Emerging Concepts for the Endoscopic Management of Superficial Esophageal Adenocarcinoma

Histopathological Assessment of the Endoscopic Resection Specimen

Background

Endoscopic resection for early neoplastic lesions of the gastrointestinal tract is nowadays the accepted and feasible method also in non-tertiary reference centers. The main clinical advantage is the preserved quality of life compared to larger surgical procedures.

Summary

Clinical colleagues need to have basic knowledge of factors that may influence the outcome of histopathology. This article discusses issues connected to the histopathological work-up of endoscopic resection specimens within in the gastrointestinal tract.

Key Messages

Besides the clinical technical prerequisites, standardized histopathology is the key element of the pathology laboratory work-up of endoscopic resection specimens. Overdiagnoses of reactive lesions as low-grade neoplasia lead to incomparable study data and although criteria to overcome this situation exist, they are not accepted worldwide, calling for further efforts in harmonization.

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.

Clinical course of gastroesophageal reflux disease and impact of treatment in symptomatic young patients

In symptomatic young patients with gastroesophageal reflux symptoms, early identification of progressive gastroesophageal reflux disease (GERD) is critical to prevent long-term complications associated with hiatal hernia, increased esophageal acid and nonacid exposure, release of proinflammatory cytokines, and development of intestinal metaplasia, endoscopically visible Barrett's esophagus, and dysplasia leading to esophageal adenocarcinoma. Progression of GERD may occur in asymptomatic patients and in those under continuous acid-suppressive medication. The long-term side effects of proton-pump inhibitors, chemopreventive agents, and radiofrequency ablation are contentious. In patients with early-stage disease, when the lower esophageal sphincter function is still preserved and before endoscopically visible Barrett's esophagus develops, novel laparoscopic procedures, such as magnetic and electric sphincter augmentation, may have a greater role than conventional surgical therapy. A multidisciplinary approach to GERD by a dedicated team of gastroenterologists and surgeons might impact the patients' lifestyle, the therapeutic choices, and the course of the disease. Biological markers are needed to precisely assess the risk of disease progression and to tailor surveillance, ablation, and management.

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 management of esophageal cancer

Esophageal cancer (EC) generally consists of squamous cell carcinoma (which arise from squamous epithelium) and adenocarcinoma (which arise from columnar epithelium). Due to the increased recognition of risk factors associated with EC and the development of screening programs, there has been an increase in the diagnosis of early EC. Early EC is amenable to curative therapy by endoscopy, which can be performed by either endoscopic resection or endoscopic ablation. Endoscopic resection consists of either endoscopic mucosal resection (preferred in cases of adenocarcinoma) or endoscopic submucosal dissection (preferred in cases of squamous cell carcinoma). Endoscopic ablation can be performed by either radiofrequency ablation, cryotherapy, argon plasma coagulation or photodynamic therapy, amongst others. Endoscopy can also assist in the management of complications post-esophageal surgery, such as anastomotic leaks and perforations. Finally, there is a growing role for endoscopy to manage end-of-life palliative symptoms, especially dysphagia. The growing use of esophageal stents, debulking therapy and dilation can assist in improving a patient’s quality of life. In this review, we examine the multiple roles of endoscopy in the management of patients with EC.

Optimizing histopathologic evaluation of EMR specimens of Barrett's esophagus-related neoplasia: a randomized study of 3 specimen handling methods

BACKGROUND AND AIMS

Endoscopic resection is the cornerstone of treatment of Barrett's esophagus (BE)-related neoplasia. However, accurate histopathologic evaluation of endoscopic resection specimens can be challenging, and the preferred specimen handling method remains unknown. Therefore, the aim of our study was to compare 3 different specimen handling methods for assessment of all clinically relevant histopathologic parameters and time required for specimen handling.

METHODS

In this multicenter, randomized study EMR specimens of BE-related neoplasia with no suspicion of submucosal invasion during endoscopy were randomized to 3 specimen handling methods: pinning on paraffin using needles, direct fixation in formalin without prior tissue handling, and the cassette technique (small box for enclosing specimens). The histopathologic evaluation scores were assessed by 2 dedicated GI pathologists blinded to the handling method.

RESULTS

Of the 126 randomized EMR specimens, 45 were assigned to pinning on paraffin, 41 to direct fixation in formalin, and 40 to the cassette technique. The percentages of specimens with overall optimal histopathologic evaluation scores were similar for the pinning method (98%; 95% confidence interval [CI], 88.0-99.9) and for no handling (90%; 95% CI, 76.9-97.3) but were significantly lower (64%; 95% CI, 47.2-78.8) for the cassette technique (P < .001). Time required for specimen handling was shortest when no handling method was used (P < .001 vs pinning and cassette).

CONCLUSIONS

Both pinning on paraffin and direct fixation in formalin resulted in optimal histopathologic evaluation scores in a high proportion of specimens, whereas the cassette technique performs significantly worse, and its use in clinical daily practice should be discouraged. Given the significantly shorter handling time, direct fixation in formalin appears to be the preferred method over pinning on paraffin. However, the latter needs to be confirmed in larger studies with inclusion of all EMR specimens. (Clinical trial registration number: ISRCTN50525266.).

Identifying DNA methylation biomarkers for non-endoscopic detection of Barrett's esophagus

We report a biomarker-based non-endoscopic method for detecting Barrett's esophagus (BE) based on detecting methylated DNAs retrieved via a swallowable balloon-based esophageal sampling device. BE is the precursor of, and a major recognized risk factor for, developing esophageal adenocarcinoma. Endoscopy, the current standard for BE detection, is not cost-effective for population screening. We performed genome-wide screening to ascertain regions targeted for recurrent aberrant cytosine methylation in BE, identifying high-frequency methylation within the CCNA1 locus. We tested CCNA1 DNA methylation as a BE biomarker in cytology brushings of the distal esophagus from 173 individuals with or without BE. CCNA1 DNA methylation demonstrated an area under the curve of 0.95 for discriminating BE-related metaplasia and neoplasia cases versus normal individuals, performing identically to methylation of VIM DNA, an established BE biomarker. When combined, the resulting two biomarker panel was 95% sensitive and 91% specific. These results were replicated in an independent validation cohort of 149 individuals who were assayed using the same cutoff values for test positivity established in the training population. To progress toward non-endoscopic esophageal screening, we engineered a well-tolerated, swallowable, encapsulated balloon device able to selectively sample the distal esophagus within 5 min. In balloon samples from 86 individuals, tests of CCNA1 plus VIM DNA methylation detected BE metaplasia with 90.3% sensitivity and 91.7% specificity. Combining the balloon sampling device with molecular assays of CCNA1 plus VIM DNA methylation enables an efficient, well-tolerated, sensitive, and specific method of screening at-risk populations for BE.

Endoscopic diagnosis and treatment of esophageal adenocarcinoma: introduction of Japan Esophageal Society classification of Barrett's esophagus

Endoscopic surveillance of Barrett's esophagus has become a foundation of the management of esophageal adenocarcinoma (EAC). Surveillance for Barrett's esophagus commonly involves periodic upper endoscopy with biopsies of suspicious areas and random four-quadrant biopsies. However, targeted biopsies using narrow-band imaging can detect more dysplastic areas and thus reduce the number of biopsies required. Several specific mucosal and vascular patterns characteristic of Barrett's esophagus have been described, but the proposed criteria are complex and diverse. Simpler classifications have recently been developed focusing on the differentiation between dysplasia and non-dysplasia. These include the Japan Esophageal Society classification, which defines regular and irregular patterns in terms of mucosal and vascular shapes. Cancer invasion depth is diagnosed by endoscopic ultrasonography (EUS); however, a meta-analysis of EUS staging of superficial EAC showed favorable pooled values for mucosal cancer staging, but unsatisfactory diagnostic results for EAC at the esophagogastric junction. Endoscopic resection has recently been suggested as a more accurate staging modality for superficial gastrointestinal cancers than EUS. Following endoscopic resection for gastrointestinal cancers, the risk of metastasis can be evaluated based on the histology of the resected specimen. European guidelines describe endoscopic resection as curative for well- or moderately differentiated mucosal cancers without lymphovascular invasion, and these criteria might be extended to lesions invading the submucosa (≤ 500 μm), i.e., to low-risk, well- or moderately differentiated tumors without lymphovascular involvement, and < 3 cm. These criteria were confirmed by a recent study in Japan.

Some observations on Barrett esophagus and associated dysplasia

Biopsy samples from esophageal columnar metaplasia and dysplasia are commonly encountered in Western pathology practice and knowing a few pitfalls can save both pathologists and patients a great deal of anxiety. Herein we discuss criteria for Barrett esophagus, evaluation of dysplasia, and some pitfalls in reviewing endoscopic mucosal resections. Also included is a summary of suggested follow-up for patients with Barrett esophagus.

Diagnosis and Management of Barrett-Related Neoplasia in the Modern Era

Whereas in the past, pathologists were hesitant to diagnose high-grade dysplasia in patients with Barrett esophagus, because this diagnosis prompted esophagectomy, current international consensus is that endoscopic treatment is the management for high-grade dysplasia and intramucosal carcinoma. Furthermore, many centers advocate endoscopic ablation for low-grade dysplasia. As such, establishing a diagnosis of dysplasia has become the key step; separation between the grades of dysplasia is less critical. This article offers some criteria for separating dysplasia from reactive changes, discusses pitfalls in interpreting endoscopic mucosal resection specimens, and outlines management strategies.

Whole greater than the parts: integrated esophageal centers (IEC) and advanced training in esophageal diseases

An integrated esophageal center (IEC) is a multidisciplinary team with expertise, skill, range, and facilities necessary to achieve optimal outcomes in patients with esophageal diseases efficiently and expeditiously. Within IEC, patients presenting with esophageal symptoms undergo a detailed clinical, functional and structural evaluation of their esophagus prior to implementation of tailored medical, endoscopic or surgical therapy. Serving as a core, the IEC clinical practice also supports research and innovation in esophageal diseases as well as public and physician education. Referrals to the unit may be primary, either from primary care or self-initiated, or secondary from other specialty practices, to reassess patients who have previously failed therapies and to manage complex or complicated cases. The fundamental goals of the IEC are to provide value for patients with esophageal diseases, streamlining complex diagnostic investigations and expediting therapies aiming at reducing costs while improving clinical outcomes, and to accelerate knowledge generation through robust interaction and cross-training across disciplines. The organization of the IEC goes beyond traditional academic and clinical silos and involves a director and administrative team coordinating faculty and fellows from both medical and surgical disciplines and supported by other clinical lines, such as radiology, pathology, etc., while it interfaces with physicians, the public, basic, translational and clinical research groups, and related industry partners.

Risk of metastasis in adenocarcinoma of the esophagus: a multicenter retrospective study in a Japanese population

BACKGROUND

Little is known about the specific risks of metastasis in esophageal adenocarcinoma in relation to invasion depth or other pathologic factors.

METHODS

We conducted a multicenter retrospective study in 13 high-volume centers in Japan from January 2000 to October 2014 to elucidate the risk of metastasis of esophageal adenocarcinoma. A total of 458 patients (217 surgically resected and 241 endoscopically resected) with esophageal adenocarcinoma or esophagogastric adenocarcinoma involving the esophagus were included. Metastasis was considered positive if there was histologically confirmed metastasis in the surgical specimen or clinically confirmed metastasis during follow-up. Metastasis was considered negative if no metastasis was identified in resected specimens and during follow-up in patients treated surgically or no metastasis during follow-up for >5 years in patients treated by endoscopic resection.

RESULTS

Metastasis was identified in 72 patients. Multivariate analysis confirmed lymphovascular involvement [odds ratio (OR) 6.20; 95 % confidence interval (CI) 3.12-12.32; p < 0.001], a poorly differentiated component (OR 3.69; 95 % CI 1.92-7.10; p < 0.001), and lesion size >30 mm (OR 3.12; 95 % CI 1.63-5.97; p = 0.001) as independent risk factors for metastasis. No metastasis was detected in patients with mucosal cancer without lymphovascular involvement and a poorly differentiated component (0/186 lesions) or in patients with cancer invading the submucosa (1-500 µm) without lymphovascular involvement, a poorly differentiated component, and ≤30 mm (0/32 lesions).

CONCLUSIONS

Mucosal and submucosal cancers (1-500 µm invasion) without risk factors have a low incidence of metastasis and may thus be good candidates for endoscopic resection.