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Rosmolen WD, Pouw RE, Bergman JJ, Sprangers MAG, Nieuwkerk PT. Reasons for fear of cancer recurrence after endoscopic treatment of T1 esophageal adenocarcinoma. A semi-structured interview study. Dis Esophagus 2024:doae067. [PMID: 39169835 DOI: 10.1093/dote/doae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 07/12/2024] [Accepted: 08/10/2024] [Indexed: 08/23/2024]
Abstract
Prior research has shown that patients with early Barrett's neoplasia treated endoscopically report at least the same level of fear for cancer recurrence as patients treated surgically for a more advanced disease stage. The aim of this qualitative study was to gain insight into the reasons why endoscopically treated patients fear or not fear cancer recurrence. Patients treated endoscopically for T1 esophageal adenocarcinoma participated in a semi-structured interview. Patients were asked open questions about their fear of cancer recurrence and presented an a priori list of possible reasons for experiencing or not experiencing fear of cancer recurrence. Data saturation was reached with 12 patients who added 7 new reasons. Reasons that induced fear of cancer recurrence were related to physical symptoms, if cancer was diagnosed as an accidental finding and experiences with cancer in close relations. Endoscopic surveillance was mentioned as a reason for not experiencing fear of cancer recurrence. Patients reduced their fear of cancer recurrence by talking to close relations and seeking distraction. Caregivers reduced patients fear of cancer recurrence by giving adequate information and by showing photo of the treatment and the results of the treatment. According to patients with early Barrett's neoplasia, receiving comprehensible information about the risk of recurrence and potential symptoms that may or may not be indicative of cancer recurrence, and continuing endoscopic surveillance, reduced fear of cancer recurrence. We recommend that healthcare providers discuss fear of cancer recurrence with their patients to enable tailoring information provision to their needs.
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Affiliation(s)
- Wilda D Rosmolen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Boelelaan 1117, 1118, 1081HV Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Boelelaan 1117, 1118, 1081HV Amsterdam, The Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Boelelaan 1117, 1118, 1081HV Amsterdam, The Netherlands
| | - Mirjam A G Sprangers
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Boelelaan 1117, 1118, 1081HV Amsterdam, The Netherlands
| | - Pythia T Nieuwkerk
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Boelelaan 1117, 1118, 1081HV Amsterdam, The Netherlands
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2
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Norton BC, Aslam N, Telese A, Papaefthymiou A, Singh S, Sehgal V, Mitchison M, Jansen M, Banks M, Graham D, Haidry R. Risk of metastasis among patients diagnosed with high-risk T1 esophageal adenocarcinoma who underwent endoscopic follow-up. Dis Esophagus 2024; 37:doae027. [PMID: 38580314 DOI: 10.1093/dote/doae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 03/05/2024] [Accepted: 03/19/2024] [Indexed: 04/07/2024]
Abstract
Esophagectomy and lymphadenectomy have been the standard of care for patients at high risk (HR) of lymph node metastasis following a diagnosis of early esophageal adenocarcinoma (OAC) after endoscopic resection (ER). However, recent cohorts suggest lymph node metastasis risk is lower than initially estimated, suggesting organ preservation with close endoscopic follow-up is a viable option. We report on the 3- and 5-year risk of lymph node/distant metastasis among patients diagnosed with early HR-T1 OAC undergoing endoscopic follow-up. Patients diagnosed with HR-T1a or T1b OAC following ER at a tertiary referral center were identified and retrospectively analyzed from clinical records between 2010 and 2021. Patients were included if they underwent endoscopic follow-up after resection and were divided into HR-T1a, low risk (LR)-T1b and HR-T1b cohorts. After ER, 47 patients underwent endoscopic follow-up for early HR OAC. In total, 39 patients had an R0 resection with a combined 3- and 5-year risk of LN/distant metastasis of 6.9% [95% confidence interval (CI): 1.8-25] and 10.9% (95% CI, 3.6-30.2%), respectively. There was no significant difference when stratifying by histopathological subtype (P = 0.64). Among those without persistent luminal disease on follow-up, the 5-year risk was 4.1% (95% CI, 0.6-26.1). Two patients died secondary to OAC with an all-cause 5-year survival of 57.5% (95% CI, 39.5-71.9). The overall risk of LN/distant metastasis for early HR T1 OAC was lower than historically reported. Endoscopic surveillance can be a reasonable approach in highly selected patients with an R0 resection and complete luminal eradication, but clear, evidence-based surveillance guidelines are needed.
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Affiliation(s)
- Benjamin Charles Norton
- Department of Gastroenterology, University College London Hospitals, London, UK
- Centre for Obesity Research, University College London, London, UK
- Department of Gastroenterology, Digestive diseases & Surgery Institute, Cleveland Clinic London, London, UK
| | - Nasar Aslam
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Andrea Telese
- Department of Gastroenterology, University College London Hospitals, London, UK
- Centre for Obesity Research, University College London, London, UK
| | | | - Shilpi Singh
- Department of Histopathology, University College London Hospitals, London, UK
| | - Vinay Sehgal
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Miriam Mitchison
- Department of Histopathology, University College London Hospitals, London, UK
| | - Marnix Jansen
- Department of Histopathology, University College London Hospitals, London, UK
| | - Matthew Banks
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - David Graham
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Rehan Haidry
- Department of Gastroenterology, Digestive diseases & Surgery Institute, Cleveland Clinic London, London, UK
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3
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Bos V, Chan MW, Pouw RE. Towards personalized management of early esophageal adenocarcinoma. Curr Opin Gastroenterol 2024; 40:299-304. [PMID: 38606810 PMCID: PMC11155290 DOI: 10.1097/mog.0000000000001030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
PURPOSE OF REVIEW This review aims to discuss recent advancements in the endoscopic management of early esophageal adenocarcinoma (T1 EAC). RECENT FINDINGS Patients with high-risk EAC (defined by the presence of deep submucosal invasion, and/or lymphovascular invasion, and/or poor differentiation) have a higher risk of lymph node metastases than those with low-risk EAC. However, more recent, endoscopically-focused studies report a lower risk of lymph node metastases and distant metastases for high-risk EAC than previously assumed. Instead of referring all high-risk EAC patients for esophagectomy after a radical endoscopic resection, an alternative approach involving regular upper endoscopy with endoscopic ultrasound may allow for detection of intra-luminal recurrence and lymph node metastases at an early and potentially curable stage. SUMMARY Endoscopic resection of mucosal and submucosal EAC might prove to be safe and curative for selected cases in the future, when followed by a strict follow-up protocol. Despite the promising results of preliminary studies, there is an ongoing need for personalized strategies and new risk stratification methods to decide on the best management for individual patients with high-risk T1 EAC.
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Affiliation(s)
- Vincent Bos
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers
- Cancer Center Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Man Wai Chan
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers
- Cancer Center Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Roos E. Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers
- Cancer Center Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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4
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Denzer UW. Endoscopic Resection of Malignancies in the Upper GI Tract: A Clinical Algorithm. Visc Med 2024; 40:116-127. [PMID: 38873624 PMCID: PMC11166903 DOI: 10.1159/000538040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/25/2024] [Indexed: 06/15/2024] Open
Abstract
Background Malignancies in the upper gastrointestinal tract are amenable to endoscopic resection at an early stage. Achieving a curative resection is the most stringent quality criterion, but post-resection risk assessment and aftercare are also part of a comprehensive quality program. Summary Various factors influence the achievement of curative resection. These include endoscopic assessment prior to resection using chromoendoscopy and HD technology. If resectability is possible, it is particularly important to delineate the lateral resection margins as precisely as possible before resection. Furthermore, the correct choice of resection technique depending on the lesion must be taken into account. Endoscopic submucosal dissection is the standard for esophageal squamous cell carcinoma and gastric carcinoma. In Western countries, it is becoming increasingly popular to treat Barrett's neoplasia over 2 cm in size and/or with suspected submucosal infiltration with en bloc resection instead of piece meal resection. After resection, risk assessment based on the histopathological resection determines the patient's individual risk of lymph node metastases, particularly in the case of high-risk lesions. This is categorized according to the current literature. Key Messages This review presents clinical algorithms for endoscopic resection of esophageal SCC, Barrett's neoplasia, and gastric neoplasia. The algorithms include the pre-resection assessment of the lesion and the resection margins, the adequate resection technique for the respective lesion, as well as the post-resection risk assessment with an evidence-based recommendation for follow-up therapy and surveillance.
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Affiliation(s)
- Ulrike Walburga Denzer
- Section of Endoscopy, Department of Gastroenterology, University Hospital Marburg, Marburg, Germany
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5
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McKay SC, Louie BE, Molena D, Andrews WG, Boerner T, Hofstetter WL, Yeung J, Darling GE, Sharata A, Peyre CG, Dunn C, Lipham JC, Marginean H, DeMeester SR. Tumor differentiation impacts response to neoadjuvant therapy and survival in patients with esophageal adenocarcinoma. J Thorac Cardiovasc Surg 2024; 167:1943-1950. [PMID: 37788788 DOI: 10.1016/j.jtcvs.2023.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVE The current staging system for esophageal adenocarcinoma only considers tumor grade in early tumors. The aim of this study was to evaluate the impact of tumor differentiation on response to neoadjuvant chemoradiotherapy and survival in patients with locally advanced esophageal adenocarcinoma. METHODS This was a multi-institution retrospective review of all patients with esophageal cancer who underwent neoadjuvant chemoradiotherapy followed by esophagectomy from January 2010 to December 2017. Response to neoadjuvant therapy and survival was compared between patients with well- or moderately differentiated (G1/2) tumors versus poorly differentiated (G3) tumors. RESULTS There were 550 patients, 485 men (88.2%) and 65 women. The median age was 61 years, and the tumor was G1/2 in 288 (52.4%) and G3 in 262 patients. Overall clinical stage before neoadjuvant therapy was similar between groups. Pathologic complete response (pCR) was found in 87 patients (15.8%). The frequency of pCR was similar between groups, but residual disease in the esophagus and lymph nodes was significantly more likely with G3 tumors. Median follow-up was 63 months and absolute survival, overall survival, and disease-free survival were all significantly worse in patients with G3 tumors. Further, even with pCR, patients with G3 tumors had significantly worse survival. CONCLUSIONS This study showed that response to neoadjuvant therapy was not affected by tumor differentiation. However, poor differentiation was associated with worse survival compared with patients with G1/2 tumors, even among those with pCR. These results suggest that poor differentiation should be considered as an added risk factor for clinical staging in patients with locally advanced esophageal adenocarcinoma.
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Affiliation(s)
- Sarah C McKay
- Oregon Clinic: Center for Advanced Surgery, Portland, Ore; Albany Medical College, Albany, NY
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Cancer Institute, Seattle, Wash
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Weston G Andrews
- Division of Thoracic Surgery, Swedish Cancer Institute, Seattle, Wash
| | - Thomas Boerner
- Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Jonathan Yeung
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Sharata
- Oregon Clinic: Center for Advanced Surgery, Portland, Ore; Department of General Surgery, University of South Florida, Tampa, Fla
| | - Christian G Peyre
- Division of Thoracic and Foregut Surgery, University of Rochester, Rochester, NY
| | - Colin Dunn
- Division of Thoracic Surgery, University of Southern California, Los Angeles, Calif
| | - John C Lipham
- Division of Thoracic Surgery, University of Southern California, Los Angeles, Calif
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Nguyen CL, Tovmassian D, Isaacs A, Falk GL. Risk of lymph node metastasis in T1 esophageal adenocarcinoma: a meta-analysis. Dis Esophagus 2024; 37:doae012. [PMID: 38391209 DOI: 10.1093/dote/doae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/29/2023] [Accepted: 02/02/2024] [Indexed: 02/24/2024]
Abstract
Patients with early (T1) esophageal adenocarcinoma (EAC) are increasingly having definitive local therapy endoscopically. Endoscopic resection is not able to pathologically stage or treat lymph node metastasis (LNM). Accurate identification of patients having nodal metastasis is critical to select endoscopic therapy over surgery. This study aimed to define the risk of LNM in T1 EAC. A meta-analysis of studies of patients who underwent surgery and lymphadenectomy with assessment of LNM was performed according to PRISMA. Main outcome was probability of LNM in T1a and T1b disease. Secondary outcomes were risk factors for LNM and rate of LNM in submucosal T1b (SM1, SM2, and SM3) disease. Registered with PROSPERO (CRD42022341794). Twenty cohort studies involving 2264 patients with T1 EAC met inclusion criteria: T1a (857 patients) with 36 (4.2%) node positive and T1b (1407 patients) with 327 (23.2%) node positive. Subgroup analysis of T1b lesions was available in 10 studies (405 patients). Node positivity for SM1, SM2, and SM3 was 16.3%, 16.2%, and 29.4%, respectively. T1 substage (odds ratio [OR] 7.72, 95% confidence interval [CI] 4.45-13.38, P < 0.01), tumor differentiation (OR 2.82, 95% CI 2.06-3.87, P < 0.01), and lymphovascular invasion (OR 13.65, 95% CI 6.06-30.73, P < 0.01) were associated with LNM. T1a disease demonstrated a 4.2% nodal metastasis rate and T1b disease a rate of 23.2%. Endoscopic therapy should be reserved for T1a disease and perhaps select T1b disease, which has a moderately high rate of nodal metastasis. There were inadequate data to stratify T1b SM disease into 'low-risk' and 'high-risk' based on tumor differentiation and lymphovascular invasion.
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Affiliation(s)
- Chu Luan Nguyen
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - David Tovmassian
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Anna Isaacs
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Gregory L Falk
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
- Sydney Heartburn Clinic, Lindfield, NSW, Australia
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7
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di Pietro M, Trudgill NJ, Vasileiou M, Longcroft-Wheaton G, Phillips AW, Gossage J, Kaye PV, Foley KG, Crosby T, Nelson S, Griffiths H, Rahman M, Ritchie G, Crisp A, Deed S, Primrose JN. National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma. Gut 2024; 73:897-909. [PMID: 38553042 PMCID: PMC11103346 DOI: 10.1136/gutjnl-2023-331557] [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] [Received: 11/16/2023] [Accepted: 02/15/2024] [Indexed: 05/12/2024]
Abstract
Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma, a cancer with very poor prognosis. The main risk factors for Barrett's oesophagus are a history of gastro-oesophageal acid reflux symptoms and obesity. Men, smokers and those with a family history are also at increased risk. Progression from Barrett's oesophagus to cancer occurs via an intermediate stage, known as dysplasia. However, dysplasia and early cancer usually develop without any clinical signs, often in individuals whose symptoms are well controlled by acid suppressant medications; therefore, endoscopic surveillance is recommended to allow for early diagnosis and timely clinical intervention. Individuals with Barrett's oesophagus need to be fully informed about the implications of this diagnosis and the benefits and risks of monitoring strategies. Pharmacological treatments are recommended for control of symptoms, but not for chemoprevention. Dysplasia and stage 1 oesophageal adenocarcinoma have excellent prognoses, since they can be cured with endoscopic or surgical therapies. Endoscopic resection is the most accurate staging technique for early Barrett's-related oesophageal adenocarcinoma. Endoscopic ablation is effective and indicated to eradicate Barrett's oesophagus in patients with dysplasia. Future research should focus on improved accuracy for dysplasia detection via new technologies and providing more robust evidence to support pathways for follow-up and treatment.
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Affiliation(s)
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | | | - Gaius Longcroft-Wheaton
- Department of Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
- Department of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Alexander W Phillips
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - James Gossage
- Department of Gastrointestinal Surgery, St Thomas' Hospital, London, UK
| | - Philip V Kaye
- Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kieran G Foley
- Division of Cancer and Genetics, Cardiff University, Cardiff, Cardiff, UK
| | - Tom Crosby
- Department of Clinical Oncology, Velindre University NHS Trust, Cardiff, UK
| | - Sophie Nelson
- Kenmore Medical Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Muksitur Rahman
- National Institute for Health and Care Excellence, London, UK
| | - Gill Ritchie
- National Institute for Health and Care Excellence, London, UK
| | - Amy Crisp
- National Institute for Health and Care Excellence, London, UK
| | - Stephen Deed
- National Institute for Health and Care Excellence, London, UK
| | - John N Primrose
- Department of Surgery, University of Southampton, Southampton, UK
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8
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Mohapatra S, Al Ghamdi SS, Charilaou P, Lopimpisuth C, Das A, Ngamruengphong S. Predictors for lymph node metastasis and survival of patients with T1b esophageal adenocarcinoma treated with surgery and endoscopic therapy: an analysis of the Surveillance, Epidemiology, and End Results database. Gastrointest Endosc 2024:S0016-5107(24)03190-0. [PMID: 38734257 DOI: 10.1016/j.gie.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 04/22/2024] [Accepted: 05/06/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND AND AIMS Limited data exist regarding the long-term outcomes of endoscopic therapy (ET) with or without chemoradiation therapy (CRT) for T1b esophageal adenocarcinoma (EAC). Our aim was to identify the risk factors for lymph node metastasis (LNM) in T1b EAC and assess how the chosen treatment modality affects overall survival (OS) and cancer-specific survival (CSS). METHODS We analyzed patients with histologically confirmed T1b EAC diagnosed between 2004 and 2018 using the Surveillance, Epidemiology, and End Results database. Focusing on T1bN0M0 staging, the patients were divided into 2 groups (ET [n = 174] and surgery [n = 769]), and OS and CSS rates were calculated. RESULTS Of 1418 patients with T1b EAC, 228 cases (16.1%) exhibited LNM at diagnosis. Notable risk factors for LNM included poorly differentiated tumor and lesion size ≥20 mm. For T1bN0M0 cases, ET was commonly performed from 2009 to 2018 (odds ratio [OR], 4.3), especially for patients aged ≥65 years (OR, 3.1) with tumor size <20 mm (OR, 2.3). During the median 50 months of follow-up, age ≥65 years (hazard ratio [HR], 1.9), ET (HR, 1.5), and CRT (HR, 1.4) were associated with poorer OS. Factors linked to decreased CSS were age ≥65 years (subhazard ratio [SHR], 1.6), poorly differentiated tumors (SHR, 1.5), and CRT (SHR, 1.5). CONCLUSIONS In T1b EAC, tumor size ≥20 mm and poor differentiation are notable risk factors for LNM. ET exhibited comparable CSS outcomes to surgery for carefully selected T1bN0M0 lesions. CRT did not provide additional survival benefit for these lesions; however, large-scale studies are required to validate this finding.
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Affiliation(s)
- Sonmoon Mohapatra
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Sarah S Al Ghamdi
- Department of Gastroenterology and Hepatology, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Paris Charilaou
- Department of Gastroenterology and Hepatology, New York Presbyterian Hospital/Weill-Cornell Medical College, New York, New York, USA
| | - Chawin Lopimpisuth
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Amit Das
- Department of Computer Science, Dartmouth College, Hanover, New Hampshire, USA
| | - Saowanee Ngamruengphong
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA.
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9
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Bollschweiler E, Hölscher AH, Markar SR, Alakus H, Drebber U, Mönig SP, Plum PS. Premature mortality for patients after completely resected early adenocarcinoma of the esophagus or stomach. Cancer Med 2024; 13:e7223. [PMID: 38778711 PMCID: PMC11112294 DOI: 10.1002/cam4.7223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/14/2024] [Accepted: 04/14/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVE To establish the life expectancy burden of esophago-gastric cancer by analyzing years of life lost (YLL) for a Western patient population after treatment of early esophageal (EAC) or early gastric (GAC) adenocarcinoma. BACKGROUND For patients with early EAC or GAC, the short-term prognosis after surgical resection is very good. Little data is available regarding long-term prognosis when compared to the general population. METHODS Two hundred and fourteen patients with pT1 EAC (n = 112) or GAC (n = 102) were included in the study. Patients with EAC underwent transthoracic en-bloc esophagectomy; those with GAC had total or subtotal gastrectomy with D2-lymphadenectomy. Surviving patients had a median follow-up of approximately 14 years. YLL was calculated using average life expectancy data from Germany. RESULTS Patients with EAC were younger (median age 61 years) than those with GAC (66 years) (p = 0.031). The male:female ratio was 10:1 for EAC and 3:2 for GAC (p < 0.001). Multivariate survival analysis showed the age of the patients ≥60 years and the existence of lymph node metastasis was associated with poor prognosis. The median YLL for all patients who died over follow-up was 8.0 years. For patients under 60 years, it was approximately 20 years, and for older patients, approximately 5 years (p < 0.001) without difference in tumor stage between these age cohorts. YLL did not differ for GAC vs. EAC. CONCLUSION After surgical resection, the prognostic burden as measured by YLL is relevant for all patients with early esophageal and gastric adenocarcinomas and especially for younger patients. Reasons for YLL need further studies.
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Affiliation(s)
| | | | - Sheraz R. Markar
- Surgical Interventional Trials Unit, Nuffield Department of SurgeryUniversity of OxfordOxfordUK
| | - Hakan Alakus
- Department of General, Visceral and Cancer SurgeryUniversity of CologneCologneGermany
| | - Uta Drebber
- Institute of Pathology, University of CologneCologneGermany
| | - Stefan Paul Mönig
- Department of Visceral SurgeryGeneva University HospitalsGenevaSwitzerland
| | - Patrick Sven Plum
- Department of Visceral, Transplantation, Thoracic and Vascular SurgeryUniversity Hospital of LeipzigLeipzigGermany
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10
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Schuring N, van Berge Henegouwen MI, Gisbertz SS. History and evidence for state of the art of lymphadenectomy in esophageal cancer surgery. Dis Esophagus 2024; 37:doad065. [PMID: 38048446 PMCID: PMC10987971 DOI: 10.1093/dote/doad065] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/29/2023] [Accepted: 11/07/2023] [Indexed: 12/06/2023]
Abstract
The current curative multimodal treatment of advanced esophageal cancers consists of neoadjuvant or perioperative chemo(radio)therapy followed by a radical surgical resection of the primary tumor and a 2- or 3-field lymphadenectomy. One of the most important predictors of long-term survival of esophageal cancer patients is lymph node involvement. The distribution pattern of lymph node metastases in esophageal cancer is unpredictable and depends on the primary tumor location, histology, T-stage and application of neoadjuvant or perioperative treatment. The optimal extent of the lymphadenectomy remains controversial; there is no global consensus on this topic yet. Some surgeons advocate an aggressive and extended lymph node dissection to remove occult metastatic disease, to optimize oncological outcomes. Others promote a more restricted lymphadenectomy, since the benefit of an extended lymphadenectomy, especially after neoadjuvant chemoradiotherapy, has not been clearly demonstrated, and morbidity may be reduced. In this review, we describe the development of lymphadenectomy, followed by a summary of current evidence for lymphadenectomy in esophageal cancer treatment.
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Affiliation(s)
- Nannet Schuring
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Gastroenterology and Hepatology, Amsterdam UMC Location University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
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11
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Probst A, Kappler F, Ebigbo A, Albers D, Faiss S, Steinbrück I, Wannhoff A, Allgaier HP, Denzer U, Rempel V, Reinehr R, Dakkak D, Mende M, Pohl J, Schaller T, Märkl B, Muzalyova A, Fleischmann C, Messmann H. Endoscopic submucosal dissection for early esophageal adenocarcinoma: low rates of metastases in mucosal cancers with poor differentiation. Gastrointest Endosc 2024:S0016-5107(24)00166-4. [PMID: 38479623 DOI: 10.1016/j.gie.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 08/03/2024]
Abstract
BACKGROUND AND AIMS Endoscopic resection is accepted as standard treatment for intramucosal esophageal adenocarcinoma (EAC) that is well or moderately differentiated. Poor differentiation (PD) is judged as a risk factor for lymph node metastasis (LNM), and surgery is recommended. However, the evidence for this recommendation is weak. The aim of this study was to analyze the clinical course of patients after endoscopic resection of EAC with PD. METHODS Patients undergoing endoscopic submucosal dissection for EAC were included from 16 German centers. Inclusion criteria were PD in the resection specimen, R0 resection, and endoscopic follow-up. Primary outcome was the metastasis rate during follow-up. Analysis was performed retrospectively in a prospectively collected database. RESULTS Twenty-five patients with PD as single risk factor (group A) and 15 patients with PD and additional risk factors (submucosal invasion and/or lymphovascular invasion) (group B) were included. The metastasis rate was was 1 of 25 (4.0%; 95% CI, .4%-17.2%) in group A and 3 of 15 (20.0%; 95% CI, 6.0%-44.4%) in group B, respectively (P = .293). The rate of EAC-associated deaths was 1 of 25 (4%; 95% CI, .4%-17.2%) versus 3 of 15 (20%; 95% CI, 6.0%-44.4%) in group B (P = .293). The overall death rate was 7 of 25 (28.0%; 95% CI, 13.5%-47.3%) versus 3 of 15 (20%; 95% CI, 6.0%-44.4%) (P = .715). Median follow-up was 30 months (interquartile range, 15-53 months). CONCLUSIONS During long-term follow-up, the risk of metastasis is low after endoscopic resection of mucosal EAC with PD as a single risk factor. A conservative approach seems justified in this small patient group. However, the treatment strategy must be determined on an individualized basis until further prospective data are available.
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Affiliation(s)
- Andreas Probst
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany.
| | - Felix Kappler
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Alanna Ebigbo
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - David Albers
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany
| | - Siegbert Faiss
- Department of Gastroenterology, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Ingo Steinbrück
- Department of Gastroenterology, Asklepios Klinik Barmbek, Hamburg, Germany; Department of Medicine and Gastroenterology, Evangelisches Diakoniekrankenhaus Freiburg, Freiburg, Germany
| | - Andreas Wannhoff
- Department of Gastroenterology, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Hans-Peter Allgaier
- Department of Medicine and Gastroenterology, Evangelisches Diakoniekrankenhaus Freiburg, Freiburg, Germany
| | - Ulrike Denzer
- Department of Gastroenterology, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Viktor Rempel
- Department of Gastroenterology, St. Anna Hospital Herne, Herne, Germany
| | - Roland Reinehr
- Department of Medicine and Gastroenterology, Elbe-Elster Klinikum, Herzberg, Germany
| | - Dani Dakkak
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany
| | - Matthias Mende
- Department of Gastroenterology, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Jürgen Pohl
- Department of Gastroenterology, Asklepios Klinik Altona, Hamburg, Germany
| | - Tina Schaller
- Pathology, Medical Faculty Augsburg, University of Augsburg, Augsburg, Germany
| | - Bruno Märkl
- Pathology, Medical Faculty Augsburg, University of Augsburg, Augsburg, Germany
| | - Anna Muzalyova
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Carola Fleischmann
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany; Department of Gastroenterology, Hepatology and Endocrinology, University Hospital, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
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Tankel J, Ijner T, Ferri C, Trottenberg T, Dehghani M, Najmeh S, Fiset PO, Alsaddah S, Cools-Lartigue J, Spicer J, Mueller C, Ferri L. Esophagectomy versus observation following endoscopic submucosal dissection of pT1b esophageal adenocarcinoma. Surg Endosc 2024; 38:1342-1350. [PMID: 38114878 DOI: 10.1007/s00464-023-10623-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Management following endoscopic submucosal dissection (ESD) of pT1b esophageal adenocarcinoma (EAC) remains controversial. This study compared pathological and survival outcomes of patients after endoscopic resection (ER) of pT1b EAC followed by either en bloc esophagectomy or observation. METHODS From 1/12 to 12/22, all patients with pT1b EAC treated with ER were identified from a prospectively maintained departmental database. ESD was curative (all of: Submucosal invasion < 500 μm; G1/2, LVI/PNI-; deep margin-) or non-curative (one or more of Submucosal invasion ≥ 500 μm; G3; LVI/PNI+; deep margin+). Patients were allocated to observation (OBS) or esophagectomy (SURG) based on patient factors/preference and pathological variables. RESULTS 56/171 ERs met the inclusion criteria. ER was curative in 8/56 (14%) and non-curative in 48/56 (86%). OBS was undertaken after 8/27 (30%) curative and 19/27 (70%) non-curative resections. All 29 SURG patients had non-curative ERs and were younger, had lower Charlson comorbidity scores and had more deep margin + lesions than OBS patients. Post-esophagectomy, 15/29 (52%) had no residual disease within the surgical specimen while pT+N-/pT-N+/pT+N+ occurred in 5/3/6 (17%/10%/21%) patients. Of those with residual disease in the surgical specimen, 12/14 (86%) had deep margin + ERs; however, only ESD instead of EMR was independently associated with a lower risk of residual disease (OR 0.431, 95% CI - 0.016 to 1.234, p = 0.045). OBS and SURG patients had equivalent overall survival outcomes and recurrence was low in both groups even following non-curative ER. Follow-up was 28 months (0-102) and 30 months (0-97), respectively. CONCLUSION In select patients, including some of those with a non-curative ESD resection of pT1B EAC, surveillance alone may be appropriate. Alternatives beyond traditional pathological features is needed to direct patient care more accurately.
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Affiliation(s)
- James Tankel
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Tvisha Ijner
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Chiara Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Talia Trottenberg
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Mehrnoush Dehghani
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Sara Najmeh
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Pierre Olivier Fiset
- Department of Pathology, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Saba Alsaddah
- Department of Pathology, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Jonathan Cools-Lartigue
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Jonathan Spicer
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Carmen Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Lorenzo Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada.
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13
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Maan ADI, Sharma P, Koch AD. Curative criteria for endoscopic treatment of oesophageal adenocarcinoma. Best Pract Res Clin Gastroenterol 2024; 68:101886. [PMID: 38522884 DOI: 10.1016/j.bpg.2024.101886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/23/2024] [Indexed: 03/26/2024]
Abstract
The incidence of oesophageal adenocarcinoma has been increasing rapidly in the Western world. A well-known risk factor for developing this type of tumour is reflux disease, which can cause metaplasia from the squamous cell mucosa to columnar epithelium (Barrett's Oesophagus) which can progress to dysplasia and eventually adenocarcinoma. With the rise of the incidence of oesophageal adenocarcinoma, research on the best way to manage this disease is of great importance and has changed treatment modalities over the last decades. The gold standard for superficial adenocarcinoma has shifted from surgical to endoscopic management when certain criteria are met. This review will discuss the different curative criteria for endoscopic treatment of oesophageal adenocarcinoma.
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Affiliation(s)
- Annemijn D I Maan
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas and VA Medical Centre, 4801 E Linwood Blvd, Kansas City, USA.
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
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14
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Leclercq P, Bisschops R, Bergman JJGHM, Pouw RE. Management of high risk T1 esophageal adenocarcinoma following endoscopic resection. Best Pract Res Clin Gastroenterol 2024; 68:101882. [PMID: 38522880 DOI: 10.1016/j.bpg.2024.101882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/17/2024] [Indexed: 03/26/2024]
Abstract
High-risk T1 esophageal adenocarcinoma (HR-T1 EAC) is defined as T1 cancer, with one or more of the following histological criteria: submucosal invasion, poorly or undifferentiated cancer, and/or presence of lympho-vascular invasion. Esophagectomy has long been the only available treatment for these HR-T1 EACs and was considered necessary because of a presumed high risk of lymph node metastases up to 46%. However, endoscopic submucosal disscection have made it possible to radically remove HR-T1 EAC, irrespective of size, while leaving the esophageal anatomy intact. Parallel to this development, new publications demonstrated that the risk of lymph node metastases for HR-T1 EAC may be even <24%. Therefore, indications for endoscopic treatment of HR-T1 EAC are being reconsidered and current research aims at finding the optimal management strategy for this indication, where watchful waiting may proof to be an acceptable strategy in selected patients. In this review, we will discuss the latest developments in this field.
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Affiliation(s)
- Philippe Leclercq
- Departement of Gastroenterology, Universitair Ziekenhuis Leuven, 49 Herestraat, 3000, LEUVEN, Belgium.
| | - Raf Bisschops
- Departement of Gastroenterology, Universitair Ziekenhuis Leuven, 49 Herestraat, 3000, LEUVEN, Belgium.
| | - Jacques J G H M Bergman
- Dept. of Gastroenterology and Hepatology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, 1081, HV, Netherlands.
| | - Roos E Pouw
- Dept. of Gastroenterology and Hepatology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, 1081, HV, Netherlands.
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15
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Waddingham W, Graham DG, Banks MR. Latest Advances in Endoscopic Detection of Oesophageal and Gastric Neoplasia. Diagnostics (Basel) 2024; 14:301. [PMID: 38337817 PMCID: PMC10855581 DOI: 10.3390/diagnostics14030301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Endoscopy is the gold standard for the diagnosis of cancers and cancer precursors in the oesophagus and stomach. Early detection of upper GI cancers requires high-quality endoscopy and awareness of the subtle features these lesions carry. Endoscopists performing surveillance of high-risk patients including those with Barrett's oesophagus, previous squamous neoplasia or chronic atrophic gastritis should be familiar with endoscopic features, classification systems and sampling techniques to maximise the detection of early cancer. In this article, we review the current approach to diagnosis of these conditions and the latest advanced imaging and diagnostic techniques.
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Affiliation(s)
- William Waddingham
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - David G. Graham
- Department of Gastroenterology, University College London NHS Foundation Trust, London NW1 2BU, UK
| | - Matthew R. Banks
- Department of Gastroenterology, University College London NHS Foundation Trust, London NW1 2BU, UK
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16
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Weusten BLAM, Bisschops R, Dinis-Ribeiro M, di Pietro M, Pech O, Spaander MCW, Baldaque-Silva F, Barret M, Coron E, Fernández-Esparrach G, Fitzgerald RC, Jansen M, Jovani M, Marques-de-Sa I, Rattan A, Tan WK, Verheij EPD, Zellenrath PA, Triantafyllou K, Pouw RE. Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2023; 55:1124-1146. [PMID: 37813356 DOI: 10.1055/a-2176-2440] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2: ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3: ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4: ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5: ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6: ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7: ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8: ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9: ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B: ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C: ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D: ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E: ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11: After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.
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Affiliation(s)
- Bas L A M Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto Portugal
| | - Massimiliano di Pietro
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Francisco Baldaque-Silva
- Advanced Endoscopy Center Carlos Moreira da Silva, Department of Gastroenterology, Pedro Hispano Hospital, Matosinhos, Portugal
- Division of Medicine, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital and University of Paris, Paris, France
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, IMAD, Centre hospitalier universitaire Hôtel-Dieu, Nantes, Nantes, France
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), Geneva, Switzerland
| | - Glòria Fernández-Esparrach
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Biomedical Research Network on Hepatic and Digestive Diseases (CIBEREHD), Barcelona, Spain
| | - Rebecca C Fitzgerald
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Marnix Jansen
- Department of Histopathology, University College London Hospital NHS Trust, London, UK
| | - Manol Jovani
- Division of Gastroenterology, Maimonides Medical Center, New York, New York, USA
| | - Ines Marques-de-Sa
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto Portugal
| | - Arti Rattan
- Department of Gastroenterology, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - W Keith Tan
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Eva P D Verheij
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Pauline A Zellenrath
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
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17
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Fernandes A, Li C, French D, Ellsmere J. Ten-year follow-up of endoscopic mucosal resection versus esophagectomy for esophageal intramucosal adenocarcinoma in the setting of Barrett's esophagus: a Canadian experience. Surg Endosc 2023; 37:8735-8741. [PMID: 37563345 DOI: 10.1007/s00464-023-10318-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/19/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is an effective treatment for esophageal intramucosal adenocarcinoma (IMC), with similar recurrence and mortality rates versus esophagectomy in up to 5 years of follow-up. Long-term outcomes to 10 years have not been studied. This retrospective study investigates IMC eradication, recurrence, morbidity and mortality at 10 years following EMR versus esophagectomy in a single Canadian institution. METHODS Patients with IMC treated via esophagectomy or EMR from 2006 to 2015 were included. Post-EMR endoscopic follow-up occurred every 3 months for 1 year, every 6 months for 2 years and every 12 months thereafter. Categorical variables were expressed as percentages and continuous variables as mean with standard deviation or median and interquartile range. The student's t-test and Fischer's exact test were used for comparisons. Survival analysis utilized the Kaplan-Meier estimator and log-rank test. RESULTS Twenty-four patients were included. Patient and tumor characteristics were similar between groups. Median follow-up for EMR and esophagectomy were 85.2 months [IQR 64.8] and 126 months [IQR 54] respectively. A mean of 1.3 EMR (SD 1.1) were required for eradication, which was seen in 12 patients (12/14, 86%). No EMR-related complications occurred. Disease progression was seen in two patients (2/14, 14%); local recurrence was seen in 1 patient (1/14, 7%). Esophagectomy eradicated IMC in 10 patients (10/10, 100%); recurrence was seen in 2 (2/10, 20%, metastatic). Major, early esophagectomy-related morbidity affected 3 patients (3/10, 30%), and late morbidity was documented for 9 (9/10, 90%). Esophagectomy and EMR had similar recurrence rates (p = 0.554). Esophagectomy was associated with significantly more procedure-related morbidity (p < 0.001). There was no difference in mortality (p = 0.442) or disease-free survival (p = 0.512) between treatment groups. CONCLUSION EMR and esophagectomy for the treatment of IMC are associated with comparable recurrence rates and disease-free survival in 10-year follow-up. EMR is associated with significantly lower procedure-associated morbidity. EMR can be used to treat T1a distal esophageal adenocarcinoma with minimal procedure-related morbidity, and acceptable oncologic outcomes in long-term follow-up.
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Affiliation(s)
- Alisha Fernandes
- Division of General and Gastrointestinal Surgery, Department of Surgery, Dalhousie University, Room 8-23/4 Victoria Building, QEII-HSC, VG Site, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Chao Li
- Division of General Surgery, Department of Surgery, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Canada
| | - Daniel French
- Division of Thoracic Surgery, Department of Surgery, Dalhousie University, Halifax, Canada
| | - James Ellsmere
- Division of General and Gastrointestinal Surgery, Department of Surgery, Dalhousie University, Room 8-23/4 Victoria Building, QEII-HSC, VG Site, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada.
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18
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Reyhani A, Gimson E, Baker C, Kelly M, Maisey N, Meenan J, Subesinghe M, Hill M, Lagergren J, Gossage J, Zeki S, Dunn J, Davies A. Multiple staging investigations may not change management in patients with high-grade dysplasia or early esophageal adenocarcinoma. Dis Esophagus 2023; 36:doad020. [PMID: 37032121 DOI: 10.1093/dote/doad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 02/20/2023] [Indexed: 04/11/2023]
Abstract
The clinical value of multiple staging investigations for high-grade dysplasia or early adenocarcinoma of the esophagus is unclear. A single-center prospective cohort of patients treated for early esophageal cancer between 2000 and 2019 was analyzed. This coincided with a transition period from esophagectomy to endoscopic mucosal resection (EMR) as the treatment of choice. Patients were staged with computed tomography (CT), endoscopic ultrasound (EUS) and 2-deoxy-2-[18F]fluoro-d-glucose (FDG) positron emission tomography(PET)/CT. The aim of this study was to assess their accuracy and impact on clinical management. 297 patients with high-grade dysplasia or early adenocarcinoma were included (endoscopic therapy/EMR n = 184; esophagectomy n = 113 [of which a 'combined' group had surgery preceded by endoscopic therapy n = 23]). Staging accuracy was low (accurate staging EMR: CT 40.1%, EUS 29.6%, FDG-PET/CT 11.0%; Esophagectomy: CT 43.3%, EUS 59.7%, FDG-PET/CT 29.6%; Combined: CT 28.6%, EUS46.2%, FDG-PET/CT 30.0%). Staging inaccuracies across all groups that could have changed management by missing T2 disease were CT 12%, EUS 12% and FDG-PET/CT 1.6%. The sensitivity of all techniques for detecting nodal disease was low (CT 12.5%, EUS 12.5%, FDG-PET/CT0.0%). Overall, FDG-PET/CT and EUS changed decision-making in only 3.2% of patients with an early cancer on CT and low-risk histology. The accuracy of staging with EUS, CT and FDG-PET/CT in patients with high-grade dysplasia or early adenocarcinoma of the esophagus is low. EUS and FDG-PET/CT added relevant staging information over standard CT in very few cases, and therefore, these investigations should be used selectively. Factors predicting the need for esophagectomy are predominantly obtained from EMR histology rather than staging investigations.
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Affiliation(s)
- A Reyhani
- Oesophagogastric research group, Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - E Gimson
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - C Baker
- Oesophagogastric research group, Guy's and St Thomas' Oesophago-gastric Centre, London, UK
| | - M Kelly
- Oesophagogastric research group, Guy's and St Thomas' Oesophago-gastric Centre, London, UK
| | - N Maisey
- Oesophagogastric research group, Guy's and St Thomas' Oesophago-gastric Centre, London, UK
| | - J Meenan
- Oesophagogastric research group, Guy's and St Thomas' Oesophago-gastric Centre, London, UK
| | - M Subesinghe
- Oesophagogastric research group, Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - M Hill
- Department of Oncology, Maidstone & Tunbridge Wells, Maidstone and Tunbridge Wells, UK
| | - J Lagergren
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J Gossage
- Oesophagogastric research group, Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - S Zeki
- Oesophagogastric research group, Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - J Dunn
- Oesophagogastric research group, Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - A Davies
- Oesophagogastric research group, Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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19
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Ramos JA, Morita Y, Toyonaga T, Carvalho D, Pedrosa MS, Arantes VN. Management of esophageal neoplasms by endoscopic submucosal dissection: experience over 100 consecutive procedures. Clin Endosc 2023; 56:613-622. [PMID: 37524567 PMCID: PMC10565440 DOI: 10.5946/ce.2022.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/07/2022] [Accepted: 11/14/2022] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic submucosal dissection (ESD) is currently considered the first-line treatment for the eradication of superficial neoplasms of the esophagus in Eastern countries. However, in the West, particularly in Latin America, the experience with esophageal ESD is still limited because of the high technical complexity required for its execution. This study aimed to present the results of the clinical application of ESD to manage superficial esophageal neoplasms in a Latin American center in over 100 consecutive cases. METHODS This retrospective study included consecutive patients who underwent endoscopic ESD for superficial esophageal neoplasms between 2009 and 2022. The following clinical outcomes were assessed: en bloc, complete, and curative resection rates, local recurrence, adverse events, and procedure-related mortality. RESULTS Esophageal ESD was performed mainly for squamous cell carcinoma (66.6%), high-grade intraepithelial neoplasia (17.1%), and adenocarcinoma (11.4%). En bloc and complete resection rates were 96.2% and 81.0%, respectively. The curative resection rate was 64.8%. Adverse events occurred in six cases (5.7%). Endoscopic follow-up was performed for an average period of 29.7 months. CONCLUSION ESD performed by trained operators is feasible, safe, and clinically effective for managing superficial neoplastic lesions of the esophagus in Latin America.
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Affiliation(s)
- Josué Aliaga Ramos
- Department of Gastroenterology, “Jose Agurto Tello-Chosica” Hospital, Lima, Perú
- Digestive Endoscopy Unit of San Pablo Clinic, Lima, Perú
- Faculty of Medicine, Cayetano Heredia Peruvian University, Lima, Perú
| | - Yoshinori Morita
- Department of Gastroenterology, Kobe University International Clinical Cancer Reserch Center, Kobe, Japan
| | - Takashi Toyonaga
- Department of Gastroenterology, Kobe University International Clinical Cancer Reserch Center, Kobe, Japan
| | - Danilo Carvalho
- Endoscopy Unit, Alfa Institute of Gastroenterology, Belo Horizonte, Brazil
| | - Moises Salgado Pedrosa
- Pathology Department, Alfa Institute of Gastroenterology, School of Medicine, Federal University of Minas Gerais, Laboratório CEAP, Belo Horizonte, Brazil
| | - Vitor N. Arantes
- Endoscopy Unit, Alfa Institute of Gastroenterology, School of Medicine, Federal University of Minas Gerais, Hospital Mater Dei Contorno, Belo Horizonte, Brazil
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20
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Frederiks CN, Overwater A, Bergman JJGHM, Pouw RE, de Keizer B, Bennink RJ, Brosens LAA, Meijer SL, van Hillegersberg R, van Berge Henegouwen MI, Ruurda JP, Gisbertz SS, Weusten BLAM. Feasibility and Safety of Tailored Lymphadenectomy Using Sentinel Node-Navigated Surgery in Patients with High-Risk T1 Esophageal Adenocarcinoma. Ann Surg Oncol 2023:10.1245/s10434-023-13317-6. [PMID: 36959491 PMCID: PMC10035969 DOI: 10.1245/s10434-023-13317-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/16/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Selective lymphadenectomy using sentinel node-navigated surgery (SNNS) might offer a less invasive alternative to esophagectomy in patients with high-risk T1 esophageal adenocarcinoma (EAC). The aim of this study was to evaluate the feasibility and safety of a new treatment strategy, consisting of radical endoscopic resection of the tumor followed by SNNS. METHODS In this multicenter pilot study, ten patients with a radically resected high-risk pT1cN0 EAC underwent SNNS. A hybrid tracer of technetium-99m nanocolloid and indocyanine green was injected endoscopically around the resection scar the day before surgery, followed by preoperative imaging. During surgery, sentinel nodes (SNs) were identified using a thoracolaparoscopic gammaprobe and fluorescence-based detection, and subsequently resected. Endpoints were surgical morbidity and number of detected and resected (tumor-positive) SNs. RESULTS Localization and dissection of SNs was feasible in all ten patients (median 3 SNs per patient, range 1-6). The concordance between preoperative imaging and intraoperative detection was high. In one patient (10%), dissection was considered incomplete after two SNs were not identified intraoperatively. Additional peritumoral SNs were resected in four patients (40%) after fluorescence-based detection. In two patients (20%), a (micro)metastasis was found in one of the resected SNs. One patient experienced neuropathic thoracic pain related to surgery, while none of the patients developed functional gastroesophageal disorders. CONCLUSIONS SNNS appears to be a feasible and safe instrument to tailor lymphadenectomy in patients with high-risk T1 EAC. Future research with long-term follow-up is warranted to determine whether this esophageal preserving strategy is justified for high-risk T1 EAC.
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Affiliation(s)
- Charlotte N Frederiks
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anouk Overwater
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Bart de Keizer
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roel J Bennink
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands.
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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21
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Fukami N. Endoscopic Submucosal Dissection in the Esophagus: Indications, Techniques, and Outcomes. Gastrointest Endosc Clin N Am 2023; 33:55-66. [PMID: 36375886 DOI: 10.1016/j.giec.2022.09.003] [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: 02/04/2023]
Abstract
Endoscopic submucosal dissection (ESD) is well-accepted endoscopic resection modality for esophageal lesions with benefits in certain situations. ESD offers potential cure for early esophageal cancer and detailed pathologic information for risk stratification. Techniques are mostly standardized, and the use of traction method is encouraged. Indication and proper techniques of ESD in esophageal disease and clinical outcomes will be discussed in this article with pearls for care planning and management during periprocedural period.
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Affiliation(s)
- Norio Fukami
- Mayo Clinic College of Medicine and Science, Mayo Clinic Arizona, 13400 E Shea Boulevard, Scottsdale, AZ 85259, USA.
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22
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Vantanasiri K, Iyer PG. State-of-the-art management of dysplastic Barrett's esophagus. Gastroenterol Rep (Oxf) 2022; 10:goac068. [PMID: 36381221 PMCID: PMC9651477 DOI: 10.1093/gastro/goac068] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 10/19/2022] [Accepted: 10/24/2022] [Indexed: 08/15/2023] Open
Abstract
Endoscopic eradication therapy (EET) has become a standard of care for treatment of dysplastic Barrett's esophagus (BE) and early Barrett's neoplasia. EET mainly consists of removal of any visible lesions via endoscopic resection and eradication of all remaining Barrett's mucosa using endoscopic ablation. Endoscopic mucosal resection and endoscopic submucosal dissection are the two available resection techniques. After complete resection of all visible lesions, it is crucial to perform endoscopic ablation to ensure complete eradication of the remaining Barrett's segment. Endoscopic ablation can be done either with thermal techniques, including radiofrequency ablation and argon plasma coagulation, or cryotherapy techniques. The primary end point of EET is achieving complete remission of intestinal metaplasia (CRIM) to decrease the risk of dysplastic recurrence after successful EET. After CRIM is achieved, a standardized endoscopic surveillance protocol needs to be implemented for early detection of BE recurrence.
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Affiliation(s)
- Kornpong Vantanasiri
- Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Prasad G Iyer
- Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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23
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Zyla RE, Kalimuthu SN. Barrett’s Esophagus and Esophageal Adenocarcinoma: A Histopathological Perspective. Thorac Surg Clin 2022; 32:413-424. [DOI: 10.1016/j.thorsurg.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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24
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Nieuwenhuis EA, van Munster SN, Meijer SL, Brosens LAA, Jansen M, Weusten BLAM, Alvarez Herrero L, Alkhalaf A, Schenk E, Schoon EJ, Curvers WL, Koch AD, van de Ven SEM, Verheij EPD, Nagengast WB, Westerhof J, Houben MHMG, Tang T, Bergman JJGHM, Pouw RE, Ooms A, Huysentruyt C, ten Kate F, Moll F, Kats-Ugurlu G, van Lijnschoten I, van de Laan J, Offerhaus J, Biermann K, Seldenrijk K, Brosens L, Meijer S, Doukas M. Analysis of metastases rates during follow-up after endoscopic resection of early "high-risk" esophageal adenocarcinoma. Gastrointest Endosc 2022; 96:237-247.e3. [PMID: 35288149 DOI: 10.1016/j.gie.2022.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/04/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS After endoscopic resection (ER) of early esophageal adenocarcinoma (EAC), the optimal management of patients with high-risk histologic features for lymph node metastases (ie, submucosal invasion, poor differentiation grade, or lymphovascular invasion) remains unclear. We aimed to evaluate outcomes of endoscopic follow-up after ER for high-risk EAC. METHODS For this retrospective cohort study, data were collected from all Dutch patients managed with endoscopic follow-up (endoscopy, EUS) after ER for high-risk EAC between 2008 and 2019. We distinguished 3 groups: intramucosal cancers with high-risk features, submucosal cancers with low-risk features, and submucosal cancers with high-risk features. The primary outcome was the annual risk for metastases during follow-up, stratified for baseline histology. RESULTS One hundred twenty patients met the selection criteria. Median follow-up was 29 months (interquartile range, 15-48). Metastases were observed in 5 of 25 (annual risk, 6.9%; 95% confidence interval [CI], 3.0-15) high-risk intramucosal cancers, 1 of 55 (annual risk, .7%; 95% CI, 0-4.0) low-risk submucosal cancers, and 3 of 40 (annual risk, 3.0%; 95% CI, 0-7.0) high-risk submucosal cancers. CONCLUSIONS Whereas the annual metastasis rate for high-risk submucosal EAC (3.0%) was somewhat lower than expected in comparison with previous reported percentages, the annual metastasis rate of 6.9% for high-risk intramucosal EAC is new and worrisome. This calls for further prospective studies and suggests that strict follow-up of this small subgroup is warranted until prospective data are available.
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Affiliation(s)
- Esther A Nieuwenhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Sanne N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marnix Jansen
- Department of Pathology, UCL Cancer Institute and University College London Hospital, NHS Trust, London, UK
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Ed Schenk
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Erik J Schoon
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands; Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Eva P D Verheij
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands, (12)Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands, (12)Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands, (12)Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | - Thjon Tang
- Department of Gastroenterology and Hepatology, Ijsselland Hospital, Capelle aan den Ijssel, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
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25
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Kamboj AK, Iyer PG. Pushing the boundaries of endoscopic management of early-stage esophageal adenocarcinoma: Caution is advisable! Gastrointest Endosc 2022; 96:248-249. [PMID: 35715236 DOI: 10.1016/j.gie.2022.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Amrit K Kamboj
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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26
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Pimentel-Nunes P, Libânio D, Bastiaansen BAJ, Bhandari P, Bisschops R, Bourke MJ, Esposito G, Lemmers A, Maselli R, Messmann H, Pech O, Pioche M, Vieth M, Weusten BLAM, van Hooft JE, Deprez PH, Dinis-Ribeiro M. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy 2022; 54:591-622. [PMID: 35523224 DOI: 10.1055/a-1811-7025] [Citation(s) in RCA: 219] [Impact Index Per Article: 109.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
ESGE recommends that the evaluation of superficial gastrointestinal (GI) lesions should be made by an experienced endoscopist, using high definition white-light and chromoendoscopy (virtual or dye-based).ESGE does not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection.ESGE recommends endoscopic submucosal dissection (ESD) as the treatment of choice for most superficial esophageal squamous cell and superficial gastric lesions.For Barrett's esophagus (BE)-associated lesions, ESGE suggests the use of ESD for lesions suspicious of submucosal invasion (Paris type 0-Is, 0-IIc), for malignant lesions > 20 mm, and for lesions in scarred/fibrotic areas.ESGE does not recommend routine use of ESD for duodenal or small-bowel lesions.ESGE suggests that ESD should be considered for en bloc resection of colorectal (but particularly rectal) lesions with suspicion of limited submucosal invasion (demarcated depressed area with irregular surface pattern or a large protruding or bulky component, particularly if the lesions are larger than 20 mm) or for lesions that otherwise cannot be completely removed by snare-based techniques.ESGE recommends that an en bloc R0 resection of a superficial GI lesion with histology no more advanced than intramucosal cancer (no more than m2 in esophageal squamous cell carcinoma), well to moderately differentiated, with no lymphovascular invasion or ulceration, should be considered a very low risk (curative) resection, and no further staging procedure or treatment is generally recommended.ESGE recommends that the following should be considered to be a low risk (curative) resection and no further treatment is generally recommended: an en bloc R0 resection of a superficial GI lesion with superficial submucosal invasion (sm1), that is well to moderately differentiated, with no lymphovascular invasion, of size ≤ 20 mm for an esophageal squamous cell carcinoma or ≤ 30 mm for a stomach lesion or of any size for a BE-related or colorectal lesion, and with no lymphovascular invasion, and no budding grade 2 or 3 for colorectal lesions.ESGE recommends that, after an endoscopically complete resection, if there is a positive horizontal margin or if resection is piecemeal, but there is no submucosal invasion and no other high risk criteria are met, this should be considered a local-risk resection and endoscopic surveillance or re-treatment is recommended rather than surgery or other additional treatment.ESGE recommends that when there is a diagnosis of lymphovascular invasion, or deeper infiltration than sm1, or positive vertical margins, or undifferentiated tumor, or, for colorectal lesions, budding grade 2 or 3, this should be considered a high risk (noncurative) resection, and complete staging and strong consideration for additional treatments should be considered on an individual basis in a multidisciplinary discussion.ESGE recommends scheduled endoscopic surveillance with high definition white-light and chromoendoscopy (virtual or dye-based) with biopsies of only the suspicious areas after a curative ESD.
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Affiliation(s)
- Pedro Pimentel-Nunes
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- Department of Surgery and Physiology, Porto Faculty of Medicine, Portugal
| | - Diogo Libânio
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Center, The Netherlands
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia and Western Clinical School, University of Sydney, Sydney, Australia
| | - Gianluca Esposito
- Department of Medical-Surgical Sciences and Translational Medicine, Sant' Andrea Hospital, Sapienza University of Rome, Italy
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Helmut Messmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Bayern, Germany
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pierre H Deprez
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
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27
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van Munster SN, Verheij EPD, Nieuwenhuis EA, Offerhaus JGJA, Meijer SL, Brosens LAA, Weusten BLAM, Alkhalaf A, Schenk EBE, Schoon EJ, Curvers WL, van Tilburg L, van de Ven SEM, Tang TJ, Nagengast WB, Houben MHMG, Seldenrijk KCA, Bergman JJGHM, Koch AD, Pouw RE. Extending treatment criteria for Barrett's neoplasia: results of a nationwide cohort of 138 endoscopic submucosal dissection procedures. Endoscopy 2022; 54:531-541. [PMID: 34592769 DOI: 10.1055/a-1658-7554] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The use of endoscopic submucosal dissection (ESD) is gradually expanding for treatment of neoplasia in Barrett's esophagus (BE). We aimed to report outcomes of all ESDs for BE neoplasia performed in the Netherlands. METHODS Retrospective assessment of outcomes, using treatment and follow-up data from a joint database. RESULTS 130/138 patients had complete ESDs, with 126/130 (97 %) en bloc resections. Median (interquartile range (IQR)) procedure time was 121 minutes (90-180). Pathology findings were high grade dysplasia (HGD) (5 %) or esophageal adenocarcinoma (EAC) T1a (43 %) or T1b (52 %; 19 % sm1, 33 % ≥ sm2). Among resections of HGD or T1a EAC lesions, 87 % (95 %CI 75 %-92 %) were both en bloc and R0; the corresponding value for T1b EAC lesions was 49 % (36 %-60 %). Among R1 resections, 10/34 (29 %) showed residual cancer, all detected at first endoscopic follow-up. The remaining 24 patients (71 %) showed no residual neoplasia. Six of these patients underwent surgery with no residual tumor; the remaining 18 underwent endoscopic follow-up during median 31 months with 1 local recurrence (annual recurrence rate 2 %). Among R0 resections, annual local recurrence rate during median 27 months was 0.5 %. CONCLUSION In expert hands, ESD allows safe removal of bulky intraluminal neoplasia and submucosal cancer. ESD of the latter showed R1 resection margins in 50 %, yet only one third had persisting neoplasia at follow-up. To better stratify R1 patients with an indication for additional surgery, repeat endoscopy after healing of the ESD might be a helpful possible prognostic factor for residual cancer.
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Affiliation(s)
- Sanne N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Eva P D Verheij
- Department of Gastroenterology and Hepatology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
| | - Esther A Nieuwenhuis
- Department of Gastroenterology and Hepatology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
| | - Johan G J A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands
| | - Ed B E Schenk
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands.,GROW: School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Laurelle van Tilburg
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Thjon J Tang
- Department of Gastroenterology and Hepatology, Ijsselland Hospital, Capelle aan den Ijssel, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, The Netherlands
| | - Kees C A Seldenrijk
- Department of Pathology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
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Martínez-Domínguez SJ, Lanas Á, Domper-Arnal MJ. Esófago de Barrett, hacia la mejora de la práctica clínica. Med Clin (Barc) 2022; 159:92-100. [DOI: 10.1016/j.medcli.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 02/07/2023]
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29
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Endoscopic Management of Barrett's Esophagus. Dig Dis Sci 2022; 67:1469-1479. [PMID: 35226224 DOI: 10.1007/s10620-022-07395-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/09/2022]
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30
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Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. Am J Gastroenterol 2022; 117:559-587. [PMID: 35354777 DOI: 10.14309/ajg.0000000000001680] [Citation(s) in RCA: 158] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 02/04/2022] [Indexed: 02/07/2023]
Abstract
Barrett's esophagus (BE) is a common condition associated with chronic gastroesophageal reflux disease. BE is the only known precursor to esophageal adenocarcinoma, a highly lethal cancer with an increasing incidence over the last 5 decades. These revised guidelines implement Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the definition and diagnosis of BE, screening for BE and esophageal adenocarcinoma, surveillance of patients with known BE, and the medical and endoscopic treatment of BE and its associated early neoplasia. Important changes since the previous iteration of this guideline include a broadening of acceptable screening modalities for BE to include nonendoscopic methods, liberalized intervals for surveillance of short-segment BE, and volume criteria for endoscopic therapy centers for BE. We recommend endoscopic eradication therapy for patients with BE and high-grade dysplasia and those with BE and low-grade dysplasia. We propose structured surveillance intervals for patients with dysplastic BE after successful ablation based on the baseline degree of dysplasia. We could not make recommendations regarding chemoprevention or use of biomarkers in routine practice due to insufficient data.
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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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32
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Frederiks CN, van de Water JMW, Ebrahimi G, Weusten BLAM. Cryoballoon ablation as salvage therapy after nonradical resection of a high-risk T1b esophageal adenocarcinoma: a case report. Eur J Gastroenterol Hepatol 2022; 34:354-357. [PMID: 34231521 DOI: 10.1097/meg.0000000000002242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Although esophagectomy with or without (neo)adjuvant chemoradiation therapy is the current standard of care for patients with early esophageal adenocarcinoma with high-risk features or after nonradical endoscopic resection of an early esophageal adenocarcinoma, not all patients are eligible for surgery due to varying reasons. In these patients, cryoballoon ablation may serve as an alternative treatment option considering the potential of deeper tissue ablation as compared to heat-based ablation techniques. We report the first case in which cryoballoon ablation was successfully performed as salvage therapy with a curative intent for positive deep resection margins after an incomplete endoscopic resection of a recurrent early esophageal adenocarcinoma.
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Affiliation(s)
- Charlotte N Frederiks
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University
| | | | - Gati Ebrahimi
- Department of Radiotherapy, Verbeeten Institute, Tilburg, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University
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33
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Gotink AW, van de Ven SEM, Ten Kate FJC, Nieboer D, Suzuki L, Weusten BLAM, Brosens LAA, van Hillegersberg R, Alvarez Herrero L, Seldenrijk CA, Alkhalaf A, Moll FCP, Schoon EJ, van Lijnschoten I, Tang TJ, van der Valk H, Nagengast WB, Kats-Ugurlu G, Plukker JTM, Houben MHMG, van der Laan JS, Pouw RE, Bergman JJGHM, Meijer SL, van Berge Henegouwen MI, Wijnhoven BPL, de Jonge PJF, Doukas M, Bruno MJ, Biermann K, Koch AD. Individual risk calculator to predict lymph node metastases in patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study. Endoscopy 2022; 54:109-117. [PMID: 33626582 DOI: 10.1055/a-1399-4989] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Lymph node metastasis (LNM) is possible after endoscopic resection of early esophageal adenocarcinoma (EAC). This study aimed to develop and internally validate a prediction model that estimates the individual risk of metastases in patients with pT1b EAC. METHODS A nationwide, retrospective, multicenter cohort study was conducted in patients with pT1b EAC treated with endoscopic resection and/or surgery between 1989 and 2016. The primary end point was presence of LNM in surgical resection specimens or detection of metastases during follow-up. All resection specimens were histologically reassessed by specialist gastrointestinal pathologists. Subdistribution hazard regression analysis was used to develop the prediction model. The discriminative ability of this model was assessed using the c-statistic. RESULTS 248 patients with pT1b EAC were included. Metastases were seen in 78 patients, and the 5-year cumulative incidence was 30.9 % (95 % confidence interval [CI] 25.1 %-36.8 %). The risk of metastases increased with submucosal invasion depth (subdistribution hazard ratio [SHR] 1.08, 95 %CI 1.02-1.14, for every increase of 500 μm), lymphovascular invasion (SHR 2.95, 95 %CI 1.95-4.45), and for larger tumors (SHR 1.23, 95 %CI 1.10-1.37, for every increase of 10 mm). The model demonstrated good discriminative ability (c-statistic 0.81, 95 %CI 0.75-0.86). CONCLUSIONS A third of patients with pT1b EAC experienced metastases within 5 years. The probability of developing post-resection metastases was estimated with a personalized predicted risk score incorporating tumor invasion depth, tumor size, and lymphovascular invasion. This model requires external validation before implementation into clinical practice.
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Affiliation(s)
- Annieke W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Fiebo J C Ten Kate
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands.,Department of Pathology, Isala Clinics, Zwolle, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Lucia Suzuki
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Cees A Seldenrijk
- Department of Pathology, Pathology DNA, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Freek C P Moll
- Department of Pathology, Isala Clinics, Zwolle, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Thjon J Tang
- Department of Gastroenterology and Hepatology, Ijsselland Hospital, Capelle aan den Ijssel, the Netherlands
| | - Hans van der Valk
- Department of Pathology, Ijselland Hospital, Capelle aan den Ijssel, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Gursah Kats-Ugurlu
- Department of Pathology, University Medical Center Groningen, Groningen, the Netherlands
| | - John T M Plukker
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | | | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Michael Doukas
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
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Zhou X, Chen H, Li S, Hua J, Zhang W, Li X, Si X, Zhang G. Treatment Options for T1 Stage Adenocarcinoma of Esophagogastric Junction: A Real-World Retrospective Cohort Study. Cancer Control 2021; 28:10732748211063955. [PMID: 34913741 PMCID: PMC8723737 DOI: 10.1177/10732748211063955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background The number of patients diagnosed with T1 stage adenocarcinoma of
esophagogastric junction (AEGJ) has been increasing. This study was
conducted to investigate the effect of different treatment options (surgery,
chemoradiation, and surgery+chemoradiation) on long-term survival in
patients with T1-stage AEGJ. Methods We searched the Surveillance, Epidemiology, and End Results (SEER) database
to identify the records of patients with T1-stage AEGJ between 2010 and
2018. Patient demographics and cancer parameters were compared among the
three groups. The Kaplan–Meier method and Cox proportional hazard modeling
were used to compare long-term survival. Results Data from 925 T1 stage AEGJ patients (surgery: n=516, surgery+chemoradiation:
n=206, chemoradiation: n=203) were collected. We found that the OS and CSS
rates of three treatment options had significant difference. Besides,
positive nodal status also showed lower OS and CSS rat. Multivariate Cox
regression analysis showed that surgery group has much lower risk of death
compared with chemoradiation group and similar risk of death compared with
surgery+chemoradiation group. Subgroup analysis suggested that in patients
with N1–N3 status had higher OS and CSS rates in surgery+chemoradiation
group. Conclusion Using SEER data, we identified a significant survival advantage with the use
of surgery compared to chemoradiation in patients with T1-stage AEGJ while
the long-term survival of patients after surgery+chemoradiation group was
not significantly different and low risk of death in positive nodal
status.
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Affiliation(s)
- Xiaoying Zhou
- Department of Gastroenterology, 74734First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Han Chen
- Department of Gastroenterology, 74734First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shuo Li
- Department of Gastroenterology, 74734First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jie Hua
- Department of Gastroenterology, 74734First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weifeng Zhang
- Department of Gastroenterology, 74734First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xueliang Li
- Department of Gastroenterology, 74734First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xinmin Si
- Department of Gastroenterology, 74734First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Guoxin Zhang
- Department of Gastroenterology, 74734First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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35
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Endoscopic management of Barrett's dysplasia and early neoplasia: efficacy, safety and long-term outcomes in a UK tertiary centre. Eur J Gastroenterol Hepatol 2021; 33:e413-e422. [PMID: 33731587 DOI: 10.1097/meg.0000000000002121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are effective treatments for dysplastic Barrett's esophagus (BE). This study evaluates efficacy, durability and safety in a single high-volume UK tertiary centre with 15-years' experience. METHODS Prospective data were collected from Nottingham University Hospitals 2004-2019 for endotherapy of dysplastic BE or intramucosal adenocarcinoma. Procedural outcome measures include complete resection, complications and surgery rates. Efficacy outcomes include complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM), recurrence, treatment failure rates, durability of RFA, median follow up and tumor-associated mortality. RESULTS A total of 319 lesions were resected; 671 RFAs were performed on 239 patients. Median age was 67 (±9.5) years, male:female ratio was 5:1 and median BE length was C3 [interquartile range (IQR): 6] M6 (IQR: 5). The most common lesion was Paris IIa (64%) with a median size of 10 mm (3-70). Final histology was adenocarcinoma in 50%. Complete resection rates were 96%. The multiband mucosectomy technique (91%) was most commonly used. The median number of RFA sessions was 3 (IQR: 2). The rates of CR-D and CR-IM were 90.4%% and 89.8% achieved after a median of 20.1 (IQR: 14) months. The most common complications: EMR was bleeding 2.2% and RFA was stricture (5.4%) requiring a median of 2 (range 1-7) dilatations. Median follow up post CR-IM/CR-D was 38 months (14-60). Metachronous lesions developed in 4.7% after CR-D and tumor-related mortality was 0.8%. Dysplasia and intestinal metaplasia-free survival at 5 years was 95 and 90%, respectively. CONCLUSION BE endotherapy is minimally invasive, effective, safe and deliverable in a day-case setting.
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Karamchandani DM, Gonzalez RS, Westerhoff M, Westbrook LM, Panarelli NC, Al-Nuaimi M, King T, Arnold CA. Measuring depth of invasion of submucosa - invasive adenocarcinoma in oesophageal endoscopic specimens: how good are we?☆. Histopathology 2021; 80:420-429. [PMID: 34519098 DOI: 10.1111/his.14566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/12/2021] [Indexed: 01/10/2023]
Abstract
AIMS Emerging data support that submucosa-invasive (pT1b) esophageal adenocarcinomas are cured via endoscopic resection, provided that invasion measures ≤500 μm, they lack other histological features predictive of nodal metastasis and have negative margins. Hence, pathologists' measurement of the depth of submucosal invasion in endoscopic resections may dictate further management (i.e. endoscopic follow-up versus oesophagectomy). In this study, we assessed the interobserver agreement in measuring the depth of submucosal invasion in oesophageal endoscopic resections. METHODS AND RESULTS Six subspecialised gastrointestinal (GI) pathologists from five academic centres independently measured the depth of submucosal invasion in μm from the deepest muscularis mucosae on 37 oesophageal endoscopic resection slides (round 1 scoring). A consensus meeting with a systematic approach for measuring and discussion of pitfalls was undertaken and remeasuring (round 2 scoring) was conducted. Interobserver agreement was assessed by the intraclass correlation coefficient (ICC) and Cohen's kappa statistics. A lack of agreement was seen among the six reviewers with a poor ICC for both rounds: 1 [0.40, 95% confidence interval (CI) = 0.26-0.56] and 2 (0.49, 95% CI = 0.34-0.63). When measurements were categorised as < or >500 μm, the overall agreement among the six reviewers was only fair for both rounds: 1 (kappa = 0.37, 95% CI = 0.22-0.53) and 2 (kappa = 0.29, 95% CI = 0.12-0.46). CONCLUSIONS Our study shows a lack of agreement among gastrointestinal pathologists in measuring the depth of submucosal invasion in oesophageal endoscopic resections despite formulating a consensus approach for scoring. If important management decisions continue to be based upon this parameter, more reproducible and concrete guidelines are needed.
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Affiliation(s)
- Dipti M Karamchandani
- Department of Pathology, 1 Penn State Health Milton S. Hershey Medical Center/Penn State College of Medicine, Hershey, PA, USA
| | | | | | | | | | - Mayyadah Al-Nuaimi
- Department of Pathology, 1 Penn State Health Milton S. Hershey Medical Center/Penn State College of Medicine, Hershey, PA, USA
| | - Tonya King
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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Duprée A, Ehlken H, Rösch T, Lüken M, Reeh M, Werner YB, de Heer J, Schachschal G, Clauditz TS, Mann O, Izbicki JR, Groth S. Laparoscopic lymph node sampling: a new concept for patients with high-risk early esophagogastric junction cancer resected endoscopically. Gastrointest Endosc 2021; 94:282-290. [PMID: 33639136 DOI: 10.1016/j.gie.2021.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 02/13/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic resection is considered a curative treatment for early upper GI cancers under certain histologic (low-risk) criteria. In tumors not completely fulfilling these criteria but resected R0 endoscopically, esophagectomy is still advised because of an increased risk of lymph node (LN) metastases (LNM). However, the benefit-risk ratio, especially in elderly patients at higher risk for radical surgery, can be debated. We now present the outcome of our case series of laparoscopic LN sampling (LLS) in patients with T1 esophagogastric junction tumors, which had been completely resected by endoscopy but did not fulfill the low-risk criteria (G1/2, m, L0, V0). METHODS Retrospective review was done of all patients with T1 cancer undergoing LLS with at least 1 high-risk parameter after endoscopic resection during an 8-year period. Repeated endoscopy with biopsy and abdominothoracic CT had been performed before. The patients were divided into 2 periods: before (n = 8) and after (n = 12) the introduction of an extended LLS protocol (additional resection of the left gastric artery). In cases of positive LN, patients underwent conventional oncologic surgery; if negative, follow-up was performed. The main outcome was the number of harvested LNs by means of LLS and the percentage of positive LNs found. RESULTS Twenty patients with cardia (n = 1) and distal esophageal/Barrett's cancer (n = 19) were included. The LN rate with use of the extended LLS technique increased by 12% (period 1: median 12 [range, 5-19; 95% CI, 3.4-15.4] vs period 2: median 17.5 [range, 12-40; 95% CI, 12.8-22.2]; P = .013). There were 2 adverse events: 1 inadvertent chest tube removal and 1 postoperative pneumonia. In 15% of cases, patients had positive LNs. and in 2 cases there was local recurrence at the endoscopic resection site, all necessitating surgery. CONCLUSIONS An extended technique of laparoscopic LN sampling appears to provide adequate LN numbers and is a safe approach with short hospital stay only. Only long-term follow-up of larger patient numbers will allow conclusions about miss rate as well as oncologic adequacy of this concept.
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Affiliation(s)
- Anna Duprée
- Departments of General and Abdominal Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Hanno Ehlken
- Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marina Lüken
- Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Reeh
- Departments of General and Abdominal Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Yuki B Werner
- Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jocelyn de Heer
- Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Guido Schachschal
- Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Till S Clauditz
- Institute of Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver Mann
- Departments of General and Abdominal Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Departments of General and Abdominal Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Groth
- Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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38
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McGoran JJ, Ragunath K. Endoscopic management of Barrett's esophagus: Western perspective of current status and future prospects. Dig Endosc 2021; 33:720-729. [PMID: 32790886 DOI: 10.1111/den.13812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 08/03/2020] [Accepted: 08/11/2020] [Indexed: 02/08/2023]
Abstract
Barrett's esophagus (BE) is a precursor to esophageal adenocarcinoma and current practice is to establish endoscopic surveillance once diagnosed, in order to identify early dysplasia and neoplasia that has the potential to undergo endoscopic eradication therapy (EET). Before embarking upon EET the clinical team has a duty to consider all viable options and come to a plan based on recent evidence. The therapeutic approach varies greatly but largely adheres to the mantra of 'Detect-Resect-Ablate', in which high-quality endoscopy identifies BE associated pathology, associated lesions (if present) undergo safe endoscopic resection and remaining intestinal metaplasia in the esophagus is ablated to prevent recurrence of dysplasia. In this review, current practice, pitfalls, complications, and the future perspectives on practice in this field are discussed. The Western perspective is focused on here, with an outline of the differences in clinical practice with Asian nations and attempts to bridge these differences.
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Affiliation(s)
- John J McGoran
- Department of Digestive Diseases, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Krish Ragunath
- Department of Gastroenterology & Hepatology, Royal Perth Hospital, Perth, WA, Australia.,Curtin University Medical School, Perth, WA, Australia
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Feasibility of sentinel node navigated surgery in high-risk T1b esophageal adenocarcinoma patients using a hybrid tracer of technetium-99 m and indocyanine green. Surg Endosc 2021; 36:2671-2679. [PMID: 34046715 PMCID: PMC8921120 DOI: 10.1007/s00464-021-08551-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 05/04/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Minimally invasive esophagectomy with two-field lymphadenectomy is standard of care for T1b esophageal adenocarcinoma (EAC) with a high risk of lymph node metastasis. Sentinel node navigation surgery (SNNS) is a well-known concept to tailor the extent of lymphadenectomy. The aim of this study was to evaluate the feasibility and safety of SNNS with a hybrid tracer (technetium-99 m/indocyanine green/nanocolloid) for patients with high-risk T1b EAC. METHODS In this prospective, multicenter pilot study, 5 patients with high-risk T1b EAC were included. The tracer was injected endoscopically around the endoscopic resection scar the day before surgery, followed by preoperative imaging (lymphoscintigraphy/SPECT-CT). During surgery, first the SNs were localized and resected based on preoperative imaging and intraoperative gammaprobe- and fluorescence-based detection, followed by esophagectomy. Primary endpoints were the percentage of patients with detectable SNs, concordance between preoperative and intraoperative SN detection, and the additive value of indocyanine green. RESULTS SNs could be identified and resected in all patients (median 3 SNs per patient, range 2-7). There was a high concordance between preoperative and intraoperative SN detection. In 2 patients additional peritumoral SNs were identified with fluorescence-based detection. None of the resected lymph nodes showed signs of (micro)metastases and no nodal metastases were detected in the surgical resection specimen. CONCLUSIONS SNNS using technetium-99 m/indocyanine green/nanocolloid seems feasible and safe in patients with high-risk T1b EAC. Indocyanine green fluorescence seems to be of additive value for detection of peritumoral SNs. Whether this approach can optimize selection for esophagectomy needs to be studied in future research.
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Wang W, Chen D, Sang Y, Chen C, Zhang Y, Mao Y, Chen Y. Endoscopic resection versus esophagectomy for patients with small-sized T1N0 esophageal cancer: A propensity-matched study. Clin Res Hepatol Gastroenterol 2021; 45:101543. [PMID: 33554864 DOI: 10.1016/j.clinre.2020.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/25/2020] [Accepted: 09/11/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Endoscopic resection (ER) has been rapidly adopted in the treatment of early-stage esophageal cancer. We aimed to compare the outcomes of ER with esophagectomy for patients with small-sized (≤2 cm) stage T1a and T1b esophageal cancer in a population-based cohort. METHODS We queried the Surveillance, Epidemiology, and End Results database for patients with T1N0M0 esophageal cancer who underwent ER or esophagectomy and generated a balanced cohort with 217 matched pairs using propensity score matching (PSM). Kaplan-Meier method and multivariable Cox regression analysis were employed to investigate the matched cohort. Subgroup analyses of T stage were also performed. RESULTS We identified 702 patients; 309 (44.0 %) underwent ER, and 393 (56.0 %) underwent esophagectomy. In the unmatched cohort, patients who underwent ER were older, more likely to have a T1a stage, and less likely to receive lymph node sampling. In the entire matched cohort, multivariate analysis found esophagectomy were associated with better overall survival (OS) (HR: 0.62, 95 % CI: 0.40-0.96, p = 0.032) than ER, but no significant difference in esophageal cancer-specific survival (ECSS) (HR: 1.37, 95 % CI: 0.64-2.96, p = 0.420) between the two procedures. The results were similar for subgroup analyses of stage T1b patients. However, ER and esophagectomy were associated with similar OS (HR: 0.74, 95 % CI: 0.41-1.36; p = 0.334) and ECSS (HR: 3.69, 95 % CI: 0.95-14.39; p = 0.060) in patients with stage T1a disease. CONCLUSIONS In patients with stage T1 esophageal cancer, ER was similar to esophagectomy in terms of oncologic outcomes. More prospective studies should be implemented to determine the optimal treatment for T1b esophageal cancer patients with risk factors.
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Affiliation(s)
- Wenjia Wang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Donglai Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Yonghua Sang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Yongsheng Zhang
- Department of Pathology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yiming Mao
- Department of Thoracic Surgery, Suzhou Kowloon Hospital Shanghai Jiaotong University School of Medicine, Suzhou, China
| | - Yongbing Chen
- Department of Thoracic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China.
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Benech N, O'Brien JM, Barret M, Jacques J, Rahmi G, Perrod G, Hervieu V, Jaouen A, Charissoux A, Guillaud O, Legros R, Walter T, Saurin JC, Rivory J, Prat F, Lépilliez V, Ponchon T, Pioche M. Endoscopic resection of Barrett's adenocarcinoma: Intramucosal and low-risk tumours are not associated with lymph node metastases. United European Gastroenterol J 2021; 9:362-369. [PMID: 32903167 PMCID: PMC8259244 DOI: 10.1177/2050640620958903] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Superficial oesophageal adenocarcinoma can be resected endoscopically, but data to define a curative endoscopic resection are scarce. Objective Our study aimed to assess the risk of lymph node metastasis depending on the depth of invasion and histological features of oesophageal adenocarcinoma. Methods We retrospectively included all patients undergoing an endoscopic resection for T1 oesophageal adenocarcinoma among seven expert centres in France in 2004–2016. Mural invasion was defined as either intramucosal or submucosal tumours; the latter were further divided into superficial submucosal (<1000 mm) and deep submucosal (>1000 mm). Absence or presence of lymphovascular invasion and/or poorly differentiated cancer (G3) defined a low‐risk or a high‐risk tumour, respectively. For submucosal tumours, invasion depth and histological features were systematically confirmed after a second dedicated histological assessment (new 2‐mm thick slices) performed by a second pathologist. Occurrence of lymph node metastasis was recorded during the follow‐up from histological or PET CT reports when an invasive procedure was not possible. Results In total, 188 superficial oesophageal adenocarcinomas were included with a median follow‐up of 34 months. No lymph node metastases occurred for intramucosal oesophageal adenocarcinomas (n = 135) even with high‐risk histological features. Among submucosal oesophageal adenocarcinomas, only tumours with lymphovascular invasion or poorly differentiated cancer or with a depth of invasion >1000 μm developed lymph node metastasis tumours (n = 10/53%; 18.9%; hazard ratio 12.04). No metastatic evolution occurred under a 1000‐mm threshold for all low‐risk tumours (0/25), nor under 1200 mm (0/1) and three over this threshold (3/13%, 23.1%). Conclusion Intramucosal and low‐risk tumours with shallow submucosal invasion up to 1200 mm were not associated with lymph node metastasis during follow‐up. In case of high‐risk features and/or deep submucosal invasion, endoscopic resections are not sufficient to eliminate the risk of lymph node metastasis, and surgical oesophagectomy should be carried out. These results must be confirmed by larger prospective series. Superficial oesophageal adenocarcinoma (OAC) can be resected endoscopically. Data to define a curative endoscopic resection with a low lymph node metastasis (LNM) risk are scarce especially for tumours invading the submucosa. Curative endoscopic resections have been reported in selected OAC invading the first 500 mm of the submucosa, but surgical series showed an LNM risk ranging from 0% to 50%, making endoscopic resection a questionable curative treatment. High‐risk histological features were not associated with LNM in intramucosal tumours. LNM occurred only for tumours invading the submucosa with a depth ≥1200 mm or with high‐risk histological features regardless of the depth of invasion. Endoscopic resection may be a valid and curative therapeutic option for all intramucosal tumours and for submucosal oesophageal adenocarcinoma with an invasion depth ≤1000 mm and low‐risk histological features.
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Affiliation(s)
- Nicolas Benech
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France
| | - Jean Marc O'Brien
- Université Claude Bernard Lyon 1, Lyon, France.,Service d'Hépato-Gastroentérologie, Hôpital de La Croix-Rousse, Hospices civils de Lyon, Lyon, France
| | | | - Jéremie Jacques
- Service d'Hepato-Gastroenterologie, Dupuytren University Hospital, Limoges, France
| | - Gabriel Rahmi
- Service d'Hepato-Gastroenterologie, Hôpital Europeen Georges Pompidou, Paris, France
| | - Guillaume Perrod
- Service d'Hepato-Gastroenterologie, Hôpital Europeen Georges Pompidou, Paris, France
| | - Valérie Hervieu
- Service d'Anatomo-Pathologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Alexandre Jaouen
- Service d'Anatomo-Pathologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Aurélie Charissoux
- Service d'Anatomo-Pathologie, Dupuytren University Hospital, Limoges, France
| | - Olivier Guillaud
- Service d'Hepato-Gastroenterologie, Clinique de la Sauvegarde, Lyon, France
| | - Romain Legros
- Service d'Hepato-Gastroenterologie, Dupuytren University Hospital, Limoges, France
| | - Thomas Walter
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Jean-Christophe Saurin
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Jérôme Rivory
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France
| | - Fréderic Prat
- Service d'Hepato-Gastroentérologie, Hôpital Cochin, Paris, France
| | - Vincent Lépilliez
- Service d'Hepato-Gastroentérologie, Mermoz Private Hospital, Lyon, France
| | - Thierry Ponchon
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,INSERM U1032, Lab Tau, Lyon, France
| | - Mathieu Pioche
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,INSERM U1032, Lab Tau, Lyon, France
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Joo DC, Kim GH, Lee BE, Lee MW, Baek DH, Song GA, Lee S, Park DY. Endoscopic Submucosal Dissection for Superficial Barrett’s Neoplasia in Korea: a Single-Center Experience. J Gastric Cancer 2021; 21:426-438. [PMID: 35079444 PMCID: PMC8753282 DOI: 10.5230/jgc.2021.21.e39] [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: 11/01/2021] [Revised: 12/18/2021] [Accepted: 12/20/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose While the incidence of Barrett’s neoplasia has been increasing in Western countries, the disease remains rare in Asian countries. Therefore, very few studies have investigated the endoscopic treatment for Barrett’s neoplasia in Korea. Endoscopic submucosal dissection (ESD) enables en bloc and complete resection of gastrointestinal neoplastic lesions. This study aimed to evaluate the therapeutic outcomes of ESD for Barrett’s neoplasia in a single center in Korea and to examine the predictive factors for incomplete resection. Materials and Methods We conducted a retrospective observational study of 18 patients who underwent ESD for superficial Barrett’s neoplasia (dysplasia and early cancer) between January 2010 and December 2019 at Pusan National University Hospital. The therapeutic outcomes of ESD and procedure-related complications were analyzed. Results En bloc resection, complete resection, and curative resection were performed in 94%, 72%, and 61% of patients, respectively. Histopathology (submucosal or deeper invasion of the tumor) was a significant predictive factor for incomplete resection (P=0.047). Procedure-related bleeding and stenosis were not observed, whereas perforation occurred in one case. During the median follow-up period of 12 months (range, 6–74 months), local recurrence occurred in 2 patients with incomplete resection, one patient underwent repeat ESD, and the other patient received concurrent chemoradiotherapy. The 3-year overall and disease-specific survival rates were 73% and 93%, respectively. Conclusions ESD seems to be an effective and safe treatment for superficial Barrett’s neoplasia in Korea. Nevertheless, the suitability of ESD for Barrett’s cancer cases should be determined considering the high risk of deep submucosal invasion.
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Affiliation(s)
- Dong Chan Joo
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Bong Eun Lee
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Moon Won Lee
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Dong Hoon Baek
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Sojeong Lee
- Department of Pathology, Pusan National University College of Medicine, Busan, Korea
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Optimizing Outcomes with Radiofrequency Ablation of Barrett's Esophagus: Candidates, Efficacy and Durability. Gastrointest Endosc Clin N Am 2021; 31:131-154. [PMID: 33213792 DOI: 10.1016/j.giec.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The treatment of early Barrett's esophagus (BE) has undergone a paradigm shift from surgical subtotal esophagectomy to organ-saving endoluminal treatment. Over the past 15 years, several high-quality studies were conducted to assess safe oncological outcome of endoscopic resection of mucosal adenocarcinoma and high-grade dysplasia. It became clear that add-on ablative therapy with radiofrequency ablation (RFA) significantly reduces recurrence risk of neoplasia after resection. In this review, we highlight the most essential elements to optimize outcomes of RFA of BE, addressing the correct indication and patient selection in combination with the most efficient and safest treatment protocols to obtain long-term durability.
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Role of Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection in the Management of Barrett's Related Neoplasia. Gastrointest Endosc Clin N Am 2021; 31:171-182. [PMID: 33213794 DOI: 10.1016/j.giec.2020.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic resection has been proven to be safe and highly effective for removing early neoplastic lesions in Barrett esophagus. It enables accurate histopathological assessment and is therefore considered as the cornerstone in the endoscopic work-up for patients with Barrett neoplasia. Various techniques are available to perform endoscopic resection. Multiband mucosectomy is the most commonly used resection technique. However, endoscopic submucosal dissection is gaining ground in the Western world. Endoscopic resection for low-risk submucosal lesions already is fully justified. Future studies have to point out whether endoscopic resection and subsequent follow-up are also justified in selected patients with high-risk submucosal tumors.
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Oetzmann von Sochaczewski C, Haist T, Pauthner M, Mann M, Braun S, Ell C, Lorenz D. Infiltration Depth is the Most Relevant Risk Factor for Overall Metastases in Early Esophageal Adenocarcinoma. World J Surg 2020; 44:1192-1199. [PMID: 31853591 DOI: 10.1007/s00268-019-05291-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Research in early esophageal adenocarcinoma focused on prediction of lymph node metastases in order to stratify patients for endoscopic treatment instead of esophagectomy. Although distant metastases were described in rates of up to 13% of patients within a follow-up of 3 years, their prediction has been neglected so far. METHODS In a secondary analysis, a cohort of 217 patients (53 T1a and 164 T1b) treated by esophagectomy was analyzed for histopathological risk factors. Their ability to predict the combination of lymph node metastases at surgery as well as metachronous locoregional and distant metastases (overall metastatic rate) was assessed by uni- and multivariate logistic regression analysis. RESULTS Tumor invasion depth was correlated with both lymph node metastases at surgery (τ = 0.141; P = .012), tumor recurrences (τ = 0.152; P = .014), and distant metastases (τ = 0.122; P = 0.04). Multivariate analysis showed an odds ratio of 1.31 (95% CI 1.02-1.67; P = .033) per increasing tumor invasion depth and of 3.5 (95% CI 1.70-6.56; P < .001) for lymphovascular invasion. The pre-planned subgroup analysis in T1b tumors demonstrated an even lower predictive ability of lymphovascular invasion with an odds ratio of 2.5 (95% CI 1.11-5.65; P = 0.028), whereas the predictive effect of sm2 (odds ratio 3.44; 95% CI 1.00-11.9; P = 0.049) and sm3 (odds ratio 3.44; 95% CI 1.00-11.9; P = 0.049) tumor invasion depth was similar. CONCLUSIONS The present report demonstrates the insufficient risk prediction of histopathologic risk factors for the overall metastatic rate.
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Affiliation(s)
| | - Thomas Haist
- Department of Surgery I, Sana Klinikum Offenbach, Offenbach, Germany
| | - Michael Pauthner
- Department of Surgery I, Sana Klinikum Offenbach, Offenbach, Germany
| | - Markus Mann
- Department of Surgery I, Sana Klinikum Offenbach, Offenbach, Germany
| | - Susanne Braun
- Institute of Pathology, Sana Klinikum Offenbach, Offenbach, Germany
| | - Christian Ell
- Department of Internal Medicine II, Sana Klinikum Offenbach, Offenbach, Germany
| | - Dietmar Lorenz
- Department of Surgery I, Klinikum Darmstadt, Grafenstraße 9, 64283, Darmstadt, Germany.
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Saunders JH, Al-Zubaidi S, Waller RC, Ortiz-Fernandez-Sordo J, Parsons SL, Ragunath K, Kaye PV. The management and long-term outcomes of endoscopic and surgical treatment of early esophageal adenocarcinoma. Dis Esophagus 2020; 33:5748091. [PMID: 32090253 DOI: 10.1093/dote/doz097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 11/19/2019] [Accepted: 11/25/2019] [Indexed: 12/11/2022]
Abstract
Endoscopic resection (ER) for early (pT1) esophageal adenocarcinoma can be justified if the rate of coexisting lymph node (LN) metastasis is less than the mortality rate from esophagectomy. This study examines endoscopic and surgical outcomes, histological assessment of submucosal (sm) disease, factors influencing LN metastasis, and the safety of treating pT1b disease endoscopically. Histopathological reexamination recorded thickness, width and depth of sm invasion, grade, presence of lymphovascular invasion (LVI), resection margin status and tumor stage. Multivariate analysis was employed to evaluate the factors influencing survival and LN metastasis. Rate of LN metastasis for pT1 low-risk (LR: sm invasion < 500 μm, G1-2, no LVI) or high-risk (HR: sm invasion >500 μm, G3-4 or LVI) disease were analyzed. Ninety three patients underwent ER and 96 underwent esophagectomy. We demonstrate conflicting histological methods of sm disease reporting, which may explain the difference in LN metastasis rate between reported surgical & endoscopic series. Multivariate analysis confirmed age, T stage, and presence of LN metastases were the independent factors predicting poor prognosis. Tumor thickness as well as grade, T stage, LVI were predictors of LN metastasis. Rates of LN metastasis are <2% in LR sm1 disease, and >15% in HR sm1 disease. Pathological reporting of sm invasion should be updated for uniform analysis of endoscopic and surgical specimens. Following rigorous histopathological examination and within a close endoscopic follow-up regimen, pT1a and pT1b LRsm1 disease may be treated with curative intent endoscopically, whereas pT1b HRsm1-sm3 disease should be offered surgery.
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Affiliation(s)
| | | | | | - Jacobo Ortiz-Fernandez-Sordo
- Gastroenterology, Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | | | - Krish Ragunath
- Gastroenterology, Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
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Outcomes of patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study. Gastrointest Endosc 2020; 92:31-39.e1. [PMID: 31953189 PMCID: PMC7321863 DOI: 10.1016/j.gie.2020.01.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The treatment of submucosal (T1b) esophageal adenocarcinoma (EAC) remains in evolution, with some evidence supporting endoscopic management of low-risk lesions. Using a multicenter cohort, we evaluated outcomes of patients with T1b EAC and predictors of survival. METHODS Patients diagnosed between 2001 and 2016 with T1b EAC were identified from 3 academic medical centers in the United States. Demographic, clinical, and outcome data were collected. Outcomes studied were overall and cancer-free survival. Cox proportional hazards models were constructed to assess independent predictors of survival. RESULTS One hundred forty-one patients were included, of whom 68 (48%) underwent esophagectomy and 73 (52%) were treated endoscopically. Most patients (85.8%) had high-risk histologic features. Thirty-day operative mortality was 2.9%. Median follow-up in the esophagectomy and endoscopic cohorts was 49.4 and 43.4 months, respectively. Patients treated endoscopically were older with higher comorbidity scores, with 46 (63%) achieving histologic remission. Nineteen patients (26.0%) also received chemoradiation. Five-year overall survival rates in the surgical and endoscopic cohorts were 89% and 59%, respectively, whereas 5-year cancer-free survival rates were 92% and 69%. Presence of high-risk histologic features was associated with reduced overall survival. CONCLUSIONS In this large multicenter study of patients with T1b EAC, esophagectomy was associated with improved overall but not cancer-free survival. High-risk histologic features were associated with poorer survival.
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Nieuwenhuis EA, Bergman JJ, Pouw RE. What to do with our T1b esophageal adenocarcinoma patients? Gastrointest Endosc 2020; 92:226. [PMID: 32586550 DOI: 10.1016/j.gie.2020.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/02/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Esther A Nieuwenhuis
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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50
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Barret M, Bibault JE, Coriat R. Organ Preservation in Early Esophageal Cancer. Gastroenterology 2020; 158:280. [PMID: 31628900 DOI: 10.1053/j.gastro.2019.05.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/17/2019] [Indexed: 12/02/2022]
Affiliation(s)
- Maximilien Barret
- Gastroenterology Department, Cochin Hospital, University of Paris and, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Emmanuel Bibault
- Radiation Oncology Department, Georges Pompidou European Hospital and, University of Paris and, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Romain Coriat
- Gastroenterology Department, Cochin Hospital, University of Paris and, Assistance Publique-Hôpitaux de Paris, Paris, France
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