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Teixeira-Farinha H, Béhal H, Cailliau E, Pasquer A, Duhamel A, Théréaux J, Chalret du Rieu M, Lefevre JH, Turner K, Mantziari S, Collet D, Piessen G, Gronnier C. Impact of primary endoscopic resection on oncological outcomes after esophagectomy for cancer: a retrospective propensity score-based cohort study. Surg Endosc 2024; 38:5169-5177. [PMID: 39039292 DOI: 10.1007/s00464-024-11077-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/08/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Esophageal cancer posed significant global health challenges, particularly due to poor survival rates, especially in advanced stages. Primary endoscopic resection had emerged as an alternative treatment for early esophageal cancer, aiming to preserve organ function and reduce surgical morbidity. METHODS This retrospective multicenter cohort study included 334 patients with early esophageal cancer (T1a-b, N0) from 30 French-speaking European centers between 2000 and 2010. Patients underwent either primary endoscopic resection followed by esophagectomy (E group, n = 36) or esophagectomy alone (S group, n = 298). Cox proportional hazards models adjusted for TNM stage and propensity score weighting were used to assess the impact of primary endoscopic resection on recurrence-free survival (RFS), overall survival (OS), and postoperative complications. RESULTS Primary endoscopic resection did not significantly influence RFS (adjusted HR 0.92, 95% CI 0.31 to 2.68, p = 0.88) or OS (adjusted HR 1.06, 95% CI 0.35 to 3.13, p = 0.92) compared to esophagectomy alone. Initial higher thromboembolic complications in the endoscopic resection group were not significant after adjustment (adjusted OR 4.73, 95% CI 0.34 to 64.27, p = 0.24). CONCLUSIONS Primary endoscopic resection followed by esophagectomy for early esophageal cancer did not alter oncological outcomes or overall survival in this retrospective cohort. These findings supported the role of primary endoscopic resection as a safe initial treatment strategy, warranting validation in larger prospective studies. REGISTRATION Our study was registered retrospectively on the Clinicaltrials.com website under the identifier NCT01927016. We acknowledge the importance of prospective registration and regret that this was not done before the commencement of the study.
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Affiliation(s)
- Hugo Teixeira-Farinha
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, Bordeaux, France
- Department of Visceral Surgery, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
| | - Hélène Béhal
- Biostatistics Department, CHU Lille, 59000, Lille, France
| | | | - Arnaud Pasquer
- Digestive Surgery Department, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Alain Duhamel
- Biostatistics Department, CHU Lille, 59000, Lille, France
| | - Jérémie Théréaux
- Department of General, Digestive and Metabolic Surgery, La Cavale Blanche University Hospital, Brest, France
| | - Mael Chalret du Rieu
- Service de Chirurgie Bariatrique, Ramsay Générale de Santé, Clinique Des Cedres, Cornebarrieu, France
| | - Jérémie H Lefevre
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Kathleen Turner
- Department of Gastrointestinal and Hepatic Surgery, Rennes University Hospital Center, Rennes, France
| | - Styliani Mantziari
- Department of Visceral Surgery, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
| | - Denis Collet
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, Bordeaux, France
- Faculty of Medicine, Bordeaux Ségalen University, Bordeaux, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, CHU Lille, Lille, France
- CNRS, Inserm, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, CHU Lille, Univ. Lille, 59000, Lille, France
| | - Caroline Gronnier
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, Bordeaux, France.
- Faculty of Medicine, Bordeaux Ségalen University, Bordeaux, France.
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, 33600, Pessac, France.
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2
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Rubenstein JH, Sawas T, Wani S, Eluri S, Singh S, Chandar AK, Perumpail RB, Inadomi JM, Thrift AP, Piscoya A, Sultan S, Singh S, Katzka D, Davitkov P. AGA Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett's Esophagus and Related Neoplasia. Gastroenterology 2024; 166:1020-1055. [PMID: 38763697 PMCID: PMC11345740 DOI: 10.1053/j.gastro.2024.03.019] [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] [Indexed: 05/21/2024]
Abstract
BACKGROUND & AIMS Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Endoscopic eradication therapy (EET) can be effective in eradicating BE and related neoplasia and has greater risk of harms and resource use than surveillance endoscopy. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for the use of EET in BE and related neoplasia. METHODS The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients, conducted an evidence review, and used the Evidence-to-Decision Framework to develop recommendations regarding the use of EET in patients with BE under the following scenarios: presence of (1) high-grade dysplasia, (2) low-grade dysplasia, (3) no dysplasia, and (4) choice of stepwise endoscopic mucosal resection (EMR) or focal EMR plus ablation, and (5) endoscopic submucosal dissection vs EMR. Clinical recommendations were based on the balance between desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS The panel agreed on 5 recommendations for the use of EET in BE and related neoplasia. Based on the available evidence, the panel made a strong recommendation in favor of EET in patients with BE high-grade dysplasia and conditional recommendation against EET in BE without dysplasia. The panel made a conditional recommendation in favor of EET in BE low-grade dysplasia; patients with BE low-grade dysplasia who place a higher value on the potential harms and lower value on the benefits (which are uncertain) regarding reduction of esophageal cancer mortality could reasonably select surveillance endoscopy. In patients with visible lesions, a conditional recommendation was made in favor of focal EMR plus ablation over stepwise EMR. In patients with visible neoplastic lesions undergoing resection, the use of either endoscopic mucosal resection or endoscopic submucosal dissection was suggested based on lesion characteristics. CONCLUSIONS This document provides a comprehensive outline of the indications for EET in the management of BE and related neoplasia. Guidance is also provided regarding the considerations surrounding implementation of EET. Providers should engage in shared decision making based on patient preferences. Limitations and gaps in the evidence are highlighted to guide future research opportunities.
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Affiliation(s)
- Joel H Rubenstein
- Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Cancer Control and Population Sciences Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Tarek Sawas
- Division of Digestive and Liver Disease, University of Texas Southwestern, Dallas, Texas
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Swathi Eluri
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida
| | - Shailendra Singh
- Division of Gastroenterology, West Virginia University, Morgantown, West Virginia; Advanced Center for Endoscopy, West Virginia University Medicine, Morgantown, West Virginia
| | - Apoorva K Chandar
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - John M Inadomi
- Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota; Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - David Katzka
- Division of Gastroenterology and Hepatology, Columbia University, New York, New York
| | - Perica Davitkov
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Division of Gastroenterology, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio
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3
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Maan ADI, Sharma P, Koch AD. Curative criteria for endoscopic treatment of oesophageal adenocarcinoma. Best Pract Res Clin Gastroenterol 2024; 68:101886. [PMID: 38522884 DOI: 10.1016/j.bpg.2024.101886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/23/2024] [Indexed: 03/26/2024]
Abstract
The incidence of oesophageal adenocarcinoma has been increasing rapidly in the Western world. A well-known risk factor for developing this type of tumour is reflux disease, which can cause metaplasia from the squamous cell mucosa to columnar epithelium (Barrett's Oesophagus) which can progress to dysplasia and eventually adenocarcinoma. With the rise of the incidence of oesophageal adenocarcinoma, research on the best way to manage this disease is of great importance and has changed treatment modalities over the last decades. The gold standard for superficial adenocarcinoma has shifted from surgical to endoscopic management when certain criteria are met. This review will discuss the different curative criteria for endoscopic treatment of oesophageal adenocarcinoma.
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Affiliation(s)
- Annemijn D I Maan
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas and VA Medical Centre, 4801 E Linwood Blvd, Kansas City, USA.
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
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Leclercq P, Bisschops R, Bergman JJGHM, Pouw RE. Management of high risk T1 esophageal adenocarcinoma following endoscopic resection. Best Pract Res Clin Gastroenterol 2024; 68:101882. [PMID: 38522880 DOI: 10.1016/j.bpg.2024.101882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/17/2024] [Indexed: 03/26/2024]
Abstract
High-risk T1 esophageal adenocarcinoma (HR-T1 EAC) is defined as T1 cancer, with one or more of the following histological criteria: submucosal invasion, poorly or undifferentiated cancer, and/or presence of lympho-vascular invasion. Esophagectomy has long been the only available treatment for these HR-T1 EACs and was considered necessary because of a presumed high risk of lymph node metastases up to 46%. However, endoscopic submucosal disscection have made it possible to radically remove HR-T1 EAC, irrespective of size, while leaving the esophageal anatomy intact. Parallel to this development, new publications demonstrated that the risk of lymph node metastases for HR-T1 EAC may be even <24%. Therefore, indications for endoscopic treatment of HR-T1 EAC are being reconsidered and current research aims at finding the optimal management strategy for this indication, where watchful waiting may proof to be an acceptable strategy in selected patients. In this review, we will discuss the latest developments in this field.
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Affiliation(s)
- Philippe Leclercq
- Departement of Gastroenterology, Universitair Ziekenhuis Leuven, 49 Herestraat, 3000, LEUVEN, Belgium.
| | - Raf Bisschops
- Departement of Gastroenterology, Universitair Ziekenhuis Leuven, 49 Herestraat, 3000, LEUVEN, Belgium.
| | - Jacques J G H M Bergman
- Dept. of Gastroenterology and Hepatology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, 1081, HV, Netherlands.
| | - Roos E Pouw
- Dept. of Gastroenterology and Hepatology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, 1081, HV, Netherlands.
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5
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Jogiat UM, Wilson H, Bédard A, Blakely P, Dang J, Sun W, Karmali S, Bédard ELR, Wong C. Optimizing management for early-stage esophageal adenocarcinoma: longitudinal results from a multidisciplinary program. Surg Endosc 2023; 37:7933-7939. [PMID: 37433910 DOI: 10.1007/s00464-023-10250-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/23/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND The management of early-stage esophageal cancer is nuanced. A multidisciplinary approach may optimize management through selection of candidates for surgical or endoscopic therapies. The objective of this research was to examine long-term outcomes of patients with early-stage esophageal cancer who undergo treatment with endoscopic resection or surgery. METHODS Data on patient demographics, co-morbidities, pathology results, OS and RFS were obtained for both the endoscopic resection group and esophagectomy group. Univariate analysis of OS and RFS were conducted using the Kaplan-Meier method with calculation of the log-rank test. Multivariate cox-proportional hazards models were created for OS and RFS using a hypothesis-driven approach. A multivariate logistic regression model was created to identify predictors of esophagectomy among patients undergoing initial endoscopic resection. RESULTS A total of 111 patients were included. The median OS for the surgery group was 67.0 months compared to 74.0 months in the endoscopic resection group (log-rank p = 0.93). The median RFS for the surgery group was 109.4 months compared to 63.3 months in the endoscopic resection group (log-rank p = 0.0127). On multivariable analysis, patients undergoing endoscopic resection had significantly worse RFS (HR 2.55, 95% CI 1.09-6.00; p = 0.032), but equivalent OS (HR 1.03, 95% CI 0.46-2.32; p = 0.941), compared to patients undergoing esophagectomy. High-grade disease (OR 5.43, 95% CI 1.13-26.10; p = 0.035) and submucosal involvement (OR 7.75, 95% CI 1.90-31.40; p = 0.004) were identified as significant predictors of proceeding to esophagectomy. CONCLUSIONS Through a multidisciplinary approach, patients with early-stage esophageal cancer achieve excellent RFS and OS. Submucosal involvement and high-grade disease place patients at increased risk for local disease recurrence; these patients may undergo endoscopic resection safely if treated with a multidisciplinary approach incorporating endoscopic surveillance and surgical consultation. Further risk-stratification models may enable better patient selection and optimization of long-term outcomes.
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Affiliation(s)
- Uzair M Jogiat
- Division of Thoracic Surgery, Department of Surgery, University of Alberta, Edmonton, Canada.
- Dvorkin Lounge Mailroom, 2G2 Walter C. Mackenzie Health Sciences Centre, University of Alberta, 8440 - 112 ST NW, Edmonton, AB, T6G 2B7, Canada.
| | - Hillary Wilson
- Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Alexandre Bédard
- Division of Thoracic Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | | | - Jerry Dang
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Warren Sun
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Shahzeer Karmali
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Eric L R Bédard
- Division of Thoracic Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Clarence Wong
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
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6
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Eusebi LH, Telese A, Castellana C, Engin RM, Norton B, Papaefthymiou A, Zagari RM, Haidry R. Endoscopic Management of Dysplastic Barrett's Oesophagus and Early Oesophageal Adenocarcinoma. Cancers (Basel) 2023; 15:4776. [PMID: 37835470 PMCID: PMC10571849 DOI: 10.3390/cancers15194776] [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: 08/23/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Barrett's oesophagus is a pathological condition whereby the normal oesophageal squamous mucosa is replaced by specialised, intestinal-type metaplasia, which is strongly linked to chronic gastro-oesophageal reflux. A correct endoscopic and histological diagnosis is pivotal in the management of Barrett's oesophagus to identify patients who are at high risk of progression to neoplasia. The presence and grade of dysplasia and the characteristics of visible lesions within the mucosa of Barrett's oesophagus are both important to guide the most appropriate endoscopic therapy. In this review, we provide an overview on the management of Barrett's oesophagus, with a particular focus on recent advances in the diagnosis and recommendations for endoscopic therapy to reduce the risk of developing oesophageal adenocarcinoma.
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Affiliation(s)
- Leonardo Henry Eusebi
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.C.); (R.M.E.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
| | - Andrea Telese
- Digestive Disease and Surgery Institute Cleveland Clinic, London SW1X 7HY, UK; (A.T.); (B.N.)
- Division of Surgery and Interventional Science, University College London, London NW1 2BU, UK
| | - Chiara Castellana
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.C.); (R.M.E.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
| | - Rengin Melis Engin
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.C.); (R.M.E.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
| | - Benjamin Norton
- Digestive Disease and Surgery Institute Cleveland Clinic, London SW1X 7HY, UK; (A.T.); (B.N.)
- Department of Gastroenterology, University College London Hospital (UCLH), London NW1 2BU, UK;
- Centre for Obesity Research, Department of Medicine, Rayne Institute, University College London, London NW1 2BU, UK
| | - Apostolis Papaefthymiou
- Department of Gastroenterology, University College London Hospital (UCLH), London NW1 2BU, UK;
| | - Rocco Maurizio Zagari
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
- Esophagus and Stomach Organic Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Rehan Haidry
- Digestive Disease and Surgery Institute Cleveland Clinic, London SW1X 7HY, UK; (A.T.); (B.N.)
- Division of Surgery and Interventional Science, University College London, London NW1 2BU, UK
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Spadaccini M, Alfarone L, Chandrasekar VT, Maselli R, Capogreco A, Franchellucci G, Massimi D, Fugazza A, Colombo M, Carrara S, Facciorusso A, Bhandari P, Sharma P, Hassan C, Repici A. What Is "Cold" and What Is "Hot" in Mucosal Ablation for Barrett's Oesophagus-Related Dysplasia: A Practical Guide. Life (Basel) 2023; 13:life13041023. [PMID: 37109552 PMCID: PMC10142767 DOI: 10.3390/life13041023] [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: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Over the last two decades, endoscopic eradication therapy has been established as the therapeutic strategy of choice for patients with Barrett's oesophagus-related dysplasia and early oesophageal adenocarcinoma. With a multimodal approach, ablative therapies have been highly effective in achieving remarkable eradication rates of metaplastic epithelium with an acceptable adverse event rate. Among ablative techniques, radiofrequency ablation is currently considered as the first-line option as its efficacy and safety are strongly supported by relevant data. Nevertheless, radiofrequency ablation is costly, and not universally available, or applicable to every situation. Moreover, primary failure and recurrence rates are not negligible. In the last few years, cryotherapy techniques and hybrid argon plasma coagulation have been increasingly assessed as potential novel ablative therapies. Preliminary data have been promising and suggest that they may even have a role as first-line options, alternatively to radiofrequency ablation. The aim of this review is to provide a practical guide for the ablation of Barrett's oesophagus, with emphasis on the different ablative options.
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Affiliation(s)
- Marco Spadaccini
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Ludovico Alfarone
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | | | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Antonio Capogreco
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Gianluca Franchellucci
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Davide Massimi
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Matteo Colombo
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth Hospitals University NHS Trust, Portsmouth PO6 3LY, UK
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO 66045, USA
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
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8
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Frederiks CN, Overwater A, Bergman JJGHM, Pouw RE, de Keizer B, Bennink RJ, Brosens LAA, Meijer SL, van Hillegersberg R, van Berge Henegouwen MI, Ruurda JP, Gisbertz SS, Weusten BLAM. Feasibility and Safety of Tailored Lymphadenectomy Using Sentinel Node-Navigated Surgery in Patients with High-Risk T1 Esophageal Adenocarcinoma. Ann Surg Oncol 2023:10.1245/s10434-023-13317-6. [PMID: 36959491 PMCID: PMC10035969 DOI: 10.1245/s10434-023-13317-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/16/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Selective lymphadenectomy using sentinel node-navigated surgery (SNNS) might offer a less invasive alternative to esophagectomy in patients with high-risk T1 esophageal adenocarcinoma (EAC). The aim of this study was to evaluate the feasibility and safety of a new treatment strategy, consisting of radical endoscopic resection of the tumor followed by SNNS. METHODS In this multicenter pilot study, ten patients with a radically resected high-risk pT1cN0 EAC underwent SNNS. A hybrid tracer of technetium-99m nanocolloid and indocyanine green was injected endoscopically around the resection scar the day before surgery, followed by preoperative imaging. During surgery, sentinel nodes (SNs) were identified using a thoracolaparoscopic gammaprobe and fluorescence-based detection, and subsequently resected. Endpoints were surgical morbidity and number of detected and resected (tumor-positive) SNs. RESULTS Localization and dissection of SNs was feasible in all ten patients (median 3 SNs per patient, range 1-6). The concordance between preoperative imaging and intraoperative detection was high. In one patient (10%), dissection was considered incomplete after two SNs were not identified intraoperatively. Additional peritumoral SNs were resected in four patients (40%) after fluorescence-based detection. In two patients (20%), a (micro)metastasis was found in one of the resected SNs. One patient experienced neuropathic thoracic pain related to surgery, while none of the patients developed functional gastroesophageal disorders. CONCLUSIONS SNNS appears to be a feasible and safe instrument to tailor lymphadenectomy in patients with high-risk T1 EAC. Future research with long-term follow-up is warranted to determine whether this esophageal preserving strategy is justified for high-risk T1 EAC.
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Affiliation(s)
- Charlotte N Frederiks
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anouk Overwater
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Bart de Keizer
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roel J Bennink
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands.
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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9
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Mejza M, Małecka-Wojciesko E. Diagnosis and Management of Barrett's Esophagus. J Clin Med 2023; 12:jcm12062141. [PMID: 36983142 PMCID: PMC10057256 DOI: 10.3390/jcm12062141] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/07/2023] [Accepted: 03/07/2023] [Indexed: 03/30/2023] Open
Abstract
Barrett's esophagus is a metaplastic change of esophageal mucosa, which can be characterized by its salmon-colored lining and the presence of columnar epithelium with goblet cells. It is a well-established precancerous state of esophageal adenocarcinoma, a tumor with very poor survival rates, which incidence is rapidly growing. Despite numerous research, the debate about its diagnosis and management is still ongoing. This article aims to provide an overview of the current recommendations and new discoveries regarding the subject.
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Affiliation(s)
- Maja Mejza
- Department of Digestive Tract Diseases, Medical University, 90-153 Lodz, Poland
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10
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Zyla RE, Kalimuthu SN. Barrett’s Esophagus and Esophageal Adenocarcinoma: A Histopathological Perspective. Thorac Surg Clin 2022; 32:413-424. [DOI: 10.1016/j.thorsurg.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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11
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Dobashi A, Li DK, Mavrogenis G, Visrodia KH, Bazerbachi F. Endoscopic Management of Esophageal Cancer. Thorac Surg Clin 2022; 32:479-495. [DOI: 10.1016/j.thorsurg.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Liu K, Aadam AA. T1b esophageal cancer: Is it time for endoscopic submucosal dissection to enter the stage? Gastrointest Endosc 2022; 96:454-456. [PMID: 35863957 DOI: 10.1016/j.gie.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 05/16/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Kevin Liu
- Department of Medicine, University of Arizona - Banner Medical Center Phoenix, Arizona, USA
| | - A Aziz Aadam
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
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13
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Cotton CC, Eluri S, Shaheen NJ. Management of Dysplastic Barrett's Esophagus and Early Esophageal Adenocarcinoma. Gastroenterol Clin North Am 2022; 51:485-500. [PMID: 36153106 PMCID: PMC10173367 DOI: 10.1016/j.gtc.2022.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
While patients with Barrett's esophagus without dysplasia may benefit from endoscopic surveillance, those with low-grade dysplasia may be managed with either endoscopic surveillance or endoscopic eradication. Patients with Barrett's esophagus with high-grade dysplasia and/or intramucosal adenocarcinoma will generally require endoscopic eradication therapy. The management of Barrett's esophagus with dysplasia and early esophageal adenocarcinoma is predominantly endoscopic, with multiple effective methods available for the resection of raised neoplasia and ablation of flat neoplasia. High-dose proton-pump inhibitor therapy is advised during the treatment of Barrett's esophagus with dysplasia and early esophageal adenocarcinoma. After the endoscopic eradication of Barrett's esophagus and associated neoplasia, surveillance is required for the diagnosis and retreatment of recurrence or progression.
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Affiliation(s)
- Cary C Cotton
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, CB#7080, 130 Mason Farm Road, Suite 4153, Chapel Hill, NC 27599-7080, USA
| | - Swathi Eluri
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, CB#7080, 130 Mason Farm Road, Suite 4142, Chapel Hill, NC 27599-7080, USA
| | - Nicholas J Shaheen
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, CB#7080, 130 Mason Farm Road, Suite 4150, Chapel Hill, NC 27599-7080, USA.
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Loughrey MB, Wong NACS. Clinical utility of GI pathology data: implications for practising pathologists. J Clin Pathol 2022; 75:519-524. [PMID: 35853655 DOI: 10.1136/jclinpath-2021-207472] [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: 01/25/2022] [Indexed: 11/04/2022]
Abstract
Gastrointestinal (GI) tract pathology represents one of the largest individual specialties within cellular pathology departments globally. As with other specialties, clear communication with clinicians providing primary care for the patient is of utmost importance for optimal management and for appropriate use of resources such as endoscopy. A wide breadth of neoplastic and inflammatory conditions afflicts the GI tract. Here, we aim to illustrate how pathology reporting of GI tract specimens influences patient management and specifically how precise reporting of key parameters in different specimen types and different disease processes can directly impact patient care. We describe the potential clinical relevance of selected pathology data items pertinent to specific conditions and highlight areas of contention with respect to the significance of some pathology features. Recent guidelines are described where a change, for example, in diagnostic criteria for a condition is described, or criteria influencing further management such as endoscopic surveillance. The aim of this review is to focus on the clinical importance of careful written communication between the pathologist and primary clinician, illustrated by selective clinical scenarios involving the upper and lower GI tracts.
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Affiliation(s)
- Maurice B Loughrey
- Department of Cellular Pathology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK .,Centre for Public Health, Queen's University Belfast, School of Medicine, Dentistry and Biomedical Sciences, Belfast, UK
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Kamboj AK, Iyer PG. Pushing the boundaries of endoscopic management of early-stage esophageal adenocarcinoma: Caution is advisable! Gastrointest Endosc 2022; 96:248-249. [PMID: 35715236 DOI: 10.1016/j.gie.2022.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Amrit K Kamboj
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Suzuki Y, Okamura T, Matsui A, Hayasaka J, Nomura K, Kikuchi D, Hoteya S. Usefulness of the Japan Esophageal Society Classification of Barrett's Esophagus for Diagnosing the Lateral Extent of Superficial Short-Segment Barrett's Esophageal Cancer. Gastrointest Tumors 2022; 9:59-68. [PMID: 36590852 PMCID: PMC9801400 DOI: 10.1159/000525586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 06/13/2022] [Indexed: 01/04/2023] Open
Abstract
Introduction The Japanese guidelines for endoscopic submucosal dissection (ESD) of Barrett's esophageal adenocarcinoma (BEA) recommend image-enhanced magnifying endoscopic examination for diagnosing the lateral extent of superficial esophageal adenocarcinoma. The Japan Esophageal Society Barrett's Esophagus (JES-BE) classification is proposed recently and is useful in terms of diagnostic accuracy. In this study, we retrospectively examined the usefulness of the JES-BE classification for differential diagnosis and determination of the extent of BEA originating in short-segment Barrett's esophagus. Methods The study reviewed 51 lesions which underwent ESD for BEA. The circumference of the esophagogastric junction was divided into four parts, and the lesions were divided into those in the right anterior portion (RA group; n = 33) and those in other portions (non-RA group; n = 18). Clinicopathological characteristics and clinical outcomes were compared between the two groups. Results JES-BE classification findings as "dysplasia" were seen in 48 out of 51 (94.1%) BEA lesions retrospectively. There was no significant difference in histological type, tumor depth, lymphovascular invasion, or the proportion of tumors with a positive or unknown horizontal or vertical margin status between the groups. The proportion of tumors with type 0-I morphology was significantly higher in the RA group (p = 0.023). The tumor size was significantly greater in the RA group (p = 0.034). According to the JES-BE classification, 31 lesions (93.9%) in the RA group and 17 lesions (94.4%) in the non-RA group were diagnosed as dysplasia. There was also no significant difference in the rate of consistency between the endoscopic and histopathological findings on the lateral extent of the lesion (90.9% vs. 83.3%; p = 0.612). Discussion/Conclusions The JES-BE classification may be useful for determining the extent of BEA.
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Endoscopic Management of Barrett's Esophagus. Dig Dis Sci 2022; 67:1469-1479. [PMID: 35226224 DOI: 10.1007/s10620-022-07395-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/09/2022]
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Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. Am J Gastroenterol 2022; 117:559-587. [PMID: 35354777 DOI: 10.14309/ajg.0000000000001680] [Citation(s) in RCA: 160] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 02/04/2022] [Indexed: 02/07/2023]
Abstract
Barrett's esophagus (BE) is a common condition associated with chronic gastroesophageal reflux disease. BE is the only known precursor to esophageal adenocarcinoma, a highly lethal cancer with an increasing incidence over the last 5 decades. These revised guidelines implement Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the definition and diagnosis of BE, screening for BE and esophageal adenocarcinoma, surveillance of patients with known BE, and the medical and endoscopic treatment of BE and its associated early neoplasia. Important changes since the previous iteration of this guideline include a broadening of acceptable screening modalities for BE to include nonendoscopic methods, liberalized intervals for surveillance of short-segment BE, and volume criteria for endoscopic therapy centers for BE. We recommend endoscopic eradication therapy for patients with BE and high-grade dysplasia and those with BE and low-grade dysplasia. We propose structured surveillance intervals for patients with dysplastic BE after successful ablation based on the baseline degree of dysplasia. We could not make recommendations regarding chemoprevention or use of biomarkers in routine practice due to insufficient data.
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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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Gotink AW, van de Ven SEM, Ten Kate FJC, Nieboer D, Suzuki L, Weusten BLAM, Brosens LAA, van Hillegersberg R, Alvarez Herrero L, Seldenrijk CA, Alkhalaf A, Moll FCP, Schoon EJ, van Lijnschoten I, Tang TJ, van der Valk H, Nagengast WB, Kats-Ugurlu G, Plukker JTM, Houben MHMG, van der Laan JS, Pouw RE, Bergman JJGHM, Meijer SL, van Berge Henegouwen MI, Wijnhoven BPL, de Jonge PJF, Doukas M, Bruno MJ, Biermann K, Koch AD. Individual risk calculator to predict lymph node metastases in patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study. Endoscopy 2022; 54:109-117. [PMID: 33626582 DOI: 10.1055/a-1399-4989] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Lymph node metastasis (LNM) is possible after endoscopic resection of early esophageal adenocarcinoma (EAC). This study aimed to develop and internally validate a prediction model that estimates the individual risk of metastases in patients with pT1b EAC. METHODS A nationwide, retrospective, multicenter cohort study was conducted in patients with pT1b EAC treated with endoscopic resection and/or surgery between 1989 and 2016. The primary end point was presence of LNM in surgical resection specimens or detection of metastases during follow-up. All resection specimens were histologically reassessed by specialist gastrointestinal pathologists. Subdistribution hazard regression analysis was used to develop the prediction model. The discriminative ability of this model was assessed using the c-statistic. RESULTS 248 patients with pT1b EAC were included. Metastases were seen in 78 patients, and the 5-year cumulative incidence was 30.9 % (95 % confidence interval [CI] 25.1 %-36.8 %). The risk of metastases increased with submucosal invasion depth (subdistribution hazard ratio [SHR] 1.08, 95 %CI 1.02-1.14, for every increase of 500 μm), lymphovascular invasion (SHR 2.95, 95 %CI 1.95-4.45), and for larger tumors (SHR 1.23, 95 %CI 1.10-1.37, for every increase of 10 mm). The model demonstrated good discriminative ability (c-statistic 0.81, 95 %CI 0.75-0.86). CONCLUSIONS A third of patients with pT1b EAC experienced metastases within 5 years. The probability of developing post-resection metastases was estimated with a personalized predicted risk score incorporating tumor invasion depth, tumor size, and lymphovascular invasion. This model requires external validation before implementation into clinical practice.
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Affiliation(s)
- Annieke W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Fiebo J C Ten Kate
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands.,Department of Pathology, Isala Clinics, Zwolle, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Lucia Suzuki
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Cees A Seldenrijk
- Department of Pathology, Pathology DNA, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Freek C P Moll
- Department of Pathology, Isala Clinics, Zwolle, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Thjon J Tang
- Department of Gastroenterology and Hepatology, Ijsselland Hospital, Capelle aan den Ijssel, the Netherlands
| | - Hans van der Valk
- Department of Pathology, Ijselland Hospital, Capelle aan den Ijssel, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Gursah Kats-Ugurlu
- Department of Pathology, University Medical Center Groningen, Groningen, the Netherlands
| | - John T M Plukker
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | | | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Michael Doukas
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
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Godat S, Marx M, Caillol F, Robert M, Autret A, Bories E, Pesenti C, Ratone JP, Schoepfer A, Poizat F, Giovannini M. Benefit of radiofrequency ablation after widespread endoscopic resection of neoplastic Barrett's esophagus in daily practice. Ann Gastroenterol 2022; 35:34-41. [PMID: 34987286 PMCID: PMC8713341 DOI: 10.20524/aog.2021.0685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/02/2021] [Indexed: 11/25/2022] Open
Abstract
Background High-grade dysplasia (HGD) and intramucosal carcinoma (IMC) in Barrett’s esophagus (BE) are now well-established indications for endoscopic resection (ER). Radiofrequency ablation (RFA) can be combined with ER in case of flat or long-segment BE ablation. We report here our experience of complementary RFA after widespread ER of neoplastic BE in daily practice. Method We retrospectively reviewed data of 89 patients, treated between 2006 and 2013 by ER alone (group 1) or by ER combined with RFA (group 2). Results Fifty-five patients in group 1 (7F/48M, mean age 68 years) underwent widespread ER with eradication of residual non-dysplastic BE. Complete eradication of HGD/IMC and intestinal metaplasia (IM) was achieved in 32/32 (100%) and 48/55 (87.3%) patients, respectively. Thirty-four patients in group 2 (3F/31M, mean age 67 years) had a multimodal treatment strategy, with widespread ER followed by RFA. Mean Prague classification of BE in this group was significantly longer (C4.4M6.6 vs. C2.7M4.5, P<0.001). Complete eradication of HGD/IMC and non-dysplastic BE was confirmed in 26/27 (96.3%) and 20/34 (58.8%) patients, respectively. There was no significant difference between groups concerning adverse events (16.4% vs. 23.5%, P=0.58) or recurrence rate of HGD/IMC (9.1% vs. 14.7%, P=0.42). The mismatch rate between preoperative and final histological diagnosis was high in both groups, at 45.5% and 26.5%. Conclusions A combination of ER and RFA can treat significantly longer neoplastic BE than ER alone, with the same efficiency and safety. Widespread ER, in contrast, is the only method of obtaining a reliable histological diagnosis.
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Affiliation(s)
- Sébastien Godat
- Division of Gastroenterology and Hepatology, CHUV, Lausanne, Switzerland (Sébastien Godat, Mariola Marx, Maxime Robert, Alain Schoepfer)
| | - Mariola Marx
- Division of Gastroenterology and Hepatology, CHUV, Lausanne, Switzerland (Sébastien Godat, Mariola Marx, Maxime Robert, Alain Schoepfer)
| | - Fabrice Caillol
- Division of Gastroenterology, Paoli-Calmettes Institute, Marseille, France (Fabrice Caillol, Erwan Bories, Jean Philippe Ratone, Marc Giovannini)
| | - Maxime Robert
- Division of Gastroenterology and Hepatology, CHUV, Lausanne, Switzerland (Sébastien Godat, Mariola Marx, Maxime Robert, Alain Schoepfer)
| | - Aurélie Autret
- Division of Biostatistics, Paoli-Calmettes Institute, Marseille, France (Aurélie Autret)
| | - Erwan Bories
- Division of Gastroenterology, Paoli-Calmettes Institute, Marseille, France (Fabrice Caillol, Erwan Bories, Jean Philippe Ratone, Marc Giovannini)
| | - Christian Pesenti
- Division of Gastroenterology, Paoli-Calmettes Institute, Marseille, France (Fabrice Caillol, Erwan Bories, Jean Philippe Ratone, Marc Giovannini)
| | - Jean Philippe Ratone
- Division of Gastroenterology, Paoli-Calmettes Institute, Marseille, France (Fabrice Caillol, Erwan Bories, Jean Philippe Ratone, Marc Giovannini)
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, CHUV, Lausanne, Switzerland (Sébastien Godat, Mariola Marx, Maxime Robert, Alain Schoepfer)
| | - Flora Poizat
- Division of Pathology, Paoli-Calmettes Institute, Marseille, France (Flora Poizat)
| | - Marc Giovannini
- Division of Gastroenterology, Paoli-Calmettes Institute, Marseille, France (Fabrice Caillol, Erwan Bories, Jean Philippe Ratone, Marc Giovannini)
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22
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Zhang LY, Kalloo AN, Ngamruengphong S. Therapeutic Endoscopy and the Esophagus: State of the Art and Future Directions. Gastroenterol Clin North Am 2021; 50:935-958. [PMID: 34717880 DOI: 10.1016/j.gtc.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Therapeutic gastrointestinal endoscopy is rapidly evolving, and this evolution is quite apparent for esophageal diseases. Minimally invasive endoluminal therapy now allows outpatient treatment of many esophageal diseases that were traditionally managed surgically. In this review article, we explore the most exciting new developments. We discuss the use of peroral endoscopic myotomy for treatment of achalasia and other related diseases, as well as the modifications that have allowed its use in treatment of Zenker diverticulum. We cover endoscopic treatment of gastroesophageal reflux disease and Barrett's esophagus. Further, we explore advanced endoscopic resection techniques.
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Affiliation(s)
- Linda Y Zhang
- Division of Gastroenterology & Hepatology, Johns Hopkins Medicine, 1800 Orleans St, Sheikh Zayed Tower, Suite M2058, Baltimore, MD 21287, USA
| | - Anthony N Kalloo
- Department of Medicine, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA; Department of Medicine, Johns Hopkins Medicine, 1800 Orleans St, Sheikh Zayed Tower, Baltimore, MD 21287, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology & Hepatology, Johns Hopkins Medicine, 4940 Eastern Avenue, A Building, 5th Floor, A-501, Baltimore, MD 21224, USA.
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Abstract
Endoscopic findings in early esophageal cancer are often subtle and require careful inspection and meticulous endoscopic examination. When dysplasia is suspected, we recommend performing 1 or 2 targeted biopsies of the abnormal area and review with a pathologist specialized in evaluating gastrointestinal diseases. In the case of adenocarcinoma, after resection of any visible cancer, residual Barrett's can be treated by ablation. Endoscopic resection can offer the opportunity for patients to avoid surgery. Further studies are needed to evaluate the optimal management of circumferential and near-circumferential lesions as well as tools and techniques to facilitate the performance of endoscopic submucosal dissection and endoscopic mucosal resection.
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24
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Deng XM, Zhu TY, Wang GJ, Gao BL, Wang JT, Li RX, Zhang YF, Ding HX. Lymph node metastasis pattern and significance of left gastric artery lymph node dissection in esophagectomy for esophageal cancers. World J Surg Oncol 2021; 19:296. [PMID: 34635107 PMCID: PMC8504036 DOI: 10.1186/s12957-021-02405-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/19/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose To investigate the lymph node metastasis pattern and significance of dissection of the left gastric artery lymph nodes in radical en bloc esophagectomy for esophageal squamous carcinomas based on the lymphatic drainage pathway revealed by carbon nanoparticle labeling. Materials and methods Patients who underwent en bloc esophagectomy endoscopically were retrospectively enrolled. Carbon nanoparticles were injected in the submucosa of upper thoracic esophagus to label the relevant draining lymph nodes. The clinical data, lymph nodes dissected, surgical technique, and complications were analyzed. Results En bloc esophagectomy was successful in all 179 patients. Metastases to the left gastric artery lymph nodes were positive in 42 patients (23.5%) but negative in 137 (76.5%). The left gastric lymph nodes were labeled, whereas no celiac lymph nodes were labeled by carbon nanoparticles. A total of 4652 lymph nodes were resected, with 26 lymph nodes per patient. Seventy-three patients had lymph node metastasis (73/179). Seventeen patients had metastasis to the recurrent laryngeal nerve lymph nodes (9.5%). The metastasis rate of the lower thoracic esophageal cancer to the left gastric artery lymph nodes was 37.0%, significantly greater than that at the middle (15.4%) or upper (6.7%) thoracic segment. The lymph node metastasis rate was significantly (P < 0.05) increased with the length of the cancerous lesion, infiltration depth, and poor differentiation. Univariate analysis revealed that the metastasis rate to the left gastric artery lymph nodes was significantly (P < 0.05) associated with paraesophageal lymph node metastasis, para-cardial lymph metastasis, and TNM classification. Multivariate analysis indicated that cancer location (odds ratio 8.32, 95% confidence interval 2.12–32.24) was significantly (P < 0.05) associated with metastasis to the left gastric artery lymph nodes, with the cancer at the middle and lower thoracic segments significantly more than in the upper thoracic segment. Conclusion Certain patterns exist in lymph node metastasis of esophageal cancer, and in radical esophagectomy of esophageal cancers, dissection of the left gastric artery lymph nodes is necessary to prevent possible residual or metastasis of esophageal squamous carcinomas based on the lymphatic drainage pathway of esophageal carcinomas demonstrated by carbon nanoparticle labeling.
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Affiliation(s)
- Xiu-Mei Deng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Tian-Yu Zhu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Guo-Jun Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China.
| | - Bu-Lang Gao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Jing-Tao Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Rui-Xin Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Yun-Fei Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Heng-Xuan Ding
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
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25
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[Treatment recommendations for early esophageal cancer : Endoscopic and surgical options]. Chirurg 2021; 92:1077-1084. [PMID: 34622303 DOI: 10.1007/s00104-021-01513-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Esophageal cancer represents a complex tumor entity with an increasing proportion of adenocarcinomas. Early esophageal cancer is staged as m1-m3 depending on the depth of infiltration into the mucosa and as sm1-sm3 depending on invasion into the submucosa. The risk of lymph node metastasis is strongly correlated with the depth of invasion and increases by leaps and bounds with submucosal infiltration. MATERIAL AND METHODS This review is based on publications retrieved by a selective database search (MEDLINE, PubMed, Cochrane Library, International Standard Randomised Controlled Trial Number, ISRCTN, registry) on the current management of early esophageal cancer. RESULTS The endoscopic diagnostics and evaluation of the dignity of superficial esophageal cancer by traditional staining techniques have been expanded by virtual chromoendoscopy. Endoscopic resection is the diagnostic and therapeutic procedure of choice for mucosal low risk adenocarcinomas (grade 1 or 2, no blood or lymph vessel invasion). Under certain prerequisites adenocarcinomas of the upper submucosa (sm1) can also be endoscopically removed. All other stages necessitate surgical treatment. In squamous cell carcinoma without risk factors a surgical oncological esophageal resection is indicated after infiltration of the third mucosal layer (m3). Endoscopic submucosal dissection (ESD) shows high rates of en bloc and R0 (curative) resections even with large lesions. CONCLUSION Borderline cases between endoscopic and surgical treatment of early esophageal cancer necessitate an interdisciplinary approach and individually adapted management, which in the locally advanced stage are always embedded in a multimodal concept.
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26
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Leggett CL, Katzka DA. As far as the AI can see. Endoscopy 2021; 53:884-885. [PMID: 34438451 DOI: 10.1055/a-1352-4811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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27
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Feasibility of sentinel node navigated surgery in high-risk T1b esophageal adenocarcinoma patients using a hybrid tracer of technetium-99 m and indocyanine green. Surg Endosc 2021; 36:2671-2679. [PMID: 34046715 PMCID: PMC8921120 DOI: 10.1007/s00464-021-08551-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 05/04/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Minimally invasive esophagectomy with two-field lymphadenectomy is standard of care for T1b esophageal adenocarcinoma (EAC) with a high risk of lymph node metastasis. Sentinel node navigation surgery (SNNS) is a well-known concept to tailor the extent of lymphadenectomy. The aim of this study was to evaluate the feasibility and safety of SNNS with a hybrid tracer (technetium-99 m/indocyanine green/nanocolloid) for patients with high-risk T1b EAC. METHODS In this prospective, multicenter pilot study, 5 patients with high-risk T1b EAC were included. The tracer was injected endoscopically around the endoscopic resection scar the day before surgery, followed by preoperative imaging (lymphoscintigraphy/SPECT-CT). During surgery, first the SNs were localized and resected based on preoperative imaging and intraoperative gammaprobe- and fluorescence-based detection, followed by esophagectomy. Primary endpoints were the percentage of patients with detectable SNs, concordance between preoperative and intraoperative SN detection, and the additive value of indocyanine green. RESULTS SNs could be identified and resected in all patients (median 3 SNs per patient, range 2-7). There was a high concordance between preoperative and intraoperative SN detection. In 2 patients additional peritumoral SNs were identified with fluorescence-based detection. None of the resected lymph nodes showed signs of (micro)metastases and no nodal metastases were detected in the surgical resection specimen. CONCLUSIONS SNNS using technetium-99 m/indocyanine green/nanocolloid seems feasible and safe in patients with high-risk T1b EAC. Indocyanine green fluorescence seems to be of additive value for detection of peritumoral SNs. Whether this approach can optimize selection for esophagectomy needs to be studied in future research.
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Miyata H, Sugimura K, Kanemura T, Takeoka T, Yamamoto M, Shinno N, Hara H, Omori T, Yamamoto S, Ishihara R, Wada H, Takahashi H, Nishimura J, Matsuda C, Yasui M, Yano M. Clinical Outcome of Additional Esophagectomy After Endoscopic Treatment for Superficial Esophageal Cancer. Ann Surg Oncol 2021; 28:7230-7239. [PMID: 33959832 DOI: 10.1245/s10434-021-09864-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/15/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Endoscopic treatment is one of the options for superficial esophageal cancer, but additional therapy such as esophagectomy or chemoradiotherapy (CRT) is sometimes needed due to noncurative resection. However, the outcome of additional therapy after endoscopic treatment has not been fully evaluated. METHODS In 160 patients with superficial esophageal cancer, including 37 patients who underwent esophagectomy and 123 patients who underwent CRT after noncurative endoscopic resection, outcomes were investigated. RESULTS The CRT group included more elderly patients than the surgery group, although there were no significant differences in tumor depth or lymphovascular invasion between the two groups. Overall survival was significantly better in the surgery group than in the CRT group (5-year overall survival: 94.3% vs. 79.9%; p = 0.039). Two (5.4%) patients in the surgery group who developed lymph node recurrence achieved complete response by chemotherapy or CRT, and 9 of 16 patients (13.0%) in the CRT group who developed recurrence underwent salvage esophagectomy or lymphadenectomy. As a result, the 5-year cause-specific survival was 100% in the surgery group and 92.8% in the CRT group. SM2 invasion (≥ SM2) was significantly associated with recurrence after CRT, while lymphatic invasion was associated with lymph node metastasis in the surgery group. CONCLUSION Endoscopic treatment combined with esophagectomy or CRT can be a curative treatment option in patients with superficial esophageal cancer. However, esophagectomy rather than CRT should be recommended for patients with massive submucosal tumor invasion due to the risk of recurrence after CRT.
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Affiliation(s)
- Hiroshi Miyata
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan.
| | - Keijirou Sugimura
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takeshi Kanemura
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Tomohira Takeoka
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masaaki Yamamoto
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Naoki Shinno
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hisashi Hara
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takeshi Omori
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Sachiko Yamamoto
- Department of Gastroenterological Medicine, Osaka International Cancer Institute, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastroenterological Medicine, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroshi Wada
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hidenori Takahashi
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Junichi Nishimura
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Chu Matsuda
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masayoshi Yasui
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masahiko Yano
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
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Optimizing Outcomes with Radiofrequency Ablation of Barrett's Esophagus: Candidates, Efficacy and Durability. Gastrointest Endosc Clin N Am 2021; 31:131-154. [PMID: 33213792 DOI: 10.1016/j.giec.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The treatment of early Barrett's esophagus (BE) has undergone a paradigm shift from surgical subtotal esophagectomy to organ-saving endoluminal treatment. Over the past 15 years, several high-quality studies were conducted to assess safe oncological outcome of endoscopic resection of mucosal adenocarcinoma and high-grade dysplasia. It became clear that add-on ablative therapy with radiofrequency ablation (RFA) significantly reduces recurrence risk of neoplasia after resection. In this review, we highlight the most essential elements to optimize outcomes of RFA of BE, addressing the correct indication and patient selection in combination with the most efficient and safest treatment protocols to obtain long-term durability.
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Sehgal V, Ragunath K, Haidry R. Measuring Quality in Barrett's Esophagus: Time to Embrace Quality Indicators. Gastrointest Endosc Clin N Am 2021; 31:219-236. [PMID: 33213797 DOI: 10.1016/j.giec.2020.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic eradication therapy is a safe and effective therapy that has revolutionized the management of patients with Barrett's esophagus (BE)-related neoplasia. Despite this, there remains significant heterogeneity in clinical practice with consequent variation in patient outcomes. The aim of this article was to align consensus statements based on the best available evidence and expert opinion from the United States and United Kingdom to develop robust and measurable quality indicators that help to ensure patients with BE-related neoplasia receive the highest possible quality of care uniformly.
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Affiliation(s)
- Vinay Sehgal
- Department of Gastroenterology and Endoscopy, University College London Hospitals NHS Foundation Trust, Ground Floor West, 250 Euston Road, London NW1 2PG, UK.
| | - Krish Ragunath
- Department of Gastroenterology, Curtin University Medical School, Royal Perth Hospital, Victoria Square, Perth, Western Australia 6000, Australia
| | - Rehan Haidry
- Department of Gastroenterology and Endoscopy, University College London Hospitals NHS Foundation Trust, Ground Floor West, 250 Euston Road, London NW1 2PG, UK
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Kumarasinghe MP, Armstrong M, Foo J, Raftopoulos SC. The modern management of Barrett's oesophagus and related neoplasia: role of pathology. Histopathology 2020; 78:18-38. [PMID: 33382493 DOI: 10.1111/his.14285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 12/13/2022]
Abstract
Modern management of Barrett's oesophagus and related neoplasia essentially focuses upon surveillance to detect early low-risk neoplastic lesions and offering organ-preserving advanced endoscopic therapies, while traditional surgical treatments of oesophagectomy and lymph node clearance with or without chemoradiation are preserved only for high-risk and advanced carcinomas. With this evolution towards figless invasive therapy, the choice of therapy hinges upon the pathological assessment for risk stratifying patients into those with low risk for nodal metastasis who can continue with less invasive endoscopic therapies and others with high risk for nodal metastasis for which surgery or other forms of treatment are indicated. Detection and confirmation of neoplasia in the first instance depends upon endoscopic and pathological assessment. Endoscopic examination and biopsy sampling should be performed according to the recommended protocols, and endoscopic biopsy interpretation should be performed applying standard criteria using appropriate ancillary studies by histopathologists experienced in the pathology of Barrett's disease. Endoscopic resections (ERs) are both diagnostic and curative and should be performed by clinicians who are skilled with advanced endoscopic techniques. Proper preparation and handling of ERs are essential to assess histological parameters that dictate the curative nature of the procedure. Those parameters are adequacy of resection and risk of lymph node metastasis. The risk of lymph node metastasis is determined by depth invasion and presence of poor differentiation and lymphovascular invasion. Those adenocarcinomas with invasion up to muscularis mucosae (pT1a) and those with superficial submucosal invasion (pT1b) up to 500 µ with no poor differentiation and lymphovascular invasion and negative margins may be considered cured by endoscopic resections.
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Affiliation(s)
- M Priyanthi Kumarasinghe
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
| | - Michael Armstrong
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
| | - Jonathan Foo
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
| | - Spiro C Raftopoulos
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
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32
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Oetzmann von Sochaczewski C, Haist T, Pauthner M, Mann M, Braun S, Ell C, Lorenz D. Infiltration Depth is the Most Relevant Risk Factor for Overall Metastases in Early Esophageal Adenocarcinoma. World J Surg 2020; 44:1192-1199. [PMID: 31853591 DOI: 10.1007/s00268-019-05291-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Research in early esophageal adenocarcinoma focused on prediction of lymph node metastases in order to stratify patients for endoscopic treatment instead of esophagectomy. Although distant metastases were described in rates of up to 13% of patients within a follow-up of 3 years, their prediction has been neglected so far. METHODS In a secondary analysis, a cohort of 217 patients (53 T1a and 164 T1b) treated by esophagectomy was analyzed for histopathological risk factors. Their ability to predict the combination of lymph node metastases at surgery as well as metachronous locoregional and distant metastases (overall metastatic rate) was assessed by uni- and multivariate logistic regression analysis. RESULTS Tumor invasion depth was correlated with both lymph node metastases at surgery (τ = 0.141; P = .012), tumor recurrences (τ = 0.152; P = .014), and distant metastases (τ = 0.122; P = 0.04). Multivariate analysis showed an odds ratio of 1.31 (95% CI 1.02-1.67; P = .033) per increasing tumor invasion depth and of 3.5 (95% CI 1.70-6.56; P < .001) for lymphovascular invasion. The pre-planned subgroup analysis in T1b tumors demonstrated an even lower predictive ability of lymphovascular invasion with an odds ratio of 2.5 (95% CI 1.11-5.65; P = 0.028), whereas the predictive effect of sm2 (odds ratio 3.44; 95% CI 1.00-11.9; P = 0.049) and sm3 (odds ratio 3.44; 95% CI 1.00-11.9; P = 0.049) tumor invasion depth was similar. CONCLUSIONS The present report demonstrates the insufficient risk prediction of histopathologic risk factors for the overall metastatic rate.
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Affiliation(s)
| | - Thomas Haist
- Department of Surgery I, Sana Klinikum Offenbach, Offenbach, Germany
| | - Michael Pauthner
- Department of Surgery I, Sana Klinikum Offenbach, Offenbach, Germany
| | - Markus Mann
- Department of Surgery I, Sana Klinikum Offenbach, Offenbach, Germany
| | - Susanne Braun
- Institute of Pathology, Sana Klinikum Offenbach, Offenbach, Germany
| | - Christian Ell
- Department of Internal Medicine II, Sana Klinikum Offenbach, Offenbach, Germany
| | - Dietmar Lorenz
- Department of Surgery I, Klinikum Darmstadt, Grafenstraße 9, 64283, Darmstadt, Germany.
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33
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Pateria P, Chong A, Muwanwella N, Siah C, Kumarasinghe P, Raftopoulos S. To Investigate Outcomes In Endoscopic Management Of Early Oesophageal Adenocarcinoma In Barrett's Oesophagus: Experience At Three Australian Tertiary Centres. Intern Med J 2020; 52:633-639. [PMID: 33073906 DOI: 10.1111/imj.15104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/05/2020] [Accepted: 10/05/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Barrett's oesophagus (BO) is known precursor of oesophageal adenocarcinoma (EAC). Early EAC includes T1a (invasion into mucosa) and T1b (invasion into submucosa but not muscularis propria). Endoscopic mucosal resection (EMR) provides accurate histological staging and definitive treatment for early EAC. Post EMR, the remaining Barrett's is eradicated with radiofrequency ablation (RFA). However, there is a paucity of long-term Australian data. AIMS To investigate the efficacy and long-term outcomes of EMR and RFA in management of early EAC. METHODS Retrospective analysis of patients early EAC treated endoscopically at three Western Australian tertiary centres, with at least 12-months follow-up, over last 10-years. RESULTS Sixty-seven patients with early EAC (61 T1a and 6 T1b) were treated with EMR. Complete Barrett's eradication was done by EMR in 31/67 patients whereas 36/67 patients underwent RFA for residual Barrett's. EMR changed pinch biopsy histology from HGD (n=33), HGD suspicious for IMC (n=5) and LGD (n=1) to early EAC in 58.2% (n=39) patients. During a mean follow-up of 37.2 months (IQR 20, 56), complete remission of dysplasia (CRD) and intestinal metaplasia (CRIM) was seen in 97% (n=65) and 89.5% (n=60) patients. One patient with T1b EAC underwent oesophagectomy. No cases developed metachronous EAC, progression to invasive adenocarcinoma or development of nodal/distant metastasis. Complications were endoscopically treated haematemesis (n=1) and strictures (n=16) requiring dilatations. 3 patients died due to causes unrelated to IMC. CONCLUSION EMR in conjunction with RFA is an effective and safe management for early EAC. EMR provides accurate staging and has low complication rates. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Puraskar Pateria
- Department of gastroenterology and hepatology, Fiona Stanley Hospital, 11, Robin Warren Dr, Murdoch, Western Australia, 6150
| | - Andre Chong
- Department of gastroenterology and hepatology, Fiona Stanley Hospital, 11, Robin Warren Dr, Murdoch, Western Australia, 6150
| | - Niroshan Muwanwella
- Department of gastroenterology and hepatology, Royal Perth Hospital, Victoria Square, Perth, Western Australia, 6000
| | - Chiang Siah
- Department of gastroenterology and hepatology, Royal Perth Hospital, Victoria Square, Perth, Western Australia, 6000
| | - Priyanthi Kumarasinghe
- Pathwest QEII Medical Centre, Hospital Avenue, Nedlands, Western Australia, 6009.,University of Western Australia, Crawley, Western Australia, 6009
| | - Spiro Raftopoulos
- Department of gastroenterology and hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, 6009.,University of Western Australia, Crawley, Western Australia, 6009
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34
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Maitra I, Date RS, Martin FL. Towards screening Barrett's oesophagus: current guidelines, imaging modalities and future developments. Clin J Gastroenterol 2020; 13:635-649. [PMID: 32495144 PMCID: PMC7519897 DOI: 10.1007/s12328-020-01135-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/21/2020] [Indexed: 02/07/2023]
Abstract
Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma (OAC). Although guidelines on the screening and surveillance exist in Barrett's oesophagus, the current strategies are inadequate. Oesophagogastroduodenoscopy (OGD) is the gold standard method in screening for Barrett's oesophagus. This invasive method is expensive with associated risks negating its use as a current screening tool for Barrett's oesophagus. This review explores current definitions, epidemiology, biomarkers, surveillance, and screening in Barrett's oesophagus. Imaging modalities applicable to this condition are discussed, in addition to future developments. There is an urgent need for an alternative non-invasive method of screening and/or surveillance which could be highly beneficial towards reducing waiting times, alleviating patient fears and reducing future costs in current healthcare services. Vibrational spectroscopy has been shown to be promising in categorising Barrett's oesophagus through to high-grade dysplasia (HGD) and OAC. These techniques need further validation through multicentre trials.
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Affiliation(s)
- Ishaan Maitra
- School of Pharmacy and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE UK
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35
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Saunders JH, Al-Zubaidi S, Waller RC, Ortiz-Fernandez-Sordo J, Parsons SL, Ragunath K, Kaye PV. The management and long-term outcomes of endoscopic and surgical treatment of early esophageal adenocarcinoma. Dis Esophagus 2020; 33:5748091. [PMID: 32090253 DOI: 10.1093/dote/doz097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 11/19/2019] [Accepted: 11/25/2019] [Indexed: 12/11/2022]
Abstract
Endoscopic resection (ER) for early (pT1) esophageal adenocarcinoma can be justified if the rate of coexisting lymph node (LN) metastasis is less than the mortality rate from esophagectomy. This study examines endoscopic and surgical outcomes, histological assessment of submucosal (sm) disease, factors influencing LN metastasis, and the safety of treating pT1b disease endoscopically. Histopathological reexamination recorded thickness, width and depth of sm invasion, grade, presence of lymphovascular invasion (LVI), resection margin status and tumor stage. Multivariate analysis was employed to evaluate the factors influencing survival and LN metastasis. Rate of LN metastasis for pT1 low-risk (LR: sm invasion < 500 μm, G1-2, no LVI) or high-risk (HR: sm invasion >500 μm, G3-4 or LVI) disease were analyzed. Ninety three patients underwent ER and 96 underwent esophagectomy. We demonstrate conflicting histological methods of sm disease reporting, which may explain the difference in LN metastasis rate between reported surgical & endoscopic series. Multivariate analysis confirmed age, T stage, and presence of LN metastases were the independent factors predicting poor prognosis. Tumor thickness as well as grade, T stage, LVI were predictors of LN metastasis. Rates of LN metastasis are <2% in LR sm1 disease, and >15% in HR sm1 disease. Pathological reporting of sm invasion should be updated for uniform analysis of endoscopic and surgical specimens. Following rigorous histopathological examination and within a close endoscopic follow-up regimen, pT1a and pT1b LRsm1 disease may be treated with curative intent endoscopically, whereas pT1b HRsm1-sm3 disease should be offered surgery.
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Affiliation(s)
| | | | | | - Jacobo Ortiz-Fernandez-Sordo
- Gastroenterology, Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | | | - Krish Ragunath
- Gastroenterology, Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
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36
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Marginean EC, Dhanpat J. Pathologic assessment of endoscopic resection specimens with superficial carcinoma of the esophagus: current practice and practical issues. Ann N Y Acad Sci 2020; 1482:130-145. [PMID: 32875588 DOI: 10.1111/nyas.14455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/01/2020] [Accepted: 07/10/2020] [Indexed: 12/16/2022]
Abstract
Endoscopic resection (ER) has become the first-line therapy for early esophageal cancer and offers a treatment alternative to surgery, owing to less morbidity and better quality of life. ER techniques include endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). EMR is faster, simpler, and cheaper than ESD, but limited by its ability to resect lesions larger than 1.5 centimeters. Piecemeal EMR has limitations, including a high local recurrence rate and a suboptimal specimen for an accurate pathologic assessment. ESD, on the other hand, allows en bloc resections with negative (R0) margins, irrespective of lesion size, providing an excellent pathologic specimen, however, is technically challenging with a higher risk of complications. The evaluation of ER specimens in pathology varies slightly from institution to institution. Our review summarizes the current practices and issues in the pathologic assessment of esophageal ER specimens, which highlights the necessity of a systematic approach and standardization of both macroscopic and microscopic evaluation. There is a need for a comprehensive and standardized pathology report that will allow for uniform terminology for endoscopists, surgeons, and pathologists, which, in turn, will result in better treatment guidance.
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Affiliation(s)
| | - Jain Dhanpat
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
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37
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Badgery H, Read M, Winter NN, Taylor ACF, Hii MW. The role of esophagectomy in the management of Barrett's esophagus with high-grade dysplasia. Ann N Y Acad Sci 2020; 1481:72-89. [PMID: 32812261 DOI: 10.1111/nyas.14439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/12/2020] [Accepted: 06/24/2020] [Indexed: 12/19/2022]
Abstract
Barrett's esophagus (BE) with high-grade dysplasia (HGD) has previously been a routine indication for esophagectomy. Recent advances in endoscopic therapy have resulted in a shift away from surgery. Current international guidelines recommend endoscopic therapy for BE with HGD irrespective of recurrence or progression of dysplasia. Current guidelines do not address the ongoing role of esophagectomy as an adjunct in the setting of failed endoscopic therapy. This review examines the role of esophagectomy as an adjunct to endoscopy in the management of patients with BE and HGD, with a specific focus on patients with persistent, progressive, or recurrent disease, disease resistant to endoscopic therapy, in patients with concomitant esophageal pathology, and in those patients in whom lifelong surveillance may not be possible or desired.
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Affiliation(s)
- Henry Badgery
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Matthew Read
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Nicole N Winter
- Department of Upper Gastrointestinal Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Andrew C F Taylor
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, the University of Melbourne, Melbourne, Victoria, Australia
| | - Michael W Hii
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
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38
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Bhatt A, Kamath S, Murthy SC, Raja S. Multidisciplinary Evaluation and Management of Early Stage Esophageal Cancer. Surg Oncol Clin N Am 2020; 29:613-630. [PMID: 32883462 DOI: 10.1016/j.soc.2020.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Early esophageal cancer involves the mucosal and submucosal layers of the esophagus. Early esophageal cancer is a heterogeneous group, and achieving optimal outcomes requires a multidisciplinary approach to align patients to their optimal treatment. Although organ-sparing endoscopic resection has become the preferred management option for superficial esophageal cancer, it is not adequate in all tumors, such as high-risk lesions with poorly differentiated pathology, lymphovascular invasion, or deep submucosal invasion. In such high-risk lesions, surgery, chemotherapy, and/or radiation may be required. In this article, we present our multidisciplinary approach to early esophageal cancer.
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Affiliation(s)
- Amit Bhatt
- Department of Gastroenterology and Hepatology, A31 desk, Cleveland, Ohio 44195, USA.
| | - Suneel Kamath
- Taussig Cancer Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Sudish C Murthy
- Department of Thoracic and Cardiovascular Surgery, J4-1, 9500 Euclid Ave, Cleveland, Ohio 44195, USA
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, J4-1, 9500 Euclid Ave, Cleveland, Ohio 44195, USA
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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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Outcomes of patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study. Gastrointest Endosc 2020; 92:31-39.e1. [PMID: 31953189 PMCID: PMC7321863 DOI: 10.1016/j.gie.2020.01.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The treatment of submucosal (T1b) esophageal adenocarcinoma (EAC) remains in evolution, with some evidence supporting endoscopic management of low-risk lesions. Using a multicenter cohort, we evaluated outcomes of patients with T1b EAC and predictors of survival. METHODS Patients diagnosed between 2001 and 2016 with T1b EAC were identified from 3 academic medical centers in the United States. Demographic, clinical, and outcome data were collected. Outcomes studied were overall and cancer-free survival. Cox proportional hazards models were constructed to assess independent predictors of survival. RESULTS One hundred forty-one patients were included, of whom 68 (48%) underwent esophagectomy and 73 (52%) were treated endoscopically. Most patients (85.8%) had high-risk histologic features. Thirty-day operative mortality was 2.9%. Median follow-up in the esophagectomy and endoscopic cohorts was 49.4 and 43.4 months, respectively. Patients treated endoscopically were older with higher comorbidity scores, with 46 (63%) achieving histologic remission. Nineteen patients (26.0%) also received chemoradiation. Five-year overall survival rates in the surgical and endoscopic cohorts were 89% and 59%, respectively, whereas 5-year cancer-free survival rates were 92% and 69%. Presence of high-risk histologic features was associated with reduced overall survival. CONCLUSIONS In this large multicenter study of patients with T1b EAC, esophagectomy was associated with improved overall but not cancer-free survival. High-risk histologic features were associated with poorer survival.
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Alzoubaidi D, Hussein M, Sehgal V, Makahamadze C, Magee CG, Everson M, Graham D, Sweis R, Banks M, Sami SS, Novelli M, Lovat L, Haidry R. Cryoballoon ablation for treatment of patients with refractory esophageal neoplasia after first line endoscopic eradication therapy. Endosc Int Open 2020; 8:E891-E899. [PMID: 32665972 PMCID: PMC7340530 DOI: 10.1055/a-1149-1414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/12/2020] [Indexed: 12/18/2022] Open
Abstract
Background and study aims Cryoablation with the Cryoballoon device is a novel ablative therapy that uses cycles of freezing and thawing to induce cell death. This single-center prospective study evaluated the feasibility of the focal cryoablation device for the treatment of areas of refractory esophageal neoplasia in patients who had undergone first line endoscopic eradication therapy (EET). Complete remission of dysplasia (CR-D) and complete remission of intestinal metaplasia (CR-IM) at first follow-up endoscopy, durability of disease reversal, rates of stenosis and adverse events were studied. Patients and methods Eighteen cases were treated. At baseline, nine patients had low-grade dysplasia (LGD), six had high-grade dysplasia (HGD) and three had intramucosal carcinoma (IMC). Median length of dysplastic Barrett's esophagus (BE) treated was 3 cm. The median number of ablations per patient was 11. Each selected area of visible dysplasia received 10 seconds of ablation. One session of cryoablation was performed per patient. Biopsies were performed at around 3 months post-ablation. Results CR-D was achieved in 78 % and CR-IM in 39 % of patients. There were no device malfunction or adverse events. Stenosis was noted in 11 % of cases. At a median follow up of 19-months, CR-D was maintained in 72 % of patients and CR-IM in 33 %. Conclusions Cryoablation appears to be a viable rescue strategy in patients with refractory neoplasia. It is well tolerated and successful in obtaining CR-D and CR-IM in patients with treatment-refractory BE. Further trials of dosimetry, efficacy and safety in treatment-naïve patients are underway.
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Affiliation(s)
- Durayd Alzoubaidi
- Division of Surgery and interventional science, University College London (UCL), London, UK
| | - Mohamed Hussein
- Division of Surgery and interventional science, University College London (UCL), London, UK
| | - Vinay Sehgal
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | | | - Cormac G. Magee
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Martin Everson
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - David Graham
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Rami Sweis
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Matthew Banks
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Sarmed S. Sami
- Division of Surgery and interventional science, University College London (UCL), London, UK
| | - Marco Novelli
- Department of Histopathology, University College London Hospital (UCLH), London, UK
| | - Laurence Lovat
- Division of Surgery and interventional science, University College London (UCL), London, UK
| | - Rehan Haidry
- Division of Surgery and interventional science, University College London (UCL), London, UK
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
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Kumarasinghe MP, Bourke MJ, Brown I, Draganov PV, McLeod D, Streutker C, Raftopoulos S, Ushiku T, Lauwers GY. Pathological assessment of endoscopic resections of the gastrointestinal tract: a comprehensive clinicopathologic review. Mod Pathol 2020; 33:986-1006. [PMID: 31907377 DOI: 10.1038/s41379-019-0443-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/27/2019] [Accepted: 12/10/2019] [Indexed: 12/13/2022]
Abstract
Endoscopic resection (ER) allows optimal staging with potential cure of early-stage luminal malignancies while maintaining organ preservation. ER and surgery are non-competing but complementary therapeutic options. In addition, histological examination of ER specimens can either confirm or refine the pre-procedure diagnosis. ER is used for the treatment of Barrett's related early carcinomas and dysplasias, early-esophageal squamous cell carcinomas and dysplasias, early gastric carcinomas and dysplasia, as well as low-risk submucosal invasive carcinomas (LR-SMIC) and, large laterally spreading adenomas of the colon. For invasive lesions, histological risk factors predict risk of lymph node metastasis and residual disease at the ER site. Important pathological risk factors predictive of lymph node metastasis are depth of tumor invasion, poor differentiation, and lymphovascular invasion. Complete resection with negative margins is critical to avoid local recurrences. For non-invasive lesions, complete resection is curative. Therefore, a systematic approach for handling and assessing ER specimens is recommended to evaluate all above key prognostic features appropriately. Correct handling starts with pinning the specimen before fixation, meticulous macroscopic assessment with orientation of appropriate margins, systematic sectioning, and microscopic assessment of the entire specimen. Microscopic examination should be thorough for accurate assessment of all pathological risk factors and margin assessment. Site-specific issues such as duplication of muscularis mucosa of the esophagus, challenges of assessing ampullectomy specimens and site-specific differences of staging of early carcinomas throughout the gastrointestinal tract (GI) tract should be given special consideration. Finally, a standard, comprehensive pathology report that allows optimal staging with potential cure of early-stage malignancies or better stratification and guidance for additional treatment should be provided.
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Affiliation(s)
- M Priyanthi Kumarasinghe
- Department of Anatomical Pathology, PathWest, QE II Medical Centre and School of Pathology and Laboratory Medicine, University of Western Australia, Hospital Avenue, Nedlands Perth, WA, 6009, Australia.
| | - Michael J Bourke
- Department of Medicine, University of Sydney, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Ian Brown
- Envoi Pathology,Unit 5, 38 Bishop Street, Kelvin Grove, QLD, 4059, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia
| | - Peter V Draganov
- Department of Medicine, University of Florida, 1329 SW 16th Street, Room # 5251, Gainesville, FL, 32608, USA
| | | | - Catherine Streutker
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Director of Pathology, St Michael's Hospital, Toronto, ON, M5B 1W9, Canada
| | - Spiro Raftopoulos
- Sir Charles Gairdner Hospital, QE II Medical Centre, Hospital Avenue, Nedlands Perth, WA, 6009, Australia
| | - Tetsuo Ushiku
- Department of Pathology, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Gregory Y Lauwers
- H. Lee Moffitt Cancer Center & Research Institute and Departments of Pathology & Cell Biology and Oncologic Sciences, University of South Florida, Tampa, FL, USA
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Rouphael C, Anil Kumar M, Sanaka MR, Thota PN. Indications, contraindications and limitations of endoscopic therapy for Barrett's esophagus and early esophageal adenocarcinoma. Therap Adv Gastroenterol 2020; 13:1756284820924209. [PMID: 32523628 PMCID: PMC7257851 DOI: 10.1177/1756284820924209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/15/2020] [Indexed: 02/04/2023] Open
Abstract
Endoscopic eradication therapy (EET) has revolutionized management of Barrett's esophagus (BE)-associated neoplasia, traditionally treated by esophagectomy, which carries very high mortality and morbidity. EET, usually performed in the outpatient setting, has a safe risk profile. It is indicated in patients with BE with high-grade dysplasia and intramucosal cancer, confirmed, and persistent low-grade dysplasia, and in highly selected cases of non-dysplastic BE and submucosal cancers. Multiple EET modalities are available and can be categorized into two groups: ablation therapies and resection techniques with resection techniques usually reserved for nodular/raised lesions or lesions with suspected neoplasia. Patients usually require multiple ablation sessions with a goal of achieving complete eradication of metaplasia. Despite very good results, EET has its limitations and is not 100% effective: it targets a small subset of patients along the spectrum of BE and esophageal adenocarcinoma, as most patients with esophageal adenocarcinoma remain asymptomatic until the disease has progressed to advanced stages. Post-ablation surveillance is mandatory, as recurrences are common. An area of concern is buried metaplasia reported to occur following ablation therapy and thought to be from de novo growth of metaplastic tissue underneath the neosquamous epithelium, following ablation. The focus of this review article is to present the indications, contraindications and limitations of EET.
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Affiliation(s)
- Carol Rouphael
- Department of Gastroenterology and Hepatology,
Cleveland Clinic, Cleveland, OH, USA
| | - Mythri Anil Kumar
- Department of Gastroenterology and Hepatology,
Cleveland Clinic, Cleveland, OH, USA
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Franklin J, Jankowski J. Recent advances in understanding and preventing oesophageal cancer. F1000Res 2020; 9. [PMID: 32399195 PMCID: PMC7194479 DOI: 10.12688/f1000research.21971.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 12/24/2022] Open
Abstract
Oesophageal cancer is a common cancer that continues to have a poor survival. This is largely in part due to its late diagnosis and early metastatic spread. Currently, screening is limited to patients with multiple risk factors via a relatively invasive technique. However, there is a large proportion of patients diagnosed with oesophageal cancer who have not been screened. This has warranted the development of new screening techniques that could be implemented more widely and lead to earlier identification and subsequently improvements in survival rates. This article also explores progress in the surveillance of Barrett’s oesophagus, a pre-malignant condition for the development of oesophageal adenocarcinoma. In recent years, advances in early endoscopic intervention have meant that more patients are considered at an earlier stage for potentially curative treatment.
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Affiliation(s)
- James Franklin
- Gastroenterology and Endoscopy Department, Kings Mill Hospital NHS Foundation Trust, Sutton-in-Ashfield, Nottinghamshire, NG17 4JL, UK
| | - Janusz Jankowski
- Gastroenterology and Endoscopy Department, Kings Mill Hospital NHS Foundation Trust, Sutton-in-Ashfield, Nottinghamshire, NG17 4JL, UK
- University of Liverpool, Liverpool, UK
- University of Roehampton, London, UK
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Yang J, Lu Z, Li L, Li Y, Tan Y, Zhang D, Wang A. Relationship of lymphovascular invasion with lymph node metastasis and prognosis in superficial esophageal carcinoma: systematic review and meta-analysis. BMC Cancer 2020; 20:176. [PMID: 32131772 PMCID: PMC7057611 DOI: 10.1186/s12885-020-6656-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 02/18/2020] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Jinxin Yang
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Zhouyi Lu
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Lintao Li
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Yong Li
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Yulong Tan
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Dekang Zhang
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China.
| | - An Wang
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
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Dugalic P, Djuranovic S, Pavlovic-Markovic A, Dugalic V, Tomasevic R, Gluvic Z, Obradovic M, Bajic V, Isenovic ER. Proton Pump Inhibitors and Radiofrequency Ablation for Treatment of Barrett's Esophagus. Mini Rev Med Chem 2020; 20:975-987. [PMID: 31644405 DOI: 10.2174/1389557519666191015203636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/04/2019] [Accepted: 06/25/2019] [Indexed: 02/07/2023]
Abstract
Gastroesophageal Reflux Disease (GERD) is characterized by acid and bile reflux in the distal oesophagus, and this may cause the development of reflux esophagitis and Barrett's oesophagus (BE). The natural histological course of untreated BE is non-dysplastic or benign BE (ND), then lowgrade (LGD) and High-Grade Dysplastic (HGD) BE, with the expected increase in malignancy transfer to oesophagal adenocarcinoma (EAC). The gold standard for BE diagnostics involves high-resolution white-light endoscopy, followed by uniform endoscopy findings description (Prague classification) with biopsy performance according to Seattle protocol. The medical treatment of GERD and BE includes the use of proton pump inhibitors (PPIs) regarding symptoms control. It is noteworthy that long-term use of PPIs increases gastrin level, which can contribute to transfer from BE to EAC, as a result of its effects on the proliferation of BE epithelium. Endoscopy treatment includes a wide range of resection and ablative techniques, such as radio-frequency ablation (RFA), often concomitantly used in everyday endoscopy practice (multimodal therapy). RFA promotes mucosal necrosis of treated oesophagal region via high-frequency energy. Laparoscopic surgery, partial or total fundoplication, is reserved for PPIs and endoscopy indolent patients or in those with progressive disease. This review aims to explain distinct effects of PPIs and RFA modalities, illuminate certain aspects of molecular mechanisms involved, as well as the effects of their concomitant use regarding the treatment of BE and prevention of its transfer to EAC.
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Affiliation(s)
- Predrag Dugalic
- Department of Gastroenterology and Hepatology, University Clinical-Hospital Centre Zemun-Belgrade, Belgrade, Serbia
| | - Srdjan Djuranovic
- Clinical Centre of Serbia, Clinic for Gastroenterology and Hepatology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Aleksandra Pavlovic-Markovic
- Clinical Centre of Serbia, Clinic for Gastroenterology and Hepatology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vladimir Dugalic
- Clinical Centre of Serbia, Clinic for Surgery, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ratko Tomasevic
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Belgrade, University Clinical-Hospital Centre Zemun-Belgrade, Belgrade, Serbia
| | - Zoran Gluvic
- Department of Endocrinology and Diabetes, Faculty of Medicine, University of Belgrade, University Clinical-Hospital Centre Zemun-Belgrade, Belgrade, Serbia
| | - Milan Obradovic
- Department of Radiobiology and Molecular Genetics, Institute of Nuclear Sciences Vinca, University of Belgrade, Belgrade, Serbia
| | - Vladan Bajic
- Department of Radiobiology and Molecular Genetics, Institute of Nuclear Sciences Vinca, University of Belgrade, Belgrade, Serbia
| | - Esma R Isenovic
- Department of Radiobiology and Molecular Genetics, Institute of Nuclear Sciences Vinca, University of Belgrade, Belgrade, Serbia
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Kumble LD, Silver E, Oh A, Abrams JA, Sonett JR, Hur C. Treatment of early stage (T1) esophageal adenocarcinoma: Personalizing the best therapy choice. World J Meta-Anal 2019; 7:406-417. [DOI: 10.13105/wjma.v7.i9.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/03/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
Esophagectomy is considered the primary form of management for esophageal adenocarcinoma (EAC); however, the surgery is associated with high rates of morbidity and mortality. For patients with early-stage EAC, endoscopic resection (ER) presents a potential curative treatment option that is less invasive and carries fewer risks procedure related risks, but it is associated with higher rates of cancer recurrence following the procedure. For some patients, age and comorbidities may prevent them from having esophagectomy as a treatment option, while other patients may be operative candidates but do not wish to undergo esophagectomy for a variety of reasons related to their values and preferences. Furthermore, while anxiety of cancer recurrence following ER may significantly diminish a patient’s quality of life (QOL), so might the morbidity surrounding esophagectomy. In addition to considering health status, patient preferences, and impacts on QOL, physicians and patients must also consider what treatments would be both beneficial and available to the patient, considering esophagectomy methods-minimally invasive vs open-or the use of chemoradiotherapy in addition to ER. Our article reviews and summarizes available treatment options for patients with early EAC and their potential effects on the health and wellbeing of patients based on the current data. We conclude with a request for more research of available options for early EAC patients, the conditions that determine when each option should be employed, and their effects not only on patient health but also QOL.
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Affiliation(s)
| | - Elisabeth Silver
- General Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Aaron Oh
- General Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Julian A Abrams
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Joshua R Sonett
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Chin Hur
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
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Oetzmann von Sochaczewski C, Haist T, Pauthner M, Mann M, Fisseler-Eckhoff A, Braun S, Ell C, Lorenz D. The overall metastatic rate in early esophageal adenocarcinoma: long-time follow-up of surgically treated patients. Dis Esophagus 2019; 32:5267101. [PMID: 30596900 DOI: 10.1093/dote/doy127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/04/2018] [Accepted: 12/05/2018] [Indexed: 12/11/2022]
Abstract
The overall metastatic potential of surgically treated early esophageal adenocarcinoma has not been studied in detail. This paper therefore assessed lymph node metastases at surgery, loco regional and distant metastases, in order to assess the metastatic potential of early esophageal adenocarcinoma. Two hundred and seventeen patients (53 T1a, 164 T1b; median follow-ups 87 and 75 months, 187 males) diagnosed with early esophageal adenocarcinoma and treated with esophagectomy in our tertiary center's database between July 2000 and December 2015 were included. All metastatic events were retrospectively analyzed, their topographic distribution was assessed, and the overall metastatic rate was calculated. Lymph node metastases occurred in 39 patients (18%) and 29 (13.4%) developed recurrences. Lymph node metastases were absent in m1 and m2 tumors and rare in m3 (1/18), m4 (5/21), and sm1 (4/42), but more frequent in sm2 (11/44) and sm3 tumors (18/78). Locoregional recurrences were exceedingly rare in m3 (2/18), m4 (1/21), sm1 (1/42), and sm2 (2/44), but frequent in sm3 (12/78). In contrast, distant metastases were more frequent with 2/18 in m3, 1/21 in m4, 4/42 in sm1, 4/44 in sm2, and 13/78 in sm3. Overall metastatic rates of 11.9% in sm1 (submucosal layer divided into equal thirds), 27.3% in sm2, and 32.1% in sm3 tumors were calculated. This first report of the metastatic potential of early esophageal adenocarcinoma provides a meticulous assessment of the overall metastatic risk. Metastatic events pose a relevant risk in surgically treated patients with esophageal adenocarcinoma with distant metastases being more frequent than locoregional recurrences.
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Affiliation(s)
| | - T Haist
- Department of Surgery I, Sana Klinikum Offenbach, Germany
| | - M Pauthner
- Department of Surgery I, Sana Klinikum Offenbach, Germany
| | - M Mann
- Department of Surgery I, Sana Klinikum Offenbach, Germany
| | - A Fisseler-Eckhoff
- Institute of Pathology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - S Braun
- Institute of Pathology, Sana Klinikum Offenbach, Germany
| | - C Ell
- Department of Internal Medicine II, Sana Klinikum Offenbach, Offenbach, Germany
| | - D Lorenz
- Department of Surgery I, Klinikum Darmstadt, Darmstadt, Germany
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Sanghi V, Amin H, Sanaka MR, Thota PN. Resection of early esophageal neoplasms: The pendulum swings from surgical to endoscopic management. World J Gastrointest Endosc 2019; 11:491-503. [PMID: 31798770 PMCID: PMC6885444 DOI: 10.4253/wjge.v11.i10.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/09/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
Esophageal cancer is a highly lethal disease and is the sixth leading cause of cancer related mortality in the world. The standard treatment is esophagectomy which is associated with significant morbidity and mortality. This led to development of minimally invasive, organ sparing endoscopic therapies which have comparable outcomes to esophagectomy in early cancer. These include endoscopic mucosal resection and endoscopic submucosal dissection. In early squamous cell cancer, endoscopic submucosal dissection is preferred as it is associated with cause specific 5-year survival rates of 100% for M1 and M2 tumors and 85% for M3 and SM1 tumors and low recurrence rates. In early adenocarcinoma, endoscopic resection of visible abnormalities is followed by ablation of the remaining flat Barrett’s mucosa to prevent recurrences. Radiofrequency ablation is the most widely used ablation modality with others being cryotherapy and argon plasma coagulation. Focal endoscopic mucosal resection followed by radiofrequency ablation leads to eradication of neoplasia in 93.4% of patients and eradication of intestinal metaplasia in 73.1% of patients. Innovative techniques such as submucosal tunneling with endoscopic resection are developed for management of submucosal tumors of the esophagus. This review includes a discussion of various endoscopic techniques and their clinical outcomes in early squamous cell cancer, adenocarcinoma and submucosal tumors. An overview of comparison between esophagectomy and endoscopic therapy are also presented.
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Affiliation(s)
- Vedha Sanghi
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Hina Amin
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
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Gockel I, Hoffmeister A. Endoscopic or Surgical Resection for Gastro-Esophageal Cancer. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:513-519. [PMID: 30149830 DOI: 10.3238/arztebl.2018.0513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 06/04/2018] [Accepted: 06/04/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Early gastro-esophageal cancer is staged as m1 to m3 depending on the infiltration of the anatomical layers of the mucosa or, analogously, as sm1 to sm3 depending on the depth of infiltration into the submucosa. The risk of lymph node metastases is low in mucosal carcinoma but increases with the depth of infiltration into the submucosa. METHODS This review is based on pertinent publications retrieved by a selective search in MEDLINE, PubMed, the Cochrane Library, and the International Standard Randomised Controlled Trial Number (ISRCTN) registry. RESULTS New technologies such as narrow-band imaging have improved the endo- scopic diagnosis and staging of early gastro-esophageal cancer. The development of endoscopic submucosal dissection has led to a higher R0 resection rate, a lower risk of recurrence, and an increase in the number of endoscopic resections that are performed with curative intent. In squamous-cell carcinoma of the esophagus, surgical oncological esophagectomy is indicated if the cancer infiltrates into the third mucosal layer (T1a, m3) or deeper. In esophageal adenocarcinoma, the prevalence of lymph node metastases is low if the cancer is restricted to the mucosa and in- creases only when the submucosa is infiltrated. In the current German S3 guideline, endoscopic resection is recommended for intramucosal adenocarcinoma as long as there are no further histopathological risk factors. Lymph node metastasis in gastric carcinoma begins in the deep mucosal infiltration stage (m3). If certain special con- ditions ("extended criteria") are met, carcinoma expanding into the first submucosal layer (sm1) can be removed endoscopically. All further stages must be treated with total or subtotal gastrectomy with systematic D2 lymphadenectomy. CONCLUSION Borderline cases between endoscopic and surgical resection of early carcinoma of the esophagus or stomach must be managed with an interdisciplinary treatment algorithm. If there is a risk of lymph node metastasis, surgical oncological resection is indicated. Such resections of gastroesophageal cancer in the locally advanced stage should always be part of a multimodal treatment approach.
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Affiliation(s)
- Ines Gockel
- Department of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig; Interdisciplinary Endoscopy and Sonography, Department of Gastroenterology and Rheumatology, University Hospital Leipzig
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