Endosonography of high-grade intra-epithelial neoplasia/early cancer

Predictors of lymph node metastasis and residual tumor in early gastric cancer patients after noncurative endoscopic resection: a systematic review and meta-analysis

BACKGROUND

It is challenging to identify the prevalence of lymph node metastasis (LNM) and residual tumor in patients with early gastric cancer (EGC) who underwent noncurative endoscopic resection (ER). This present meta-analysis was aimed to establish imperative potential predictive factors in order to select the optimal treatment method.

METHODS

A systematic literature search of PubMed, Embase, and Cochrane Library databases was performed through 1 February 2019 to identify relevant studies, which investigated risk factors for LNM and residual tumor in patients with EGC who underwent noncurative ER. Eligible data were systematically reviewed through a meta-analysis.

RESULTS

Overall, 12 studies investigating the risk factor of LNM were included, totaling 3015 patients, 7 of which also involved cancer residues. After the present meta-analysis, six predictors, including tumor size >30 mm, tumor invasion depth (⩾500 μm from the muscularis mucosae), macroscopic appearance, undifferentiated histopathological type, positive vertical margin, and presence of lymphovascular invasion (including lymphatic invasion and vascular invasion) were significantly associated with LNM, whereas tumor size >30 mm, positive horizontal margin, and positive vertical margin were identified as significant predictors for the risk of residual tumor. No evidence of publication bias was observed.

CONCLUSIONS

Six and three variables were established as significant risk factors for LNM and residual tumor in patients with EGC who underwent noncurative ER, respectively. Patients with EGC who present these risk factors after noncurative ER are strongly suggested to receive additional surgery, while others might be suitable for strict follow-up. This might shed some new light on the selection of follow-up treatment for noncurative ER.

Evaluation of transabdominal ultrasound after oral administration of an echoic cellulose-based gastric ultrasound contrast agent for gastric cancer

Background

With the remarkable improvements in ultrasound equipment, transabdominal ultrasound after oral administration of an echoic cellulose-based gastric ultrasound contrast agent (TUS-OCCA) has recently been suggested to be effective in initial screening of gastric cancer. The aim of this study was to evaluate the diagnostic value of TUS-OCCA for gastric cancer.

Methods

Consecutive patients with gastric cancers who underwent resection in our hospital were enrolled. Before the lesion was resected, TUS-OCCA examination was performed by a skilled examiner who was blinded to the site, size, and endoscopy diagnosis of the lesion. TUS-OCCA findings were compared with those of endoscopy and pathological diagnoses as the gold standard.

Results

There were a total of 288 consecutive patients enrolled in the study, including 228 with advanced gastric cancers (T2–T4 stage), 50 with early gastric cancer (26 with stage T1b and 24 with stage T1a), and 10 with high-grade intraepithelial neoplasia. TUS-OCCA had a detection rate of 100 % (228/228) for advanced gastric cancers, 77 % (20/26) for stage T1b, 67 % (16/24) for stage T1a, and 60 % (6/10) for high-grade intraepithelial neoplasia. The majority of patients with undetectable neoplasms using TUS-OCCA were obese (body mass index, 28.7–31.8 kg/m²). The overall accuracy of TUS-OCCA in determining the T stage of gastric cancer was 77.3 % (62.5 % for T1a, 70 % for T1b, 71.1 % for T2, 85.2 % for T3, and 73.3 % for T4).

Conclusions

These findings indicate that TUS-OCCA achieved a high detection rate for gastric cancers and was useful in assessing the degree of gastric cancer invasion.

Multidisciplinary treatment of T1a adenocarcinoma in Barrett's esophagus: contemporary comparison of endoscopic and surgical treatment in physiologically fit patients

BACKGROUND

Previous reports comparing endoscopic therapy (ET) and surgical therapy (ST) have predominantly assessed patients with high-grade dysplasia. The study aim was to compare ET to ST in physiologically fit patients with cT1a adenocarcinoma (EAC).

METHODS

Review of two prospective databases yielded 100 patients presenting with clinical cT1a EAC between 2000 and 2013. Only physiologically fit patients who were candidates for either treatment were analyzed.

RESULTS

Presenting patient characteristics were similar between ET (n = 36) and ST groups (n = 49). Surgical patients were less likely to be staged with EMR (43 vs 100 %) and were associated with mass lesions >1 cm at EGD (p = 0.01), multifocal EAC (p = 0.03), and positive margins for EAC on EMR (p < 0.05). On multivariate analysis, only multifocal HGD was an independent factor for surgery. Following esophagectomy, R0 resection rates for Barrett's esophagus and cancer were 100 %. Incidence of surgery decreased over the study period from 85 to 25 %. All ET patients had EMR, and 28 patients underwent additional ablative therapies for Barrett's esophagus. Following ET, eradication rates of EAC, dysplasia, and BE were 92, 81, and 53 %, respectively. Morbidity rates were comparable between groups (ST 51 % vs ET 39 %, p = 0.31). In-hospital mortality rate was zero in each group. Recurrence rates in ST and ET group were 2 and 11 % (p = 0.08). In the ET group, two patients with endoluminal cancer recurrence after complete eradication underwent esophagectomy. Age-adjusted overall survival was comparable.

CONCLUSION

In high-volume esophageal centers, ST and ET provide equally safe and effective treatment for cT1a EAC in medically fit patients. While the results of this study provide a historical perspective and clearly demonstrate an evolution toward ET over time, the appropriate treatment modality is best selected in a multidisciplinary fashion with EMR providing the most accurate staging. In endoscopically treated patients, indefinite endoscopic follow-up required, however, standardized long-term follow-up protocols are needed.

Redefining early gastric cancer

BACKGROUND

The problem is that current definitions of early gastric cancer allow the inclusion of regional lymph node metastases. The increasing use of endoscopic submucosal dissection to treat early gastric cancer is a concern because regional lymph nodes are not addressed. The aim of the study was thus to critically evaluate current evidence with regard to tumour-specific factors associated with lymph node metastases in "early gastric cancer" to develop a more precise definition and improve clinical management.

METHODS

A systematic and comprehensive search of major reference databases (MEDLINE, EMBASE, PubMed and the Cochrane Library) was undertaken using a combination of text words "early gastric cancer", "lymph node metastasis", "factors", "endoscopy", "surgery", "lymphadenectomy" "mucosa", "submucosa", "lymphovascular invasion", "differentiated", "undifferentiated" and "ulcer". All available publications that described tumour-related factors associated with lymph node metastases in early gastric cancer were included.

RESULTS

The initial search yielded 1494 studies, of which 42 studies were included in the final analysis. Over time, the definition of early gastric cancer has broadened and the indications for endoscopic treatment have widened. The mean frequency of lymph node metastases increased on the basis of depth of infiltration (mucosa 6% vs. submucosa 28%), presence of lymphovascular invasion (absence 9% vs. presence 53%), tumour differentiation (differentiated 13% vs. undifferentiated 34%) and macroscopic type (elevated 13% vs. flat 26%) and tumour diameter (≤2 cm 8% vs. >2 cm 25%).

CONCLUSION

There is a need to re-examine the diagnosis and staging of early gastric cancer to ensure that patients with one or more identifiable risk factor for lymph node metastases are not denied appropriate chemotherapy and surgical resection.

Management of Barrett's oesophagus and intramucosal oesophageal cancer: a review of recent development

Barrett's oesophagus is the most important and recognizable precursor lesion for oesophageal adenocarcinoma, which is the one of the fastest growing cancers in the Western World. The incidence of oesophageal adenocarcinoma has increased 600% in the United States between 1975 and 2001 and is thought to represent a real increase in burden rather than a result of histologic or anatomical misclassification or overdiagnosis. Thus, the cancer risk in Barrett's oesophagus has to be managed and involves prevention (surveillance endoscopy), treating underlying gastroesophageal reflux disease (medically and or surgically) and endoscopic therapy to remove diseased epithelium in appropriate patient subgroups. In the last decade, new developments in imaging and molecular markers as well as an armamentarium of novel and effective endoscopic eradication therapy has become available to the endoscopist to combat this exponential rise in oesophageal adenocarcinoma. Paradoxically, the cancer risk in Barrett's oesophagus gets progressively downgraded which raises fundamental questions about our understanding of the known and unknown risk factors and molecular aberrations that are involved in the Barrett's metaplasia-dysplasia-carcinoma sequence. Future research has to be directed at these areas to fine tune our screening and surveillance programs to identify more accurately the high-risk group of progressors to oesophageal adenocarcinoma who would benefit most from endoscopic therapy.

Endotherapy for Barrett's esophagus

Endotherapy is now the mainstay of therapy for Barrett's associated neoplasia. The approach should begin with confirmation of neoplasia by a gastrointestinal pathologist, patient counseling, and appropriate endoscopic work up. Detailed examination with high-resolution white light endoscopy is the most important tool for detection of neoplasia. Further validation studies are needed for many enhanced imaging modalities before being recommended as part of the standard work up and assessment of patients with Barrett's esophagus (BE). Endoscopic mucosal resection is required for any visible lesion in the setting of dysplasia for accurate histological diagnosis. The remainder of the epithelium may be treated with resection or ablative therapy, followed by adequate surveillance. Patients with nondysplastic Barrett's require further risk stratification before incorporation of ablative therapy for this population. The future will fortify the endoscopic role in Barrett's with validation trials for endoscopic assessment, further long-term results for each of the treatment modalities, potential risk stratification for patients with BE, and improved guidelines for surveillance after therapy.

An update in endoscopic management of gastric cancer

PURPOSE OF REVIEW

Gastric cancer remains a prevalent disease with a 5-year mortality rate of less than 25%. This review focuses on the endoscopic detection, staging, and management of gastric adenocarcinoma.

RECENT FINDINGS

Confocal laser endomicroscopy and narrow band imaging have a 77-99.4% sensitivity for early cancer detection, a significant improvement when compared with white light endoscopy. Proper staging can be accomplished through endoscopic ultrasound and multidetector row-computed tomography, with accuracy as high as 90.1%. Endoscopic management of early gastric cancer is minimally invasive and can be preferable to surgery. In properly selected patients, endoscopic submucosal dissection has been found to have 100% 5-year survival.

SUMMARY

The recent advances in gastric cancer have greatly improved the care we can offer our patients in gastric oncology. The emerging technologies will hopefully continue to promote this trend.

The role of surgery in the management of Barrett's esophagus (from dysplasia to cancer)

The goal of this review is to evaluate, through a review of the surgical literature, the role of esophagectomy in the management of Barrett's esophagus as it evolves histologically from intestinal metaplasia through increasing grades of dysplasia to adenocarcinoma. We precisely define the indications and therapeutic modalities of esophagectomy for high-grade dysplasia, superficial adenocarcinoma, and invasive adenocarcinoma.

Endotherapy for Barrett's esophagus: Which, how, when, and who?

Recent developments in endoscopic therapeutic options for Barrett's esophagus (BE) early neoplasia have resulted in a dramatic paradigm shift in its clinical management. With multiple endoscopic choices available, it is important to discern subtle differences between these approaches based on the available current data and known limitations of each modality. The goals of endoscopic therapy of Barrett's neoplasia are to preserve the esophagus while ablating or removing the entire BE segment. This article reviews the currently available BE endoscopic treatments with emphasis on appropriate selection of patients, indications and timing of use, and clinical management considerations.

Staging of early adenocarcinoma in Barrett's esophagus

The main goal in the staging of patients with early neoplasia arising in the context of Barrett's esophagus (BE) is to identify individuals who are eligible for endoscopic therapy and differentiate them from those who require surgical management. To make the proper patient selection a combined staging strategy consisting of endoscopy evaluation, endoscopic ultrasonography, and endoscopic mucosal resection is necessary. In this article, the authors summarize the evidence behind each different staging modality in the setting of early BE adenocarcinoma and propose a staging approach that helps to select patients who are suitable for endoscopic therapy.

Esophageal resection for high-grade dysplasia and intramucosal carcinoma: When and how?

High-grade dysplasia (HGD) and intramucosal carcinoma (IMC) in the setting of Barrett’s esophagus have traditionally been treated with esophagectomy. However, with the advent of endoscopic mucosal resection and endoscopic ablative therapies, endoscopic therapy at centers with expertise is now an established treatment of Barrett’s-esophagus-related neoplasia, including HGD and IMC. Esophagectomy is today reserved for more selected cases with submucosal invasion, evidence for lymph node metastasis, or unsuccessful endoscopic therapy.

Optimal endoluminal treatment of Barrett's esophagus: integrating novel strategies into clinical practice

Endoluminal therapy has become the first-choice treatment over the last 5 years for early Barrett's neoplasia limited to the mucosa. Long-term follow-up data on endoscopic resection have demonstrated the oncological safety of endoscopic resection in comparison to surgery. However, there is a high rate of recurrent disease, which can be avoided using additional ablation of the remaining Barrett. Radiofrequency ablation was recently introduced as an efficacious means to ablate Barrett's epithelium with a better safety profile than older ablation techniques. Recent studies show that endoscopic resection can be safely combined with radiofrequency ablation for treating dysplastic Barrett's after removal of visible lesions. This constitutes a completely new treatment paradigm that will be integrated in routine clinical practice in the forthcoming years.