metaplasia. RESULTS We found 9 articles describing 34 patients with neoplasia appearing in buried metaplasia (31 after PDT). We found five articles describing a baseline prevalence of buried metaplasia (before ablation) ranging from 0% to 28%. In 22 reports on PDT for 953 patients, buried metaplasia was found in 135 (14.2%); in 18 reports on RFA for 1,004 patients, buried metaplasia was found in only 9 (0.9%). A major problem limiting the conclusions that can be drawn from these reports is that they do not describe specifically how frequently biopsy specimens contained sufficient subepithelial lamina propria to be informative for buried metaplasia. CONCLUSIONS Endoscopic ablation can bury metaplastic glands with neoplastic potential but, even without ablation, buried metaplasia often is found in areas where Barrett's epithelium abuts squamous epithelium. Buried metaplasia is reported less frequently after RFA than after PDT. However, available reports do not provide crucial information on the adequacy of biopsy specimens and, therefore, the frequency and importance of buried metaplasia after endoscopic ablation remain unclear.
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Affiliation(s)
- Nathan A. Gray
- Department of Medicine, VA North Texas Healthcare System and the University of Texas Southwestern Medical Center , Dallas , Texas , USA
| | - Robert D. Odze
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School , Boston , Massachusetts , USA
| | - Stuart Jon Spechler
- Department of Medicine, VA North Texas Healthcare System and the University of Texas Southwestern Medical Center , Dallas , Texas , USA
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37
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Efficacy and safety of EMR to completely remove Barrett's esophagus: experience in 41 patients. Gastrointest Endosc 2011; 74:761-71. [PMID: 21824611 DOI: 10.1016/j.gie.2011.06.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 06/14/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND EMR is typically used to remove focal abnormalities of the esophageal mucosa. However, larger areas of Barrett's esophagus (BE) can be resected through side-by-side resections. OBJECTIVE To assess the efficacy and safety of EMR to completely remove BE. DESIGN Retrospective, single-center study. SETTING University of Iowa Hospitals and Clinics. PATIENTS Between January 2006 and December 2010, 46 patients underwent EMR for complete removal of BE. Three were lost to follow-up, one died of unrelated causes before completion, and one was still undergoing EMR treatment at the conclusion of the study. The remaining 41 patients were included for analysis. The worst histologic grade was low-grade dysplasia in 4 patients, high-grade dysplasia without cancer in 26 patients, and high-grade dysplasia with superficial adenocarcinoma in 11 patients. BE was circumferential in 65.9% of cases, and the mean (± SD) length was 3.3 ± 2.3 cm. INTERVENTION EMR was performed by using a cap (n = 4), a multiband ligator device (n = 31), or both (n = 6), with a mean (± SD) of 2.4 ± 1.2 sessions per patient. MAIN OUTCOME MEASUREMENTS Remission rates and complications. RESULTS Remission of high-grade dysplasia and cancer, all dysplasia, and all BE was achieved in 94.6%, 85.4%, and 78.0%, respectively. Complications included minor bleeding (31.7%), perforations (4.9%), and strictures (43.9%). All complications were managed conservatively. LIMITATIONS Retrospective design. CONCLUSION Complete removal of BE with EMR is effective but associated with a high complication rate, which is mainly related to stricture formation. This needs to be considered when choosing between available treatment modalities.
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38
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Leung WD, Chennat J. Comparison of endoscopic and surgical resection of intramucosal carcinoma in Barrett's esophagus. Expert Rev Gastroenterol Hepatol 2011; 5:575-8. [PMID: 21910574 DOI: 10.1586/egh.11.65] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The optimal management of intramucosal carcinoma in Barrett's esophagus continues to be controversial. To date, there has not been a lot of research directly comparing endoscopic versus surgical management of intramucosal carcinoma. Previous studies have shown that both modalities to have excellent outcomes. The reviewed article is a matched retrospective cohort study from two high-volume centers, which shows both modalities to be effective, but an associated higher morbidity rate and risk for procedure-related mortality in the surgical group, and higher recurrence rate in the endoscopic therapy group. The study is discussed in the context of the current state of knowledge regarding Barrett's esophagus and intramucosal carcinoma, in particular outcomes and limitations of the present study.
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Affiliation(s)
- Wesley D Leung
- Center for Endoscopic Research and Therapeutics, Section of Gastroenterology, Department of Medicine, The University of Chicago Medical Center, 5758 South Maryland Avenue, MC 9028, Chicago, IL 60637, USA
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39
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Manner H, Pech O, Ell C. Barrett's: evolving techniques for dysplasia detection and endoscopic resection. Semin Thorac Cardiovasc Surg 2011; 22:321-9. [PMID: 21549272 DOI: 10.1053/j.semtcvs.2011.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2011] [Indexed: 12/23/2022]
Abstract
Advanced endoscopic imaging techniques have made the early diagnosis of neoplastic lesions in Barrett's esophagus easier. A new chapter in minimal invasive cancer therapy has been opened. Endoscopic treatment of early neoplasia in Barrett's esophagus (high-grade intraepithelial neoplasia and mucosal adenocarcinoma) has become the method of choice in most countries. Long-term results for endoscopic treatment in a large group of patients are now available. These emerging data suggest that endoscopic therapy is safe and highly effective with long-term complete remission rates of more than 94%. All visible lesions should be treated by endoscopic resection for histologic confirmation of the neoplastic lesion rather than by ablative techniques. After successful endoscopic resection of all visible and localizable high-grade intraepithelial neoplasia and mucosal cancer, ablative treatment of the remaining Barrett's epithelium at risk should be performed to reduce the rate of recurrent or metachronous neoplasia.
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Affiliation(s)
- Hendrik Manner
- Department of Gastroenterology and Hepatology, HSK Wiesbaden, Germany.
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40
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Comparison between endoscopic and surgical resection of mucosal esophageal adenocarcinoma in Barrett's esophagus at two high-volume centers. Ann Surg 2011; 254:67-72. [PMID: 21532466 DOI: 10.1097/sla.0b013e31821d4bf6] [Citation(s) in RCA: 210] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Esophagectomy has previously been the gold standard for patients with mucosal adenocarcinoma in Barrett's esophagus (Barrett's carcinoma, BC). Because of the minimal invasiveness and excellent results obtained with endoscopic resection (ER), the latter has become an accepted alternative. However, few data have so far been published comparing the 2 treatment methods. METHODS A total of 114 patients with mucosal BC who were treated surgically or endoscopically in 2 high-volume centers were included in this study. Between 1996 and 2009, 38 patients with mucosal BC received transthoracic esophageal resection with 2-field lymphadenectomy (median 29 lymph nodes removed; all pN0) in the Department of Surgery at the University of Cologne. Seventy-six patients with BC treated with ER followed by argon-plasma-coagulation of the remaining non-dysplastic Barrett's esophagus in the Department of Gastroenterology in Wiesbaden were matched according to the following criteria: age, gender, infiltration depth (pT1m1-3), differentiation grade (G1/2 vs. 3) and follow-up period. RESULTS There were no significant differences between the 2 groups with regard to epidemiologic and tumor criteria. Complete remission (CR) was achieved in all patients in the surgery group and all but 1 patient in the ER group (98.7%; the patient died of other causes before CR was achieved). Major complications after surgery occurred in 32% of the patients, significantly more often than in the ER group (0% major complications, P < 0.001). The 90-day mortality rates were 0% in the ER group and 2.6% in the surgical group (1 of 38; P = 0.333). The median follow-up periods were 4.1 years in the ER group and 3.7 years in the surgical group. During this period, 1 patient in the ER group had a local recurrence and 4 had metachronous neoplasia (overall recurrence rate 6.6%). However, repeat endoscopic treatment was possible in all of the patients, and the long-term CR rates in the surgical and ER groups were 100% and 98.7%, respectively. No tumor-related mortality was observed in either group. CONCLUSIONS For patients with mucosal BC, both surgery and ER are effective treatment modalities. Surgery is associated with a higher morbidity rate and shows a risk for procedure-related mortality. However, the recurrence rate is higher in patients treated with ER, so that thorough follow-up procedures are mandatory.
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41
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Duplicated muscularis mucosae invasion has similar risk of lymph node metastasis and recurrence-free survival as intramucosal esophageal adenocarcinoma. Am J Surg Pathol 2011; 35:1045-53. [PMID: 21602659 DOI: 10.1097/pas.0b013e318219ccef] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Duplicated muscularis mucosae (MM) in early esophageal adenocarcinoma (EAC) can cause overstaging of the disease on endoscopic ultrasound and pathology specimens. No study has determined the correlation between lymph node metastasis and invasion in the space between duplicated MM in pathologic tumor stage (pT) 1 EAC. Hematoxylin and eosin-stained slides from surgically resected pT1 EAC (n=99) were reviewed for tumor configuration, grade, level of invasion (lamina propria/inner MM, space between duplicated MM, and submucosa), quantitative depth of invasion in millimeter, and lymphovascular invasion (LVI). These pathologic characteristics were correlated with lymph node status and recurrence-free survival (RFS). All specimens had duplicated MM with thick-walled blood vessels. Tumor differentiation was well in 37, moderate in 47, and poor in 15 specimens. EAC invaded the lamina propria/inner MM in 28 cases, duplicated MM space in 41 cases, and submucosa in 30 cases. LVI was identified in 23 tumors. Eleven patients had lymph node metastasis. Quantitative depth of invasion as a continuous variable (P=0.002), poorly differentiated histology (P=0.028), presence of LVI (P=0.001), and submucosal invasion versus duplicated MM/lamina propria invasion (P=0.02) were associated with increased risk of lymph node metastasis and shorter RFS by univariate analysis. By multivariate analysis, LVI was an independent predictor of lymph node status and RFS. EAC invasion into the space between duplicated MM confers a similar risk of lymph node metastasis and recurrence as those of intramucosal EAC, and LVI is the best predictor of lymph node status and RFS in pT1 EAC.
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Abstract
PURPOSE OF REVIEW This article discusses the various management options and gaps in knowledge in our current understanding of the epidemiology and neoplastic progression of Barrett's esophagus and how this affects the decision to treat patients with nondysplastic Barrett's esophagus (NDBE). RECENT FINDINGS Barrett's esophagus is the only known risk factor for esophageal adenocarcinoma (EAC), the most rapidly rising cancer in terms of incidence in the United States. The current management strategy is to enroll patients with Barrett's esophagus in surveillance programs. Despite these efforts, the incidence of EAC has continued to rise. Recent studies have shown endoscopic ablation therapies to be relatively safe and effective in the eradication of NDBE. However, all studies performed to date were cohort in nature with no randomized controlled trial data available at this time. At present, several critical questions remain unanswered: Will treatment of NDBE eliminate the risk of developing cancer? If not, just how effective is the treatment? Is it durable? Can surveillance be stopped after ablation? What are the risks? Would such treatment be cost-effective? SUMMARY It is possible that if future data can affirmatively answer some of these questions, ablation of NDBE would be reasonable in selected patients; however, until then, a wait and watch approach is likely to be the best option for most low-risk patients.
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Abstract
INTRODUCTION Esophageal cancer remains a challenging clinical problem, with overall long-term survivorship consistently at a level of approximately 30%. The incidence of esophageal cancer is increasing worldwide, with the most dramatic increase being seen with respect to esophageal adenocarcinoma. DISCUSSION Pretreatment staging accuracy has improved with the utilization of CT and PET scans, as well as endoscopic ultrasound and endoscopic mucosal resection. In an increasing percentage of patients, endoscopic techniques are being utilized in selected patients for the treatment of high-grade dysplasia in Barrett's and intramucosal cancer. Surgery remains the treatment of choice in all appropriate patients with invasive and locoregional esophageal cancer, although multimodality therapy is now used in most patients with stage II or stage III disease. CONCLUSION Outcomes for esophagectomy have been dominated by concerns regarding high mortality and morbidity; however, mortality rates associated with esophageal resection have dramatically decreased, especially in high-volume specialty centers. This manuscript highlights some of the evolutionary issues associated with staging and endoscopic and surgical treatments of Barrett's and esophageal cancer.
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SPECHLER STUARTJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ. American Gastroenterological Association technical review on the management of Barrett's esophagus. Gastroenterology 2011; 140:e18-52; quiz e13. [PMID: 21376939 PMCID: PMC3258495 DOI: 10.1053/j.gastro.2011.01.031] [Citation(s) in RCA: 783] [Impact Index Per Article: 60.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Hirasawa K, Kokawa A, Oka H, Yahara S, Sasaki T, Nozawa A, Tanaka K. Superficial adenocarcinoma of the esophagogastric junction: long-term results of endoscopic submucosal dissection. Gastrointest Endosc 2010; 72:960-6. [PMID: 21034897 DOI: 10.1016/j.gie.2010.07.030] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Accepted: 07/21/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) was recently introduced as a treatment option for superficial adenocarcinoma of the esophagogastric junction (EGJ); however, its long-term clinical outcomes have not been fully evaluated. OBJECTIVE To assess the long-term outcomes of ESD for patients with superficial adenocarcinoma of the EGJ. DESIGN Retrospective review from a single institution. SETTING University hospital. PATIENTS Fifty-eight patients, 46 men and 12 women (mean 69.3 years), with 39 T1m and 19 T1sm adenocarcinomas of the EGJ treated from June 2000 to May 2009. INTERVENTIONS ESD procedures were performed with typical sequences. MAIN OUTCOME MEASUREMENTS Complications, en bloc resection rate, curative resection rate, local recurrence, and distant metastases after ESD were evaluated. Curative resection is histologically defined as being free of resection margins and any evidence of deep submucosal invasion, undifferentiated carcinoma, and lymphovascular invasion. RESULTS There were no major complications except for 3 patients with ulcer bleeding without the need for blood transfusion and 1 patient with esophageal stenosis. The rates of en bloc resection and curative resection were 100% and 79%, respectively. Twelve resections were histologically considered noncurative; these patients underwent additional ESD (n = 1) or surgical resection (n = 8). Local or distant recurrences were not observed in any patient achieving curative resection during follow-up (median 36.6 months, range 4-94 months). LIMITATIONS Retrospective design and single-site data collection. CONCLUSIONS Long-term outcomes after ESD are favorable. ESD may be adopted as a treatment of choice for superficial adenocarcinoma of the EGJ.
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Affiliation(s)
- Kingo Hirasawa
- Gastroenterological Center and Department of Pathology, Yokohama City University Medical Center, Minami-ku, Yokohama, Japan
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Gan S, Watson DI. New endoscopic and surgical treatment options for early esophageal adenocarcinoma. J Gastroenterol Hepatol 2010; 25:1478-84. [PMID: 20796143 DOI: 10.1111/j.1440-1746.2010.06421.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Although the outcome for advanced stage esophageal cancer is poor, the early detection and treatment of early stage disease is usually associated with a much better outcome. Until recently, esophagectomy has been the treatment of choice in fit patients. However, morbidity is significant, and this has encouraged the development of newer endoscopic treatments that preserve the esophagus. These techniques include ablation and mucosal resection. Promising results are described, and endoscopic methods might provide a reasonable alternative for the treatment of early esophageal cancer. However, follow-up remains short and endoscopic treatment does not deal with potential lymphatic spread. Hence, careful selection is required. Minimally invasive techniques for esophageal resection have also been shown to be feasible, although there is only limited evidence that they reduce postoperative morbidity. Better data are still required to demonstrate improved outcomes from endoscopic treatment and minimally invasive esophagectomy.
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Affiliation(s)
- Susan Gan
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
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Schembre D, Arai A, Levy S, Farrell-Ross M, Low D. Quality of life after esophagectomy and endoscopic therapy for Barrett's esophagus with dysplasia. Dis Esophagus 2010; 23:458-64. [PMID: 20113322 DOI: 10.1111/j.1442-2050.2009.01042.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophagectomy (EG) and endoscopic therapy (ET) can eradicate Barrett's esophagus with early neoplasia. Their relative effect on quality of life is unknown. The 36-item Short Form Health Survey (SF-36) and Gastrointestinal Quality of Life Index (GIQLI) questionnaires were sent to all patients who underwent either EG or ET at our institution over the last 9 years. Groups were stratified by age and American Society of Anesthesia (ASA) class. Surveys were sent to 77 patients and completed by 14 EG (50%) and by 28 ET patients (57%). The average time between treatment and survey was 4 years in the ET group and 5 years in the EG group. There were no significant differences in SF-36 scores between EG and ET patients except for superior physical functioning among EG patients 65 and older QOL scores among EG and ET groups were not significantly different than sex age-matched controls. GIQLI scores were similar between ET and EG patients of all ages (P= 0.60). GIQLI scores were higher among younger ET patients than young EG patients (P= 0.049). GIQLI scores also tended to be higher among ASA 1 and 2 ET patients than ASA 1 and 2 EG patients, but this did not reach statistical significance (P= 0.09). EG and ET for early Barrett's neoplasia appear to have similar impact on QOL 1 year or more after treatment compared with age-matched controls. Negative QOL impact appears to be greater for younger patients undergoing EG than for ET.
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Affiliation(s)
- D Schembre
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA 98101, USA.
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The safety and effectiveness of endoscopic and non-endoscopic approaches to the management of early esophageal cancer: a systematic review. Cancer Treat Rev 2010; 37:11-62. [PMID: 20570442 DOI: 10.1016/j.ctrv.2010.04.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 04/13/2010] [Accepted: 04/25/2010] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Traditionally, management of early cancer (stages 0-IIA) has comprised esophagectomy, either alone or in combination with chemotherapy and/or radiotherapy. Recent efforts to improve outcomes and minimize side-effects have focussed on minimally invasive, endoscopic treatments that remove lesions while sparing healthy tissue. This review assesses their safety and efficacy/effectiveness relative to traditional, non-endoscopic treatments for early esophageal cancer. METHODS A systematic review of peer-reviewed studies was performed using Cochrane guidelines. Bibliographic databases searched to identify relevant English language studies published in the last 3 years included: PubMed (i.e., MEDLINE and additional sources), EMBASE, CINAHL, The Cochrane Library, the UK Centre for Reviews and Dissemination (NHS EED, DARE and HTA) databases, EconLit and Web of Science. Web sites of professional associations, relevant cancer organizations, clinical practice guidelines, and clinical trials were also searched. Two independent reviewers selected, critically appraised, and extracted information from studies. RESULTS The review included 75 studies spanning 3124 patients and 10 forms of treatment. Most studies were of short term duration and non-comparative. Adverse events reported across studies of endoscopic techniques were similar and less significant compared to those in the studies of non-endoscopic techniques. Complete response rates were slightly lower for photodynamic therapy (PDT) relative to the other endoscopic techniques, possibly due to differences in patient populations across studies. No studies compared overall or cause-specific survival in patients who received endoscopic treatments vs. those who received non-endoscopic treatments. DISCUSSION Based on findings from this review, there is no single "best practice" approach to the treatment of early esophageal cancer.
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Bisschops R. Optimal endoluminal treatment of Barrett's esophagus: integrating novel strategies into clinical practice. Expert Rev Gastroenterol Hepatol 2010; 4:319-33. [PMID: 20528119 DOI: 10.1586/egh.10.20] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Endoluminal therapy has become the first-choice treatment over the last 5 years for early Barrett's neoplasia limited to the mucosa. Long-term follow-up data on endoscopic resection have demonstrated the oncological safety of endoscopic resection in comparison to surgery. However, there is a high rate of recurrent disease, which can be avoided using additional ablation of the remaining Barrett. Radiofrequency ablation was recently introduced as an efficacious means to ablate Barrett's epithelium with a better safety profile than older ablation techniques. Recent studies show that endoscopic resection can be safely combined with radiofrequency ablation for treating dysplastic Barrett's after removal of visible lesions. This constitutes a completely new treatment paradigm that will be integrated in routine clinical practice in the forthcoming years.
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Affiliation(s)
- Raf Bisschops
- University Hospital Leuven, Department of Gatsroenterology, 49 Herestraat, 3000 Leuven, Belgium.
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Greenwald BD, Dumot JA, Abrams JA, Lightdale CJ, David DS, Nishioka NS, Yachimski P, Johnston MH, Shaheen NJ, Zfass AM, Smith JO, Gill KRS, Burdick JS, Mallat D, Wolfsen HC. Endoscopic spray cryotherapy for esophageal cancer: safety and efficacy. Gastrointest Endosc 2010; 71:686-93. [PMID: 20363410 PMCID: PMC3144145 DOI: 10.1016/j.gie.2010.01.042] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Accepted: 01/08/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few options exist for patients with localized esophageal cancer ineligible for conventional therapies. Endoscopic spray cryotherapy with low-pressure liquid nitrogen has demonstrated efficacy in this setting in early studies. OBJECTIVE To assess the safety and efficacy of cryotherapy in esophageal carcinoma. DESIGN Multicenter, retrospective cohort study. SETTING Ten academic and community medical centers between 2006 and 2009. PATIENTS Subjects with esophageal carcinoma in whom conventional therapy failed and those who refused or were ineligible for conventional therapy. INTERVENTIONS Cryotherapy with follow-up biopsies. Treatment was complete when tumor eradication was confirmed by biopsy or when treatment was halted because of tumor progression, patient preference, or comorbid condition. MAIN OUTCOME MEASUREMENTS Complete eradication of luminal cancer and adverse events. RESULTS Seventy-nine subjects (median age 76 years, 81% male, 94% with adenocarcinoma) were treated. Tumor stage included T1-60, T2-16, and T3/4-3. Mean tumor length was 4.0 cm (range 1-15 cm). Previous treatment including endoscopic resection, photodynamic therapy, esophagectomy, chemotherapy, and radiation therapy failed in 53 subjects (67%). Forty-nine completed treatment. Complete response of intraluminal disease was seen in 31 of 49 subjects (61.2%), including 18 of 24 (75%) with mucosal cancer. Mean (standard deviation) length of follow-up after treatment was 10.6 (8.4) months overall and 11.5 (2.8) months for T1 disease. No serious adverse events were reported. Benign stricture developed in 10 (13%), with esophageal narrowing from previous endoscopic resection, radiotherapy, or photodynamic therapy noted in 9 of 10 subjects. LIMITATIONS Retrospective study design, short follow-up. CONCLUSIONS Spray cryotherapy is safe and well tolerated for esophageal cancer. Short-term results suggest that it is effective in those who could not receive conventional treatment, especially for those with mucosal cancer.
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