Feasibility of endoscopic resection in superficial esophageal squamous carcinoma

Tumor thickness as a novel risk factor for lymph node metastasis by superficial squamous cell carcinoma of head and neck

Narrow-band imaging combined with magnified endoscopy has enabled the detection of superficial squamous cell carcinoma of the head and neck (SSCCHN) that has been resected with minimally invasive treatment, preserving vocalization and swallowing functions. However, risk factors of lymph node metastasis (LNM) must be identified, as some patients with LNM have a poor prognosis. From an initial 599 patients with 700 lesions who underwent trans-oral surgery in 27 Japanese hospitals (a nationwide registration survey), we enrolled 541 patients with 633 SSCCHNs, as indicated by central pathological diagnoses. All pathological specimens for each patient were examined using 20 pathological factors that are thought to affect the LNM of SSCCHN. In all, 24 (4.4%) of the 568 SSCCHNs exhibited LNM, and all 24 had at least one solitary nest of epithelial neoplastic cells present in the stroma, clearly separated from the intraepithelial carcinoma. Multivariate analysis also showed that tumor thickness (p = 0.0132, RR: 7.85, 95% confidence interval [CI]: 1.54-40.02), and an INFc pattern classified as infiltrating growth (INF) with unclear boundaries between tumor and non-tumor tissues (p = 0.0003, RR: 14.47, 3.46-60.46), and tumor budding (p = 0.0019, RR: 4.35, CI: 1.72-11.01) were significantly associated with LNM. Solitary nests may be indicative of LNM. In addition, tumor thickness was revealed to be a risk factor for LNM in SSCCHNs using pT factors that do not include an invasion depth element because of the anatomical absence of the muscularis mucosae.

Risk factors for lymph node metastasis in superficial esophageal squamous cell carcinoma

In this editorial, we comment on the article by Wang et al published in the recent issue of the World Journal of Gastroenterology in 2023. We focused on identifying risk factors for lymph node metastasis (LNM) in superficial esophageal squamous cell carcinoma (SESCC) patients and how to construct a simple and reliable clinical prediction model to assess the risk of LNM in SESCC patients, thereby helping to guide the selection of an appropriate treatment plan. The current standard treatment for SESCC is radical esophagectomy with lymph node dissection. However, esophagectomy is associated with considerable morbidity and mortality. Endoscopic resection (ER) offers a safer and less invasive alternative to surgical resection and can enable the patient's quality of life to be maintained while providing a satisfactory outcome. However, since ER is a localized treatment that does not allow for lymph node dissection, the risk of LNM in SESCC limits the effectiveness of ER. Understanding LNM status can aid in determining whether patients with SESCC can be cured by ER without the need for additional esophagectomy. Previous studies have shown that tumor size, macroscopic type of tumor, degree of differentiation, depth of tumor invasion, and lymphovascular invasion are factors associated with LNM in patients with SESCC. In addition, tumor budding is commonly associated with LNM, recurrence, and distant metastasis, but this topic has been less covered in previous studies. By comprehensively evaluating the above risk factors for LNM, useful evidence can be obtained for doctors to select appropriate treatments for SESCC patients.

A retrospective cohort study to observe the efficacy and safety of Endoscopic Submucosal Dissection (ESD) with adjuvant radiotherapy for T1a-MM/T1b-SM Esophageal Squamous Cell Carcinoma (ESCC)

BACKGROUND AND AIM

The clinical outcome of endoscopy submucosal dissection with subsequent radiotherapy for esophageal squamous cell carcinoma remain unclear. In this study we aim to investigate the efficacy and safety of endoscopic submucosal dissection with adjuvant radiotherapy in the treatment of superficial esophageal squamous cell carcinoma involving the muscularis mucosae (T1a-MM) or the submucosa < 200 μm (T1b-SM1).

METHODS

We analyzed 20 patients with pathologically confirmed T1a-MM or T1b-SM1 esophageal squamous cell carcinoma treated by endoscopic submucosal dissection from 2016 to 2020 in Lihuili Hospital, 9 patients received adjuvant radiotherapy (RT group) and 11 patients received did not (non-RT group).

RESULTS

All 20 patients underwent en bloc resection, and both the vertical and horizontal margins were negative. There was no recurrence or lymph node metastasis in the RT group, and no serious complications or death were observed. In the non-RT group, 2 patients had local recurrence and 1 had distant metastasis. None of the 20 patients died of esophageal carcinoma.

CONCLUSIONS

Adjuvant radiotherapy following endoscopic submucosal dissection may be a safe and effective method for the treatment of T1a-MM/T1b-SM1 superficial esophageal squamous cell carcinoma.

Type B2 vessels and infiltrative growth patterns b and c are associated with lymphatic invasion in pT1a-lamina propria mucosa esophageal squamous cell carcinoma

BACKGROUND

Tumor growth pattern correlates with outcomes in patients with esophageal squamous cell carcinoma (ESCC), however, the clinical significance of the tumor growth pattern in pT1a-lamina propria mucosa (LPM) type of ESCC was unclear. This study was conducted to clarify clinicopathological features of tumor growth patterns in pT1a-LPM type ESCC and the relationship between tumor growth patterns and magnifying endoscopic findings.

METHODS

Eighty-seven lesions diagnosed as pT1a-LPM ESCC were included. Clinicopathological findings including tumor growth pattern and narrow band imaging with magnifying endoscopy (NBI-ME) in the LPM area were investigated.

RESULTS

Eighty-seven lesions were classified as infiltrative growth pattern-a (INF-a): expansive growth (n = 81), INF-b: intermediate growth (n = 4) and INF-c: infiltrative growth pattern (n = 2). Lymphatic invasion was shown in one INF-b and one INF-c lesion. NBI-ME and histopathological images were matched for 30 lesions. The microvascular pattern was classified into types B1 (n = 23) and B2 (n = 7) using the JES classification. All 23 type B1 lesions were classified as INF-a without lymphatic invasion. Type B2 lesions were classified as INF-a (n = 2), INF-b (n = 4) and INF-c (n = 1), and lymphatic invasion was present in two lesions (INF-b and INF-c). The rate of lymphatic invasion was significantly higher in type B2 than type B1 (p = 0.048).

CONCLUSIONS

The tumor growth pattern of pT1a-LPM ESCC was mostly INF-a in type B1 patterns. Type B2 patterns are rarely present in pT1a-LPM ESCC, however lymphatic invasion with INF-b or INF-c was frequently observed. Careful observation before endoscopic resection with NBI-ME is important to identify B2 patterns to predict histopathology.

Radiotherapy Improves Survival of Patients With Lymphovascular Invasion in pT1b Esophageal Squamous Cell Cancer After Endoscopic Submucosal Dissection

INTRODUCTION

Adjuvant radiotherapy is recommended for pT1b esophageal squamous cell cancer (ESCC) after endoscopic submucosal dissection (ESD). However, it is unclear whether additional radiotherapy can improve patient survival. This study aimed to evaluate the efficacy of adjuvant radiotherapy after ESD for pT1b ESCC.

METHODS

This was a multicenter, cross-sectional study involving 11 hospitals in China. Between January 2010 and December 2019, patients with T1bN0M0 ESCC treated with or without adjuvant radiotherapy after ESD were included. Survival between groups was compared.

RESULTS

Overall, 774 patients were screened, and 161 patients were included. Forty-seven patients (29.2%) received adjuvant radiotherapy after ESD (RT group) and 114 (70.8%) underwent ESD alone (non-RT group). There were no significant differences in overall survival (OS) and disease-free survival (DFS) between the RT and non-RT groups. Lymphovascular invasion (LVI) was the only prognostic factor. In the LVI+ group, adjuvant radiotherapy significantly improved survival (5-year OS: 91.7% vs 59.5%, P = 0.050; 5-year DFS: 92.9% vs 42.6%, P = 0.010). In the LVI- group, adjuvant radiotherapy did not improve survival (5-year OS: 83.5% vs 93.9%, P = 0.148; 5-year DFS: 84.2% vs 84.7%, P = 0.907). The standardized mortality ratios were 1.52 (95% confidence interval 0.04-8.45) in the LVI+ group with radiotherapy and 0.55 (95% confidence interval 0.15-1.42) in the LVI- group without radiotherapy.

DISCUSSION

Adjuvant radiotherapy could improve survival in pT1b ESCC with LVI+ other than LVI- after ESD. Selective adjuvant radiotherapy based on LVI status achieved survival rates similar to those of the general population.

Long-term clinical outcomes of patients diagnosed with pT1a-muscularis mucosae with lymphovascular invasion or pT1b after endoscopic resection for cT1N0M0 esophageal squamous cell carcinoma

BACKGROUND

Endoscopic resection (ER) is performed for early esophageal squamous cell carcinoma (ESCC) cases. Additional esophagectomy or chemoradiotherapy is recommended for non-curative resection (NCR) even with pathologically negative vertical margins (pVM0); however, their clinical outcomes remain unknown. We examined the long-term clinical outcomes of NCR for ESCCs according to additional treatments.

METHODS

We retrospectively analyzed the data of patients who underwent ER for cT1N0M0 ESCC between 2009 and 2017 judged to have NCR, which defined when pathologically diagnosed as invading the submucosa (SM) or muscularis mucosae (MM) involving lymphovascular invasion (LVI), pVM0, and endoscopically judged as negative horizontal margin. Additional esophagectomy (involving three-field lymphadenectomy), chemoradiotherapy [mainly cisplatin and 5-fluorouracil with concurrent radiotherapy (41.4 Gy)], or observation was undertaken. Thereafter, computed tomography was performed every 6-12 months. The cumulative recurrence (CRR) and recurrence-free survival (RFS) rates were evaluated.

RESULTS

Eighty-nine patients were included. Among them, 14 had pathologically diagnosed pMM with LVI; 9 and 6, and 32 and 28 patients had pSM1 and pSM2 without and with LVI. Twenty-one patients underwent observation, whereas 18 and 50 underwent esophagectomy and chemoradiotherapy. During the 60.6-month median follow-up period, nine patients had recurrence; among them, six patients had occurrence at > 4 years after ER. The 5-year CRR/RFS rates were 35.7%/48.1%, 13.4%/80.4%, and 0.0%/98.0% in the observation, esophagectomy, and chemoradiotherapy groups, respectively (observation vs. chemoradiotherapy; P < 0.001).

CONCLUSIONS

Additional treatments showed better long-term outcomes than observation for patients with NCR. As recurrence may occur at > 4 years after ER, careful long-term follow-up examinations are needed.

Additional Radiotherapy With or Without Chemotherapy Following Endoscopic Resection for Stage I Esophageal Carcinoma: A Pilot Study

Objective: To evaluate the safety and efficacy of additional radiotherapy after endoscopic resection (ER) for stage I esophageal carcinoma (EC) with high-risk factors. Materials and methods: Patients with stage cT1N0M0 EC who underwent ER and additional radiotherapy between January 2010 and August 2019 at our institution were retrospectively included. Overall survival (OS), disease-free survival (DFS), cancer-specific survival (CSS), local control rate, regional control rate, common acute toxicities, esophageal stricture, and dysphagia were analyzed. Results: Thirty-one consecutive patients were included in the study. The median age was 62 years (range, 49-78). Thirty patients (96.8%) had squamous cell carcinoma, and one patient (3.2%) had adenosquamous cell carcinoma. Twenty-six patients (83.9%) had submucosal invasion, 15 patients (48.4%) had lymphovascular invasion, and one patient (3.2%) had a venous invasion. The 1-, 3-, and 5-year OS rates were 100.0%, 86.9%, and 68.5%, respectively. The corresponding DFS rates were 100.0%, 85.2%, and 75.8%, respectively. The corresponding CSS rates were 100.0%, 89.8%, and 78.6%, respectively. The local and regional control rates were 100.0% and 93.5%, respectively. No grade 4-5 acute toxicities were observed. Fifteen patients (48.4%) were endoscopically diagnosed with esophageal strictures after ER. At the last follow-up, 28 patients (90.5%) were able to eat a regular diet, one patient (3.2%) could eat a soft diet, one needed a semifluid diet, and only one (3.2%) had to eat a fluid diet. Conclusions: For patients with stage I EC, additional radiotherapy following ER is safe and effective, with the swallowing function well-preserved. Nevertheless, prospective studies are needed to verify these results.

Retrospective analysis of predictive factors for lymph node metastasis in superficial esophageal squamous cell carcinoma

This study aimed to identify the risk factors of lymph node metastasis (LNM) in superficial esophageal squamous cell carcinoma and use these factors to establish a prediction model. We retrospectively analyzed the data from training set (n = 280) and validation set (n = 240) underwent radical esophagectomy between March 2005 and April 2018. Our results of univariate and multivariate analyses showed that tumor size, tumor invasion depth, tumor differentiation and lymphovascular invasion were significantly correlated with LNM. Incorporating these 4 variables above, model A achieved AUC of 0.765 and 0.770 in predicting LNM in the training and validation sets, respectively. Adding macroscopic type to the model A did not appreciably change the AUC but led to statistically significant improvements in both the integrated discrimination improvement and net reclassification improvement. Finally, a nomogram was constructed by using these five variables and showed good concordance indexes of 0.765 and 0.770 in the training and validation sets, and the calibration curves had good fitting degree. Decision curve analysis demonstrated that the nomogram was clinically useful in both sets. It is possible to predict the status of LNM using this nomogram score system, which can aid the selection of an appropriate treatment plan.

Current Status of Image-Enhanced Endoscopy for Early Identification of Esophageal Neoplasms

Advanced esophageal cancer is known to have a poor prognosis. The early detection of esophageal neoplasms, including esophageal dysplasia and early esophageal cancer, is highly important for the accurate treatment of the disease. However, esophageal dysplasia and early esophageal cancer are usually subtle and can be easily missed. In addition to the early detection, proper pretreatment evaluation of the depth of invasion of esophageal cancer is very important for curative treatment. The progression of non-invasive diagnosis via image-enhanced endoscopy techniques has been shown to aid the early detection and estimate the depth of invasion of early esophageal cancer and, as a result, may provide additional opportunities for curative treatment. Here, we review the advancement of image-enhanced endoscopy-related technologies and their role in the early identification of esophageal neoplasms.

[Clinical Practice Guideline for Endoscopic Resection of Early Gastrointestinal Cancer]

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by en bloc fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

Close Observation versus Additional Surgery after Noncurative Endoscopic Resection of Esophageal Squamous Cell Carcinoma

INTRODUCTION

After noncurative endoscopic submucosal dissection (ESD) of superficial esophageal squamous cell carcinoma (SESCC), additional esophagectomy is generally recommended. However, considering its high mortality and morbidity, it is uncertain if additional surgery improves the clinical outcomes. This study aimed to compare the clinical outcomes between patients who were observed without additional treatment and those who underwent radical esophagectomy.

METHODS

A total of 52 patients with SESCC who underwent complete but noncurative ESD from January 2008 to December 2016 at the Samsung Medical Center and Asan Medical Center in Korea were retrospectively analyzed. Clinicopathologic characteristics and oncologic outcomes were compared between the observation group (n = 23) and the additional surgery group (n = 29).

RESULTS

During a mean follow-up of 34.4 and 41.7 months, respectively, the rates of death (observation vs. surgery, 17.4 vs. 10.3%; p = 0.686), recurrence (observation vs. surgery, 13 vs. 17.2%; p = 1.000), and disease-specific death (observation vs. surgery, 4.3 vs. 6.9%; p = 1.000) did not significantly differ between the 2 groups. The 3-year overall survival was 86.3 and 96.4%, respectively (p = 0.776). The 3-year recurrence-free survival (observation vs. surgery, 85.0 vs. 88.7%; p = 0.960) and disease-specific survival (observation vs. surgery, 95.2 vs. 96.4%; p = 0.564) also did not significantly differ.

CONCLUSIONS

The clinical outcomes of close observation of noncuratively resected SESCC are comparable to those of additional surgery, at least in the midterm. The wait-and-see strategy could be a feasible management option after noncurative ESD of SESCC in selected patients.

Endoscopic resection with adjuvant treatment versus esophagectomy for early-stage esophageal cancer

Objective

To evaluate the outcome following the strategy of endoscopic R0 resection (ER) plus adjuvant treatment (AT) versus esophagectomy for esophageal squamous cell cancer in T1a invading muscularis mucosa (M3)-T1b stage.

Methods

We evaluated the outcomes of 46 esophageal squamous cell cancer (ESCC) patients with T1aM3-T1b stage who underwent ER + AT from the Esophageal Cancer Endoscopic Therapy Consortium (ECETC) and compared these outcomes to 92 patients who underwent esophagectomy. Propensity score matching (1:2) was used, with overall survival (OS) and relapse-free survival (RFS) being compared between the two groups.

Results

During a median follow-up of 32 months, there were no statistical differences (P = 0.226) in OS between the two groups. The 1-, 2-, and 3-year overall survival in the esophagectomy group was 95%, 91%, and 84%, respectively. There were no mortalities within three years in the ER + AT group. The RFS between the two groups was also not significantly different (P = 0.938). The 1-, 2-, and 3-year RFS of patients in the esophagectomy group was 90%, 90%, and 83%, respectively, while it was 97%, 94%, and 74% in the ER + AT group, respectively. The local recurrence rates between the two groups were not significantly different (P = 0.277).

Conclusions

This first multicenter analysis showed similar outcomes were found regarding OS and RFS between the two groups in T1aM3-T1b stage patients. ER + AT may be considered in high-risk patients or for those who refuse esophagectomy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08466-2.

Long-term Outcomes and Factors Affecting the Survival of Patients with Mucosal Esophageal Squamous Cell Carcinoma

Background/Aims

Data regarding the prognosis of early esophageal cancer are lacking. This study investigated the long-term outcomes and factors affecting the survival of patients with mucosal esophageal squamous cell carcinoma (T1aESCC).

Methods

We analyzed the clinical and tumor-specific parameters of 263 patients who received surgical resection (SR; n=63) or endoscopic resection (ER; n=200) for T1aESCC. Underlying comorbidities were scored using the Charlson Comorbidity Index (CCI). Overall survival (OS) was the primary outcome, and multivariate regression analysis was performed to predict factors for OS.

Results

Of the study patients (age, 64.5±8.0 years), the CCI was 1.0±1.4 in the ER group and 0.6±0.9 in the SR group (p=0.107). The 5-year OS rate during follow-up (54.4±20.4 months) was 85.7% (ER group, 86.8%; SR group, 82.4%; p=0.631). The cumulative 5-year incidence of esophageal cancer recurrence was 10.5% in the ER group (vs 0% in the SR group). The overall mortality rate was 12.9% (12.0% in the ER group and 15.9% in the SR group; p=0.399). The most common cause of mortality was second primary cancers in the ER group (75%) and organ dysfunction or postoperative complications in the SR group (70%). According to multivariate analysis, only CCI was significantly associated with OS (p<0.001). The 5-year OS rate in patients with a CCI >2 and in those with a CCI ≤2 was 60.2% and 88.2%, respectively (p<0.001). The treatment method (ER vs SR) was not a significant affecting factor (p=0.238).

Conclusions

The long-term prognosis of patients with T1aESCC was significantly associated with underlying comorbidities.

Novel Endoscopic Criteria for Predicting Tumor Invasion Depth in Superficial Esophageal Squamous Carcinoma

BACKGROUND

Accurate prediction of tumor invasion depth in superficial esophageal squamous carcinoma (SESC) is essential for deciding the appropriate treatment strategy. We proposed novel endoscopic criteria to differentiate between mucosal and submucosal esophageal cancers and to evaluate the diagnostic accuracy and usefulness of the criteria.

METHODS

A total of 352 patients who underwent endoscopic or surgical resection for SESC between 1991 and 2010 were included. First, the novel endoscopic criteria were created based on the endoscopic features of 60 randomly selected patients as follows: for T1m cancers, I. flat or slightly elevated or depressed lesion with smooth/even surface of any size, II. slightly elevated lesion of ≤ 1 cm with granular or uneven surface, III. hyperemic flat lesion of ≤ 3 cm with granular or uneven surface, IV. slightly depressed lesion of ≤ 2 cm with uneven surface and for T1sm cancers, I. irregularly (unevenly) nodular or protruded lesion of any size, II. slightly elevated lesion of > 1 cm with granular or uneven surface, III. hyperemic flat lesion of > 3 cm with granular or uneven surface, IV. irregularly (unevenly) depressed lesion of > 2 cm, and V. ulcerative lesion of any size. Next, the endoscopic findings of the remaining 292 patients were reviewed according to the criteria.

RESULTS

The accuracy of novel endoscopic criteria was 79.5% (232/292). The sensitivity and specificity of mucosal cancers were 78.4% and 81.0%, respectively, whereas those for submucosal cancers were 81.0% and 78.4%, respectively. The accuracy for mucosal cancers was high (97.3%, 72/74) when the lesions were flat or slightly elevated/depressed with smooth/even surface regardless of size, whereas that for submucosal cancers was high (85.7%, 18/21) when the lesions were irregular/nodular protrusions regardless of size. In multivariate analysis, macroscopic type IIb lesion was identified as an independent factor affecting accuracy (P < 0.05). The difference in recurrence-free survival rates between endoscopically mucosal and submucosal cancers was significant (P = 0.026).

CONCLUSION

The novel endoscopic criteria appear to be accurate and useful in predicting invasion depth in SESC. Our criteria might help not only to decide the treatment strategy between surgery and endoscopic resection but also to predict the outcomes of SESC.

Clinical practice guideline for endoscopic resection of early gastrointestinal cancer

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by en bloc fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

Lymph node metastatic patterns and its clinical significance for thoracic superficial esophageal squamous cell carcinoma

Background and objectives

The optimal therapeutic method for patients with superficial esophageal squamous cell carcinoma (sESCC) remains to be established.

Methods

Clinical data of all the patients from 2002 to 2014 who underwent curative esophagectomy and three-field lymphadenectomy for thoracic sESCC were collected based on a prospectively-maintained database. The pattern of lymph node metastasis was analyzed based on the depth of tumor invasion, tumor location and surgical fields.

Results

The involved lymph node region was associated to the tumor location, however, upper mediastinal and perigastric region was the most vulnerable region. The incidence of lymph node metastasis increased with the depth of tumor invasion. No lymph node involvement was found in tumors invading proper mucosa (M2), while the pattern of positive lymph nodes in tumors invading the deepest 1/3 submucosa was similar to that in advanced ESCC. Lymphatic invasion, tumor location and upper mediastinal lymph node involvement were independent predictors for cervical lymph node metastasis. For patients without lymphatic invasion, the positive predictive value of upper mediastinal lymph node metastasis for positive cervical lymph node was low (0 ~ 25%), while the negative predictive value was extremely high, wherever the tumor located (93.8 ~ 100%).

Conclusions

Tumors invading till proper mucosa was the best indication for endoscopic mucosa resection. Mediastinal-abdominal lymphadenectomy was essential for sESCC invading beyond proper mucosa. For those without lymphatic invasion, cervical lymphadenectomy might be avoided in case of negative upper mediastinal lymph node.

Endoscopic Resection for the Treatment of Superficial Esophageal Neoplasms

Superficial esophageal neoplasms (SENs) are being diagnosed increasingly frequently due to the screening endoscopy and advances in endoscopic techniques. Endoscopic resection (ER) is a relatively noninvasive treatment method with low morbidity and mortality that provides excellent oncologic outcomes. Endoscopic submucosal dissection is associated with higher rates of en bloc, complete and curative resections and lower rates of local recurrence than endoscopic mucosal resection. The most serious complication of ER is stricture, the treatment and prevention of which are crucial to maintain the patient’s quality of life. ER for SEN is feasible, effective, and safe and can be considered a first-line treatment for SENs in which it is technically feasible.

Does a history of head and neck cancer affect outcome of endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma?

Background and study aims  Esophageal squamous cell carcinoma (ESCC) is the most common secondary tumor in patients with head and neck squamous cell cancer (HNSCC). Currently, endoscopic submucosal dissection (ESD) is the preferred approach to manage superficial ESCC, however, it remains to be elucidated whether patients with HNSCC and early ESCC managed by ESD have different outcomes. Patients and methods  We retrospectively analyzed esophageal ESD for early ESCC from September 2009 to September 2017 and the following variables: demographics, tumor and specimen size, Paris classification, location, en bloc and R0 resection rates, overall survival (OS) and adverse events (AEs). To reduce selection bias, propensity score matching was applied to compare the results. Results  Eighty-nine ESDs were performed in 81 consecutive patients (47 with HNSCC and 34 without HNSCC). Patients with HNSCC who developed superficial ESCC were found to be younger and to refer a more frequent history of alcohol ingestion and smoking. There was no difference in lesion size, number of lesions, procedure time, en bloc resection rate, R0 resection rate, local recurrence and adverse event rate between the two groups. The histological depth of invasion for patients with HNSCC was significantly shallower before ( P  = 0.016) and after ( P  = 0.047) matching. The overall survival rate was similar in both groups. Conclusions  Patients with HNSCC have earlier detection of ESCC, probably due to endoscopic screening. Previous history of chemoradiation and surgery for HNSCC does not affect procedure time, AEs and OS.

Clinical Practice Guideline for Endoscopic Resection of Early Gastrointestinal Cancer

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by en bloc fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

Nomogram for prediction of lymph node metastasis in patients with superficial esophageal squamous cell carcinoma

BACKGROUND AND AIM

Knowledge of lymph node metastasis (LNM) status is crucial to determine whether patients with superficial esophageal squamous cell carcinoma (ESCC) can be cured with endoscopic resection alone, without the need for additional esophagectomy. The present study aimed to identify predictive factors and develop a prediction model for LNM in patients with superficial ESCC.

METHODS

Clinicopathologic data from 501 patients with superficial ESCC treated with radical esophagectomy were reviewed. Stepwise logistic regression analysis determined the predictors of LNM. Using these predictors, a nomogram for predicting the risk of LNM was constructed and internally validated using a bootstrap resampling method.

RESULTS

LNM rates of tumors invading the lamina propria, muscularis mucosa, and SM1 layers were 3.7%, 15.5%, and 40.7%, respectively. Deep tumor invasion depth, moderately or poorly differentiated histology, and lymphovascular invasion were independent predictors of LNM. ESCC with muscularis mucosa and SM1 invasion had odds ratios of 3.635 and 11.834, respectively, compared with that for ESCC confined to the lamina propria. Large tumor size (>2.0 cm) and presence of tumor budding showed borderline significance for LNM prediction. These five variables were incorporated into a nomogram. A constructed nomogram showed good calibration and good discrimination with an area under the receiver-operating characteristic curve (area under the curve [AUC]) of 0.812. After bootstrapping, AUC was 0.811.

CONCLUSIONS

We developed a nomogram that can facilitate individualized prediction of risk of LNM in patients with superficial ESCC. This model can aid in decision-making for the need for additional esophagectomy after endoscopic resection for superficial ESCC.

Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer

The Japan Gastroenterological Endoscopy Society has developed endoscopic submucosal dissection/endoscopic mucosal resection guidelines. These guidelines present recommendations in response to 18 clinical questions concerning the preoperative diagnosis, indications, resection methods, curability assessment, and surveillance of patients undergoing endoscopic resection for esophageal cancers based on a systematic review of the scientific literature.

Clinical Practice Guideline for Endoscopic Resection of Early Gastrointestinal Cancer

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by <i>en bloc</i> fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

Relationship of lymphovascular invasion with lymph node metastasis and prognosis in superficial esophageal carcinoma: systematic review and meta-analysis

Background

The development of tumor cells inside the lymphatics or blood vessels is known as lymphovascular invasion (LVI). The correlation between LVI, lymph node metastasis (LNM), and the diagnosis of superficial esophageal carcinoma (SEC) remains unclear.

Methods

We searched Embase, PubMed, Web of Science, and Cochrane Library databases for prospective articles to better understand the relationship between LVI, LNM, and SEC diagnosis.

Results

We included 23 articles containing data for 4749 patients (range: 54–598) in our meta-analysis. The hazard ratio between LVI and overall survival (OS) was 1.85 with 95% confidence interval (CI) (1.10–3.11, P = 0.02). LNM rate was higher in SEC patients with LVI than SEC patients without LVI (univariate: OR = 4.94, 95% CI: 3.74–6.53, P < 0.0001; multivariate: OR = 5.72, 95%CI: 4.38–7.4, P < 0.0001). No obvious publication was found.

Conclusions

The results indicate that LVI plays a dominant role in the prognosis of LNM in SEC and in the prognostic prediction for SEC.

Macroscopic Assessment and Sampling of Endoscopic Resection Specimens for Squamous Epithelial Malignancies with Superficial Involvement of Esophagus

Endoscopic resection is commonly used for superficial squamous cell carcinoma or high-grade dysplasia of esophageal squamous cell carcinoma. The depth of invasion, clearance from resection margins, and other pathological parameters are important parameters to be examined. The depth of invasion by carcinoma is associated with the risk of lymph node metastases. In endoscopic resection of superficial squamous malignancies of the esophagus, proper pathological examination of the resected specimen could guide the management of the patients in terms of the need for additional treatment, including lymph node dissection, chemotherapy, and radiation therapies.

Risk factors for Mallory-Weiss Tear during endoscopic submucosal dissection of superficial esophageal neoplasms

BACKGROUND

Adverse events during endoscopic submucosal dissection (ESD) of superficial esophageal neoplasms, such as perforation and bleeding, have been well-documented. However, the Mallory-Weiss Tear (MWT) during esophageal ESD remains under investigation.

AIM

To investigate the incidence and risk factors of the MWT during esophageal ESD.

METHODS

From June 2014 to July 2017, patients with superficial esophageal neoplasms who received ESD in our institution were retrospectively analyzed. The clinicopathological characteristics of the patients were collected. Patients were divided into an MWT group and non-MWT group based on whether MWT occurred during ESD. The incidence of MWTs was determined, and the risk factors for MWT were then further explored.

RESULTS

A total of 337 patients with 373 lesions treated by ESD were analyzed. Twenty patients developed MWTs during ESD (5.4%). Multivariate analysis identified that female sex (OR = 5.36, 95%CI: 1.47-19.50, P = 0.011) and procedure time longer than 88.5 min (OR = 3.953, 95%CI: 1.497-10.417, P = 0.005) were independent risk factors for an MWT during ESD. The cutoff value of the procedure time for an MWT was 88.5 min (sensitivity, 65.0%; specificity, 70.8%). Seven of the MWT patients received endoscopic hemostasis. All patients recovered satisfactorily without surgery for the laceration.

CONCLUSION

The incidence of MWTs during esophageal ESD was much higher than expected. Although most cases have a benign course, fatal conditions may occur. We recommend inspection of the stomach during and after the ESD procedure for timely management in cases of bleeding MWTs or even perforation outside of the procedure region.

Predicting lymph node metastasis for endoscopic resection of superficial esophageal squamous cell carcinoma

OBJECTIVE

The aims of this study were to identify risk factors for lymph node metastasis and develop a reliable risk stratification system.

METHODS

Between May 2001 and December 2015, 262 patients who underwent endoscopic resection or surgery for superficial esophageal squamous cell carcinoma were enrolled. We evaluated possible predictive factors for lymph node metastasis: age, gender, tumor length, tumor area, circumferential spread, tumor location, gross appearance, depth of invasion, tumor differentiation, and lymphovascular invasion.

RESULTS

The incidence of lymph node metastasis was 14.5% (38/262). In multivariate analysis, tumor size (>15 mm), depth of invasion (submucosal invasion), and lymphovascular invasion were significantly associated with lymph node metastasis. These factors were included in the risk stratification system and assigned scores; the total risk stratification system score was 0 to 6. The area under the receiver operating characteristic curve for predicting lymph node metastasis was 0.869 (95% confidence interval, 0.813-0.926). The high-risk group (risk stratification system score ≥3) exhibited a significantly higher risk of lymph node metastasis than the low-risk group (score <3) (26.5% vs 1.6%). There was no lymph node metastasis in patients with a risk stratification system of 0. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the risk stratification system were 94.7%, 55.4%, 26.5%, 98.4%, and 61.1%, respectively.

CONCLUSIONS

We developed a risk stratification system that should facilitate the identification of patients with a high or low risk of lymph node metastasis. This may aid the precise selection of patients who can undergo endoscopic resection.

Long-Term Survival and Tumor Recurrence in Patients with Superficial Esophageal Cancer after Complete Non-Curative Endoscopic Resection: A Single-Center Case Series

Background/Aims

To report the long-term survival and tumor recurrence outcomes in patients with superficial esophageal cancer (SEC) after complete non-curative endoscopic resection (ER).

Methods

We retrieved ER data for 24 patients with non-curatively resected SEC. Non-curative resection was defined as the presence of submucosal and/or lymphovascular invasion on ER pathology. Relevant clinical and tumor-specific parameters were reviewed.

Results

The mean age of the 24 study patients was 66.3±8.3 years. Ten patients were closely followed up without treatment, while 14 received additional treatment. During a mean follow-up of 59.0±33.2 months, the 3- and 5-year survival rates of all cases were 90.7% and 77.6%, respectively. The 5-year overall survival rates were 72.9% in the close observation group and 82.1% in the additional treatment group (p=0.958). The 5-year cumulative incidences of all cases of recurrence (25.0% vs. 43.3%, p=0.388), primary EC recurrence (10.0% vs. 16.4%, p=0.558), and metachronous EC recurrence (16.7% vs. 26.7%, p=0.667) were similar between the two groups.

Conclusions

Patients with non-curatively resected SEC showed good long-term survival outcomes. Given the similar oncologic outcomes, close observation may be an option with appropriate caution taken for patients who are medically unfit to receive additional therapy.

[Endoscopic Treatment for Esophageal Cancer]

Esophageal cancer incidence rate per 100,000 is 4.7 in 2013, which accounts for 1.1% of the total cancer incidence in Korea. Superficial esophageal squamous cell carcinoma is frequently detected in persons undergoing upper endoscopy for gastrointestinal symptoms or for gastric cancer screening. Esophagectomy with lymph node dissection is the standard treatment for esophageal cancer. However, given the considerable morbidity and mortality of esophagectomy, endoscopic resection has become the standard of care for most cases of superficial esophageal squamous cell carcinoma without metastasis. In addition, endoscopic submucosal dissection has increased the cure rate, even when the tumor is large, compared to endoscopic mucosal resection. Thus, endoscopic submucosal dissection is the treatment of choice for superficial esophageal squamous cell carcinoma with a negligible risk of lymph node metastasis. Endoscopic resection is usually associated with a low risk of morbidity and no mortality, and has also shown favorable long-term outcomes. However, the long-term risk of metastasis remains after endoscopic resection, which varies according to the characteristics of tumor. This review describes the indication and outcomes of endoscopic resection, complications of endoscopic resection, and management after treatment.

Endoscopic prediction model for differentiating upper submucosal invasion (< 200 μm) and beyond in superficial esophageal squamous cell carcinoma

Esophageal endoscopic submucosal dissection (ESD) can be attempted in superficial esophageal squamous cell carcinoma (SESCC) invading the upper submucosal layer (SM1: invasion < 200 μm). This study aimed to determine endoscopic predictive features associated with beyond SM1 invasion in SESCC and establish a predictive model using the identified features. This study retrospectively analyzed 203 esophageal ESD for SESCC. Endoscopic images were reviewed by two endoscopists. Tumors were evaluated for main shape, sizes, and surface characteristics. The association between each endoscopic feature and beyond SM1 invasion was evaluated. Using the significant endoscopic features in multivariate analysis, a predictive model for beyond SM1 invasion in SESCC was established. Among 203 SESCCs, 40 (19.7%) invaded beyond SM1. Multivariate analysis revealed that surface nodularity [odds ratio (OR) 41.340, 95% confidence interval (CI) 8.492–201.252, p < 0.001], surface granularity (OR 18.682, 95% CI 4.818–72.440, p < 0.001), surface unevenness, (OR 4.107, 95% CI 1.160–14.543, p = 0.029), deep depression (OR 27.490, 95% CI 2.897–260.853, p = 0.004), and thick notch (OR 41.701, 95% CI 6.646–261.672, p < 0.001) were independently associated with beyond SM1 invasion. An established model showed an area under the curve of 0.921 with 95% CI 0.881–0.960. The best cut-off value showed the following: sensitivity, 0.85; specificity, 0.83; positive predictive value, 0.55; and negative predictive value, 0.96. In conclusion, endoscopic features can predict beyond SM1 invasion in SESCC. Our prediction model is potentially useful for screening ESD candidates in SESCC.

Does delayed esophagectomy after endoscopic resection affect outcomes in patients with stage T1 esophageal cancer? A propensity score-based analysis

BACKGROUND

Although endoscopic resection (ER) may be sufficient treatment for early-stage esophageal cancer, additional treatment is recommended when there is a high risk of cancer recurrence. It is unclear whether delaying esophagectomy by performing and assessing the success of ER affects outcomes as compared with immediate esophagectomy without ER. Additionally, long-term survival after sequential ER and esophagectomy required further investigation.

METHODS

Between 2011 and 2015, 48 patients with stage T1 esophageal cancer underwent esophagectomy after ER with curative intent at our institution. Two-to-one propensity score methods were used to identify 96 matched-control patients who were treated with esophagectomy only using baseline patient, tumor characteristics and surgical approach. Time from initial evaluation to esophagectomy, relapse-free survival, overall survival, and postoperative complications were compared between the propensity-matched groups.

RESULTS

In the ER + esophagectomy group, the time from initial evaluation to esophagectomy was significantly longer than in the esophagectomy only group (114 vs. 8 days, p < 0.001). The incidence of dense adhesion (p = 0.347), operative time (p = 0.867), postoperative surgical complications (p = 0.966), and postoperative length of hospital stay (p = 0.125) were not significantly different between the groups. Moreover, recurrence-free survival and overall survival were also similar between the two groups (p = 0.411 and p = 0.817, respectively).

CONCLUSIONS

Treatment of stage T1 esophageal cancer with ER prior to esophagectomy did not increase the difficulty of performing esophagectomy or the incidence of postoperative complications and did not affect survival after esophagectomy. These results suggest that ER can be recommended for patients with stage T1 cancer even if esophagectomy is warranted eventually.

Clinical implication of endoscopic gross appearance in superficial esophageal squamous carcinoma: revisited

BACKGROUND

Standard endoscopic appearance is essential for the diagnosis and treatment of superficial esophageal squamous carcinoma (SESC). The aim of this study was to investigate the association between the endoscopic gross appearance and the clinicopathologic characteristics of SESC.

METHODS

We retrospectively analyzed the clinicopathologic characteristics of SESC according to gross endoscopic appearance in 275 patients with SESC that underwent esophagectomy or endoscopic resection (ER).

RESULTS

The proportion of type I or type III gross appearance, and that of types IIa, IIb, or IIc, were 26.2 and 73.8%, respectively. Type I or type III gross appearance was significantly associated with the female sex, submucosal invasion, lymphovascular invasion (LVI), and lymph node metastasis (LNM). In addition, younger age, larger tumor size, higher proportion of circumferential extension, type I or type III endoscopic gross appearance, submucosal invasion, moderate or poorly differentiated carcinoma, and LVI were significantly associated with LNM. Multivariate logistic regression analysis determined that independent predictors of LNM in patients with SESC included endoscopic gross appearance, submucosal invasion, and presence of LVI. Additionally, type I or type III endoscopic gross appearance lesions were more likely to have submucosal invasion than types IIa, IIb, or IIc. Risk factors for submucosal invasion included a gross appearance of type I or type III, moderately or poorly differentiated tumors, and presence of LVI.

CONCLUSIONS

We found that SESC clinical features are correlated with the endoscopic appearance. Therefore, we suggest that the endoscopic gross appearance may be a candidate for additive criteria in the indications for ER.

Endoscopic and Oncologic Outcomes of Endoscopic Resection for Superficial Esophageal Neoplasm

BACKGROUND/AIMS

Endoscopic resection (ER) of superficial esophageal neoplasm (SEN) is a technically difficult procedure. We investigated the clinical outcomes of ER for SEN to determine its feasibility and effectiveness.

METHODS

Subjects who underwent ER for SEN at Asan Medical Center between December 1996 and December 2010 were eligible. The clinical features of patients and tumors, histopathological characteristics, adverse events, ER results and survival were investigated.

RESULTS

A total of 129 patients underwent ER for 147 SENs. En bloc resection (EnR) was performed in 118 lesions (80.3%). Complete resection (CR) was accomplished in 128 lesions (86.5%), and curative resection (CuR) was performed in 118 lesions (79.7%). The EnR, CR, and CuR rates were significantly greater in the endoscopic submucosal dissection group when compared to those in the endoscopic resection group. Adverse events occurred in 22 patients (17.1%), including bleeding (n=2, 1.6%), perforation (n=12, 9.3%), and stricture (n=8, 6.2%). Local tumor recurrence occurred in 2.0% of patients during a median follow-up of 34.8 months. The 5-year overall and disease-specific survival rates were 94.0% and 97.5%, respectively.

CONCLUSIONS

ER is a feasible and effective method for the treatment of SEN as indicated by favorable clinical outcomes.

The Role of Endosonography in the Staging of Gastrointestinal Cancers

Endosonography (EUS) enables the acquisition of clear images of the gastrointestinal tract wall and the surrounding structures. EUS enables much greater accuracy for staging decisions compared to computed tomography. Surgery for esophageal cancer has a high rate of morbidity and mortality, and it is important to decide on an appropriate treatment method through pre-surgical evaluation. Minimal invasive surgery is widely used for the treatment of gastrointestinal cancer, and endoscopic submucosal dissection is a safe treatment method for early cancer of the gastrointestinal tract that does not result in lymph node metastasis. EUS is essential for pre-surgical evaluation for all esophageal cancers. The use of EUS can effectively reduce unnecessary surgeries and thereby allow for appropriate treatment planning for patients. A number of different diagnostic modalities are available, but EUS is still the mainstay for pre-surgical evaluation of esophageal cancer. The role of EUS for early stomach cancer treatment as a tool for determining the need for endoscopic resection and for pre-surgical assessment is increasing.

Efficacy and safety of endoscopic submucosal dissection for superficial squamous esophageal neoplasia: a meta-analysis

BACKGROUND AND AIMS

Although endoscopic submucosal dissection (ESD) has grown popular in resecting lesions in the stomach, the application of ESD to the esophagus has been limited by greater technical difficulty. An increasing number of series have recently reported the application of ESD to esophageal lesions. The aim of the present systemic review and meta-analysis was to evaluate the efficacy and safety of ESD for esophageal lesions.

METHODS

Comprehensive literature searches (1999-2012) were performed on studies that reported ESD for the removal of esophageal neoplasia. Primary outcome measures were pooled estimates of complete resection rate and en bloc resection rate. Secondary outcome measures were pooled estimates of complication rates.

RESULTS

A total of 15 studies provided data on 776 ESD-treated lesions. The pooled estimate of complete resection rate was 89.4% (95% CI 86.2-91.9%). The pooled estimate of en bloc resection was 95.1% (95% CI 92.6-96.8%). The pooled estimates of complications of ESD such as bleeding, perforation, and stenosis were 2.1, 5.0, and 11.6%, respectively.

CONCLUSIONS

ESD appeared to be an extremely effective technique to achieve complete resection of esophageal neoplasia. The very low rate of complications also shows the potential safety of this approach.

Predicting the invasion depth of esophageal squamous cell carcinoma: comparison of endoscopic ultrasonography and magnifying endoscopy

OBJECTIVE

Predicting the invasion depth of superficial esophageal squamous cell carcinoma (SESCC) is important when selecting among therapeutic strategies. The aim of this study was to compare magnifying endoscopy with narrow-band imaging (ME-NBI) with endoscopic ultrasonography (EUS) for predicting the depth of tumor invasion in patients with SESCC.

METHODS

This study enrolled 51 patients with SESCC (52 SESCC lesions) who underwent both ME-NBI and EUS at Pusan National University Hospital during 2010-2013. We reviewed the patients' medical records and compared ME-NBI and EUS findings with histopathological results according to clinicopathological factors.

RESULTS

A total of 46 lesions in 45 patients were included in the final analysis. ME-NBI and EUS had overall accuracies of 76.1% and 84.8%, respectively, in distinguishing mucosal from non-mucosal cancers. There were no differences between ME-NBI and EUS in terms of sensitivities and specificities in distinguishing mucosal from non-mucosal cancers (p = 0.500 and p = 0.688, respectively). When both ME-NBI and EUS suggested a mucosal depth of lesion invasion, the frequency of mucosal cancer in the final histopathology was 94%. However, if either ME-NBI or EUS suggested a non-mucosal depth of invasion, the frequency of mucosal cancer was only 21%.

CONCLUSION

ME-NBI and EUS are accurate predictors of SESCC invasion depth. If both methods suggest a mucosal depth of lesion invasion, the accuracy of the prediction is increased. Therefore, when possible, it would be better to evaluate the invasion depth of SESCC using both ME-NBI and EUS before deciding to perform endoscopic resection.

Clinicopathologic factors influencing the accuracy of EUS for superficial esophageal carcinoma

AIM: To identify clinicopathologic factors influencing the accuracy of a high-frequency catheter probe endoscopic ultrasonography (EUS) for superficial esophageal carcinomas (SECs).

METHODS: A total of 126 patients with endoscopically suspected SEC, who underwent EUS and curative treatment at Pusan National University Hospital during 2005-2013, were enrolled. We reviewed the medical records of the 126 patients and compared EUS findings with histopathologic results according to clinicopathologic factors.

RESULTS: A total of 114 lesions in 113 patients were included in the final analysis. The EUS assessment of tumor invasion depth was accurate in 78.9% (90/114) patients. Accuracy did not differ according to histologic type, tumor differentiation, tumor location, or macroscopic shape. However, accuracy significantly decreased for tumors ≥ 3 cm in size (P = 0.002). Overestimation and underestimation of the invasion depth occurred for 11 (9.6%) and 13 lesions (11.4%), respectively. In multivariate analyses, tumor size ≥ 3 cm was the only factor significantly associated with EUS accuracy (P = 0.031), and was specifically associated with the underestimation of invasion depth.

CONCLUSION: EUS using a high-frequency catheter probe generally provides highly accurate assessments of SEC invasion depth, but its accuracy decreases for tumors ≥ 3 cm.

Clinicopathologic factors predicting lymph node metastasis in superficial esophageal squamous cell carcinoma

OBJECTIVE

Surgical resection is the treatment of choice for superficial esophageal squamous cell carcinoma (SESCC), but it is associated with high mortality and morbidity rates. Recently, endoscopic resection for SESCC has been indicated for patients with a low risk of lymph node metastasis (LNM). Therefore, to successfully treat SESCC with endoscopic resection, it is very important to identify patients with a low risk for LNM. The objective of this study was to investigate clinicopathologic factors that predict LNM in patients who underwent esophagectomy for SESCC.

METHODS

The study included 104 patients with SESCC from three university hospitals in Pusan, Korea. Clinicopathologic factors were evaluated to identify independent factors predicting LNM by univariate and multivariate analyses.

RESULTS

In univariate analysis, the depth of tumor invasion and lymphovascular invasion had significant influences on LNM (p=0.001 and p<0.001, respectively). Gross type, tumor size, and tumor differentiation were not predictive for LNM. In multivariate analysis, the depth of tumor invasion and lymphovascular invasion were significantly associated with LNM in patients with SESCC (OR 9.04, p=0.049; OR 11.61, p=0.002, respectively).

CONCLUSIONS

The depth of tumor invasion and lymphovascular invasion were independent predictors of LNM in patients with SESCC. Therefore, endoscopic resection could be performed in patients with SESCC that is limited to the mucosa, without lymphovascular invasion.

The role of endoscopic ultrasonography in T staging: early gastric cancer and esophageal cancer

While a number of diagnostic methods have been developed, endoscopic ultrasound (EUS) still takes the most important role in the preoperative evaluation of esophageal cancer. EUS can detect lesions of all esophageal cancer and can accurately perform T staging. In a recent meta-analysis of EUS in esophageal cancer, the sensitivity and specificity of EUS on esophageal cancer were 81.6% and 99.4% in T1, 81.4% and 96.3% in T2, 91.4% and 94.4% in T3, and 92.4% and 97.4% in T4, respectively. The use of EUS can reduce unnecessary surgeries and lead to apply proper treatments to patients. The advance of endoscopic submucosal dissection have necessitated the presurgical detection of early cancer lesions without lymph node metastasis. Understanding the practical meanings of images shown by EUS is important to decide patients for whom endoscopic treatments can be effective. In early gastric cancer, EUS can accurately predict mucosal and SM1 (invasion into the submucosal layer of less than 500 µm from muscularis mucosa) lesions, which are considered as good indications for endoscopic treatments.

Multidisciplinary management of esophageal cancer

This article reviews the current management of esophageal cancer, including staging and treatment options, as well as providing support for using multidisciplinary teams to better manage esophageal cancer patients.

Avanços na abordagem do carcinoma precoce de esôfago

Nos países ocidentais, o carcinoma de células escamosas de esôfago (CCE) geralmente é detectado em estágio avançado, quando as possibilidades de cura são remotas e o prognóstico reservado. Entretanto, nos anos recentes, ocorreu uma série de avanços na abordagem do CCE de esôfago, tais como a identificação dos grupos de risco para o surgimento desta neoplasia; o uso da endoscopia de alta resolução e cromoendoscopia com lugol favorecendo o diagnóstico do CCE em estágios iniciais; e o desenvolvimento de técnicas endoscópicas de ressecção tumoral endoluminal em monobloco denominada dissecção endoscópica de submucosa. Este progresso tem possibilitado a aplicação do tratamento endoscópico minimamente invasivo com potencial curativo em pacientes selecionados com CCE superficial de esôfago. O presente artigo de revisão, elaborado por um grupo multicêntrico internacional, tem como objetivo primário contribuir para o entendimento dos principais avanços recentes ocorridos no manejo do CCE precoce de esôfago. Como objetivo secundário, pretende propiciar uma revisão detalhada e minuciosa da estratégia técnica de DES desenvolvida pelos experts japoneses, de forma a colaborar para a difusão deste conceito e a incorporação destas tecnologias na Medicina Brasileira e Latino-americana.