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Malick A, Ferris JS, Hur C, Abrams JA, Soroush A. Racial, Ethnic, and Sex Differences in Incidence-Based Mortality of Aggregate Upper Gastrointestinal Cancers. Clin Transl Gastroenterol 2024; 15:e00745. [PMID: 39007497 PMCID: PMC11346873 DOI: 10.14309/ctg.0000000000000745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024] Open
Abstract
INTRODUCTION Current strategies for upper gastrointestinal (UGI) cancer screening primarily target cancer-specific risk, with the strongest focus on esophageal adenocarcinoma (EAC). However, all UGI cancers are amendable to screening and early detection with an upper endoscopic examination. This study assesses and explores incidence-based mortality (IBM) for cumulative UGI cancers, aiming to identify race-based or sex-based disparities. METHODS We used Surveillance, Epidemiology, and End Results Research data to analyze patients diagnosed with EAC, esophageal squamous cell carcinoma, cardia gastric cancer, noncardia gastric cancer, or colorectal adenocarcinoma from 2000 to 2019. Age-adjusted IBM was calculated as a rate per 100,000 population and stratified by sex and race/ethnicity. We also compared UGI cancer IBM with that of colorectal cancer, a cancer with established population-wide endoscopic screening guidelines. RESULTS Cumulative IBM for UGI cancers was 8.40 (95% confidence interval [CI] 8.34-8.46). The highest cancer-specific IBM rates were for EAC (2.26, 95% CI 2.23-2.29), followed by noncardia gastric cancer (2.07, 95% CI 2.04-2.10), cardia gastric cancer (1.60, 95% CI 1.57-1.62), esophageal squamous cell carcinoma (1.21, 95% CI 1.19-1.23), and miscellaneous UGI cancer (1.27, 95% CI 1.13-1.40). UGI cancer IBM was highest among Black men (16.43, 95% CI 15.97-16.89), American Indian/Alaska Native men (15.23, 95% CI 13.75-16.82), and Hispanic men (13.76, 95% CI 13.42-14.11). These rates are significantly greater than among White men (12.81, 95% CI 12.68-12.95). DISCUSSION UGI cancers impose a significantly higher mortality burden on non-White population subgroups that are not currently targeted by any systematic screening approach.
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Affiliation(s)
- Alyyah Malick
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Jennifer S. Ferris
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Chin Hur
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Julian A. Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Ali Soroush
- Division of Data Driven and Digital Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Kahn A, Song K, Dhaliwal L, Thanawala S, Hagen CE, Agarwal S, McDonald NM, Gabre JT, Falk GW, Ginsberg GG, Wolfsen HC, Ramirez FC, Leggett CL, Wang KK, Iyer PG. Long-term outcomes following successful endoscopic treatment of T1 esophageal adenocarcinoma: a multicenter cohort study. Gastrointest Endosc 2023; 98:713-721. [PMID: 37356631 DOI: 10.1016/j.gie.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND AND AIMS Endoscopic eradication therapy (EET) is guideline endorsed for management of early-stage (T1) esophageal adenocarcinoma (EAC). Patients with baseline high-grade dysplasia (HGD) and EAC are at highest risk of recurrence after successful EET, but limited data exist on long-term (>5 year) recurrence outcomes. Our aim was to assess the incidence and predictors of long-term recurrence in a multicenter cohort of patients with T1 EAC treated with EET. METHODS Patients with T1 EAC achieving successful endoscopic cancer eradication with a minimum of 5 years' clinical follow-up were included. The primary outcome was neoplastic recurrence, defined as dysplasia or EAC, and it was characterized as early (<2 years), intermediate (2-5 years), or late (>5 years). Predictors of recurrence were assessed by time to event analysis. RESULTS A total of 84 T1 EAC patients (75 T1a, 9 T1b) with a median 9.1 years (range, 5.1-18.3 years) of follow-up were included. The overall incidence of neoplastic recurrence was 2.0 per 100 person-years of follow-up. Seven recurrences (3 dysplasia, 4 EAC) occurred after 5 years of EAC remission. Overall, 88% of recurrences were treated successfully endoscopically. EAC recurrence-related mortality occurred in 3 patients at a median of 5.2 years from EAC remission. Complete eradication of intestinal metaplasia was independently associated with reduced recurrence (hazard ratio, .13). CONCLUSIONS Following successful EET of T1 EAC, neoplastic recurrence occurred after 5 years in 8.3% of cases. Careful long-term surveillance should be continued in this patient population. Complete eradication of intestinal metaplasia should be the therapeutic end point for EET.
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Affiliation(s)
- Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Kevin Song
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Lovekirat Dhaliwal
- Department of Internal Medicine, Louisiana State University Health, Shreveport, Louisiana, USA
| | - Shivani Thanawala
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catherine E Hagen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Siddharth Agarwal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas M McDonald
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joel T Gabre
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gary W Falk
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory G Ginsberg
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Francisco C Ramirez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.
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Shi K, Yang Z, Leng K. Treatment for T1 colorectal cancers substratified by site and size: "horses for courses". Front Med (Lausanne) 2023; 10:1230844. [PMID: 37901402 PMCID: PMC10602675 DOI: 10.3389/fmed.2023.1230844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/21/2023] [Indexed: 10/31/2023] Open
Abstract
Background Owing to advances in diagnostic technology, the diagnosis of T1 colorectal cancers (CRCs) continues to increase. However, the optimal management of T1 CRCs in the Western Hemisphere remains unclear due to limited population-based data directly comparing the efficacy of endoscopic therapy (ET) and surgical resection (SR). The purpose of this study was to report outcome data from a large Western cohort of patients who underwent ET or SR for early CRCs. Methods The SEER-18 database was used to identify patients with T1 CRCs diagnosed from 2004 to 2018 treated with ET or SR. Multivariable logistic regression models were employed to identify variables related to lymph node metastasis (LNM). Rates of ET and 1-year relative survival were calculated for each year. Effect of ET or SR on overall survival and cancer-specific survival was compared using Kaplan-Meier method stratified by tumor size and site. Results A total of 28,430 T1 CRCs patients were identified from 2004 to 2018 in US, with 22.7% undergoing ET and 77.3% undergoing SR. The incidence of T1 CRCs was 6.15 per 100,000 person-years, with male patients having a higher incidence. Left-sided colon was the most frequent location of tumors. The utilization of ET increased significantly from 2004 to 2018, with no significant change in 1-year relative survival rate. Predictors of LNM were age at diagnosis, sex, race, tumor size, histology, grade, and location. The 5-year relative survival rates were 91.4 and 95.4% for ET and SR, respectively. Subgroup analysis showed that OS and CSS were similar between ET and SR in T1N0M0 left-sided colon cancers with tumors 2 cm or less and in rectal cancers with tumors 1 cm or less. Conclusion Our study showed that ET was feasible and safe for patients with left-sided T1N0M0 colon cancers and tumors of 2 cm or less, as well as T1N0M0 rectal cancers and tumors of 1 cm or less. Therefore, the over- and under-use of ET should be avoided by carefully selecting patients based on tumor size and site.
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Affiliation(s)
- Kexin Shi
- The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Zhen Yang
- Department of Hepatopancreatobiliary Surgery, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
- Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, China
| | - Kaiming Leng
- Department of Hepatopancreatobiliary Surgery, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
- Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, China
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Böhme F, Racz K, Sebesta C, Sebesta C. [Esophageal Cancer]. Wien Med Wochenschr 2023; 173:209-215. [PMID: 36318394 DOI: 10.1007/s10354-022-00972-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 09/05/2022] [Indexed: 05/31/2023]
Abstract
Esophageal cancer has poor prognosis and high letality. With yearly 600,000 new cases worldwide it ist he sixt most common cancer worldwide and the eight most deadly. Squamous cell carcinoma is more common in Africa and Asia, whereas incidence of adenocarcinoma ist increasing in Norh America and Europe. Riskfactors include alcohol, smoking, obesity, esophageal stenosis or achalasia. Currently there are no recommendations for prevention strategies or cancer screening. Symptoms in early stages are unspecific, so diagnosis is made late. Diagnostics include gastroscopy, CT, PET and endosonography. Therapeutic approaches are depending on disease stage and patients general condition. In early stages endoscopic resection is the treatment of choice. In higher stages theraoy consists of surgical resection and radiochemotherapy. Generalised stade ist treated with palliative systemic therapy and local interventions.
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Affiliation(s)
- Felix Böhme
- 2. Medizinische Abteilung, Klinik Donaustadt, Langobardenstraße 122, 1220, Wien, Österreich.
| | - Krisztina Racz
- 2. Medizinische Abteilung, Klinik Donaustadt, Langobardenstraße 122, 1220, Wien, Österreich
| | - Christian Sebesta
- 2. Medizinische Abteilung, Klinik Donaustadt, Langobardenstraße 122, 1220, Wien, Österreich
| | - Christian Sebesta
- 2. Medizinische Abteilung, Klinik Donaustadt, Langobardenstraße 122, 1220, Wien, Österreich
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Chen H, Wu J, Guo W, Yang L, Lu L, Lin Y, Wang X, Zhang Y, Chen X. Clinical models to predict lymph nodes metastasis and distant metastasis in newly diagnosed early esophageal cancer patients: A population-based study. Cancer Med 2023; 12:5275-5292. [PMID: 36205033 PMCID: PMC10028124 DOI: 10.1002/cam4.5334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 09/14/2022] [Accepted: 09/25/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with early esophageal cancer (EC) receive individualized therapy based on their lymph node metastasis (LNM) and distant metastasis (DM) status; however, deficiencies in current clinical staging techniques and the issue of cost-effectiveness mean LNM and DM often go undetected preoperatively. We aimed to develop three clinical models to predict the likelihood of LNM, DM, and prognosis in patients with early EC. METHOD The Surveillance, Epidemiology, and End Results database was queried for T1 EC patients from 2004 to 2015. Multivariable logistic regression and Cox proportional hazards models were used to recognize the risk factors of LNM and DM, predict overall survival (OS), and develop relevant nomograms. Receiver operating characteristic (ROC)/concordance index and calibration curves were used to evaluate the discrimination and accuracy of the three nomograms. Decision curve analyses (DCAs), clinical impact curves, and subgroups based on model scores were used to determine clinical practicability. RESULTS The area under the curve of the LNM and DM nomograms were 0.668 and 0.807, respectively. The corresponding C-index of OS nomogram was 0.752. Calibration curves and DCA showed an effective predictive accuracy and clinical applicability. In patients with T1N0M0 EC, surgery alone (p < 0.01) proved a survival advantage. Chemotherapy and radiotherapy indicated a better prognosis in the subgroup analysis for T1 EC patients with LNM or DM. CONCLUSIONS We created three nomograms to predict the likelihood of LNM, DM, and OS probability in patients with early EC using a generalizable dataset. These useful visual tools could help clinical physicians deliver appropriate perioperative care.
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Affiliation(s)
- Hong Chen
- Department of Oncology, The 900th Hospital of the People's Liberation Army Joint Service Support Force, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, 350025, China
| | - Junxian Wu
- Department of Gastroenterology, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian, 362000, China
| | - Wanting Guo
- Department of Oncology, The 900th Hospital of the People's Liberation Army Joint Service Support Force, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, 350025, China
| | - Lihang Yang
- Department of Oncology, The 900th Hospital of the People's Liberation Army Joint Service Support Force, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, 350025, China
| | - Linbin Lu
- Department of Oncology, The 900th Hospital of the People's Liberation Army Joint Service Support Force, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, 350025, China
| | - Yihong Lin
- Department of Oncology, The 900th Hospital of the People's Liberation Army Joint Service Support Force, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, 350025, China
| | - Xuewen Wang
- Department of Oncology, The 900th Hospital of the People's Liberation Army Joint Service Support Force, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, 350025, China
| | - Yan Zhang
- Department of Oncology, The 900th Hospital of the People's Liberation Army Joint Service Support Force, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, 350025, China
| | - Xi Chen
- Department of Oncology, The 900th Hospital of the People's Liberation Army Joint Service Support Force, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, 350025, China
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Choi KKH, Sanagapalli S. Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies. World J Gastrointest Oncol 2022; 14:568-586. [PMID: 35321279 PMCID: PMC8919017 DOI: 10.4251/wjgo.v14.i3.568] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 11/12/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.
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Affiliation(s)
- Kevin Kyung Ho Choi
- AW Morrow Gastroenterology Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, NSW, Australia
| | - Santosh Sanagapalli
- Department of Gastroenterology, St Vincent’s Hospital, Darlinghurst 2010, NSW, Australia
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Ye H, Chen P, Wang YF, Cai XJ. Endoscopic Versus Surgical Therapy for Early Esophagogastric Junction Adenocarcinoma Based on Lymph Node Metastasis Risk: A Population-Based Analysis. Front Oncol 2021; 11:716470. [PMID: 34976786 PMCID: PMC8718685 DOI: 10.3389/fonc.2021.716470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background In this study, we aimed to compare the prognosis and lymph node metastasis (LNM) risk in patients with early-stage esophagogastric junction (EGJ) adenocarcinoma after endoscopic treatment (ET) or radical surgery. Methods We collected data from eligible patients based on the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2016. Logistic regression analysis was used to determine independent predictors of LNM (examination of at least 16 lymph nodes). Cox regression analysis and propensity score-matched (PSM) analysis were subsequently utilized to compare the overall survival (OS) and cancer-specific survival (CSS) of patients treated with ET or radical surgery. Results In total, 3708 patients were identified. Among them, 856 patients had greater than or equal to 16 examined lymph nodes (LNs) (LNE≥16). The LNM rates were 18.8% in all patients 8.3% in T1a patients and 24.6% in T1b patients. Independent predictors of LNM were submucosal invasion, tumor size ≥3cm and decreasing differentiation (P<0.05). The LNM rate decreased to approximately 5.3% in T1b tumors with well differentiation and tumor size <3cm. However, the LNM incidence increased to 17.9% or 33.3% in T1a tumors with poor differentiation or with both tumor size≥3cm and poor differentiation. Cox regression analysis demonstrated CSS was not significantly different in early-stage EGJ adenocarcinoma patients undergoing ET and those treated with radical surgery (HR= 1.004, P=0.974), which were robustly validated after PSM analysis. Moreover, subgroup analysis stratified by T1a and T1b showed similar results. Conclusions The findings of this study indicated ET as an alternative to radical surgery in early EGJ adenocarcinoma.
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Affiliation(s)
- Hua Ye
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Gastrointestinal and Hernia Ward, HwaMei Hospital, University Of Chinese Academy Of Sciences, Ningbo, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, China
| | - Ping Chen
- Department of Gastrointestinal and Hernia Ward, HwaMei Hospital, University Of Chinese Academy Of Sciences, Ningbo, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, China
| | - Yi-Fan Wang
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiu-Jun Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Xiu-Jun Cai,
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Abstract
Esophageal cancer (EC) often cannot be discovered in time because of its asymptomatic or symptom-atypical characteristics in early stage. The risk and probability of lymph node metastasis and distant metastasis increase correspondingly as the cancer aggressively invades deeper layers. Treatment regimens may be shifted to surgery and chemoradiotherapy (CRT) from endoscopic eradication therapy (EET) with poor quality of life and prognosis. It is imperative to identify dysplasia and EC early and enable early curative endoscopic treatments. Newer methods have been attempted in the clinical setting to achieve early detection at a more microscopic and precise level. Newer imaging techniques and artificial intelligence (AI) technology have been involved in targeted biopsies and will gradually unveil the visualization of pathology in the future. Early detection and diagnosis are the prerequisite to choose personal and precise treatment regimens. EET has also been undergoing development and improvement to benefit more patients as the first option or the firstly chosen alternative therapy, when compared with esophagectomy. More clinical studies are needed to provide more possibilities for EET.
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Affiliation(s)
- Hang Yang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Wu Hou District, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Wu Hou District, China
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Wang W, Chen D, Sang Y, Chen C, Zhang Y, Mao Y, Chen Y. Endoscopic resection versus esophagectomy for patients with small-sized T1N0 esophageal cancer: A propensity-matched study. Clin Res Hepatol Gastroenterol 2021; 45:101543. [PMID: 33554864 DOI: 10.1016/j.clinre.2020.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/25/2020] [Accepted: 09/11/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Endoscopic resection (ER) has been rapidly adopted in the treatment of early-stage esophageal cancer. We aimed to compare the outcomes of ER with esophagectomy for patients with small-sized (≤2 cm) stage T1a and T1b esophageal cancer in a population-based cohort. METHODS We queried the Surveillance, Epidemiology, and End Results database for patients with T1N0M0 esophageal cancer who underwent ER or esophagectomy and generated a balanced cohort with 217 matched pairs using propensity score matching (PSM). Kaplan-Meier method and multivariable Cox regression analysis were employed to investigate the matched cohort. Subgroup analyses of T stage were also performed. RESULTS We identified 702 patients; 309 (44.0 %) underwent ER, and 393 (56.0 %) underwent esophagectomy. In the unmatched cohort, patients who underwent ER were older, more likely to have a T1a stage, and less likely to receive lymph node sampling. In the entire matched cohort, multivariate analysis found esophagectomy were associated with better overall survival (OS) (HR: 0.62, 95 % CI: 0.40-0.96, p = 0.032) than ER, but no significant difference in esophageal cancer-specific survival (ECSS) (HR: 1.37, 95 % CI: 0.64-2.96, p = 0.420) between the two procedures. The results were similar for subgroup analyses of stage T1b patients. However, ER and esophagectomy were associated with similar OS (HR: 0.74, 95 % CI: 0.41-1.36; p = 0.334) and ECSS (HR: 3.69, 95 % CI: 0.95-14.39; p = 0.060) in patients with stage T1a disease. CONCLUSIONS In patients with stage T1 esophageal cancer, ER was similar to esophagectomy in terms of oncologic outcomes. More prospective studies should be implemented to determine the optimal treatment for T1b esophageal cancer patients with risk factors.
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Affiliation(s)
- Wenjia Wang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Donglai Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Yonghua Sang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Yongsheng Zhang
- Department of Pathology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yiming Mao
- Department of Thoracic Surgery, Suzhou Kowloon Hospital Shanghai Jiaotong University School of Medicine, Suzhou, China
| | - Yongbing Chen
- Department of Thoracic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China.
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The Next Endoscopic Frontier: Considering a Career in Resection Endoscopy. ACG Case Rep J 2021; 8:e00515. [PMID: 34368385 PMCID: PMC8337043 DOI: 10.14309/crj.0000000000000515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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11
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Pourmousavi MK, Wang R, Kerdsirichairat T, Kamal A, Akshintala VS, Hajiyeva G, Lopimpisuth C, Hanada Y, Kumbhari V, Singh VK, Khashab MA, Brewer OG, Shin EJ, Canto MI, Lennon AM, Ngamruengphong S. Comparable Cancer-Specific Mortality of Patients With Early Gastric Cancer Treated With Endoscopic Therapy vs Surgical Resection. Clin Gastroenterol Hepatol 2020; 18:2824-2832.e1. [PMID: 32389885 DOI: 10.1016/j.cgh.2020.04.085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Endoscopic therapy is used commonly for superficial gastric cancer with very low risk of metastasis to the lymph nodes. However, limited population-based studies from the West have evaluated long-term outcomes of patients who received endoscopic therapy vs surgery. METHODS We used the Surveillance Epidemiology and End Results database to identify and compare features and outcomes of patients who underwent endoscopic therapy (n = 786) or surgery (n = 2577) for Tis or T1aN0M0 superficial gastric cancer, diagnosed from 1998 to 2014. Multivariate logistic regression was performed to identify factors associated with endoscopic therapy. Overall survival and gastric cancer-specific survival times were compared after we controlled for covariates. RESULTS Use of endoscopic therapy increased from 15.1% of cases in 1998 to 2000 to 39.0% of cases in 2013 to 2014. Endoscopic therapy was used more frequently in patients who were older, female, or Caucasian, or with lesions that were located in the proximal stomach or were limited in depth (Tis vs T1a) and size, compared with surgery. The median follow-up time was 59 months (interquartile range, 31-102 mo). Percentages of 5-year overall and cancer-specific survival were 57% and 99% in the endoscopic therapy group and 76% and 95% in the surgery group. After we adjusted for clinical factors using a multivariate Cox proportional hazards model, we found no significant difference in gastric cancer-specific mortality between patients who received endoscopic therapy vs surgery (hazard ratio, 1.42; 95% CI, 0.91-2.23; P = .12). CONCLUSIONS In an analysis of a large population database, we found an increased trend in endoscopic therapy for superficial gastric cancer compared with surgery from 1998 through 2014. Patients who received endoscopic therapy vs surgery had comparable long-term cancer-specific mortality.
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Affiliation(s)
| | - Rui Wang
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland; Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | | | - Ayesha Kamal
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Venkata S Akshintala
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Gulara Hajiyeva
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Chawin Lopimpisuth
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Yuri Hanada
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Olaya Gutierrez Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Marcia I Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Anne Marie Lennon
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
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McCarty JC, Parker RK, Vidri RJ, Robinson KA, Lipsitz S, Gangadharan SP, Iyer PG. A retrospective cohort study of endoscopic therapy and esophagectomy for stage 1 esophageal cancer: less is more. Gastrointest Endosc 2020; 92:23-30. [PMID: 32276764 DOI: 10.1016/j.gie.2020.01.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Current guidelines recommend consideration of endoscopic therapy (ET) when treating select stage I esophageal cancers. The proportion of esophageal cancers treated with ET compared with esophagectomy has increased over time. Overall and cancer-specific survival have not been shown to be superior with ET in prior population-based studies. We thus evaluated cancer-specific survival comparing patients treated with ET and esophagectomy. METHODS We performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results database from 2004 to 2015 of patients with node-negative, superficial (T1a/T1b), esophageal cancer treated with ET or esophagectomy. Competing-risks models were used to compare cancer-specific survival. Cox proportional hazards models were used to assess overall survival. Subgroup analysis was performed comparing time periods 2004 to 2009 and 2010 to 2015. RESULTS Of 2133 included individuals, 772 (36.2%) underwent ET and 1361 (63.8%) underwent esophagectomy. Unadjusted 5-year survival for cancer-specific death was 87.7% (95% confidence interval [CI], 84.2-90.5) for ET and 82.4% (95% CI, 80.0- 84.5) for esophagectomy (P = .002). Within the adjusted competing-risk model, cancer-specific survival was superior in patients treated with ET compared with esophagectomy (subdistribution hazard ratio [SHR], 1.92; 95% CI, 1.35-2.74; P < .001). From 2004 to 2009, the SHR for esophagectomy was 1.68 (95% CI, 1.07-2.66; P = .024); whereas from 2010 to 2015, the SHR for esophagectomy was 2.02 (95% CI, 1.08-3.76; P = .027). CONCLUSIONS ET was associated with improved cancer-specific survival compared with esophagectomy in stage I esophageal cancer. This advantage was more pronounced for patients treated after 2009, potentially because of increasing clinician expertise in performing ET and patient selection.
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Affiliation(s)
- Justin C McCarty
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA; Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert K Parker
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA; Department of Surgery, Tenwek Hospital, Bomet, Kenya; Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Roberto J Vidri
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA; Department of Surgery, St Mary's Regional Medical Center, Lewiston, Maine, USA
| | - Kortney A Robinson
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA; Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Stuart Lipsitz
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Sidhu P Gangadharan
- Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Spadaccini M, Bhandari P, Maselli R, Spaggiari P, Alkandari AA, Varytimiadis L, Semeraro R, Di Leo M, Galtieri PA, Craviotto V, Lamonaca L, D'Amico F, Attardo S, Brambilla T, Sharma P, Hassan C, Repici A. Multi-band mucosectomy for neoplasia in patients with Barrett's esophagus: in vivo comparison between two different devices. Surg Endosc 2019; 34:3845-3852. [PMID: 31586245 DOI: 10.1007/s00464-019-07150-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 09/24/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Multi-band mucosectomy (MBM) is effective and safe for Barrett's neoplasia. No studies have yet compared the efficacy and safety of the MBM devices commercially available: Duette™ (CookMedical) and Captivator™ (BostonScientific). Our aim is to compare the two devices. METHODS This is a dual-center retrospective case-control study (Rozzano, Portsmouth) comparing efficacy, safety, and histology of resected specimens between Duette™ (DUE) and Captivator™ (CAPT). Efficacy was assessed by R0 and local recurrence (LR) rate. Bleedings, perforations, and strictures were recorded as safety outcomes. Moreover, the specimens were re-examined by two pathologists, blinded about the study group, to assess the maximum thickness of both the whole specimens and the resected submucosal layer. RESULTS Seventy-six patients (38 per group) were included. The two groups did not differ in terms of baseline characteristics. R0 resection was achieved in 96.7% versus 96.3% (p = ns) and LR were recorded in 4/38 (10.5%) versus 3/38 (7.9%) in DUE and CAPT group, respectively (p = ns). Considering Duette™ versus Captivator™, 2 versus 3 patients developed a symptomatic stricture. Only one post-procedural bleeding occurred (Captivator™). Maximum medium thicknesses of specimens and of resected submucosa did not differ between the groups. CONCLUSIONS MBM is safe and effective for resecting visible lesions using either of the two available devices.
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Affiliation(s)
- Marco Spadaccini
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, PO6 3LY, UK
| | - Roberta Maselli
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Paola Spaggiari
- Pathology Unit, Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Asma A Alkandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, PO6 3LY, UK
| | - Lazaros Varytimiadis
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, PO6 3LY, UK
| | - Rossella Semeraro
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Milena Di Leo
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Piera Alessia Galtieri
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Vincenzo Craviotto
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Laura Lamonaca
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Ferdinando D'Amico
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Simona Attardo
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | | | - Prateek Sharma
- Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, 64128, USA
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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14
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Hasson RM, Phillips JD. Editorial "Discrepancy Between the Clinical and Final Pathological Findings of Lymph Node Metastasis in Superficial Esophageal Cancer". Ann Surg Oncol 2019; 26:2662-2664. [PMID: 31228137 DOI: 10.1245/s10434-019-07501-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Rian M Hasson
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | - Joseph D Phillips
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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15
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Ramay FH, Vareedayah AA, Visrodia K, Iyer PG, Wang KK, Eluri S, Shaheen NJ, Reddy R, Martin LW, Greenwald BD, Edwards MA. What Constitutes Optimal Management of T1N0 Esophageal Adenocarcinoma? Ann Surg Oncol 2019; 26:714-731. [DOI: 10.1245/s10434-018-07118-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Indexed: 12/27/2022]
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16
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Yuan B, Liu L, Huang H, Li D, Shen Y, Wu B, Liu J, Yang M, Wang Z, Lu H, Liu Y, Liao L, Wang F. Comparison of the short-term and long-term outcomes of surgical treatment versus endoscopic treatment for early esophageal squamous cell neoplasia larger than 2 cm: a retrospective study. Surg Endosc 2018; 33:2304-2312. [DOI: 10.1007/s00464-018-6524-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/11/2018] [Indexed: 12/23/2022]
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17
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Chilukuri P, Gromski MA, Johnson CS, Ceppa DKP, Kesler KA, Birdas TJ, Rieger KM, Fatima H, Kessler WR, Rex DK, Al-Haddad M, DeWitt JM. Impact of the development of an endoscopic eradication program for Barrett's esophagus with high grade dysplasia or early adenocarcinoma on the frequency of surgery. Endosc Int Open 2018; 6:E1085-E1092. [PMID: 30211296 PMCID: PMC6133650 DOI: 10.1055/a-0640-3030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/12/2018] [Indexed: 11/20/2022] Open
Abstract
Background and aims The impact of the advent of an institutional endoscopic eradication therapy (EET) program on surgical practice for Barrett's esophagus (BE)-associated high grade dysplasia (HGD) or suspected T1a esophageal adenocarcinoma (EAC) is unknown. The aims of this study are to evaluate the different endoscopic modalities used during development of our EET program and factors associated with the use of EET or surgery for these patients after its development. Methods Patients who underwent primary endoscopic or surgical treatment for BE-HGD or early EAC at our hospital between January 1992 and December 2014 were retrospectively identified. They were categorized by their initial modality of treatment during the first year, and the impact over time for choice of therapy was assessed by multivariable logistic regression. Results We identified 386 patients and 80 patients who underwent EET and surgery, respectively. EET included single modality therapy in 254 (66 %) patients and multimodal therapy in 132 (34 %) patients. Multivariable logistic regression showed that, for each subsequent study year, EET was more likely to be performed in patients who were older ( P = 0.0009), with shorter BE lengths ( P < 0.0001), and with a pretreatment diagnosis of HGD ( P = 0.0054) compared to surgical patients. The diagnosis of EAC did not increase the utilization of EET compared to surgery as time progressed ( P = 0.8165). Conclusion The introduction of an EET program at our hospital increased the odds of utilizing EET versus surgery over time for initial treatment of patients who were older, had shorter BE lengths or the diagnosis of BE-HGD, but not in patients with EAC.
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Affiliation(s)
- Prianka Chilukuri
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark A. Gromski
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Duy Khanh P. Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenneth A. Kesler
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas J. Birdas
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Karen M. Rieger
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hala Fatima
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - William R. Kessler
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Douglas K. Rex
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John M. DeWitt
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA,Corresponding author John M. DeWitt, MD Indiana University School of Medicine550 University BlvdSuite 4100IndianapolisIN 46202-5250USA+1-317-948-8144
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18
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Friedland S, Triadafilopoulos G. Can endoscopic resection for Barrett's dysplasia and early cancer be curative? Ann N Y Acad Sci 2018; 1434:54-58. [PMID: 29752721 DOI: 10.1111/nyas.13715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/11/2018] [Accepted: 03/16/2018] [Indexed: 12/23/2022]
Abstract
Effective endoscopic treatments for dysplasia and early (intramucosal) cancer, together with expanded and rigorous screening programs to detect Barrett's esophagus, could help reverse the increase in the incidence of esophageal cancer and reduce esophageal cancer-related mortality. In this review, we discuss the long-term outcomes for mucosal resection for dysplasia and early cancer and compares them to esophagectomy as the standard of care choice. Eendoscopic resection for Barrett's dysplasia and early cancer can be curative but only when the lesion can be classified as: Paris type I (polypoid); Paris IIa (slightly elevated); Paris IIb (flat); Paris IIc (slightly depressed); histological grades G1 and G2; high-grade dysplasia. The size of the lesion is important, since <20 mm diameter lesions can be removed using endoscopic mucosal resection or, if they are larger, by endoscopic submucosal dissection. Proper imaging and lesion characterization followed by endoscopic resection as needed are essential in diagnostic and therapeutic decision making. Mucosal (T1a) Barrett's cancer and low-risk submucosal cancers have a minimal risk for lymph node metastasis and local endoscopic treatment is justified. Long-term outcomes of endoscopic therapy are same as surgery.
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Affiliation(s)
- Shai Friedland
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - George Triadafilopoulos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
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19
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Endoscopic submucosal dissection compared to endoscopic mucosal resection for early Barrett esophagus neoplasia. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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20
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Plum PS, Hölscher AH, Pacheco Godoy K, Schmidt H, Berlth F, Chon SH, Alakus H, Bollschweiler E. Prognosis of patients with superficial T1 esophageal cancer who underwent endoscopic resection before esophagectomy—A propensity score-matched comparison. Surg Endosc 2018. [DOI: 10.1007/s00464-018-6139-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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21
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Hospital of Diagnosis Influences the Probability of Receiving Curative Treatment for Esophageal Cancer. Ann Surg 2018; 267:303-310. [DOI: 10.1097/sla.0000000000002063] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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22
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Esophagectomy versus endoscopic resection for patients with early-stage esophageal adenocarcinoma: A National Cancer Database propensity-matched study. J Thorac Cardiovasc Surg 2018; 155:2211-2218.e1. [PMID: 29455958 DOI: 10.1016/j.jtcvs.2017.11.111] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 10/07/2017] [Accepted: 11/22/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Endoscopic resection has been rapidly adopted in the treatment of early-stage esophageal tumors. We compared the outcomes after esophagectomy or endoscopic resection for stage T1a adenocarcinoma. METHODS We queried the National Cancer Database for patients with T1a esophageal adenocarcinoma who underwent esophagectomy or endoscopic resection and generated a balanced cohort with 735 matched pairs using propensity-score matching. We then performed a multivariable Cox regression analysis on the matched and unmatched cohorts. RESULTS We identified 2173 patients; 1317 (60.6%) underwent esophagectomy, and 856 (39.4%) underwent endoscopic resection. In the unmatched cohort, patients who underwent esophagectomy were younger, more often not treated in academic settings, and more likely to have comorbidities (30.4% vs 22.5%, P = .002). They had longer hospital stays and more readmissions than patients who underwent endoscopic resection. Factors positively affecting overall survival were younger age, resection at an academic medical center, and lower Charlson-Deyo comorbidity score. In the matched cohort, patients who underwent esophagectomy had longer hospital stays and were more likely to be readmitted within 30 days (7.0% vs 0.6%, P < .001). When a time period-specific partition was applied, endoscopic resection had a lower death hazard 0 to 90 days after resection (hazard ratio, 0.15; P = .003), but this was reversed for survival greater than 90 days (hazard ratio, 1.34; P = .02). CONCLUSIONS In patients with early-stage esophageal adenocarcinoma, survival appears equivalent after endoscopic resection or esophagectomy, but endoscopic resection is associated with shorter hospital stays, fewer readmissions, and less 90-day mortality. In patients surviving more than 90 days, esophagectomy may provide better overall survival.
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23
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di Pietro M, Canto MI, Fitzgerald RC. Endoscopic Management of Early Adenocarcinoma and Squamous Cell Carcinoma of the Esophagus: Screening, Diagnosis, and Therapy. Gastroenterology 2018; 154:421-436. [PMID: 28778650 PMCID: PMC6104810 DOI: 10.1053/j.gastro.2017.07.041] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 12/16/2022]
Abstract
Because the esophagus is easily accessible with endoscopy, early diagnosis and curative treatment of esophageal cancer is possible. However, diagnosis is often delayed because symptoms are not specific during early stages of tumor development. The onset of dysphagia is associated with advanced disease, which has a survival at 5 years lower than 15%. Population screening by endoscopy is not cost-effective, but a number of alternative imaging and cell analysis technologies are under investigation. The ideal screening test should be inexpensive, well tolerated, and applicable to primary care. Over the past 10 years, significant progress has been made in endoscopic diagnosis and treatment of dysplasia (squamous and Barrett's), and early esophageal cancer using resection and ablation technologies supported by evidence from randomized controlled trials. We review the state-of-the-art technologies for early diagnosis and minimally invasive treatment, which together could reduce the burden of disease.
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Affiliation(s)
| | - Marcia I Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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24
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Zeng Y, Liang W, Liu J, He J. Endoscopic Treatment Versus Esophagectomy for Early-Stage Esophageal Cancer: a Population-Based Study Using Propensity Score Matching. J Gastrointest Surg 2017; 21:1977-1983. [PMID: 29030780 DOI: 10.1007/s11605-017-3563-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/24/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic treatment (ET) is an alternative for selected patients with early-stage esophageal cancer. The primary aim of this study was to compare overall survival (OS) and esophageal cancer-specific survival (ECSS) of such patients after ET or esophagectomy. METHODS Propensity score matching (PSM) and Cox regression analysis were used to compare OS and ECSS of 2661 patients with ET or esophagectomy for early-stage (Tis-T1N0M0) disease. Patient information was retrieved from the Surveillance, Epidemiology, and End Results database. Subgroup analyses by T stage and tumor histology were also performed. RESULTS There were significant differences in age, sex ratio, year of diagnosis, cancer site, cancer stage, differentiation grade, tumor histology, tumor size, lymph nodes examined, and receipt of radiation therapy in the two treatment groups. PSM created 621 patient pairs. Multivariate analysis found no significant differences in OS (HR = 1.216, P = 0.279) or ECSS (HR = 0.692, P = 0.179) in the esophagectomy and ET groups. The results were similar for subgroup analyses limited to stage Tis, T1a, and T1b patients. ET was also associated with similar OS and ECSS in esophageal adenocarcinoma and squamous cell carcinoma patients. CONCLUSION In this population-based study using PSM, patients with stage Tis and T1N0M0 esophageal cancer with ET had OS and ECSS comparable to those treated by esophagectomy after adjusting for clinical variables. The results support ET as an alternative to esophagectomy in early esophageal cancer.
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Affiliation(s)
- Yuan Zeng
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No 151, Yanjiang Rd, Guangzhou, 510120, Guangdong Province, People's Republic of China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Wenhua Liang
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No 151, Yanjiang Rd, Guangzhou, 510120, Guangdong Province, People's Republic of China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jun Liu
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No 151, Yanjiang Rd, Guangzhou, 510120, Guangdong Province, People's Republic of China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jianxing He
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No 151, Yanjiang Rd, Guangzhou, 510120, Guangdong Province, People's Republic of China. .,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China.
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25
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Newton AD, Predina JD, Xia L, Roses RE, Karakousis GC, Dempsey DT, Williams NN, Kucharczuk JC, Singhal S. Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk. Ann Surg Oncol 2017; 25:318-325. [PMID: 29147928 DOI: 10.1245/s10434-017-6238-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND In early-stage esophageal adenocarcinoma (EAC), esophagectomy improves staging but also increases mortality compared with endoscopic resection. Our objective was to quantify esophagectomy mortality and lymph node metastasis (LNM) risk in early-stage EAC to improve surgical treatment allocation. METHODS We identified National Cancer Database (2004-2014) patients with nonmetastatic, Tis, T1a, or T1b EAC who had primary surgical resection and microscopic examination of at least 15 lymph nodes. Univariate and multivariable logistic regression identified predictors of LNM. Cox regression identified predictors of death. The Kaplan-Meier method predicted overall survival (OS). RESULTS In 782 patients, LNM rates were: all patients 13.8%, Tis 0%, T1a 3.6%, T1b 23.4%. Independent predictors of LNM were submucosal invasion, lymphovascular invasion (LVI), decreasing differentiation, and tumor size ≥ 2 cm (P < 0.05). For T1a tumors with poor differentiation or size ≥ 2 cm, LNM rates were 10.2 and 6.7%, respectively; 90-day mortality was 3.1%. The LNM rate in well differentiated T1b tumors < 2 cm was 4.2%; 90-day mortality was 6.0%. Estimated 5-year OS was 80.2% versus 64.4% (T1a vs. T1b). LNM increased risk of death for T1a (hazard ratio [HR] 8.52, 95% confidence interval [CI] 3.13-23.22, P < 0.001) and T1b tumors (HR 2.52, 95% CI 1.59-4.00, P < 0.001). CONCLUSIONS In T1a EAC with poor differentiation or size ≥ 2 cm, esophagectomy should be considered, whereas in T1b EAC with low-risk features (well-differentiated T1b EAC < 2 cm without LVI), endoscopic resection may be sufficient. Treatment guidelines for early-stage EAC should include all high-risk tumor features for LNM and stage-specific esophagectomy mortality.
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Affiliation(s)
- Andrew D Newton
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.
| | - Jarrod D Predina
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Leilei Xia
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Daniel T Dempsey
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Noel N Williams
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
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26
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Tsai FC, Ghorbani S, Greenwald BD, Jang S, Dumot JA, McKinley MJ, Shaheen NJ, Habr F, Wolfsen HC, Abrams JA, Lightdale CJ, Nishioka NS, Johnston MH, Zfass A, Coyle WJ. Safety and efficacy of endoscopic spray cryotherapy for esophageal cancer. Dis Esophagus 2017; 30:1-7. [PMID: 28881903 DOI: 10.1093/dote/dox087] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 06/03/2017] [Indexed: 12/11/2022]
Abstract
Although surgery is traditionally the standard of care for esophageal cancer, esophagectomy carries significant morbidity. Alternative endoscopic therapies are needed for patients who are not candidates for conventional treatment. The objective of this study is to assess the safety, efficacy, and tolerability of spray cryotherapy of esophageal adenocarcinoma. This study includes patients with esophageal adenocarcinoma who had failed or were not candidates for conventional therapy enrolled retrospectively and prospectively in an open-label registry and patients in a retrospective cohort from 11 academic and community practices. Endoscopic spray cryotherapy was performed until biopsy proven local tumor eradication or until treatment was halted due to progression of disease, patient withdrawal or comorbidities. Eighty-eight patients with esophageal adenocarcinoma (median age 76, 80.7% male, mean length 5.1 cm) underwent 359 treatments (mean 4.4 per patient). Tumor stages included 39 with T1a, 25 with T1b, 9 with unspecified T1, and 15 with T2. Eighty-six patients completed treatment with complete response of intraluminal disease in 55.8%, including complete response in 76.3% for T1a, 45.8% for T1b, 66.2% for all T1, and 6.7% for T2. Mean follow-up was 18.4 months. There were no deaths or perforations related to spray cryotherapy. Strictures developed in 12 of 88 patients (13.6%) but were present before spray cryotherapy in 3 of 12. This study suggests that endoscopic spray cryotherapy is a safe, well-tolerated, and effective treatment option for early esophageal adenocarcinoma.
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Affiliation(s)
- F C Tsai
- Scripps Clinic, La Jolla, California
| | | | - B D Greenwald
- University of Maryland School of Medicine and Greenebaum Cancer Center, Baltimore, Maryland
| | - S Jang
- Cleveland Clinic, Cleveland, Ohio
| | | | - M J McKinley
- North Shore LIJ Health System and ProHEALTHcare Associates, Syosset & Lake Success, New York
| | - N J Shaheen
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - F Habr
- Alpert School of Medicine of Brown University, Providence, Rhode Island
| | - H C Wolfsen
- Mayo Clinic Jacksonville, Jacksonville, Florida
| | - J A Abrams
- Columbia University Medical Center, New York, New York
| | - C J Lightdale
- Columbia University Medical Center, New York, New York
| | - N S Nishioka
- Massachusetts General Hospital, Boston, Massachusetts
| | - M H Johnston
- Lancaster Gastroenterology, Inc., Lancaster, Pennsylvania
| | - A Zfass
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - W J Coyle
- Scripps Clinic, La Jolla, California
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Lockwood R, Ozanne E, Hur C, Yachimski P. Patient decision-making and clinical outcomes following endoscopic therapy or esophagectomy for Barrett's neoplasia. Endosc Int Open 2017; 5:E1128-E1135. [PMID: 29124122 PMCID: PMC5677463 DOI: 10.1055/s-0043-118096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 06/27/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The objective of this study was to assess patient involvement in decision-making, decision confidence, and decision regret among patients who had undergone endoscopic eradication therapy (EET) or esophagectomy for Barrett's esophagus (BE) associated neoplasia. PATIENTS AND METHODS Patients with BE high grade dysplasia or intramucosal (T1a) adenocarcinoma who had undergone EET or esophagectomy were invited to complete a survey. RESULTS The cohort included 50 subjects, 70 % (35/50) of whom had undergone EET and 30 % (15/50) of whom had undergone esophagectomy. Subjects who underwent esophagectomy were more likely to report post-treatment dysphagia (47 % vs 14 %, P = 0.03), post-treatment dietary modification (73 % vs 6 %, P < 0.0001), and were less likely to view their post-treatment health favorably. However, when asked whether they had selected the right treatment, a high degree of confidence was reported by both groups (mean 9.8 for EET vs 9.3 for esophagectomy on a 0 - 10 scale, P = 0.12). In fact, 97 % (34/35) of EET patients and 80 % (12/15) of esophagectomy patients indicated they would select the same treatment option ( P = 0.08). CONCLUSIONS Patients who have undergone EET or surgery for BE neoplasia report a high degree of involvement in the decision-making process. Although EET patients report fewer symptom-specific outcomes, measures of decision confidence and decision regret do not differ between the two treatment groups.
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Affiliation(s)
- Robert Lockwood
- Division of Gastroenterology, Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Chin Hur
- Harvard Medical School, Institute for Technology Assessment and Gastrointestinal Unit, Boston, MA, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA,Corresponding author Patrick Yachimski, MD MPH Vanderbilt University Medical Center1301 Medical Center DriveTVC 1660NashvilleTN 37232-5280USA+1-615-343-6229
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Endoscopic submucosal dissection for Barrett's early neoplasia: a multicenter study in the United States. Gastrointest Endosc 2017; 86:600-607. [PMID: 27688205 DOI: 10.1016/j.gie.2016.09.023] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 09/18/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The role of endoscopic submucosal dissection (ESD) in Barrett's early neoplasia is not well defined, with most studies originating from Asia and Europe. We aimed to assess the efficacy, safety, and results of ESD in Barrett's esophagus (BE) with high-grade dysplasia (HGD) and early adenocarcinoma (EAC) across centers in the United States. METHODS Multicenter retrospective analysis on 46 patients with BE who underwent ESD for BE-HGD or EAC, or both, between January 2010 and April 2015. The primary endpoint was the rate of en bloc resection. Secondary aims included rate of R0 (complete) and curative resection, a comparison of pre- and post-ESD histology, procedure-related adverse events, and rate of remission at follow-up. RESULTS Median age was 69 years (range, 42-82 years). The median resected specimen size was 45 mm (range, 13-125 mm). En bloc and curative resection rates were 96% (44/46) and 70% (32/46), respectively. Most lesions (11/20; 55%) diagnosed as BE-HGD on biopsy were upstaged to intramucosal or invasive EAC on post-ESD histopathology. There were 4 early (<48 hours) adverse events (3 bleeding and 1 perforation), and all were treated endoscopically. Seven patients (15%) developed esophageal strictures that were managed endoscopically. Complete remission of BE neoplasia was found in 100% (32/32) of patients with curative resection at median follow-up of 11 months (range, 2-25 months). CONCLUSIONS This is the largest multicenter series of ESD for early neoplastic BE from the United States. ESD appears to be safe and effective, with high en bloc and curative resection rates in the treatment of early BE neoplasia.
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Comparison of Endoscopic Resection and Minimally Invasive Esophagectomy in Patients With Early Esophageal Cancer. J Clin Gastroenterol 2017; 51:223-227. [PMID: 27306943 DOI: 10.1097/mcg.0000000000000560] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine whether endoscopic resection (ER) and minimally invasive esophagectomy (MIE) are safe and effective for treating squamous intraepithelial neoplasia of the esophagus. MATERIALS AND METHODS This study retrospectively analyzed a total of 99 consecutive patients with pathologically confirmed early esophageal cancer between December 2007 and 2011. ER was performed in 59 patients, whereas MIE was performed in 40 patients. We compared the 2 groups according to R0 resection rates, treatment-related complications, mean hospital stay, local recurrence rates, and 3- and 4-year overall survival. RESULTS No significant differences were found in the R0 resection rates between ER and MIE (94.9% vs. 97.5%, P>0.05). The occurrence rate of minor complications in the ER group was significantly lower than that in the thoracoscopic esophagectomy group (11.8% vs. 32.5%, P>0.05). The mean operative time in the ER group was 74±23 minutes, which was significantly shorter than that in the MIE group (298±46 min). The average length of hospital stay in the ER group was significantly shorter than that in the MIE group (P<0.001). No significant differences were observed in the local recurrence rates between the 2 groups (P>0.05). Similarly, no differences were found in the 3-year survival rate (ER: 96.6%, vs. MIE: 97.5%, P>0.05) and 4-year survival rate (ER: 91.5% vs. MIE: 90%, P>0.05) between the 2 groups. CONCLUSIONS ER achieves the same positive results as MIE in the treatment of early esophageal cancer and is associated with a lower complication rate, a shorter recovery time, and a similar survival rate. However, multiple ER procedures were required for several patients in this study.
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Bustamante FAC, Hourneaux DE Moura EG, Bernardo W, Sallum RAA, Ide E, Baba E. SURGERY VERSUS ENDOSCOPIC THERAPIES FOR EARLY CANCER AND HIGH-GRADE DYSPLASIA IN THE ESOPHAGUS: a systematic review. ARQUIVOS DE GASTROENTEROLOGIA 2017; 53:10-9. [PMID: 27281499 DOI: 10.1590/s0004-28032016000100004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/19/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Esophageal cancer occurs as a local disease in 22% of cases, and a minority of this disease is limited to the mucosa or submucosa (early lesions). Endoscopic mucosal resection, endoscopic submucosal dissection, photodynamic therapy, laser therapy, and argon plasma coagulation have emerged as alternatives to surgical resection for early lesions. OBJECTIVE The aim of this systematic review is to identify studies that statistically compare survival, disease-free survival, morbidity and mortality associated with the procedure, and mortality associated with cancer in the endoscopic versus surgical therapies. DATA SOURCES A systematic review using MEDLINE, COCHRANE, EMBASE, EBSCO, LILACS, Library University of Sao Paulo, BVS, and SCOPE. STUDY SELECTION Randomized controlled trial, controlled clinical trial, clinical trial, and cohort study. CRITERIA - Studies that statistically compare survival, disease-free survival, morbidity and mortality associated with the procedure, and mortality associated with cancer in patients who underwent endoscopic and surgical therapy for early lesions of esophageal cancer. DATA EXTRACTION Independent extraction of the articles by two authors using predefined data fields, including study quality indicators. LIMITATION Only retrosprospective cohort studies comparing the endoscopic and surgical therapies were recovered. RESULTS The survival rates after 3 and 5 years were different and exhibited superiority with the surgical therapies over time. Endoscopy is superior in the control of mortality related to cancer with a high rate of disease recurrence. With regard to the comorbidity and the mortality associated with the procedure, endoscopy is superior. CONCLUSION There is no evidence from clinical trials. In this systematic review, surgical therapies showed superiority for survival, and endoscopic therapies showed superiority in the control of mortality related to cancer with a high rate of disease recurrence; also, for the comorbidity and the mortality associated with the procedure, endoscopy is superior. Prospective, controlled trials with large sample sizes are necessary to confirm the results of the current analysis.
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Affiliation(s)
- Fabio Alberto Castillo Bustamante
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| | - Eduardo Guimarães Hourneaux DE Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| | - Wanderley Bernardo
- Projeto Diretrizes, Associação Médica Brasileira, São Paulo, SP, Brasil, Associação Médica Brasileira, São Paulo SP , Brasil
| | - Rubens Antonio Aissar Sallum
- Divisão de Cirurgia Esofágica, Departamento de Gastroenterologia, Hospital das Clinicas Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Departamento de Gastroenterologia, Hospital das Clinicas, Universidade de São Paulo, São Paulo SP , Brazil
| | - Edson Ide
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| | - Elisa Baba
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
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Qiao YM, Zhang Y. Immunotherapy for esophageal cancer: Current studies and future perspectives. Shijie Huaren Xiaohua Zazhi 2016; 24:4739-4751. [DOI: 10.11569/wcjd.v24.i36.4739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Esophageal cancer is one of the most common malignant tumors of the digestive system, and China has the highest morbidity and mortality rates of esophageal cancer in the world. Currently, main therapies for esophageal cancer include endoscopy, surgery, chemotherapy, and radiotherapy. These traditional treatments have appreciated clinical effects, but the prognosis of this malignancy is still poor. There is accumulating evidence that tumor immune microenvironment plays a key role in the development and progression of esophageal cancer. Recent clinical investigations and ongoing studies indicate that immunotherapy might have a great potential in the treatment of patients with esophageal cancer. Future studies will identify treatment strategies that can maximize therapeutic benefits by combining immunotherapies with existing and novel treatment modalities.
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Ballard DD, Choksi N, Lin J, Choi EY, Elmunzer BJ, Appelman H, Rex DK, Fatima H, Kessler W, DeWitt JM. Outcomes of submucosal (T1b) esophageal adenocarcinomas removed by endoscopic mucosal resection. World J Gastrointest Endosc 2016; 8:763-769. [PMID: 28042390 PMCID: PMC5159674 DOI: 10.4253/wjge.v8.i20.763] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/23/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To investigate the outcomes and recurrences of pT1b esophageal adenocarcinoma (EAC) following endoscopic mucosal resection (EMR) and associated treatments.
METHODS Patients undergoing EMR with pathologically confirmed T1b EAC at two academic referral centers were retrospectively identified. Patients were divided into 4 groups based on treatment following EMR: Endoscopic therapy alone (group A), endoscopic therapy with either chemotherapy, radiation or both (group B), surgical resection (group C) or no further treatment/lost to follow-up (< 12 mo) (group D). Pathology specimens were reviewed by a central pathologist. Follow-up data was obtained from the academic centers, primary care physicians and/or referring physicians. Univariate analysis was performed to identify factors predicting recurrence of EAC.
RESULTS Fifty-three patients with T1b EAC underwent EMR, of which 32 (60%) had adequate follow-up ≥ 12 mo (median 34 mo, range 12-103). There were 16 patients in group A, 9 in group B, 7 in group C and 21 in group D. Median follow-up in groups A to C was 34 mo (range 12-103). Recurrent EAC developed overall in 9 patients (28%) including 6 (38%) in group A (median: 21 mo, range: 6-73), 1 (11%) in group B (median: 30 mo, range: 30-30) and 2 (29%) in group C (median 21 mo, range: 7-35. Six of 9 recurrences were local; of the 6 recurrences, 5 were treated with endoscopy alone. No predictors of recurrence of EAC were identified.
CONCLUSION Endoscopic therapy of T1b EAC may be a reasonable strategy for a subset of patients including those either refusing or medically unfit for esophagectomy.
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Yachimski P, Hur C. Endoscopic therapy versus surgery for T1 colon cancer: defining model clinical practice. Gastrointest Endosc 2016; 84:995-996. [PMID: 27855802 PMCID: PMC6738565 DOI: 10.1016/j.gie.2016.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 05/30/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Patrick Yachimski
- Division of Gastroenterology, Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chin Hur
- Institute for Technology Assessment and Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Cummings LC, Kou TD, Schluchter MD, Chak A, Cooper GS. Outcomes after endoscopic versus surgical therapy for early esophageal cancers in an older population. Gastrointest Endosc 2016; 84:232-240.e1. [PMID: 26801375 PMCID: PMC4949078 DOI: 10.1016/j.gie.2016.01.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 01/05/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic treatment of early esophageal cancer provides an alternative to esophagectomy, which older patients may not tolerate. Population-based data regarding short-term outcomes and recurrence after endoscopic treatment for esophageal cancer are limited. We compared short-term outcomes, treated recurrence, and survival after endoscopic versus surgical therapy for early esophageal cancers in an older population. METHODS We conducted a retrospective cohort study identifying patients aged ≥66 years with Tis or T1a tumors without nodal involvement diagnosed from 1994 to 2011 from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. RESULTS Of 2193 patients, 41% (n = 893) underwent esophagectomy, and 12% (n = 255) underwent endoscopic treatment within 6 months of diagnosis. Those treated endoscopically were older and more likely to have a Charlson comorbidity score ≥2. A composite endpoint, hospitalization and/or adverse events at 60 days, was higher in surgical patients than in the endoscopic treatment group (30% vs 12%; P < .001). In a Cox model stratified by histology, adjusting for other factors, endoscopic treatment was associated with improved 2-year survival (hazard ratio 0.51; 95% CI, 0.36-0.73). CONCLUSIONS In this older population, a composite short-term endpoint was worse in the surgical group. Endoscopic treatment was associated with improved survival through 2 years. These results suggest that endoscopic treatment is a reasonable approach for early esophageal cancers in the elderly.
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Affiliation(s)
- Linda C. Cummings
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
- Case Western Reserve University, Cleveland, Ohio
| | | | | | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
- Case Western Reserve University, Cleveland, Ohio
| | - Gregory S. Cooper
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
- Case Western Reserve University, Cleveland, Ohio
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El-Serag HB, Naik AD, Duan Z, Shakhatreh M, Helm A, Pathak A, Hinojosa-Lindsey M, Hou J, Nguyen T, Chen J, Kramer JR. Surveillance endoscopy is associated with improved outcomes of oesophageal adenocarcinoma detected in patients with Barrett's oesophagus. Gut 2016; 65:1252-60. [PMID: 26311716 DOI: 10.1136/gutjnl-2014-308865] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 07/22/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The effectiveness of surveillance endoscopy in patients with Barrett's oesophagus (BE) for reducing oesophageal adenocarcinoma (EAC)-related mortality in patients with BE is unclear. METHODS This is a cohort study of patients with BE diagnosed in the National Veterans Affairs hospitals during 2004-2009 excluding those with conditions that affect overall survival. We identified those diagnosed with EAC after BE diagnosis through 2011 and conducted chart reviews to identify BE surveillance programme, and indication for EAC diagnosis, verify diagnosis, stage, therapy and cause of death. We examined the association between surveillance indication for EAC diagnosis with or without surveillance programme and EAC stage and treatment receipt in logistic regression models, and with time to death or cancer-related death using a Cox proportional hazards regression model. RESULTS Among 29 536 patients with BE, 424 patients developed EAC during a mean follow-up of 5.0 years. A total of 209 (49.3%) patients with EAC were in BE surveillance programme and were diagnosed as a result of surveillance endoscopy. These patients were more likely to be diagnosed at an early stage (stage 0 or 1: 74.7% vs 56.2, p<0.001), survived longer (median 3.2 vs 2.3 years; p<0.001) and have lower cancer-related mortality (34.0% vs 54.0%, p<0.0001) and had a trend to receive oesophagectomy (51.2% vs 42.3%; p=0.07) than 215 patients diagnosed by non-BE surveillance endoscopy (17.2% of whom were BE surveillance failure). BE surveillance endoscopy was associated with a decreased risk of cancer-related death (HR 0.47, 0.35 to 0.64), which was largely explained by the early stage of EAC at the time of diagnosis. Similarly, the adjusted mortality for patients with cancer in a prior surveillance programme for overall death was 0.63 (0.47 to 0.84) compared with patients with cancer not in a surveillance programme. CONCLUSIONS Surveillance endoscopy among patients with BE is associated with significantly better EAC outcomes including cancer-related mortality compared with other non-surveillance endoscopy.
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Affiliation(s)
- Hashem B El-Serag
- Department of Medicine, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Aanand D Naik
- Department of Medicine, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Zhigang Duan
- Department of Medicine, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Mohammad Shakhatreh
- Department of Medicine, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Ashley Helm
- Department of Medicine, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Amita Pathak
- Department of Medicine, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Marilyn Hinojosa-Lindsey
- Department of Medicine, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jason Hou
- Department of Medicine, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Theresa Nguyen
- Department of Medicine, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - John Chen
- The University of Kansas School of Medicine, Internal Medicine, Kansas City, Kansas, USA
| | - Jennifer R Kramer
- Department of Medicine, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Sengupta N, Sawhney MS. Advances in Imaging and Endoluminal Therapies for Early Esophageal and Gastric Cancers. Ann Surg Oncol 2016; 23:3774-3779. [PMID: 27464607 DOI: 10.1245/s10434-016-5425-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Indexed: 12/22/2022]
Affiliation(s)
- Neil Sengupta
- Section of Gastroenterology, University of Chicago Medical Center, Chicago, IL, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
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Goense L, van Rossum PSN, Kandioler D, Ruurda JP, Goh KL, Luyer MD, Krasna MJ, van Hillegersberg R. Stage-directed individualized therapy in esophageal cancer. Ann N Y Acad Sci 2016; 1381:50-65. [PMID: 27384385 DOI: 10.1111/nyas.13113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/05/2016] [Indexed: 12/16/2022]
Abstract
Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.
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Affiliation(s)
- Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter S N van Rossum
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daniela Kandioler
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Khean-Lee Goh
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Mark J Krasna
- Meridian Cancer Care, Jersey Shore University Medical Center, Neptune, New Jersey
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Vaezi MF, Brill JV, Mills MR, Bernstein BB, Ness RM, Richards WO, Brillstein L, Leibowitz R, Strople K, Montgomery EA, Patel K. An Episode Payment Framework for Gastroesophageal Reflux Disease: Symptomatic Gastroesophageal Reflux Disease, Dysplastic and Nondysplastic Barrett's Esophagus, and Anti-Reflux Surgical and Endoscopic Interventions. Gastroenterology 2016; 150:1009-18. [PMID: 26907603 DOI: 10.1053/j.gastro.2016.02.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Michael F Vaezi
- Divison of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joel V Brill
- Predictive Health, LLC, Paradise Valley, Arizona
| | | | - Brett B Bernstein
- Albert Einstein College of Medicine at Beth Israel Medical Center, New York, New York
| | - Reid M Ness
- Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Rebecca Leibowitz
- American Gastroenterological Association Institute, Bethesda, Maryland
| | - Ken Strople
- Palisades Healthcare Solutions, LLC, Camarillo, California
| | | | - Kavita Patel
- Center for Health Policy, Brookings Institute, Washington, DC
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Chadwick G, Riley S, Hardwick RH, Crosby T, Hoare J, Hanna G, Greenaway K, Varagunam M, Cromwell DA, Groene O. Population-based cohort study of the management and survival of patients with early-stage oesophageal adenocarcinoma in England. Br J Surg 2016; 103:544-52. [PMID: 26865114 DOI: 10.1002/bjs.10116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/12/2015] [Accepted: 12/21/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Until recently, oesophagectomy was the treatment of choice for early oesophageal cancer. Endoscopic treatment has been introduced relatively recently. This observational national database study aimed to describe how endoscopic therapy has been introduced in England and to examine the safety of this approach. METHODS A population-based cohort study was undertaken of patients diagnosed with oesophageal adenocarcinoma between October 2007 and June 2009 using three linked national databases. Patients with early-stage disease (T1 tumours with no evidence of spread) were identified, along with the primary treatment modality where treatment intent was curative. Short-term outcomes after treatment and 5-year survival were evaluated. RESULTS Of 5192 patients diagnosed with oesophageal adenocarcinoma, 306 (5·9 per cent) were considered to have early-stage disease before any treatment, of whom 239 (79·9 per cent of 299 patients with data on treatment intent) were managed with curative intent. Of 175 patients who had an oesophagectomy, 114 (65·1 (95 per cent c.i. 57·6 to 72·7) per cent) survived for 5 years. Among these, 47 (30·3 per cent of 155 patients with tissue results available) had their disease upstaged after pathological staging; this occurred more often in patients who did not have staging endoscopic ultrasonography before surgery. Of 41 patients who had an endoscopic resection, 27 (66 (95 per cent c.i. 49 to 80) per cent) survived for 5 years. Repeat endoscopic therapy was required by 23 (56 per cent) of these 41 patients. CONCLUSION Between 2007 and 2009, oesophagectomy remained the initial treatment of choice (73·2 per cent) among patients with early-stage oesophageal cancer treated with curative intent; one in five patients were managed endoscopically, and this treatment was more common in elderly patients. Although the groups had different patient characteristics, 5-year survival rates were similar.
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Affiliation(s)
- G Chadwick
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Gastroenterology, St Mary's Hospital, London, UK
| | - S Riley
- Department of Gastroenterology, Northern General Hospital, Sheffield, UK
| | - R H Hardwick
- Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - T Crosby
- Velindre Cancer Centre, Cardiff, UK
| | - J Hoare
- Department of Gastroenterology, St Mary's Hospital, London, UK
| | - G Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
| | - K Greenaway
- Health and Social Care Information Centre, Leeds, UK
| | - M Varagunam
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - D A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - O Groene
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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40
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Schmidt HM, Mohiuddin K, Bodnar AM, El Lakis M, Kaplan S, Irani S, Gan I, Ross A, Low DE. Multidisciplinary treatment of T1a adenocarcinoma in Barrett's esophagus: contemporary comparison of endoscopic and surgical treatment in physiologically fit patients. Surg Endosc 2015; 30:3391-401. [PMID: 26541725 DOI: 10.1007/s00464-015-4621-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 10/09/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Previous reports comparing endoscopic therapy (ET) and surgical therapy (ST) have predominantly assessed patients with high-grade dysplasia. The study aim was to compare ET to ST in physiologically fit patients with cT1a adenocarcinoma (EAC). METHODS Review of two prospective databases yielded 100 patients presenting with clinical cT1a EAC between 2000 and 2013. Only physiologically fit patients who were candidates for either treatment were analyzed. RESULTS Presenting patient characteristics were similar between ET (n = 36) and ST groups (n = 49). Surgical patients were less likely to be staged with EMR (43 vs 100 %) and were associated with mass lesions >1 cm at EGD (p = 0.01), multifocal EAC (p = 0.03), and positive margins for EAC on EMR (p < 0.05). On multivariate analysis, only multifocal HGD was an independent factor for surgery. Following esophagectomy, R0 resection rates for Barrett's esophagus and cancer were 100 %. Incidence of surgery decreased over the study period from 85 to 25 %. All ET patients had EMR, and 28 patients underwent additional ablative therapies for Barrett's esophagus. Following ET, eradication rates of EAC, dysplasia, and BE were 92, 81, and 53 %, respectively. Morbidity rates were comparable between groups (ST 51 % vs ET 39 %, p = 0.31). In-hospital mortality rate was zero in each group. Recurrence rates in ST and ET group were 2 and 11 % (p = 0.08). In the ET group, two patients with endoluminal cancer recurrence after complete eradication underwent esophagectomy. Age-adjusted overall survival was comparable. CONCLUSION In high-volume esophageal centers, ST and ET provide equally safe and effective treatment for cT1a EAC in medically fit patients. While the results of this study provide a historical perspective and clearly demonstrate an evolution toward ET over time, the appropriate treatment modality is best selected in a multidisciplinary fashion with EMR providing the most accurate staging. In endoscopically treated patients, indefinite endoscopic follow-up required, however, standardized long-term follow-up protocols are needed.
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Affiliation(s)
- Henner M Schmidt
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Kamran Mohiuddin
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Artur M Bodnar
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Mustapha El Lakis
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Stephen Kaplan
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Shayan Irani
- Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Ian Gan
- Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andrew Ross
- Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Donald E Low
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA.
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41
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David WJ, Qumseya BJ, Qumsiyeh Y, Heckman MG, Diehl NN, Wallace MB, Raimondo M, Woodward TA, Wolfsen HC. Comparison of endoscopic treatment modalities for Barrett's neoplasia. Gastrointest Endosc 2015; 82:793-803.e3. [PMID: 26071064 DOI: 10.1016/j.gie.2015.03.1979] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/27/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND There are few data comparing endoscopic treatment outcomes for Barrett's esophagus (BE). OBJECTIVE To compare treatment outcomes in BE patients treated with radiofrequency ablation (RFA), RFA after EMR, and porfimer sodium photodynamic therapy (Ps-PDT). DESIGN Retrospective, observational study. SETTING Single tertiary center between 2001 and 2013. PATIENTS A total of 342 BE patients treated with RFA (n = 119), EMR+RFA (n = 98), and Ps-PDT (n = 125). MAIN OUTCOME MEASUREMENTS Rates of complete remission of intestinal metaplasia (CRIM), BE recurrence, and adverse events. RESULTS Baseline BE high-grade dysplasia (HGD) and adenocarcinoma were more common in the Ps-PDT group (89%) compared with the EMR-RFA (70%) and RFA (37%) groups. At a median follow-up of 14.2 months, 173 patients (50.6%) achieved CRIM. CRIM was significantly more common in Ps-PDT patients compared with RFA (P < .001) and EMR-RFA (P < .001) patients on multivariable analysis. In patients who achieved CRIM, the rates of subsequent BE recurrence were relatively similar among the 3 groups. Although the rates of bleeding were similar, strictures were less common in RFA patients (2.4%) compared with EMR-RFA (13.3%, P = .001) and Ps-PDT (10.4%, P =.043) patients. CONCLUSION This study of endoscopic treatment for Barrett's dysplasia and neoplasia found that complete remission was achieved more often and more rapidly after Ps-PDT with similar disease recurrence rates compared with EMR or RFA. Adverse events were more common after EMR and Ps-PDT. Further studies are required to determine which ablation and resection techniques are ideally suited for each BE patient.
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Affiliation(s)
- Waseem J David
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bashar J Qumseya
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA; Florida State University, Archbold Medical Group, Thomasville, Georgia, USA
| | - Yazen Qumsiyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA; University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Massimo Raimondo
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Timothy A Woodward
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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42
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Abstract
Early esophageal cancer is confined to the mucosa or submucosa of the esophagus. While most esophageal cancer is detected at an advanced stage (requiring surgical resection, chemotherapy, and radiation), early-stage mucosal lesions may be detected through Barrett's surveillance programs or incidentally on diagnostic upper endoscopies performed for other reasons. These early-stage cancers are often amenable to endoscopic therapies, including mucosal resection, ablation, and cryotherapy. Studies suggest equivalent survival rates and reduced morbidity but higher recurrence rates with endoscopic removal of early-stage cancers compared to surgical resection. There is emerging data regarding the efficacy and long-term outcomes of endoscopic therapy for early esophageal cancer that is promising, and further research is needed to better define the role of endoscopic therapy in the management of early esophageal cancer.
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Affiliation(s)
- Vaishali Patel
- Division of Gastroenterology, Duke University Medical Center, 190 Grey Elm Trail, Durham, NC, 27713, USA,
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44
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Leggett CL, Lewis JT, Wu TT, Schleck CD, Zinsmeister AR, Dunagan KT, Lutzke LS, Wang KK, Iyer PG. Clinical and histologic determinants of mortality for patients with Barrett's esophagus-related T1 esophageal adenocarcinoma. Clin Gastroenterol Hepatol 2015; 13:658-64.e1-3. [PMID: 25151255 PMCID: PMC4336231 DOI: 10.1016/j.cgh.2014.08.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 08/11/2014] [Accepted: 08/11/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Superficial (T1) esophageal adenocarcinoma (EAC) commonly is treated by endoscopic resection, yet little is known about factors that predict outcomes of this approach. We assessed clinical and histologic variables associated with the overall survival times of patients with T1 EAC who received therapy. METHODS In a retrospective analysis, we collected data from patients who underwent endoscopic mucosal resection (EMR) for T1 EAC (194 patients with T1a and 75 patients with T1b) at the Mayo Clinic, from 1995 through 2011. EMR specimens were reviewed systematically for depth of invasion, presence of lymphovascular invasion, grade of differentiation, and status of resection margins. Kaplan-Meier curves and proportional hazards regression models were used in statistical analyses. RESULTS Demographic characteristics were similar between patients with T1a and T1b EAC. Overall survival at 5 years after EMR was 74.4% for patients with T1a (95% confidence interval [CI], 67.6%-81.8%) and 53.2% for patients with T1b EAC (95% CI, 40.3%-70.1%). Of surviving patients with T1a EAC, 94.1% remained free of cancer (95% CI, 89.8%-98.5%), and 94.7% of surviving patients with T1b EAC remained free of cancer (95% CI, 85.2%-100%). A multivariable model associated older age (per 10-year increment), evidence of lymphovascular invasion, and deep margin involvement with reduced overall survival in patients with T1 EAC. CONCLUSIONS Systematic assessment of EMR specimens can help predict mortality and potentially guide treatment options for patients with T1 EAC.
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Affiliation(s)
- Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Jason T Lewis
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Tsung Teh Wu
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Cathy D Schleck
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Alan R Zinsmeister
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Kelly T Dunagan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Lori S Lutzke
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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45
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Abstract
Esophagectomy has been the traditional therapy for high-grade dysplasia and intramucosal cancer. Though surgery can completely resect the cancer and the affected lymph nodes, it carries significant morbidity and mortality (often exceeds 2%). New developments in endoscopy have provided less-invasive therapies that can also be used to stage tissue invasion of cancer; they include esophageal mucosal resection (EMR) and endoscopic submucosal dissection. Additional endoscopic therapies include photodynamic therapy, radiofrequency ablation (RFA) and argon plasma coagulation. Combining EMR that targets the cancer and RFA that targets the surrounding Barrett's esophagus offers an alternative to the operative approach when there is no lymph node metastasis. Arguments for surgical esophagectomy include concern for missed lymph node metastasis and incomplete endoscopic resection. Based on EMR's high neoplasia eradication rate and its fewer and more manageable complications, EMR, especially when combined with RFA, appears to be a viable alternative to surgery in early submucosal cancers, that is, sm1.
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Affiliation(s)
- Ioana Smith
- Division of Gastroenterology, University of Alabama, Birmingham, AL, USA
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47
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Jovani M, Wallace M. Is complete endoscopic resection still a viable option for Barrett's-related dysplasia and neoplasia? Clin Gastroenterol Hepatol 2014; 12:2011-4. [PMID: 25004460 DOI: 10.1016/j.cgh.2014.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 06/30/2014] [Accepted: 06/30/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Manol Jovani
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Michael Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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48
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Qumseya B, David W, Woodward TA, Raimondo M, Wallace MB, Wolfsen HC, Lukens FJ. Safety of esophageal EMR in elderly patients. Gastrointest Endosc 2014; 80:586-591. [PMID: 24703086 DOI: 10.1016/j.gie.2014.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 02/06/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND EMR is commonly used to remove suspicious esophageal lesions among patients with Barrett's esophagus (BE). BE primarily affects older patients. Yet, the safety profile of EMR in elderly patients has not been well-described. OBJECTIVE We aimed to study the safety profile of EMR in elderly patients compared with younger patients. DESIGN Retrospective, observational, descriptive study that used a prospective database. SETTING Tertiary-care referral center. PATIENTS A total of 136 patients who underwent esophageal EMR for BE. INTERVENTIONS EMR with/without ablative therapy. MAIN OUTCOME MEASUREMENTS The rate of adverse events, including bleeding, stricture formation, and perforation between elderly (aged ≥75 years) and younger (aged <75 years) patients. RESULTS We identified 136 patients who underwent esophageal EMR who were followed-up in our clinic. Of those, 40% (n = 55) were aged ≥75 years (elderly group) and 60% (n = 81) were aged <75 years (younger group). There was no difference in rate of stricture formation or early or delayed bleeding when we compared elderly patients to younger patients. None of the patients had esophageal perforation. On multivariable logistic regression analysis, controlling for patient sex, EMR technique, and underlying pathology, older age was not associated with increased odds of adverse events (OR 0.88; 95% confidence interval, 0.42-1.9; P = .75). LIMITATIONS Single-center experience. CONCLUSION Rates of adverse events from EMR appear to be similar in elderly patients compared with younger patients. Overall, esophageal EMR seems to offer an acceptable safety profile in elderly patients.
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Affiliation(s)
- Bashar Qumseya
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Waseem David
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Timothy A Woodward
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Massimo Raimondo
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Herbert C Wolfsen
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Frank J Lukens
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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49
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Abstract
Barrett’s esophagus (BE) develops as a consequence of chronic esophageal acid exposure, and is the major risk factor for esophageal adenocarcinoma (EAC). The practices of endoscopic screening for—and surveillance of—BE, while widespread, have failed to reduce the incidence of EAC. The majority of EACs are diagnosed in patients without a known history of BE, and current diagnostic tools are lacking in their ability to stratify patients with BE into those at low risk and those at high risk for progression to malignancy. Nonetheless, advances in endoscopic imaging and mucosal therapeutics have provided unprecedented opportunities for intervention for BE, and have vastly altered the approach to management of BE-associated mucosal neoplasia.
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Affiliation(s)
- Patrick Yachimski
- Division of Gastroenterology Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA Division of Gastroenterology & Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chin Hur
- Division of Gastroenterology Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA Division of Gastroenterology & Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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50
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Hammoud GM, Hammad H, Ibdah JA. Endoscopic assessment and management of early esophageal adenocarcinoma. World J Gastrointest Oncol 2014; 6:275-288. [PMID: 25132925 PMCID: PMC4133795 DOI: 10.4251/wjgo.v6.i8.275] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 04/08/2014] [Accepted: 07/17/2014] [Indexed: 02/05/2023] Open
Abstract
Esophageal carcinoma affects more than 450000 people worldwide and the incidence is rapidly increasing. In the United States and Europe, esophageal adenocarcinoma has superseded esophageal squamous cell carcinoma in its incidence. Esophageal cancer has a high mortality rates secondary to the late presentation of most patients at advanced stages. Endoscopic screening is recommended for patients with multiple risk factors for cancer in Barrett’s esophagus. These risk factors include chronic gastroesophageal reflux disease, hiatal hernia, advanced age, male sex, white race, cigarette smoking, and obesity. The annual risk of esophageal cancer is approximately 0.25% for patients without dysplasia and 6% for patients with high-grade dysplasia. Twenty percent of all esophageal adenocarcinoma in the United States is early stage with disease confined to the mucosa or submucosa. The significant morbidity and mortality of esophagectomy make endoscopic treatment an attractive option. The American Gastroenterological Association recommends endoscopic eradication therapy for patients with high-grade dysplasia. Endoscopic modalities for treatment of early esophageal adenocarcinoma include endoscopic resection techniques and endoscopic ablative techniques such as radiofrequency ablation, photodynamic therapy and cryoablation. Endoscopic therapy should be precluded to patients with no evidence of lymphovascular invasion. Local tumor recurrence is low after endoscopic therapy and is predicted by poor differentiation of tumor, positive lymph node and submucosal invasion. Surgical resection should be offered to patients with deep submucosal invasion.
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