Endoscopic resection

LMX1B involved in the radioresistance, proliferation and migration of esophageal cancer cells

OBJECTIVES

Esophageal cancer (EC) is one of the most difficult malignancies to cure. The radioresistance remains a major obstacle for effective treatment of EC.

METHODS

Esophageal cancer radioresistant cell lines were screened by the cumulative dose of radiation assays. qRT-PCR and Western blotting assays were used to detect the expression of LMXIB in EC. The survival fraction experiments were performed to test the effects of LMXIB in the radioresistance of EC. Following, the ionizing radiation and clonogenic, cell proliferation, wound healing and Flow cytometry apoptosis assays were used to characterize the properties of these cell lines.

RESULTS

We found that the LMX1B gene, encoding a LIM-homeodomain transcription factor, is expressed in a higher level in the radio-resistant EC cell lines. The following radiation assays revealed that LMX1B promotes the radioresistance of EC cells. Moreover, LMX1B plays roles in the proliferation, cell migration and apoptosis of EC cells.

CONCLUSION

All these results indicated that LMX1B is a key regulator involved in the radioresistance of EC, which might be used as a biomarker to guide the clinical therapy of EC.

Endoscopic Treatment of Early-Stage Esophageal Cancer

PURPOSE OF REVIEW

Esophageal cancer is a leading cause of global cancer-related mortality. Here, we discuss the major endoscopic treatment modalities for management of early esophageal cancer (EEC).

RECENT FINDINGS

Advances in endoscopic imaging and therapy have shifted the paradigm of managing early esophageal cancers. Though esophagectomy remains the preferred management for advanced cancers, guidelines now recommend endoscopic resection followed by ablative therapy for early (Tis and T1a) cancers. Available data suggests endoscopic treatment is comparable to surgery with regard to overall and cancer-specific survival with lower procedural morbidity and mortality. Endoscopic modalities are emerging as frontline treatment options for patients with early esophageal cancers. Accurate clinical staging with assessment of disease extent, tumor grade, and risk of nodal metastases is crucial when determining eligibility for endoscopic management of EEC. High-quality routine surveillance endoscopy is critical in patients who have undergone resection and/or ablation.

Surveillance or resection after chemoradiation in esophageal cancer

The treatment of locally advanced esophageal cancer continues to evolve. Previously, surgery was considered the foundation of treatment, but chemoradiation (CRT) has taken on a larger role both in the neoadjuvant setting and as definitive treatment. It has become clear that although some patients benefit from esophagectomy after CRT, a large subset of patients likely derive no benefit, and may be harmed by surgery. Some patients are cured from CRT alone and therefore do not need surgery. Another group of patients likely have metastatic disease at the time of local therapy that is just undetected on imaging and also do not benefit from surgery. A third group of patients will have persistent locoregional disease only after CRT. This last group is the subset who will actually benefit from surgery, but this likely comprises only a minority of patients with locally advanced disease. A strategy to maximize survival while minimizing unnecessary surgery is a reasonable goal, but present technology does not allow us to do this with certainty. Thus, the decision of whether to pursue resection or surveillance after CRT can be difficult as clinicians and patients try to balance the goal of maximizing the likelihood of cure against the risk of surgery and its impact on quality of life.

Endoscopic Management of Early Esophagogastric Cancer

Esophagogastric cancer accounts for the second most common cause of cancer-related mortality worldwide. Significant efforts have been made to detect these malignancies at an earlier stage through the implementation of screening programs in high-risk individuals using advanced diagnostic techniques. Endoscopic management techniques, such as endoscopic mucosal resection and endoscopic submucosal dissection, have consistently demonstrated excellent outcomes in the management of these lesions. These techniques are associated with a lower risk of morbidity and mortality when compared with traditional surgical management.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Endoscopic Management of Early Esophageal Cancer

The absolute incidence of esophageal adenocarcinoma has increased 7-fold over the past 5 decades, and esophageal adenocarcinoma is the most rapidly increasing epithelial malignancy in the United States. The incidence of early esophageal cancer has also increased proportionately. In the past decade, radiofrequency ablation has become the standard first-line therapy for high-grade dysplasia when found in the precursor lesion to esophageal adenocarcinoma, Barrett's esophagus. Success in the endoscopic management of high-grade dysplasia has furthered efforts to treat early esophageal cancers endoscopically. Although surgery remains the mainstay of treatment for more advanced tumors, national guidelines now recommend endoscopic mucosal resection followed by radiofrequency ablation for intramucosal carcinomas and T1a cancers. T1b cancers represent a more challenging group-very good results have been reported in highly selected subsets of patients with T1b tumors; however, many recommendations favor individualization or a surgical approach for this stage. This review examines the current data and recommendations regarding the endoscopic management of early esophageal adenocarcinomas.

How Commonly Is the Diagnosis of Gastric Low Grade Dysplasia Upgraded following Endoscopic Resection? A Meta-Analysis

Gastric dysplasia is a well-known precancerous lesion. Though the diagnosis of gastric low grade dysplasia (LGD) is generally made from endoscopic forceps biopsy (EFB), the accuracy is doubtful after numerous EFB-proven gastric LGD were upgraded to gastric high grade dysplasia (HGD) or even carcinoma (CA) by further diagnostic test with the procedure of endoscopic resection (ER). We aimed to evaluate the upgraded diagnosis rate (UDR) and the risk factors by ER in EFB-proven gastric LGD lesions. Two investigators independently searched studies reporting the UDR by ER in EFB-proven gastric LGD lesions from databases and analyzed the overall UDR, HGD-UDR and CA-UDR. The pooled UDR by ER in EFB-proven gastric LGD lesions was 25.0% (95% CI, 20.2%-29.8%), made up of HGD-UDR and CA-UDR by rates of 16.7% (95% CI, 12.8%-20.6%) and 6.9% (95% CI, 4.2%-9.6%) respectively. Lesion size larger than 2 cm, surface with depression and nodularity under endoscopic examinations were the major risk factors associated with UDR. In conclusion, one quarter of EFB-proven gastric LGD lesions will be diagnosed as advanced lesions, including gastric HGD (16.7%) and gastric CA (6.9%) by ER. The diagnosis of those LGD lesions with an endoscopic diameter larger than 2cm, and depressed or nodular surface are more likely to be upgraded after ER.

Outcomes in the management of esophageal cancer

Esophageal cancer rates have continued to rise in the Western World. Esophageal cancer will be responsible for an estimated 15,450 deaths in the United States in 2014 alone. Esophageal resection with or without preoperative therapy remains the mainstay of treatment. Advances in surgical technique and perioperative care have improved short-term outcomes considerably by decreasing operative mortality. Despite these advances though, esophagectomy remains a procedure associated with considerable morbidity from a wide range of complications. Prompt recognition and treatment of complications can lower overall morbidity and mortality. Unfortunately, long-term outcomes remain poor as the vast majority of patients present with loco-regionally advanced or metastatic disease. Surgery by itself provides poor loco-regional control and fails to address micrometastatic disease. Neoadjuvant chemotherapy or chemoradiation provides a modest survival advantage compared to surgical resection alone. Future gains in understanding the molecular biology of esophageal cancer will hopefully lead to improved therapeutics and resultant outcomes.

Outcomes of patients receiving additional esophagectomy after endoscopic resection for clinically mucosal, but pathologically submucosal, squamous cell carcinoma of the esophagus

PURPOSE

This study investigated the actual rate or extent of lymph node metastasis or the survival outcomes among patients that underwent esophagectomy with lymph node dissection after ESD for clinical mucosal, but pathological submucosal, esophageal cancer.

METHODS

Seventeen patients that received esophagectomy with two- or three-field lymph node dissection as additional treatment after ESD for clinical mucosal, but pathological submucosal, esophageal cancer between 2006 and 2010 were analyzed. The rate and extent of lymph node metastasis and the patient outcomes were determined.

RESULTS

The tumor depths were diagnosed as SM1 in 8 (47 %) patients and SM2 in 9 (53 %), based on the analyses of resected specimens. Lymphatic invasion was evident in 13 (76 %) patients, while venous invasion was detected in 5 (29 %). Five (29 %) patients had pathologically detected lymph node involvement. Seven (0.8 %) of the 890 dissected nodes showed cancer involvement. Three patients had one involved node in the mediastinum or abdomen, and 2 patients had 2 involved nodes in the abdomen. The patients were followed up for 11-71 months (median 23 months), and all were alive without recurrence at the final follow-up.

CONCLUSION

Twenty-nine percent of the patients diagnosed with clinically mucosal, but pathologically submucosal, thoracic squamous cell esophageal cancer after ESD had 1-2 cancer-involved lymph nodes in the lower mediastinum and abdomen. Esophagectomy with lymph node dissection is therefore considered to be a necessary and effective additional treatment for these patients.

Treatments for esophageal cancer: a review

Esophageal cancer is the eighth most common form of cancer worldwide. The treatments for esophageal cancer depend on its etiology. For mucosal cancer, endoscopic mucosal resection and endoscopic submucosal dissection are standard, while for locally advanced cancer, esophagectomy remains the mainstay. The three most common techniques for thoracic esophagectomy are the transhiatal approach, the Ivor Lewis esophagectomy (right thoracotomy and laparotomy), and the McKeown technique (right thoracotomy followed by laparotomy and neck incision with cervical anastomosis). Surgery for carcinoma of the cervical esophagus requires an extensive procedure with laryngectomy in many cases. When the tumor is more advanced, neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy is added. The theoretical advantages of adding chemotherapy to the treatment of esophageal cancer are potential tumor down-staging prior to surgery, as well as targeting micrometastases and, thus, decreasing the risk of distant metastasis. Cisplatin- and 5-fluorouracil-based regimes are used worldwide. Chemoradiotherapy is the standard for unresectable esophageal cancer and could also be considered as an option for resectable tumors. For patients who are medically or technically inoperable, concurrent chemoradiotherapy should be the standard of care. Although neoadjuvant chemoradiotherapy followed by surgery or salvage surgery after definitive chemoradiotherapy is a practical treatment; judicious patient selection is crucial. It is important to have a thorough understanding of these therapeutic modalities to assist in this endeavor.

Clinical value of multiband mucosectomy for the treatment of squamous intraepithelial neoplasia of the esophagus

BACKGROUND AND AIM

To evaluate the clinical value of multiband mucosectomy (MBM) for the treatment of squamous intraepithelial neoplasia of the esophagus.

METHODS

A total of 51 lesions located at esophagus from 43 patients were treated with MBM, among which 11 were diagnosed as middle-grade intraepithelial neoplasia, 25 as high-grade intraepithelial neoplasia, and 15 as early esophageal cancer pathologically. Primary end-points were the rate of complete endoscopic resection and the mean operation time; the second end-points were the postoperative local recurrence rate and acute plus early complications. The histopathological results were compared between pre-MBM biopsy and MBM specimens. All patients were followed up endoscopically.

RESULTS

A total of 52 MBM procedures with 180 resections were performed in 43 patients. The complete endoscopic resection was achieved in 92.3% (95% confidence interval [CI] 81.8-96.9%). The sizes of the lesions ranged from 10 × 8 mm to 25 × 23 mm. The mean operation time is 37 ± 5 min. The operative acute bleeding complication was 7.6% (95% CI 3-18.1%); no perforations occurred. Early complications consisted of delayed bleeding (one patient 1.9%; 95% CI 0.3-10.1%) and slight esophageal stenosis (one patient). The histopathological diagnosis of 26 cases (51%) was consistent between biopsy and MBM samples, while 20 lesions exhibited higher grade dysplasia. The local recurrence rate was 6.9% (3/43) at 1 year, 9.3% (4/43) at 2 years, and 9.3% at 2.5 years. No death occurred during follow-up.

CONCLUSIONS

MBM is a safe and effective technique for the treatment of early esophageal cancer and precancerous lesions.

Evaluation of the risk of lymph node metastasis using CRP 1846C>T genetic polymorphism in submucosal thoracic esophageal squamous cell carcinoma

BACKGROUND

More than 40 % of patients with submucosal esophageal squamous cell carcinoma (ESCC) have lymph node metastasis. Furthermore, the potential presence of undetectable metastasis before treatment prompts surgeons to be aggressive with respect to lymph node dissection. Extending the indication for endoscopic resection, a minimally invasive treatment, to superficial ESCCs will require more accurate and individualized evaluation of lymph node metastasis.

METHODS

The study participants were 121 esophageal cancer patients who underwent curative surgery for thoracic submucosal ESCC at three Japanese hospitals. DNA was extracted from blood samples, and the C-reactive protein (CRP) 1846C>T genetic polymorphism (rs1205) was investigated using polymerase chain reaction-restriction fragment length polymorphism. We then evaluated the value of CRP 1846C>T polymorphism for diagnosis of lymph node metastasis.

RESULTS

Forty-nine (40 %) patients had lymph node metastasis. The CRP 1846 C/T genotype was C/C in 19 patients, C/T in 57 patients, and T/T in 45 patients. Fisher's exact analysis of the CRP 1846C>T polymorphism showed a significantly higher frequency of lymph node involvement with the T/T genotype. Univariate and multivariate logistic regression models revealed that patients carrying the 1846 T/T genotype had a significantly greater likelihood of developing lymph node metastasis (odds ratio >2.6). Combining the CRP 1846 C/T genotype with clinical diagnosis, mainly using CT, brought a negative predictive value of 80 % to diagnosing lymph node involvement.

CONCLUSIONS

CRP genetic polymorphism may be a novel predictor of risk of lymph node metastasis in ESCC, which could enable better evaluation of the necessity for lymph node dissection.

Multimodal treatment of esophageal cancer

BACKGROUND

The treatment of localized esophageal cancer has been debated controversially over the past decades. Neoadjuvant treatment was used empirically, but evidence was limited due to the lack of high-quality confirmatory studies. Meanwhile, data have become much clearer due to recently published well-conducted randomized controlled trials and meta-analyses.

METHODS

Neoadjuvant and perioperative platinum fluoropyrimidine-based combination chemotherapy has now an established role in the treatment of stage II and stage III esophageal adenocarcinoma and cancer of the esophago-gastric junction. Neoadjuvant chemoradiation is now the standard of care for treating stage II and stage III esophageal squamous cell cancer and can also be considered for treating esophageal adenocarcinoma.

RESULTS

Patients with esophageal squamous cell cancer treated with definitive chemoradiation achieve comparable long-term survival compared with surgery. Short-term mortality is less with chemoradiation alone, but local tumor control is significantly better with surgery.

CONCLUSION

This expert review article outlines current data and literature and delineates recommendable treatment guidelines for localized esophageal cancer.

Reducing complications in upper gastrointestinal endoscopy

This article reviews the principal aspects related to sedation in endoscopy and to the prevention of adverse events in some of the most frequently performed therapeutic upper gastrointestinal (GI) endoscopic procedures (esophageal dilation and stenting, endoscopic resection of upper GI early neoplasia, hemostasis of upper GI bleeding and percutaneous endoscopic gastrostomy insertion). These procedures have an inherent risk of negative outcomes that cannot be entirely avoided. Endoscopic procedures are best performed by well-trained, competent and thoughtful endoscopists in facilities suited to provide for patient safety. Attention to clinical risk management may effectively reduce the frequency and intensity of adverse events, enhance recognition and early detection, and improve responsiveness.