Can the Risk of Lymph Node Metastases Be Gauged in Endoscopically Resected Submucosal Esophageal Adenocarcinomas? A Multi-Center Study

ANPEP/CD13 Expression as a Marker of Lymphovascular Invasion and Survival in Esophageal Adenocarcinoma

BACKGROUND

The presence of lymphovascular invasion (LVI) in early esophageal adenocarcinoma (EAC) is associated with more aggressive disease. Molecular markers associated with LVI are still largely unknown. Using a combination of transcriptomic analysis and validation experiments, we sought to describe markers for LVI and survival.

METHODS

We performed NanoString expression profiling using RNA from 60 EAC specimens collected from surgery-only cases between 2000 and 2012. Differentially expressed genes (DEGs) were correlated with pathologic characteristics (T and N status and presence of LVI). Kaplan-Meier and Cox regression analyses were used to correlate gene expression with overall survival. Expression of alanyl aminopeptidase, membrane (ANPEP)/CD13 was validated by immunohistochemistry (IHC) in EAC tissue microarray and in EAC cell lines.

RESULTS

We identified >20 up-regulated DEGs in tumor samples containing LVI. Multivariable analysis showed depth of invasion and ANPEP/CD13 expression were independently associated with overall survival, whereas nodal status was not. IHC analysis demonstrated overexpression of the ANPEP/CD13 protein in dysplastic Barrett esophagus and EAC tumors. Kaplan-Meier analysis showed that patients with higher RNA expression and strongly positive ANPEP/CD13 membrane IHC-Histoscore staining have shorter survival (P = .002). Down-regulation of ANPEP/CD13 expression by short hairpin RNA vector reduces colony formation, migration, and invasion of FLO-1 EAC cells. Overexpression of CD13 in SKGT4 EAC cells increases colony formation, motility, and invasion in vitro.

CONCLUSIONS

Elevated expression of ANPEP/CD13 indicates shorter survival of EAC patients and a more invasive phenotype of cancer cells in vitro. Validation in a larger sample group is required to better understand the clinical significance of ANPEP/CD13 and other candidate genes.

Esophagectomy versus observation following endoscopic submucosal dissection of pT1b esophageal adenocarcinoma

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.

Management of high risk T1 esophageal adenocarcinoma following endoscopic resection

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.

Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

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.

Efficacy of endoscopic therapy for T1b esophageal cancer and construction of prognosis prediction model: a retrospective cohort study

BACKGROUND

The efficacy of endoscopic therapy on the long-term survival outcomes of T1b oesophageal cancer (EC) is unclear, this study was designed to clarify the survival outcomes of endoscopic therapy and to construct a model for predicting the prognosis in T1b EC patients.

METHODS

This study was performed using the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2017 of patients with T1bN0M0 EC. Cancer-specific survival (CSS) and overall survival (OS) were compared between endoscopic therapy group, esophagectomy group and chemoradiotherapy group, respectively. Stabilized inverse probability treatment weighting was used as the main analysis method. The propensity score matching method and an independent dataset from our hospital were used as sensitivity analysis. The least absolute shrinkage and selection operator regression (Lasso) was employed to sift variables. A prognostic model was then established and was verified in two external validation cohorts.

RESULTS

The unadjusted 5-year CSS was 69.5% (95% CI, 61.5-77.5) for endoscopic therapy, 75.0% (95% CI, 71.5-78.5) for esophagectomy and 42.4% (95% CI, 31.0-53.8) for chemoradiotherapy. After stabilized inverse probability treatment weighting adjustment, CSS and OS were similar in endoscopic therapy and esophagectomy groups ( P =0.32, P =0.83), while the CSS and OS of chemoradiotherapy patients were inferior to endoscopic therapy patients ( P <0.01, P <0.01). Age, histology, grade, tumour size, and treatment were selected to build the prediction model. The area under the curve of receiver operating characteristics of 1, 3, and 5 years in the validation cohort 1 were 0.631, 0.618, 0.638, and 0.733, 0.683, 0.768 in the validation cohort 2. The calibration plots also demonstrated the consistency of predicted and actual values in the two external validation cohorts.

CONCLUSION

Endoscopic therapy achieved comparable long-term survival outcomes to esophagectomy for T1b EC patients. The prediction model developed performed well in calculating the OS of patients with T1b EC.

Feasibility and Safety of Tailored Lymphadenectomy Using Sentinel Node-Navigated Surgery in Patients with High-Risk T1 Esophageal Adenocarcinoma

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.

Oesophagectomy following noncurative endoscopic resection for oesophageal carcinoma: does interval matter?

OBJECTIVES

Oesophagectomy was always recommended after noncurative endoscopic resection (ER). And the optimal time interval from ER to oesophagectomy remains unclear. This study was to explore the effect of interval on pathologic stage and prognosis.

METHODS

We included 155 patients who underwent ER for cT1N0M0 oesophageal cancer and then received subsequent oesophagectomy from 2009 to 2019. Overall survival and disease-free survival (DFS) were analysed to find an optimal cut-off of interval from ER to oesophagectomy. In addition, pathologic stage after ER was compared to that of oesophagectomy. Logistic regression model was built to identify risk factors for pathological upstage.

RESULTS

The greatest difference of DFS was found in the groups who underwent oesophagectomy before and after 30 days (P = 0.016). Among total 155 patients, 106 (68.39%) received oesophagectomy within 30 days, while 49 (31.61%) had interval over 30 days. Comparing the pathologic stage between ER and oesophagectomy, 26 patients had upstage and thus had worse DFS (hazard ratio = 3.780, P = 0.042). T1b invasion, lymphovascular invasion and interval >30-day group had a higher upstage rate (P = 0.014, P < 0.001 and P < 0.001, respectively). And they were independent risk factors for pathologic upstage (odds ratio = 3.782, 4.522 and 2.844, respectively).

CONCLUSIONS

It was the first study exploring the relationship between time interval and prognosis in oesophageal cancer. The longer interval between noncurative ER and additional oesophagectomy was associated with a worse DFS, so oesophagectomy was recommended performed within 1 month after ER. Older age, T1b stage, lymphovascular invasion and interval >30 days were significantly associated with pathologic upstage, which is related to the worse outcome too.

Measuring the Submucosal Depth of Invasion in Endoscopic Mucosal Resections for Barrett-associated Adenocarcinoma: Practical Issues and Relevance for the Decision for Esophagectomy

CONTEXT.—

Endoscopic mucosal resection (EMR) has made it possible for Barrett esophagus patients with superficial cancers to be treated without esophagectomy. Recent guidelines recommend measuring depth of invasion (DOI) in submucosal cancers based on reports that in low-risk cancers, submucosal invasion 500 μm or less is associated with low nodal metastasis rates. However, pathologists face challenges in reproducibly measuring DOI.

OBJECTIVE.—

To determine how often DOI measurements could impact treatment and to evaluate reproducibility in measuring submucosal DOI in EMR specimens.

DESIGN.—

Consecutive adenocarcinoma EMR cases were identified, including cases of "low histologic risk" submucosal cancer, as follows: those with negative deep margins, no high-grade histology (G3), and no lymphovascular invasion. Submucosal DOI was measured by 7 pathologists according to guidelines.

RESULTS.—

Of 213 cancer EMR cases, 46 were submucosa invasive and 6 cases were low histologic risk submucosal cancers for which measurement could impact decision-making. Of these low histologic risk cases, 3 were categorized as superficial, indicating that measurement would be a clinically actionable decision point in only 1.4% of adenocarcinoma EMRs. Interobserver agreement for in-depth categorization between 7 pathologists was moderate (κ = 0.42), and the range of measurements spanned the 500-μm relevant threshold in 40 of 55 measured samples (72.7%).

CONCLUSIONS.—

While therapeutic decisions would rarely have depended on DOI measurements alone in our cohort, interobserver variability raises concerns about their use as a sole factor on which to offer patients conservative therapy. Responsibly reporting and clinically using submucosal DOI measurements will require practical experience troubleshooting common histologic artifacts, as well as multidisciplinary awareness of the impact of variable specimen-handling practices.

State-of-the-art imaging in oesophago-gastric cancer

Radiological investigations are essential in the management of oesophageal and gastro-oesophageal junction cancers. The current multimodal combination of CT, 18F-fluorodeoxyglucose positron emission tomography combined with CT (PET/CT) and endoscopic ultrasound (EUS) has limitations, which hinders the prognostic and predictive information that can be used to guide optimum treatment decisions. Therefore, the development of improved imaging techniques is vital to improve patient management. This review describes the current evidence for state-of-the-art imaging techniques in oesophago-gastric cancer including high resolution MRI, diffusion-weighted MRI, dynamic contrast-enhanced MRI, whole-body MRI, perfusion CT, novel PET tracers, and integrated PET/MRI. These novel imaging techniques may help clinicians improve the diagnosis, staging, treatment planning, and response assessment of oesophago-gastric cancer.

Analysis of metastases rates during follow-up after endoscopic resection of early "high-risk" esophageal adenocarcinoma

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.

Long-term outcomes of endoscopic mucosal resection for early-stage esophageal adenocarcinoma

BACKGROUND

With growing application of endoscopic therapy for early-stage esophageal cancer, we sought to review our experience of endoscopic mucosal resections (EMRs). The aim of our study was to understand the natural course of these patients, especially with positive margins.

METHODS

A prospectively maintained database of all patients undergoing endoscopic therapies at Georgetown University Hospital for esophageal cancer was used for the analysis between 2010 and 2020.

RESULTS

Of 80 patients in the EMR database, 35 were performed as index cases for esophageal adenocarcinoma. Majority (74.3%) had a pre-treatment ultrasound confirming absence of regional adenopathy. There were no post-EMR bleeding or perforation events requiring re-intervention. Complete R0 resection was achieved in 22/35 (62.9%) after initial EMR. Thirteen patients had positive margins. Of these 13 patients, only 7 patients underwent repeat endoscopic resection, 2 underwent subsequent esophagectomy, 2 received definitive radiation given poor surgical candidacy, and 2 were lost to follow-up. Overall and 5-year survival of all patients undergoing EMR was 67.9 months and 85%, respectively. Subset analysis of the 13 patients with R1 resection demonstrated an overall survival of 49.2 months and 60% 5-year survival vs overall survival of 78.9 months and 93% 5-year survival for R0 resection. At a median follow-up of 60.5 months, cancer recurrence occurred in 3 patients. All of them were successfully managed with repeat EMR.

CONCLUSIONS

Endoscopic resections represent a safe and effective treatment for early-stage esophageal cancer. Patients with high-risk features should be counseled to undergo an esophagectomy if they are operable candidates.

The evolution of endoscopic therapy for Barrett's esophagus

Barrett’s esophagus is the condition in which a metaplastic columnar epithelium replaces the stratified squamous epithelium that normally lines the distal esophagus. The condition develops as a consequence of chronic gastroesophageal reflux disease and predisposes the patient to the development of esophageal adenocarcinoma. The diagnosis and management of Barrett’s esophagus have undergone dramatic changes over the years and continue to evolve today. Endoscopic eradication therapy has revolutionized the management of dysplastic Barrett’s esophagus and early esophageal adenocarcinoma by significantly reducing the morbidity and mortality associated with the prior gold standard of therapy, esophagectomy. The purpose of this review is to highlight current principles in the management and endoscopic treatment of this disease.

Endoscopic resection of Barrett's adenocarcinoma: Intramucosal and low-risk tumours are not associated with lymph node metastases

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.

Infiltration Depth is the Most Relevant Risk Factor for Overall Metastases in Early Esophageal Adenocarcinoma

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.

Role of Imaging in Esophageal Cancer Management in 2020: Update for Radiologists

OBJECTIVE. The purpose of this article is to discuss the role of imaging in the management of esophageal cancer. CONCLUSION. A multimodality-based approach to imaging is essential in clinical practice to achieve the best possible outcome for patients with esophageal cancer. Radiologists must be aware of the strengths and limitations of different imaging modalities in various clinical settings. The role of a radiologist is to combine information from anatomic and functional imaging, assess metastatic disease and changes in the primary tumor during treatment, and identify anatomic complications after treatment.

The management and long-term outcomes of endoscopic and surgical treatment of early esophageal adenocarcinoma

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.

Outcomes of patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study

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.

Workload, Recurrence, Quality of Life and Long-term Efficacy of Endoscopic Therapy for High-grade Dysplasia and Intramucosal Esophageal Adenocarcinoma

OBJECTIVE

To review the workload, type and frequency of recurrence, long-term quality of life (QOL), and late oncologic outcomes with endoscopic therapy.

BACKGROUND

The short-term oncologic efficacy of endoscopic resection (ER) and ablation for patients with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC) is well-established in the literature.

METHODS

A retrospective chart review was performed of the initial 40 patients who had endoscopic therapy from 2001 to 2010 at 1 center by 1 physician.

RESULTS

Initial pathology was HGD in 22 and IMC in 18 patients, but 9 patients (41%) with HGD progressed to invasive cancer during endotherapy. The median follow-up was 82 months. Four patients had an esophagectomy, and in the remaining 36 patients, 70 ERs and 111 ablations were performed. The median number of endoscopic sessions was 4 in patients with short segment compared with 7 in patients with long-segment Barrett's. Complete resolution of intestinal metaplasia (CRIM) was achieved in 30 patients (83%) at a median of 21 months. In 18 patients (60%), CRIM was maintained, whereas 12 patients developed recurrence at a median of 14 months. Additional endotherapy (n = 11) led to CRIM again in 10 patients (83%). There were no cancer deaths when CRIM was achieved. Overall survival with endotherapy was 73% at 5 years and 67% at 10 years. Quality of life (QOL) was below population means in 4 of 8 areas, but alimentary satisfaction was good after endotherapy.

CONCLUSIONS

Endotherapy is successful in most patients, but multiple sessions are usually required and disease progression can occur. Once CRIM is achieved, recurrence is common and mandates continued endoscopic follow-up. QOL is impaired with endotherapy, but alimentary satisfaction and oncologic outcomes support esophageal preservation with endotherapy for patients with HGD or IMC.

The overall metastatic rate in early esophageal adenocarcinoma: long-time follow-up of surgically treated patients

The overall metastatic potential of surgically treated early esophageal adenocarcinoma has not been studied in detail. This paper therefore assessed lymph node metastases at surgery, loco regional and distant metastases, in order to assess the metastatic potential of early esophageal adenocarcinoma. Two hundred and seventeen patients (53 T1a, 164 T1b; median follow-ups 87 and 75 months, 187 males) diagnosed with early esophageal adenocarcinoma and treated with esophagectomy in our tertiary center's database between July 2000 and December 2015 were included. All metastatic events were retrospectively analyzed, their topographic distribution was assessed, and the overall metastatic rate was calculated. Lymph node metastases occurred in 39 patients (18%) and 29 (13.4%) developed recurrences. Lymph node metastases were absent in m1 and m2 tumors and rare in m3 (1/18), m4 (5/21), and sm1 (4/42), but more frequent in sm2 (11/44) and sm3 tumors (18/78). Locoregional recurrences were exceedingly rare in m3 (2/18), m4 (1/21), sm1 (1/42), and sm2 (2/44), but frequent in sm3 (12/78). In contrast, distant metastases were more frequent with 2/18 in m3, 1/21 in m4, 4/42 in sm1, 4/44 in sm2, and 13/78 in sm3. Overall metastatic rates of 11.9% in sm1 (submucosal layer divided into equal thirds), 27.3% in sm2, and 32.1% in sm3 tumors were calculated. This first report of the metastatic potential of early esophageal adenocarcinoma provides a meticulous assessment of the overall metastatic risk. Metastatic events pose a relevant risk in surgically treated patients with esophageal adenocarcinoma with distant metastases being more frequent than locoregional recurrences.

Endoscopic or Surgical Resection for Gastro-Esophageal Cancer

BACKGROUND

Early gastro-esophageal cancer is staged as m1 to m3 depending on the infiltration of the anatomical layers of the mucosa or, analogously, as sm1 to sm3 depending on the depth of infiltration into the submucosa. The risk of lymph node metastases is low in mucosal carcinoma but increases with the depth of infiltration into the submucosa.

METHODS

This review is based on pertinent publications retrieved by a selective search in MEDLINE, PubMed, the Cochrane Library, and the International Standard Randomised Controlled Trial Number (ISRCTN) registry.

RESULTS

New technologies such as narrow-band imaging have improved the endo- scopic diagnosis and staging of early gastro-esophageal cancer. The development of endoscopic submucosal dissection has led to a higher R0 resection rate, a lower risk of recurrence, and an increase in the number of endoscopic resections that are performed with curative intent. In squamous-cell carcinoma of the esophagus, surgical oncological esophagectomy is indicated if the cancer infiltrates into the third mucosal layer (T1a, m3) or deeper. In esophageal adenocarcinoma, the prevalence of lymph node metastases is low if the cancer is restricted to the mucosa and in- creases only when the submucosa is infiltrated. In the current German S3 guideline, endoscopic resection is recommended for intramucosal adenocarcinoma as long as there are no further histopathological risk factors. Lymph node metastasis in gastric carcinoma begins in the deep mucosal infiltration stage (m3). If certain special con- ditions ("extended criteria") are met, carcinoma expanding into the first submucosal layer (sm1) can be removed endoscopically. All further stages must be treated with total or subtotal gastrectomy with systematic D2 lymphadenectomy.

CONCLUSION

Borderline cases between endoscopic and surgical resection of early carcinoma of the esophagus or stomach must be managed with an interdisciplinary treatment algorithm. If there is a risk of lymph node metastasis, surgical oncological resection is indicated. Such resections of gastroesophageal cancer in the locally advanced stage should always be part of a multimodal treatment approach.

Accuracy of Clinical Staging and Outcome With Primary Resection for Local-Regionally Limited Esophageal Adenocarcinoma

OBJECTIVE

The aim of this study was to determine the accuracy of clinical staging, to assess survival with surgical resection alone, and to determine factors associated with understaging in patients with esophageal adenocarcinoma thought to have limited local-regional disease.

BACKGROUND

Primary surgical resection is the preferred treatment in patients with esophageal adenocarcinoma clinically staged to have limited nodal disease. This approach requires reliable clinical staging.

METHODS

A retrospective chart review was performed of all patients who had primary esophagectomy for clinical stage T1-3 N0-1 adenocarcinoma (seventh edition AJCC) from January 2002 to May 2013. Clinical and pathologic stages were compared and overall survival was analyzed.

RESULTS

There were 88 patients who met inclusion criteria. Final pathology confirmed appropriate clinical staging (≤T3N1) in 76% of patients (67/88). There were 21 patients who were understaged (>T3N1), and in all cases, understaging was based on the presence of advanced nodal (N2 or N3) disease. Factors independently associated with understaging were the presence of dysphagia, tumor length >3 cm, and poor differentiation. At a median follow-up of 35 months, 63% of all patients (55/88) remain alive. The 5-year survival in correctly staged patients was 67%, compared with 33% for those who were understaged (P < 0.0001).

CONCLUSIONS

Modern clinical staging will accurately identify the majority of patients with esophageal adenocarcinoma and limited local-regional disease (≤pT3N1). Survival with surgery alone in correctly staged patients was excellent and unlikely to be improved with neoadjuvant therapy. A combination of dysphagia, poor differentiation, and tumor length >3 cm was associated with understaging in 92% of patients. Patients with these factors are likely to have more advanced disease than clinically suspected and may benefit from neoadjuvant therapy before resection.

Do pathologists agree with each other on the histological assessment of pT1b oesophageal adenocarcinoma?

Background

In early (T1) oesophageal adenocarcinoma (OAC), the histological profile of an endoscopic resection specimen plays a pivotal role in the prediction of lymph node metastasis and the potential need for oesophagectomy with lymphadenectomy.

Objective

To evaluate the inter-observer agreement of the histological assessment of submucosal (pT1b) OAC.

Methods

Surgical and endoscopic resection specimens with pT1b OAC were independently reviewed by three gastrointestinal pathologists. Agreement was determined by intraclass correlation coefficient for continuous variables, and Fleiss' kappa (κ) for categorical variables. Bland–Altman plots of the submucosal invasion depth were made.

Results

Eighty-five resection specimens with pT1b OAC were evaluated. The agreement was good for differentiation grade (κ=0.77, 95% confidence interval (CI) 0.68–0.87), excellent for lymphovascular invasion (κ=0.88, 95% CI 0.76–1.00) and moderate for submucosal invasion depth using the Paris and Pragmatic classifications (κ=0.60, 95% CI 0.49–0.72 and κ=0.42, 95% CI 0.33–0.51, respectively). Systematic mean differences between pathologists were detected for the measurement of submucosal invasion depth, ranging from 297 µm to 602 µm.

Conclusions

A substantial discordance was found between pathologists for the measurement of submucosal invasion depth in pT1b OAC. Differences may lead to an over- or underestimation of the lymph node metastasis risk, with grave implications for the treatment strategy. Review by a second gastrointestinal pathologist is recommended to improve differentiating between a favourable and an unfavourable histological profile.

Histopathology of Barrett’s Esophagus and Early-Stage Esophageal Adenocarcinoma: An Updated Review

Esophageal adenocarcinoma carries a very poor prognosis. For this reason, it is critical to have cost-effective surveillance and prevention strategies and early and accurate diagnosis, as well as evidence-based treatment guidelines. Barrett’s esophagus is the most important precursor lesion for esophageal adenocarcinoma, which follows a defined metaplasia–dysplasia–carcinoma sequence. Accurate recognition of dysplasia in Barrett’s esophagus is crucial due to its pivotal prognostic value. For early-stage esophageal adenocarcinoma, depth of submucosal invasion is a key prognostic factor. Our systematic review of all published data demonstrates a “rule of doubling” for the frequency of lymph node metastases: tumor invasion into each progressively deeper third of submucosal layer corresponds with a twofold increase in the risk of nodal metastases (9.9% in the superficial third of submucosa (sm1) group, 22.0% in the middle third of submucosa (sm2) group, and 40.7% in deep third of submucosa (sm3) group). Other important risk factors include lymphovascular invasion, tumor differentiation, and the recently reported tumor budding. In this review, we provide a concise update on the histopathological features, ancillary studies, molecular signatures, and surveillance/management guidelines along the natural history from Barrett’s esophagus to early stage invasive adenocarcinoma for practicing pathologists.

Endoscopic management of dysplasia and early oesophageal cancer

In the past decade there have been technological advances in Endoscopic Eradication Therapy (EET) for the management of patients with oesophageal neoplasia and early cancer. Multiple endoscopic techniques now exist for both squamous and Barrett's oesophagus associated neoplasia or early cancer. A fundamental aspect of endotherapy is removal of the target lesion by endoscopic mucosal resection, or endosopic submucosal dissection. Residual tissue is subsequently ablated to remove the risk of recurrence. The most validated technique for Barrett's oesophagus is radiofrequency ablation, but other techniques such as hybrid-APC and cryotherapy also show good results. This chapter will discuss the evolution of EET, and which patients are most likely to benefit. It will also explore the evidence behind the success of different techniques and provide practical advice on how to carry out the endoscopic techniques with a focus on radiofrequency ablation and endoscopic mucosal resection in particular.

Risk of lymph node metastases in patients with T1b oesophageal adenocarcinoma: A retrospective single centre experience

AIM

To assess clinical outcomes for submucosal (T1b) oesophageal adenocarcinoma (OAC) patients managed with either surgery or endoscopic eradication therapy.

METHODS

Patients found to have T1b OAC following endoscopic resection between January 2008 to February 2016 at University College London Hospital were retrospectively analysed. Patients were split into low-risk and high-risk groups according to established histopathological criteria and were then further categorised according to whether they underwent surgical resection or conservative management. Study outcomes include the presence of lymph-node metastases, disease-specific mortality and overall survival.

RESULTS

A total of 60 patients were included; 22 patients were surgically managed (1 low-risk and 21 high-risk patients) whilst 38 patients were treated conservatively (12 low-risk and 26 high-risk). Overall, lymph node metastases (LNM) were detected in 10 patients (17%); six of these patients had undergone conservative management and LNM were detected at a median of 4 mo after endoscopic mucosal resection (EMR). All LNM occurred in patients with high-risk lesions and this represented 21% of the total high-risk lesions. Importantly, there was no statistically significant difference in tumor-related deaths between those treated surgically or conservatively (P = 0.636) and disease-specific survival time was also comparable between the two treatment strategies (P = 0.376).

CONCLUSION

T1b tumours without histopathological high-risk markers of LNM can be treated endoscopically with good out-comes. In selected patients, endoscopic therapy may be appropriate for high-risk lesions.

Endoscopic Resection in the Esophagus

The article is a review of the principles behind endoscopic resection of esophageal dysplasia and early cancers. The techniques of endoscopic mucosal resection and endoscopic submucosal dissection are reviewed, and the supporting literature compared. Endoscopic resection is compared with esophagectomy for the management of these lesions and current areas of controversy with regard to T1b lesions and gastroesophageal reflux following resection are addressed.

A nomogram for predicting lymph node metastasis in surgically resected T1 esophageal squamous cell carcinoma

Background

Endoscopic therapies for T1 esophageal carcinoma have been increasingly used around the world. However, the procedures are limited by without lymph nodes harvested. The risk of lymph node metastasis (LNM) should been established. Our objective was to construct a nomogram model for predict risks of LNM in patients with pT1 esophageal squamous cell carcinoma (ESCC).

Methods

We reviewed the records of 221 patients with pT1 ESCC who underwent surgical resection and radical lymphadenectomy. Clinicopathological variables were analyzed univariate and multivariate logistic regression analysis. A nomogram for predicting risk of LNM was constructed and validated using bootstrap resampling.

Results

Of the 221 patients, 53 patients had been examined as LNM. Following multivariate analysis, poor differentiation (P=0.0006), lymphovascular invasion (P<0.0001) and SM3 (tumor invades the lower third of the submucosal layer) (P=0.0192) cancer were significantly independent risk factors for LNM and were entered into the nomogram. The nomogram showed a robust discrimination, with an area under the receiver operating characteristic curve (AUC) of 0.8667. The calibration curves for the probability of LNM showed optimal agreement between the probability as predicted by the nomogram and the actual probability.

Conclusions

We established a nomogram that can provide individual predicting for LNM in T1 ESCC, and this model has the potential clinical utility in making therapeutic procedures.

Endoscopic management and follow-up of patients with a submucosal esophageal adenocarcinoma

Introduction

The risk of lymph node metastases (LNM) in submucosal esophageal adenocarcinoma (EAC) patients is subject to debate. These patients might be treated endoscopically if the risk of LNM appears to be low.

Objective

The objective of this article is to evaluate the outcome of patients who underwent an endoscopic resection (ER) and subsequent endoscopic follow-up for a submucosal EAC.

Methods

All patients who underwent ER for submucosal EAC between January 2012 and August 2016 and were subsequently managed with endoscopic follow-up were retrospectively identified. Primary outcome was the number of patients diagnosed with LNM; secondary outcomes included intraluminal recurrences.

Results

Thirty-five patients (median age 68 years) were included: 17 low-risk (submucosal invasion <500 microns, G1–G2, no lymphovascular invasion (LVI)), and 18 high-risk (submucosal invasion >500 microns, and/or G3–G4, and/or LVI, and/or a tumor-positive deep resection margin (R1)) EACs. After a median follow-up of 23 (IQR 15–43) months, in which patients underwent a median of six (IQR 4–8) endoscopies and a median of four (IQR 2–8) endoscopic ultrasound procedures, none of the included patients were diagnosed with LNM. Five (14%) patients developed a local intraluminal recurrence a median of 18 (IQR 11–21) months after baseline ER that were treated endoscopically.

Conclusions

In 35 patients with a submucosal EAC, no LNM were found during a median follow-up of 23 months. Endoscopic therapy may be an alternative for surgery in selected patients with a submucosal EAC.

Pilot-study on the feasibility of sentinel node navigation surgery in combination with thoracolaparoscopic lymphadenectomy without esophagectomy in early esophageal adenocarcinoma patients

High-risk submucosal esophageal adenocarcinoma's might be treated curatively by means of radical endoscopic resection, followed by thoracolaparoscopic lymphadenectomy without concomitant esophagectomy. A preclinical study has shown the feasibility and safety of this approach; however, no studies are performed in a clinical setting. In addition, sentinel node navigation surgery could be valuable in tailoring the extent of the lymphadenectomy. This study aimed to evaluate the feasibility and safety of thoracolaparoscopic lymphadenectomy without esophagectomy (phase I) and sentinel node navigation surgery (phase II) in patients with early esophageal adenocarcinoma. Patients with T1N0M0 early esophageal adenocarcinoma scheduled for esophagectomy without neoadjuvant therapy were included. Phase I: Two-field, esophagus preserving, thoracolaparoscopic lymphadenectomy was performed, followed by esophagectomy in the same session. Primary outcome parameters were the number of lymph nodes resected, and number of retained lymph nodes in the esophagectomy specimen. Phase II: A radioactive tracer was injected endoscopically the day before surgery. Static imaging was performed 15 and 120 minutes after injection. The day of surgery, sentinel node navigation surgery followed by esophagectomy was performed. Primary outcome parameters were the percentage of patients with a detectable sentinel node, and the concordance between static imaging and probe-based detection of sentinel node. Phase I: Five patients were included, and a median of 30 (IQR: 25-46) lymph nodes was resected. A median of 6 (IQR: 2-9) retained lymph nodes was found in the esophagectomy specimen. No acute adverse events occurred, but near the end of lymphadenectomy esophageal discoloration was observed, possibly indicating ischemia. Phase II: In all five included patients sentinel nodes could be visualized and resected, at a median of 3 (IQR: 2-5) locations. There was a high concordance between imaging and probe-based detection of sentinel nodes. In conclusion, sentinel node navigation surgery followed by lymphadenectomy without concomitant esophagectomy seems feasible in patients with high-risk submucosal early esophageal adenocarcinoma. More evidence is however needed before applying this technique in clinical practice.

Outcome with Primary En-bloc Esophagectomy for Submucosal Esophageal Adenocarcinoma

BACKGROUND

Intramucosal esophageal adenocarcinoma can be reliably treated endoscopically. Controversy exists about the use of endotherapy versus esophagectomy for submucosal tumors. Increasingly endotherapy is considered for submucosal tumors in part because of the presumed high mortality with esophagectomy and the perceived poor prognosis in patients with nodal disease. This study was designed to assess survival following primary en bloc esophagectomy (EBE) in patients with submucosal esophageal adenocarcinoma (EAC).

METHODS

This is a retrospective review of all patients who underwent EBE for submucosal EAC between 1998 and 2015. No patient had neoadjuvant therapy.

RESULTS

There were 32 patients (28M/4F; median age 64 years). The median tumor size was 1.5 cm (0.4-8.0), and the median number of resected nodes was 48 (23-85). There was one perioperative death. Lymph node metastases were present in 7 patients (22%). There was one involved node in four patients and 2, 3, and 31 nodes in one patient each. The one N3 patient received adjuvant therapy. The median follow-up was 87 months. Overall survival at 5 and 10 years was 84 and 70% respectively. Disease-specific survival at 10 years was 90%. Eight patients died, but only three deaths (9%) were related to EAC. Disease-specific survival at 10 years in node-positive patients was 71%.

CONCLUSIONS

Survival after primary en bloc esophagectomy for submucosal adenocarcinoma was excellent even in node-positive patients. Mortality with esophagectomy was low and far less than the 22% risk of node metastases in patients with submucosal tumor invasion. Esophagectomy should remain the preferred treatment for T1b esophageal adenocarcinoma.

Current Concepts in Treatment of Barrett's Esophagus With and Without Dysplasia

BACKGROUND

Around 10-15% of patients with gastroesophageal reflux disease will develop Barrett's esophagus (BE). The development of novel endoscopic modalities has changed the management of BE in the last decade.

AIM

The aim of this study was to review the current evidence for the treatment of BE with and without dysplasia.

RESULTS

In patients with BE without dysplasia, antireflux surgery should not be suggested as a modality to prevent the malignant transformation of BE, but its indications should be the same as for other patients with gastroesophageal reflux. Endoscopic surveillance at intervals of 3-5 years is recommended for these patients. For patients with BE with low-grade dysplasia, radiofrequency ablation (RFA) is the preferred treatment modality, while endoscopic surveillance every 12 months is an acceptable alternative in patients with life-limiting comorbidities. For most patients with BE and high-grade dysplasia, RFA is the preferred treatment strategy. Patients with intramucosal adenocarcinoma (T1a), should be treated with EMR followed by ablative therapy, in order to eradicate the remaining intestinal metaplasia. Endoscopic resection may be suitable for low-risk T1b tumors (well-differentiated, without lymphovascular invasion, and with superficial submucosal invasion); however, further data are necessary to better risk stratify this group.

CONCLUSIONS

Patients with BE without dysplasia should undergo endoscopic surveillance every 3-5 years. Endoscopic ablative therapy (RFA) is the preferred treatment modality for dysplastic BE. Patients with T1a adenocarcinoma should be treated with EMR followed by ablative therapy. Low-risk T1b tumors may be suitable for endoscopic resection.

Using the National Cancer Database to create a scoring system that identifies patients with early-stage esophageal cancer at risk for nodal metastases

OBJECTIVES

Endoscopic resection is gaining popularity as a treatment for early-stage esophageal adenocarcinoma, particularly for T1a tumors. The goal of this study was to create a scoring system to reflect the risk of nodal metastases in early-stage esophageal adenocarcinoma to be used after endoscopic resection to better individualize treatment.

METHODS

The National Cancer Database was queried for patients with T1a or T1b esophageal adenocarcinoma who underwent esophagectomy. We identified variables affecting nodal metastases using multivariable logistic regression, which we then used to create a scoring system. We stratified the model for T1a or T1b tumors, tested model discrimination, and validated the models by refitting in 1000 bootstrap samples. C-statistics greater than 0.7 were considered relevant.

RESULTS

We identified 1283 patients with T1a or T1b tumors; 146 had nodal metastases (11.4%). Tumor category (pT1a vs pT1b), grade, and size and the presence of angiolymphatic invasion significantly affected the risk of nodal metastases. We assigned points to each variable and added them to get a risk score. In patients with T1a tumors, less than 3% of patients with a risk score of 3 or less had nodal metastases, whereas 16.1% of patients with a risk score of 5 or greater had nodal metastases. In patients with T1b tumors, less than 5% of patients with a risk score of 2 or less had nodal metastases, whereas 41% of patients with a score of 6 or greater had nodal metastases (c-statistic = 0.805).

CONCLUSIONS

The proposed scoring system seems to be useful in discriminating risk of nodal metastases in patients with T1a or T1b esophageal adenocarcinoma and may be useful in directing patients who received endoscopic resection to esophagectomy or careful follow-up.

Oesophageal cancer

Oesophageal cancer is the sixth most common cause of cancer-related death worldwide and is therefore a major global health challenge. The two major subtypes of oesophageal cancer are oesophageal squamous cell carcinoma (OSCC) and oesophageal adenocarcinoma (OAC), which are epidemiologically and biologically distinct. OSCC accounts for 90% of all cases of oesophageal cancer globally and is highly prevalent in the East, East Africa and South America. OAC is more common in developed countries than in developing countries. Preneoplastic lesions are identifiable for both OSCC and OAC; these are frequently amenable to endoscopic ablative therapies. Most patients with oesophageal cancer require extensive treatment, including chemotherapy, chemoradiotherapy and/or surgical resection. Patients with advanced or metastatic oesophageal cancer are treated with palliative chemotherapy; those who are human epidermal growth factor receptor 2 (HER2)-positive may also benefit from trastuzumab treatment. Immuno-oncology therapies have also shown promising early results in OSCC and OAC. In this Primer, we review state-of-the-art knowledge on the biology and treatment of oesophageal cancer, including screening, endoscopic ablative therapies and emerging molecular targets, and we discuss best practices in chemotherapy, chemoradiotherapy, surgery and the maintenance of patient quality of life.

Management of Nodular Neoplasia in Barrett's Esophagus: Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection

Endoscopic resection has proven highly effective and safe in the removal of focal early neoplastic lesions in Barrett's esophagus and is considered the cornerstone of endoscopic treatment. Several techniques are available for endoscopic resection in Barrett's esophagus. The most widely used technique for piecemeal resection of early Barrett's neoplasia is the ligate-and-cut technique. Newer techniques such as endoscopic submucosal dissection may also play a role in the treatment of neoplastic Barrett's esophagus. Treatment of early Barrett's neoplasia should be centralized and limited to expert centers with a high-volume load and sufficient expertise in the detection and treatment of esophageal neoplasia.

Esophagectomy for Superficial Esophageal Neoplasia

Endoscopic therapies have become the standard of care for most cases of Barrett's esophagus with high-grade dysplasia or intramucosal adenocarcinoma. Despite a rapid and dramatic evolution in treatment paradigms, esophagectomy continues to occupy a place in the therapeutic armamentarium for superficial esophageal neoplasia. The managing physician must remain cognizant of the limitations of endoscopic approaches and consider surgical resection when they are exceeded. Esophagectomy, performed at experienced centers for appropriately selected patients with early-stage disease can be undertaken with the expectation of cure as well as low mortality, acceptable morbidity, and good long-term quality of life.