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Iwai N, Dohi O, Yamada S, Ishida T, Fukui A, Horie R, Yasuda T, Yamada N, Horii Y, Majima A, Zen K, Yagi N, Naito Y, Itoh Y. Clinical Outcomes of Follow-Up Observation After Endoscopic Submucosal Dissection for Esophageal Squamous Cell Carcinoma Invading the Muscularis Mucosa Without Lymphovascular Involvement. Dig Dis Sci 2023; 68:3679-3687. [PMID: 37470897 DOI: 10.1007/s10620-023-08034-9] [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: 12/08/2022] [Accepted: 07/03/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND The therapeutic approach after endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) diagnosed as pathological T1a-muscularis mucosa (pT1a-MM) without lymphovascular involvement (LVI) remains uncertain. We aimed to determine whether observation after ESD is acceptable for patients without LVI showing pT1a-MM cancer. METHODS We retrospectively registered 566 ESCC patients who were treated with ESD at ten institutions between January 2007 and December 2015. Of those, 447 cases showing pT1a-epithelium/lamina propria mucosa (EP/LPM) without LVI and vertical margin (VM) (EP/LPM group), and 41 cases showing pT1a-MM without LVI and VM (MM group) were analyzed in this investigation. The clinical outcomes were assessed between the groups. RESULTS The 5 year cumulative incidence of metastatic recurrence was 0.5% and 3.3% in the EP/LPM and MM groups, respectively (P = 0.121). Two cases showing pT1a-EP/LPM and one showing pT1a-MM experienced lymph node recurrence. The 5 year cumulative incidence of local recurrence was 1.5% and 3.8% in the EP/LPM and MM groups, respectively (P = 0.455). The 5 year disease-specific survival (DSS) rate was 99.3% and 96.6% in the EP/LPM and MM groups, respectively (P = 0.118), whereas the 5 year overall survival rate was significantly higher in the EP/LPM group than in the MM group (92.6% versus 81.1%, respectively; P = 0.021). CONCLUSIONS As regards metastatic recurrence and DSS, ESCC patients with pT1a-MM without LVI showed favorable outcomes that were equivalent to those with pT1a-EP/LPM, even when they were not treated with additional therapy after ESD.
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Affiliation(s)
- Naoto Iwai
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, Fukuchiyama, Kyoto, Japan
- Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kawaramachi Hirokoji Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Osamu Dohi
- Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kawaramachi Hirokoji Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Shinya Yamada
- Department of Gastroenterology and Hepatology, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
| | - Tsugitaka Ishida
- Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kawaramachi Hirokoji Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Akifumi Fukui
- Department of Gastroenterology, North Medical Center, Kyoto Prefectural University of Medicine, Yosanocho, Kyoto, Japan
| | - Ryusuke Horie
- Department of Gastroenterology, JCHO Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Takeshi Yasuda
- Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kawaramachi Hirokoji Kamigyo-ku, Kyoto, 602-8566, Japan
- Department of Gastroenterology, Asahi University Hospital, Gifu, Japan
| | - Nobuhisa Yamada
- Department of Gastroenterology, Matsushita Memorial Hospital, Moriguchi, Osaka, Japan
| | - Yusuke Horii
- Department of Gastroenterology, Medical Corporation Keishinkai, Kyoto Kizugawa Hospital, Joyo, Kyoto, Japan
| | - Atsushi Majima
- Department of Gastroenterology and Hepatology, Omihachiman Community Medical Center, Omihachiman, Shiga, Japan
| | - Keika Zen
- Department of Gastroenterology and Hepatology, Otsu City Hospital, Otsu, Shiga, Japan
| | - Nobuaki Yagi
- Department of Gastroenterology, Asahi University Hospital, Gifu, Japan
| | - Yuji Naito
- Department of Human Immunology and Nutrition Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshito Itoh
- Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kawaramachi Hirokoji Kamigyo-ku, Kyoto, 602-8566, Japan
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2
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Abstract
Esophageal cancer (EC) often cannot be discovered in time because of its asymptomatic or symptom-atypical characteristics in early stage. The risk and probability of lymph node metastasis and distant metastasis increase correspondingly as the cancer aggressively invades deeper layers. Treatment regimens may be shifted to surgery and chemoradiotherapy (CRT) from endoscopic eradication therapy (EET) with poor quality of life and prognosis. It is imperative to identify dysplasia and EC early and enable early curative endoscopic treatments. Newer methods have been attempted in the clinical setting to achieve early detection at a more microscopic and precise level. Newer imaging techniques and artificial intelligence (AI) technology have been involved in targeted biopsies and will gradually unveil the visualization of pathology in the future. Early detection and diagnosis are the prerequisite to choose personal and precise treatment regimens. EET has also been undergoing development and improvement to benefit more patients as the first option or the firstly chosen alternative therapy, when compared with esophagectomy. More clinical studies are needed to provide more possibilities for EET.
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Affiliation(s)
- Hang Yang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Wu Hou District, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Wu Hou District, China
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3
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Kim SH, Hong SJ. Current Status of Image-Enhanced Endoscopy for Early Identification of Esophageal Neoplasms. Clin Endosc 2021; 54:464-476. [PMID: 34304482 PMCID: PMC8357583 DOI: 10.5946/ce.2021.186] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/14/2021] [Indexed: 12/14/2022] Open
Abstract
Advanced esophageal cancer is known to have a poor prognosis. The early detection of esophageal neoplasms, including esophageal dysplasia and early esophageal cancer, is highly important for the accurate treatment of the disease. However, esophageal dysplasia and early esophageal cancer are usually subtle and can be easily missed. In addition to the early detection, proper pretreatment evaluation of the depth of invasion of esophageal cancer is very important for curative treatment. The progression of non-invasive diagnosis via image-enhanced endoscopy techniques has been shown to aid the early detection and estimate the depth of invasion of early esophageal cancer and, as a result, may provide additional opportunities for curative treatment. Here, we review the advancement of image-enhanced endoscopy-related technologies and their role in the early identification of esophageal neoplasms.
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Affiliation(s)
- Shin Hee Kim
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Department of Biostatistics, Soonchunghyang University School of Medicine, Bucheon, Korea
| | - Su Jin Hong
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Department of Biostatistics, Soonchunghyang University School of Medicine, Bucheon, Korea
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4
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Wang A, Lu L, Fan J, Wang S, Chen X. Lymph node metastatic patterns and its clinical significance for thoracic superficial esophageal squamous cell carcinoma. J Cardiothorac Surg 2020; 15:262. [PMID: 32958015 PMCID: PMC7507729 DOI: 10.1186/s13019-020-01302-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/08/2020] [Indexed: 01/02/2023] Open
Abstract
Background and objectives The optimal therapeutic method for patients with superficial esophageal squamous cell carcinoma (sESCC) remains to be established. Methods Clinical data of all the patients from 2002 to 2014 who underwent curative esophagectomy and three-field lymphadenectomy for thoracic sESCC were collected based on a prospectively-maintained database. The pattern of lymph node metastasis was analyzed based on the depth of tumor invasion, tumor location and surgical fields. Results The involved lymph node region was associated to the tumor location, however, upper mediastinal and perigastric region was the most vulnerable region. The incidence of lymph node metastasis increased with the depth of tumor invasion. No lymph node involvement was found in tumors invading proper mucosa (M2), while the pattern of positive lymph nodes in tumors invading the deepest 1/3 submucosa was similar to that in advanced ESCC. Lymphatic invasion, tumor location and upper mediastinal lymph node involvement were independent predictors for cervical lymph node metastasis. For patients without lymphatic invasion, the positive predictive value of upper mediastinal lymph node metastasis for positive cervical lymph node was low (0 ~ 25%), while the negative predictive value was extremely high, wherever the tumor located (93.8 ~ 100%). Conclusions Tumors invading till proper mucosa was the best indication for endoscopic mucosa resection. Mediastinal-abdominal lymphadenectomy was essential for sESCC invading beyond proper mucosa. For those without lymphatic invasion, cervical lymphadenectomy might be avoided in case of negative upper mediastinal lymph node.
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Affiliation(s)
- An Wang
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Lu Lu
- Department of Pathology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jie Fan
- Department of Pathology, Huashan Hospital, Fudan University, Shanghai, China
| | - Shaohua Wang
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
| | - Xiaofeng Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
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5
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Gong EJ, Kim DH. Endoscopic Treatment for Esophageal Cancer. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2019. [DOI: 10.7704/kjhugr.2019.19.3.156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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6
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Zhuge L, Wang S, Xie J, Huang B, Zheng D, Zheng S, Mao H, Pennathur A, Sanchez MV, Luketich JD, Xiang J, Chen H, Zhang J. A model based on endoscopic morphology of submucosal esophageal squamous cell carcinoma for determining risk of metastasis on lymph nodes. J Thorac Dis 2018; 10:6846-6853. [PMID: 30746230 DOI: 10.21037/jtd.2018.11.77] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background It is important to identify patients with esophageal squamous cell carcinoma (ESCC) in T1b stage that are the least likely to metastasize on the lymph nodes, to undergo endoscopic resection, especially for the patients unfit for esophagectomy. The relationship between endoscopic morphology and frequency of nodal metastasis has never been well studied. The aims of the study were to investigate the predictive value of endoscopic morphology for lymphatic metastasis, and to develop a risk stratification model in submucosal (T1b) ESCC. Methods Pathologic variables of patients with T1b ESCC who underwent esophagectomy from 2006 through 2016 were collected and divided into training sets (patients between 2006 and 2011) and validation sets (patients between 2012 and 2016). The endoscopic morphology of the tumor was determined by analyzing endoscopic reports according to the Paris classification. The correlation between the clinicopathological factors and nodal metastasis was examined. A prediction model was developed to estimate the risk of metastasis using these predictors. Results A total of 175 patients were included in this study. A tumor with an endoscopic shape of flat type (0-II type as Paris classification was defined) was significantly related to lower risk of lymphatic metastasis with the frequency of 15.5% (OR: 3.049, 95% CI: 1.363-6.819, P=0.005). The combination of endoscopic morphology with other pathologic characteristics including lymphovascular invasion, length of tumor, depth of tumor invasion into submucosa, and tumor differentiation improved the predictive value of the nodal metastasis. The risk stratification model was developed with a C-index of 0.726 (95% CI: 0.702-0.751), which identified a low risk subgroup with a lymph node rate of 7.2%. Conclusions Our results suggest that when a tumor is in flat shape (0-II type) it is related to a less lymphatic metastasis, and the combination of the endoscopic morphology with the other four pathologic variables can yield a more robust approach to predict the risk of lymphatic metastasis in submucosal ESCC.
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Affiliation(s)
- Lingdun Zhuge
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Shengfei Wang
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Juntao Xie
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Binhao Huang
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Difan Zheng
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Shanbo Zheng
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Hengyu Mao
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Arjun Pennathur
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Manuel Villa Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Jiaqing Xiang
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Haiquan Chen
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Jie Zhang
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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7
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Sawas T, Visrodia KH, Zakko L, Lutzke LS, Leggett CL, Wang KK. Clutch cutter is a safe device for performing endoscopic submucosal dissection of superficial esophageal neoplasms: a western experience. Dis Esophagus 2018; 31:5043491. [PMID: 29939257 DOI: 10.1093/dote/doy054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Although the endoscopic submucosal dissection (ESD) has been established to be more efficacious in the treatment of superficial gastrointestinal neoplasia than the piecemeal resection, its use is still limited due to the concern about serious adverse events particularly in the west. Newer ESD knives have been developed that have been said to be safer than the first-generation devices. We aimed to report a Western single center experience regarding the initial safety and performance of ESD for superficial esophageal neoplasia treated with the Clutch Cutter (DP2618DT; Fujifilm Corporation, Tokyo, Japan). Our main outcome was safety in terms of bleeding or perforation. Secondary outcomes included en bloc resection and the R0 resection. Fourteen patients with superficial esophageal neoplasia underwent 15 ESDs using the Clutch Cutter. The mean age was 65 ± 16.7 years and 10 (71.4%) males. Eight (57%) patients had esophageal adenocarcinoma, 3 (21.4%) had high-grade dysplasia, 1 (7%) had nodular low-grade dysplasia, and 2 (14.3%) had squamous cell carcinoma. Mild anticipated intraprocedural bleeding was present with most procedures. However, no significant postoperative bleeding or perforation was encountered. One patient had mild chest pain postprocedure. En bloc resection was achieved in all lesions 100%. Histological R0 was achieved in 5/12 lesions (41.6%). The mean length of the resected area was 24.8 ± 13 mm (IQR: 17-30 mm). All patients were safely discharged home after overnight observation. In conclusion, this is the largest series of esophageal ESD using the multimodal Clutch Cutter in the United States; we found that the device effectively achieved en bloc resection of superficial esophageal neoplasia without significant adverse events. The use of the Clutch Cutter should be considered as one option to minimize adverse events during ESD in the Western population.
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Affiliation(s)
- T Sawas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K H Visrodia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - L Zakko
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - L S Lutzke
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - C L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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8
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Min YW, Lee H, Song BG, Min BH, Kim HK, Choi YS, Lee JH, Hwang NY, Carriere KC, Rhee PL, Kim JJ, Zo JI, Shim YM. Comparison of endoscopic submucosal dissection and surgery for superficial esophageal squamous cell carcinoma: a propensity score-matched analysis. Gastrointest Endosc 2018; 88:624-633. [PMID: 29750981 DOI: 10.1016/j.gie.2018.04.2360] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) has been widely accepted for treating superficial esophageal squamous cell carcinoma (SESCC). However, long-term outcomes of ESD and esophagectomy for SESCC have not been compared. We compared the clinical outcomes of ESD and esophagectomy in a matched cohort. METHODS Patients who underwent ESD and esophagectomy for SESCC were included. We selected SESCCs without obvious submucosal invasion from the surgical database by reviewing endoscopic images. To minimize the effect of selection bias, propensity score matching was performed. Overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and metachronous RFS were compared between the 2 groups. Adverse event rates were also compared. RESULTS In a matched cohort of 120 pairs, OS, DSS, and RFS were comparable between the 2 groups. The 5-year OS, DSS, and RFS rates were 93.9% versus 91.2%, 100% versus 97.4%, and 92.8% versus 95.3% for the ESD and esophagectomy groups, respectively. The metachronous RFS was worse in the ESD group than in the esophagectomy group (P = .004). The 5-year metachronous RFS rates were 90.3% versus 100% for the ESD and esophagectomy groups, respectively. The esophagectomy group showed a higher overall adverse event rate than the ESD group (55.5% vs 18.5%, P < .0001). In each subgroup of mucosal and submucosal cancer, OS, DSS, and RFS were also comparable between the 2 groups. CONCLUSIONS ESD provides long-term outcomes comparable with esophagectomy in patients with SESCC without endoscopic evidence of obvious submucosal invasion. ESD should be considered as the first-line treatment for these patients.
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Affiliation(s)
- Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byeong Geun Song
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Na-Young Hwang
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keumhee C Carriere
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae J Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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9
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Malik S, Sharma G, Sanaka MR, Thota PN. Role of endoscopic therapy in early esophageal cancer. World J Gastroenterol 2018; 24:3965-3973. [PMID: 30254401 PMCID: PMC6148428 DOI: 10.3748/wjg.v24.i35.3965] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 07/23/2018] [Accepted: 08/01/2018] [Indexed: 02/06/2023] Open
Abstract
Esophageal carcinoma is a highly lethal cancer associated with high morbidity and mortality. Esophageal squamous cell carcinoma and esophageal adenocarcinoma are the two distinct histological types. There has been significant progress in endoscopic diagnosis and treatment of early stages of cancer using resection and ablation techniques, as shown in several trials in the recent past. Earlier detection of esophageal cancer and advances in treatment modalities have lead to improvement in the 5-year survival from 5% to about 20% in the past decade. Endoscopic eradication therapy is the preferred modality of treatment in cancer limited to mucosal layer of the esophagus as there is very low risk of lymph node metastasis, leading to high cure rates, low risk of recurrence and with few adverse effects. The most common adverse events seen are strictures, bleeding and rarely perforation which can be endoscopically managed. In patients with recurrent advanced disease or invasive tumor, esophagectomy with lymph node dissection remains the mainstay of treatment. There is debate on post-endoscopic surveillance with some studies suggesting closer follow up with upper endoscopy every 6 mo for the first 1-2 years and then annually for the 3 years while others recommending the appropriate action only if symptoms or other abnormalities develop. Overall, the field of endoscopic therapy is still evolving and focus should be placed on careful patient selection using a multidisciplinary approach.
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Affiliation(s)
- Sonika Malik
- Department of Internal Medicine, Cleveland Clinic Akron General Medical Center, Akron, OH 44307, United States
| | - Gautam Sharma
- Department of Anesthesiology, University Hospitals, Cleveland, OH 44106, United States
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Digestive Disease Surgery Institute, Cleveland Clinic, OH 44195, United States
| | - Prashanthi N Thota
- Department of Gastroenterology, Digestive Disease Surgery Institute, Cleveland Clinic, OH 44195, United States
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10
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Kidane B, Ali A, Sulman J, Wong R, Knox JJ, Darling GE. Health-related quality of life measure distinguishes between low and high clinical T stages in esophageal cancer. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:270. [PMID: 30094256 DOI: 10.21037/atm.2018.06.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Functional Assessment of Cancer Therapy-Esophagus (FACT-E) is a health-related quality of life (HRQOL) instrument validated in patients with esophageal cancer. It is made up of both a general component and an esophageal cancer subscale (ECS). Our objective was to explore the relationship between baseline FACT-E, ECS and clinically determined T-stage in patients with stage II-IV cancer of the gastroesophageal junction or thoracic esophagus. Methods Data from four prospective studies in Canadian academic hospitals were combined. These were consecutive and eligible patients treated between 1996 and 2014 with clinical stage II-IV cancer of the gastroesophageal junction or thoracic esophagus. All patients completed pre-treatment FACT-E. Parametric (ANOVA) and non-parametric (Kruskal-Wallis) analyses were performed. Results Of the 135 patients that were deemed eligible, the T-stage distribution determined clinically was: 10 (7.4%) T1, 33 (24.4%) T2, 79 (58.5%) T3 and 13 (9.6%) T4. Parametric analysis showed no significant association between FACT-E & T-stage, although there was a trend towards significance (P=0.08). Non-parametric analysis showed a significant association between FACT-E and T-stage (P=0.05). Post-hoc tests identified that the most significant differences in FACT-E scores were between T1 and T3 patients. Both parametric (P=0.002) and non-parametric (P=0.003) analyses showed an association between ECS & T-stage. Post-hoc analyses showed significant differences in ECS scores between T1 and higher T-stages (P<0.01). Conclusions Patient-reported HRQOL scores appear to be significantly different in patients with clinical T1 esophageal cancer as compared to those with higher clinical T stages. Since distinguishing T1 from T2/T3 lesions is important in guiding the most appropriate treatment modality and since EUS appears to have difficulties reliably making such T-stage distinctions, FACT-E and ECS scores may be helpful as an adjunct to guide decision-making.
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Affiliation(s)
- Biniam Kidane
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, MB, Canada.,Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - Amir Ali
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - Joanne Sulman
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada.,Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Rebecca Wong
- Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
| | - Jennifer J Knox
- Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada.,Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada.,Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
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11
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Min YW. [Endoscopic Treatment for Esophageal Cancer]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 71:116-123. [PMID: 29566472 DOI: 10.4166/kjg.2018.71.3.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Esophageal cancer incidence rate per 100,000 is 4.7 in 2013, which accounts for 1.1% of the total cancer incidence in Korea. Superficial esophageal squamous cell carcinoma is frequently detected in persons undergoing upper endoscopy for gastrointestinal symptoms or for gastric cancer screening. Esophagectomy with lymph node dissection is the standard treatment for esophageal cancer. However, given the considerable morbidity and mortality of esophagectomy, endoscopic resection has become the standard of care for most cases of superficial esophageal squamous cell carcinoma without metastasis. In addition, endoscopic submucosal dissection has increased the cure rate, even when the tumor is large, compared to endoscopic mucosal resection. Thus, endoscopic submucosal dissection is the treatment of choice for superficial esophageal squamous cell carcinoma with a negligible risk of lymph node metastasis. Endoscopic resection is usually associated with a low risk of morbidity and no mortality, and has also shown favorable long-term outcomes. However, the long-term risk of metastasis remains after endoscopic resection, which varies according to the characteristics of tumor. This review describes the indication and outcomes of endoscopic resection, complications of endoscopic resection, and management after treatment.
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Affiliation(s)
- Yang Won Min
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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12
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Bae J, Shin IS, Min YW, Sohn I, Ahn JH, Lee H, Min BH, Lee JH, Rhee PL, Kim JJ. Endoscopic prediction model for differentiating upper submucosal invasion (< 200 μm) and beyond in superficial esophageal squamous cell carcinoma. Oncotarget 2018; 9:9156-9165. [PMID: 29507680 PMCID: PMC5823657 DOI: 10.18632/oncotarget.23900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 11/09/2017] [Indexed: 01/12/2023] Open
Abstract
Esophageal endoscopic submucosal dissection (ESD) can be attempted in superficial esophageal squamous cell carcinoma (SESCC) invading the upper submucosal layer (SM1: invasion < 200 μm). This study aimed to determine endoscopic predictive features associated with beyond SM1 invasion in SESCC and establish a predictive model using the identified features. This study retrospectively analyzed 203 esophageal ESD for SESCC. Endoscopic images were reviewed by two endoscopists. Tumors were evaluated for main shape, sizes, and surface characteristics. The association between each endoscopic feature and beyond SM1 invasion was evaluated. Using the significant endoscopic features in multivariate analysis, a predictive model for beyond SM1 invasion in SESCC was established. Among 203 SESCCs, 40 (19.7%) invaded beyond SM1. Multivariate analysis revealed that surface nodularity [odds ratio (OR) 41.340, 95% confidence interval (CI) 8.492–201.252, p < 0.001], surface granularity (OR 18.682, 95% CI 4.818–72.440, p < 0.001), surface unevenness, (OR 4.107, 95% CI 1.160–14.543, p = 0.029), deep depression (OR 27.490, 95% CI 2.897–260.853, p = 0.004), and thick notch (OR 41.701, 95% CI 6.646–261.672, p < 0.001) were independently associated with beyond SM1 invasion. An established model showed an area under the curve of 0.921 with 95% CI 0.881–0.960. The best cut-off value showed the following: sensitivity, 0.85; specificity, 0.83; positive predictive value, 0.55; and negative predictive value, 0.96. In conclusion, endoscopic features can predict beyond SM1 invasion in SESCC. Our prediction model is potentially useful for screening ESD candidates in SESCC.
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Affiliation(s)
- Joohwan Bae
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In Seub Shin
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Insuk Sohn
- Biostatistics and Clinical Epidemiology Center, Research Institute for Future Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joong Hyun Ahn
- Biostatistics and Clinical Epidemiology Center, Research Institute for Future Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae J Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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13
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Schwameis K, Green KM, Worrell SG, Samaan J, Cooper S, Tatishchev S, Oh DS, Hagen JA, DeMeester SR. Outcome with Primary En-bloc Esophagectomy for Submucosal Esophageal Adenocarcinoma. Ann Surg Oncol 2017; 24:3921-3925. [PMID: 28975518 DOI: 10.1245/s10434-017-6091-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Intramucosal esophageal adenocarcinoma can be reliably treated endoscopically. Controversy exists about the use of endotherapy versus esophagectomy for submucosal tumors. Increasingly endotherapy is considered for submucosal tumors in part because of the presumed high mortality with esophagectomy and the perceived poor prognosis in patients with nodal disease. This study was designed to assess survival following primary en bloc esophagectomy (EBE) in patients with submucosal esophageal adenocarcinoma (EAC). METHODS This is a retrospective review of all patients who underwent EBE for submucosal EAC between 1998 and 2015. No patient had neoadjuvant therapy. RESULTS There were 32 patients (28M/4F; median age 64 years). The median tumor size was 1.5 cm (0.4-8.0), and the median number of resected nodes was 48 (23-85). There was one perioperative death. Lymph node metastases were present in 7 patients (22%). There was one involved node in four patients and 2, 3, and 31 nodes in one patient each. The one N3 patient received adjuvant therapy. The median follow-up was 87 months. Overall survival at 5 and 10 years was 84 and 70% respectively. Disease-specific survival at 10 years was 90%. Eight patients died, but only three deaths (9%) were related to EAC. Disease-specific survival at 10 years in node-positive patients was 71%. CONCLUSIONS Survival after primary en bloc esophagectomy for submucosal adenocarcinoma was excellent even in node-positive patients. Mortality with esophagectomy was low and far less than the 22% risk of node metastases in patients with submucosal tumor invasion. Esophagectomy should remain the preferred treatment for T1b esophageal adenocarcinoma.
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Affiliation(s)
- Katrin Schwameis
- Department of Thoracic Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Kyle M Green
- Department of Thoracic Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Stephanie G Worrell
- Department of Thoracic Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Jamil Samaan
- Department of Thoracic Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Shannon Cooper
- Department of Thoracic Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Sergei Tatishchev
- Department of Pathology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Daniel S Oh
- Department of Thoracic Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Jeffrey A Hagen
- Department of Thoracic Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Steven R DeMeester
- The Oregon Clinic, Gastrointestinal & Minimally Invasive Surgery, Portland, OR, USA.
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14
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Raghu Subramanian C, Triadafilopoulos G. Diagnosis and therapy of esophageal squamous cell dysplasia and early esophageal squamous cell cancer. Gastroenterol Rep (Oxf) 2017. [DOI: 10.1093/gastro/gox022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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15
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Wang Z, Lu H, Wu L, Yuan B, Liu J, Shi H, Wang F. Long-term outcomes of endoscopic multiband mucosectomy for early esophageal squamous cell neoplasia: a retrospective, single-center study. Gastrointest Endosc 2016; 84:893-899. [PMID: 27108060 DOI: 10.1016/j.gie.2016.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 04/07/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic multiband mucosectomy (EMBM) has been used to treat early Barrett's esophagus and esophagogastric junction neoplasia, yet it is seldom reported for the treatment of early esophageal squamous cell neoplasia. Here we retrospectively evaluated the feasibility, safety, and efficacy of EMBM for early esophageal squamous cell neoplasia. METHODS A total of 125 patients were included in the study. Lesions were delineated using electrocoagulation and resected using the EMBM technique. The primary outcomes were local recurrence and adverse events. Secondary outcomes were histology of the endoscopic resection specimens, specimen area, and speed of resection. All patients were followed up endoscopically. RESULTS There were 135 esophageal lesions, of which 40 were pathologically diagnosed as low-grade intraepithelial neoplasia, 57 as high-grade intraepithelial neoplasia, 34 as early esophageal cancer, and 4 as squamous epithelium without neoplasia. No severe adverse events were observed, except for 1 perforation, which was treated by application of clips. The median follow-up was 27.75 months. Three patients had local recurrence and were endoscopically treated again. Local recurrence rate was 2.4% (3/125). No deaths occurred during the follow-up. All specimens were visible with a dividing rule, and the mean specimen area was 4.63 cm2. Mean operation time was 31.2 ± 17.4 minutes. Mean speed of resection was 6.74 min/cm2. CONCLUSIONS EMBM seems to be effective and safe for patients with early esophageal squamous cell neoplasia. The long-term recurrence rate is low.
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Affiliation(s)
- Zhenkai Wang
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
| | - Heng Lu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
| | - Lin Wu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
| | - Boshi Yuan
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
| | - Jiong Liu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
| | - Hui Shi
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
| | - Fangyu Wang
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
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16
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Jiang D, Li X, Wang H, Xu C, Li X, Sujie A, Zeng H, Hou Y, Zhong Y. A retrospective study of endoscopic resection for 368 patients with early esophageal squamous cell carcinoma or precancerous lesions. Surg Endosc 2016; 31:2122-2130. [PMID: 27837320 DOI: 10.1007/s00464-016-5208-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/20/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND To retrospectively investigate the clinicopathological features and prognosis of early esophageal squamous cell neoplasm (ESCN) treated with endoscopic resection (ER), especially, to compare the prognosis in patients with sm2 cancer and non-sm2 cancer. METHODS From 2007 to 2013, 368 patients were included in our analysis. RESULTS The patients were 252 (68.5 %) men and 116 (31.5 %) women with a median age of 61 (range 16-84 years) years. Hyperplasia, mild dysplasia, moderate dysplasia, severe dysplasia, m1, m2, m3, sm1, and sm2 were diagnosed in 47 (12.8 %), 27 (7.3 %), 34 (9.2 %), 61 (16.6 %), 54 (14.7 %), 38 (10.3 %), 63 (17.1 %), 12 (3.3 %), and 32 (8.7 %) cases. The mean (range) follow-up time was 29 (0-84) months. The cumulative overall 1-, 3-, and 5-year metachronous esophageal lesion rates were 4.1, 12.9, and 32.6 %. The incidence of lymph node or distant metastasis was 1.54 % in m3, 6.25 % in sm2, and 0 in other subgroups. The overall 1-, 3-, and 5-year survival rates were 99.5, 97.3, and 87.5 %. There was significant difference between sm2 and non-sm2 patients in metastatic rate (P = 0.021); however, no difference existed between m3 patients and sm2 patients (P = 0.252). The difference of metachronous esophageal lesion (P = 0.401) and survival (P = 0.634) between sm2 and non-sm2 patients was not obvious. CONCLUSIONS Our study showed that ER was an effective and relatively safe treatment for superficial ESCN. ER is still appropriate in select sm2 patients. To monitor the second primary cancer in sm2 is necessary during the follow-up.
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Affiliation(s)
- Dongxian Jiang
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, 200032, People's Republic of China
| | - Xuquan Li
- Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, People's Republic of China
| | - Haixing Wang
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, 200032, People's Republic of China
| | - Chen Xu
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, 200032, People's Republic of China
| | - Xiaojing Li
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, 200032, People's Republic of China
| | - Akesu Sujie
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, 200032, People's Republic of China
| | - Haiying Zeng
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, 200032, People's Republic of China
| | - Yingyong Hou
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, 200032, People's Republic of China.
| | - Yunshi Zhong
- Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, People's Republic of China.
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17
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Park HC, Kim DH, Gong EJ, Na HK, Ahn JY, Lee JH, Jung KW, Choi KD, Song HJ, Lee GH, Jung HY, Kim JH. Ten-year experience of esophageal endoscopic submucosal dissection of superficial esophageal neoplasms in a single center. Korean J Intern Med 2016; 31:1064-1072. [PMID: 27618866 PMCID: PMC5094928 DOI: 10.3904/kjim.2015.210] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 08/24/2015] [Accepted: 08/29/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic submucosal dissection (ESD) of a superficial esophageal neoplasm (SEN) is a technically difficult procedure. We investigated the clinical outcomes of ESD to determine its feasibility and effectiveness for the treatment of SEN. METHODS Patients who underwent ESD for SEN between August 2005 and June 2014 were eligible for this study. The clinical features of patients and tumors, histopathologic characteristics, adverse events, results of endoscopic resection, and survival were investigated. RESULTS ESD was performed in 225 patients with 261 lesions, including 70 cases (26.8%) of dysplasias and 191 cases (73.2%) of squamous cell carcinomas. The median age was 65 years (range, 44 to 86), and the male to female ratio was 21.5:1. Median tumor size was 37 mm (range, 5 to 85) and median procedure time was 45 minutes (range, 9 to 160). En bloc resection was performed in 245 of 261 lesions (93.9%), with complete resection in 234 lesions (89.7%) and curative resection in 201 lesions (77.0%). Adverse events occurred in 33 cases (12.6%), including bleeding (1.5%), perforation (4.6%), and stricture (6.5%). During a median follow-up period of 35.0 months (interquartile range, 18 to 62), none of the patients showed local recurrence. The 5-year overall and disease-specific survival rates were 89.7% and 100%, respectively. CONCLUSIONS ESD is a feasible and effective procedure for the treatment of SEN based on our 10-year experience, which showed favorable outcomes.
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Affiliation(s)
- Hyung Chul Park
- Department of Internal Medicine Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jeong Gong
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Ho Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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18
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Kim YI, Lee JH, Kook MC, Lee JY, Kim CG, Ryu KW, Kim YW, Choi IJ. Lymph node metastasis risk according to the depth of invasion in early gastric cancers confined to the mucosal layer. Gastric Cancer 2016; 19:860-8. [PMID: 26304170 DOI: 10.1007/s10120-015-0535-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 08/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Early gastric cancers (EGCs) within the mucosal layer of the gastric wall have a small risk of lymph node (LN) metastasis. METHODS We reviewed clinicopathology data for patients who underwent surgery for EGC between 2001 and 2013 at the National Cancer Center, Korea. Poisson regression analyses were performed to compare the risk of LN metastasis according to the depth of tumor invasion in patients with mucosal EGCs. RESULTS Among the 1776 EGC patients included, 580 (32.7 %) had tumors confined to the lamina propria (LP; LP group) and 1196 (67.3 %) had tumors invading the muscularis mucosae (MM; MM group). Seventy-one patients (4.0 %) had LN metastasis, and the MM group had a significantly higher rate of LN metastasis (59 patients, 4.9 %) than the LP group (12 patients, 2.1 %; P = 0.004). A multivariate analysis showed that tumors invading the MM (adjusted risk ratio 1.95; P = 0.045) were significantly associated with LN metastasis in addition to well-known risk factors, including tumor size greater than 3 cm, presence of ulceration, undifferentiated histologic type, and lymphovascular invasion. The incidence of LN metastasis was 1.87 % (95 % confidence interval 0.23-6.59 %) within tumors invading the MM that met the expanded criterion for endoscopic resection of differentiated histologic type of size 3 cm or smaller with ulceration. LN metastasis was not found in tumors meeting the absolute criteria for endoscopic resection. CONCLUSIONS EGCs invading the MM had a higher rate of lymph node metastasis than those confined to the LP. Further study is needed to evaluate whether different curative treatment criteria are needed for LP-confined and MM-invading EGCs.
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Affiliation(s)
- Young-Il Kim
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro Ilsandong-gu, Goyang, Gyeonggi, 410-769, Korea
| | - Jun Ho Lee
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro Ilsandong-gu, Goyang, Gyeonggi, 410-769, Korea.,Department of Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Myeong-Cherl Kook
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro Ilsandong-gu, Goyang, Gyeonggi, 410-769, Korea
| | - Jong Yeul Lee
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro Ilsandong-gu, Goyang, Gyeonggi, 410-769, Korea
| | - Chan Gyoo Kim
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro Ilsandong-gu, Goyang, Gyeonggi, 410-769, Korea
| | - Keun Won Ryu
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro Ilsandong-gu, Goyang, Gyeonggi, 410-769, Korea
| | - Young-Woo Kim
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro Ilsandong-gu, Goyang, Gyeonggi, 410-769, Korea
| | - Il Ju Choi
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro Ilsandong-gu, Goyang, Gyeonggi, 410-769, Korea.
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Furukawa T, Hamai Y, Hihara J, Emi M, Yamakita I, Ibuki Y, Okada M. Clinical Significance of FDG-PET to Predict Pathologic Tumor Invasion and Lymph Node Metastasis of Superficial Esophageal Squamous Cell Carcinoma. Ann Surg Oncol 2016; 23:4086-4092. [PMID: 27352201 DOI: 10.1245/s10434-016-5359-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Indexed: 01/19/2023]
Abstract
PURPOSE To determine the preoperative ability of [18F]-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) to predict pathologic tumor invasion and lymph node status in cT1N0M0 esophageal squamous cell carcinoma (ESCC). METHODS We retrospectively analyzed 40 consecutive patients diagnosed with cT1N0M0 ESCC between February 2006 and April 2011. All patients were treated by esophagectomy with two- or three-field lymphadenectomy without neoadjuvant therapy. We evaluated the relevance between clinical variables including maximum standardized uptake values (SUVmax) of the primary tumor on FDG-PET and pathologic tumor invasion and lymph node status using a logistic regression model. RESULTS Tumors invaded the middle submucosal layer (SM2) and beyond in 21 (52.5 %) patients, and 6 (15 %) had lymph node metastases. The areas under receiver operating characteristic (ROC) curves for SUVmax of the primary tumor used to predict factors involved in tumor infiltration to SM2 or deeper and lymph node metastasis were 0.75 (p = 0.006) and 0.79 (p = 0.025), respectively. The optimal SUVmax cutoff was 2.7. The findings of univariate and multivariate analyses identified SUVmax as the only significant preoperative predictor associated with tumor infiltration into SM2 or beyond and lymph node metastasis. Furthermore, SUVmax ≥ 2.7 of the primary tumor on FDG-PET was associated with poor recurrence-free and disease-specific survival (p = 0.019 and p = 0.012, respectively). CONCLUSIONS FDG-PET is helpful for diagnosing tumors that can infiltrate SM2 and beyond as well as occult lymph node metastasis of cT1N0M0 ESCC that are valuable indications in deciding therapeutic strategies for superficial ESCC.
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Affiliation(s)
- Takaoki Furukawa
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoichi Hamai
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan.
| | - Jun Hihara
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Manabu Emi
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Ichiko Yamakita
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yuta Ibuki
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Morihito Okada
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
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20
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Gong EJ, Jung HY. Endoscopic Submucosal Dissection for Superficial Esophageal Neoplasm: A Growing Body of Evidence. Clin Endosc 2016; 49:101-3. [PMID: 26983549 PMCID: PMC4821517 DOI: 10.5946/ce.2016.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 03/05/2016] [Accepted: 03/06/2016] [Indexed: 11/26/2022] Open
Affiliation(s)
- Eun Jeong Gong
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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21
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Park JS, Youn YH, Park JJ, Kim JH, Park H. Clinical Outcomes of Endoscopic Submucosal Dissection for Superficial Esophageal Squamous Neoplasms. Clin Endosc 2016; 49:168-75. [PMID: 26867548 PMCID: PMC4821515 DOI: 10.5946/ce.2015.080] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 07/12/2015] [Accepted: 07/15/2015] [Indexed: 02/06/2023] Open
Abstract
Background/Aims: Endoscopic treatment has been broadly applied to superficial esophageal neoplasms. Endoscopic submucosal dissection (ESD) allows for high rates of en bloc resection, precise histological assessment, and low rates of local recurrence. The aim of this study was to evaluate the outcomes of ESD for superficial esophageal neoplasms. Methods: We retrospectively reviewed 36 esophageal ESDs for superficial squamous neoplasms in 32 patients between March 2009 and August 2014 at Gangnam Severance Hospital. Results: The median patient age was 64 years, and 30 men were included. The indications were early squamous cell carcinoma in 26 lesions, adenoma with high-grade dysplasia in five lesions, and low-grade dysplasia in five lesions. The en bloc resection and R0 resection rates were 97.2% (35 of 36) and 91.7% (33 of 36), respectively. Microperforation and post-ESD bleeding occurred in 5.6% (2 of 36) and 5.6% (2 of 36), respectively. Post-ESD esophageal strictures developed in five patients (13.9%). Five patients (15.6%) had an additional treatment after ESD (concurrent chemoradiation therapy in three, radiation therapy in one, and surgery in one patient). There was no disease-specific mortality during the median follow-up of 31 months. Conclusions: Favorable clinical outcomes were observed in ESD for superficial esophageal squamous neoplasms. Esophageal ESD could be a good treatment option in terms of efficacy and safety.
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Affiliation(s)
- Jung Soo Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hoon Youn
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jie-Hyun Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyojin Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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22
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Lee HJ, Lee H, Park JC, Shin SK, Lee SK, Lee YC. Treatment Strategy after Endoscopic Resection of Superficial Esophageal Squamous Cell Carcinoma: A Single Institution Experience. Gut Liver 2015; 9:714-9. [PMID: 25473076 PMCID: PMC4625699 DOI: 10.5009/gnl14142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 07/03/2014] [Accepted: 07/07/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to analyze and propose a treatment strategy after endoscopic resection of superficial esophageal squamous cell carcinoma in a single institution. METHODS This is a retrospective review of 37 patients who were treated by endoscopic resection during a 6-year period. RESULTS The mean tumor size was 11.5±5.5 mm (range, 3 to 31 mm). Thirty-one lesions (83.8%) were treated by endoscopic submucosal dissection, and six lesions were treated by endoscopic mucosal resection (16.2%). The en bloc resection rate and complete resection rate were 91.9% and 81.8%, respectively. The tumor invasion depth was diagnosed as epithelial in five cases (13.5%), lamina propria mucosa in 12 cases (32.4%), muscularis mucosa in 10 cases (27.0%) and submucosa in 10 cases (27.0%). The complication rate was 13.5% and included three cases (8.1%) of perforation. Ten patients who had muscularis mucosa and submucosa lesions received additional treatments, including six patients who were treated with esophagectomy, three patients who were treated with radiotherapy and one patient who was treated with chemoradiotherapy. One patient with lamina propria lesions received radiotherapy due to a positive resection margin. The median follow-up duration was 22 months (range, 4 to 79 months), and no recurrence or metastasis was noted during follow-up. CONCLUSIONS Tailored management after endoscopic treatment of superficial esophageal squamous cell carcinoma can offer an acceptable oncologic outcome in early esophageal carcinoma.
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Affiliation(s)
- Hyun Jik Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul,
Korea
| | - Hyuk Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul,
Korea
| | - Jun Chul Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul,
Korea
| | - Sung Kwan Shin
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul,
Korea
| | - Sang Kil Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul,
Korea
| | - Yong Chan Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul,
Korea
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Kim DH, Jung HY, Gong EJ, Choi JY, Ahn JY, Kim MY, Choi KS, Lee JH, Choi KD, Song HJ, Lee GH, Kim JH, Park YS, Baek S. Endoscopic and Oncologic Outcomes of Endoscopic Resection for Superficial Esophageal Neoplasm. Gut Liver 2015; 9:470-7. [PMID: 25473069 PMCID: PMC4477990 DOI: 10.5009/gnl13263] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 12/26/2013] [Accepted: 05/05/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic resection (ER) of superficial esophageal neoplasm (SEN) is a technically difficult procedure. We investigated the clinical outcomes of ER for SEN to determine its feasibility and effectiveness. METHODS Subjects who underwent ER for SEN at Asan Medical Center between December 1996 and December 2010 were eligible. The clinical features of patients and tumors, histopathological characteristics, adverse events, ER results and survival were investigated. RESULTS A total of 129 patients underwent ER for 147 SENs. En bloc resection (EnR) was performed in 118 lesions (80.3%). Complete resection (CR) was accomplished in 128 lesions (86.5%), and curative resection (CuR) was performed in 118 lesions (79.7%). The EnR, CR, and CuR rates were significantly greater in the endoscopic submucosal dissection group when compared to those in the endoscopic resection group. Adverse events occurred in 22 patients (17.1%), including bleeding (n=2, 1.6%), perforation (n=12, 9.3%), and stricture (n=8, 6.2%). Local tumor recurrence occurred in 2.0% of patients during a median follow-up of 34.8 months. The 5-year overall and disease-specific survival rates were 94.0% and 97.5%, respectively. CONCLUSIONS ER is a feasible and effective method for the treatment of SEN as indicated by favorable clinical outcomes.
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Affiliation(s)
- Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Eun Jeong Gong
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Ji Young Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Mi Young Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Kwi-Sook Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Jin Ho Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Young Soo Park
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Seunghee Baek
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
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Pech O. Nodes or no nodes? The lymph node metastasis risk of T1 esophageal cancer revisited. J Natl Cancer Inst 2014; 106:dju174. [PMID: 25031275 DOI: 10.1093/jnci/dju174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Oliver Pech
- Affiliation of author: Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital (Krankenhaus Barmherzige Brüder), Regensburg, Germany.
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25
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Merkow RP, Bilimoria KY, Keswani RN, Chung J, Sherman KL, Knab LM, Posner MC, Bentrem DJ. Treatment trends, risk of lymph node metastasis, and outcomes for localized esophageal cancer. J Natl Cancer Inst 2014; 106:dju133. [PMID: 25031273 DOI: 10.1093/jnci/dju133] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Endoscopic resection is increasingly used to treat localized, early-stage esophageal cancer. We sought to assess its adoption, characterize the risks of nodal metastases, and define differences in procedural mortality and 5-year survival between endoscopic and surgical resection in the United States. METHODS From the National Cancer Data Base, patients with T1a and T1b lesions were identified. Treatment patterns were characterized, and hierarchical regression methods were used to define predictors and evaluate outcomes. All statistical tests were two-sided. RESULTS Five thousand three hundred ninety patients were identified and underwent endoscopic (26.5%) or surgical resection (73.5%). Endoscopic resection increased from 19.0% to 53.0% for T1a lesions (P < .001) and from 6.6% to 20.9% for T1b cancers (P < .001). The strongest predictors of endoscopic resection were depth of invasion (T1a vs T1b: odds ratio [OR] = 4.45; 95% confidence interval [CI] = 3.76 to 5.27) and patient age of 75 years or older (vs age less than 55 years: OR = 4.86; 95% CI = 3.60 to 6.57). Among patients undergoing surgery, lymph node metastasis was 5.0% for T1a and 16.6% for T1b lesions. Predictors of nodal metastases included tumor size greater than 2 cm (vs. <2 cm) and intermediate-/high-grade lesions (vs low grade). For example, 0.5% of patients with low-grade T1a lesions less than 2 cm had lymph node involvement. The risk of 30-day mortality was less after endoscopic resection (hazard ratio [HR] = 0.33; 95% CI = 0.19 to 0.58) but greater for conditional 5-year survival (HR = 1.63; 95% CI = 1.07 to 2.47). CONCLUSIONS Endoscopic resection has become the most common treatment of T1a esophageal cancer and has increased for T1b cancers. It remains important to balance the risk of nodal metastases and procedural risk when counseling patients regarding their treatment options.
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Affiliation(s)
- Ryan P Merkow
- Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB).
| | - Karl Y Bilimoria
- Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB)
| | - Rajesh N Keswani
- Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB)
| | - Jeanette Chung
- Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB)
| | - Karen L Sherman
- Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB)
| | - Lawrence M Knab
- Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB)
| | - Mitchell C Posner
- Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB)
| | - David J Bentrem
- Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB)
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Lee MW, Kim GH, I H, Park DY, Baek DH, Lee BE, Song GA. Predicting the invasion depth of esophageal squamous cell carcinoma: comparison of endoscopic ultrasonography and magnifying endoscopy. Scand J Gastroenterol 2014; 49:853-61. [PMID: 24957951 DOI: 10.3109/00365521.2014.915052] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Predicting the invasion depth of superficial esophageal squamous cell carcinoma (SESCC) is important when selecting among therapeutic strategies. The aim of this study was to compare magnifying endoscopy with narrow-band imaging (ME-NBI) with endoscopic ultrasonography (EUS) for predicting the depth of tumor invasion in patients with SESCC. METHODS This study enrolled 51 patients with SESCC (52 SESCC lesions) who underwent both ME-NBI and EUS at Pusan National University Hospital during 2010-2013. We reviewed the patients' medical records and compared ME-NBI and EUS findings with histopathological results according to clinicopathological factors. RESULTS A total of 46 lesions in 45 patients were included in the final analysis. ME-NBI and EUS had overall accuracies of 76.1% and 84.8%, respectively, in distinguishing mucosal from non-mucosal cancers. There were no differences between ME-NBI and EUS in terms of sensitivities and specificities in distinguishing mucosal from non-mucosal cancers (p = 0.500 and p = 0.688, respectively). When both ME-NBI and EUS suggested a mucosal depth of lesion invasion, the frequency of mucosal cancer in the final histopathology was 94%. However, if either ME-NBI or EUS suggested a non-mucosal depth of invasion, the frequency of mucosal cancer was only 21%. CONCLUSION ME-NBI and EUS are accurate predictors of SESCC invasion depth. If both methods suggest a mucosal depth of lesion invasion, the accuracy of the prediction is increased. Therefore, when possible, it would be better to evaluate the invasion depth of SESCC using both ME-NBI and EUS before deciding to perform endoscopic resection.
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Affiliation(s)
- Moon Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine , Busan , Korea
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27
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Jung JI, Kim GH, I H, Park DY, Kim TK, Cho YH, Sung YW, Choi MK, Lee BE, Song GA. Clinicopathologic factors influencing the accuracy of EUS for superficial esophageal carcinoma. World J Gastroenterol 2014; 20:6322-6328. [PMID: 24876754 PMCID: PMC4033471 DOI: 10.3748/wjg.v20.i20.6322] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 01/27/2014] [Accepted: 03/05/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify clinicopathologic factors influencing the accuracy of a high-frequency catheter probe endoscopic ultrasonography (EUS) for superficial esophageal carcinomas (SECs).
METHODS: A total of 126 patients with endoscopically suspected SEC, who underwent EUS and curative treatment at Pusan National University Hospital during 2005-2013, were enrolled. We reviewed the medical records of the 126 patients and compared EUS findings with histopathologic results according to clinicopathologic factors.
RESULTS: A total of 114 lesions in 113 patients were included in the final analysis. The EUS assessment of tumor invasion depth was accurate in 78.9% (90/114) patients. Accuracy did not differ according to histologic type, tumor differentiation, tumor location, or macroscopic shape. However, accuracy significantly decreased for tumors ≥ 3 cm in size (P = 0.002). Overestimation and underestimation of the invasion depth occurred for 11 (9.6%) and 13 lesions (11.4%), respectively. In multivariate analyses, tumor size ≥ 3 cm was the only factor significantly associated with EUS accuracy (P = 0.031), and was specifically associated with the underestimation of invasion depth.
CONCLUSION: EUS using a high-frequency catheter probe generally provides highly accurate assessments of SEC invasion depth, but its accuracy decreases for tumors ≥ 3 cm.
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28
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Moon JY, Kim GH, Kim JH, Kim HH, Ryu KD, Park SO, Lee BE, Song GA. Clinicopathologic factors predicting lymph node metastasis in superficial esophageal squamous cell carcinoma. Scand J Gastroenterol 2014; 49:589-94. [PMID: 24641315 DOI: 10.3109/00365521.2013.838604] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Surgical resection is the treatment of choice for superficial esophageal squamous cell carcinoma (SESCC), but it is associated with high mortality and morbidity rates. Recently, endoscopic resection for SESCC has been indicated for patients with a low risk of lymph node metastasis (LNM). Therefore, to successfully treat SESCC with endoscopic resection, it is very important to identify patients with a low risk for LNM. The objective of this study was to investigate clinicopathologic factors that predict LNM in patients who underwent esophagectomy for SESCC. METHODS The study included 104 patients with SESCC from three university hospitals in Pusan, Korea. Clinicopathologic factors were evaluated to identify independent factors predicting LNM by univariate and multivariate analyses. RESULTS In univariate analysis, the depth of tumor invasion and lymphovascular invasion had significant influences on LNM (p=0.001 and p<0.001, respectively). Gross type, tumor size, and tumor differentiation were not predictive for LNM. In multivariate analysis, the depth of tumor invasion and lymphovascular invasion were significantly associated with LNM in patients with SESCC (OR 9.04, p=0.049; OR 11.61, p=0.002, respectively). CONCLUSIONS The depth of tumor invasion and lymphovascular invasion were independent predictors of LNM in patients with SESCC. Therefore, endoscopic resection could be performed in patients with SESCC that is limited to the mucosa, without lymphovascular invasion.
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Affiliation(s)
- Jung Youn Moon
- Department of Internal Medicine, Pusan National University School of Medicine , Busan , Korea
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29
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He LJ, Shan HB, Luo GY, Li Y, Zhang R, Gao XY, Wang GB, Lin SY, Xu GL, Li JJ. Endoscopic ultrasonography for staging of T1a and T1b esophageal squamous cell carcinoma. World J Gastroenterol 2014; 20:1340-1347. [PMID: 24574809 PMCID: PMC3921517 DOI: 10.3748/wjg.v20.i5.1340] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 09/24/2013] [Accepted: 09/29/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the accuracy of Endoscopic ultrasound (EUS) in staging and sub-staging T1a and T1b esophageal squamous cell carcinoma (ESCC).
METHODS: A retrospective analysis involving 72 patients with pathologically confirmed T1a or T1b ESCC, was undertaken between January 2005 and December 2011 in Sun Yat-sen University Cancer Center. The accuracy and efficiency of EUS for detecting stages T1a and T1b ESCC were examined.
RESULTS: The overall accuracy of EUS for detecting stage T1a or T1b ESCC was 70.8% (51/72), and the sensitivity was 74.3%. 77.8% (7/9) of lesions originated in the upper thoracic region, 73.1% (38/52) in the mid-thoracic region and 72.7% (8/11) in the lower thoracic region. Multivariate analysis revealed that the diagnostic accuracy of EUS was closely related to lesion length (F = 4.984, P = 0.029).
CONCLUSION: EUS demonstrated median degree of accuracy for distinguishing between stages T1a and T1b ESCC. Therefore, it is necessary to improve EUS for staging early ESCC.
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30
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Kim C, Hong SJ, Han JP, Jung HJ, Jeong ES, Goong HJ, Kim H, Lee SH, Ko BM, Lee MS. Clinical Outcomes of the Endoscopic Treatments for the Early Esophageal Carcinoma and Dysplasia. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2014. [DOI: 10.7704/kjhugr.2014.14.3.187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Cheol Kim
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Su Jin Hong
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jae Pil Han
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Hee Jae Jung
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Eun Soo Jeong
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Hyeon Jeong Goong
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Heejun Kim
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Seoung Ho Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Bong Min Ko
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Moon Sung Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
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Higuchi K, Tanabe S, Azuma M, Katada C, Sasaki T, Ishido K, Naruke A, Katada N, Koizumi W. A phase II study of endoscopic submucosal dissection for superficial esophageal neoplasms (KDOG 0901). Gastrointest Endosc 2013; 78:704-10. [PMID: 23680178 DOI: 10.1016/j.gie.2013.04.182] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 04/15/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Most previous studies of endoscopic submucosal dissection (ESD) for superficial esophageal neoplasms were retrospective; prospective studies are scant. OBJECTIVE To prospectively assess the efficacy and safety of ESD for superficial esophageal neoplasms. DESIGN Phase II study. SETTING University hospital. PATIENTS Fifty-two patients (median age 68 years; 48 men) who had a histologic diagnosis of superficial esophageal cancer without metastasis on CT or high-grade intraepithelial neoplasia (HGIN) were enrolled from April 2009 through November 2011. INTERVENTION ESD was used to treat 56 lesions. All procedures were done by 4 endoscopists who each had previously performed ESD in more than 100 patients with gastric tumors. MAIN OUTCOME MEASUREMENTS The primary endpoint was the R0 resection rate, and secondary endpoints were the safety and the rate of accurately diagnosing tumor depth on endoscopic examination. RESULTS The median treatment time was 69 minutes (24-168 minutes). The histopathologic diagnosis was squamous cell carcinoma in 49 lesions, HGIN in 5, and tubular adenocarcinoma in 2. The en bloc resection rate and R0 resection rate were 100% and 94.6%, respectively. The rates of adverse events during ESD and after ESD were 22.2% and 53.8%, respectively, but most events were mild. One patient (1.9%) had mediastinal emphysema without perforation. The rate of accurately diagnosing tumor depth on endoscopic examination was 76.8%. LIMITATIONS Single-center, nonrandomized study. CONCLUSION Our study showed that ESD was an effective and relatively safe treatment for superficial esophageal neoplasms. ESD may be a useful treatment option for superficial esophageal neoplasms in hospitals with endoscopists who are experts in performing ESD for gastric tumors. ( CLINICAL TRIAL REGISTRATION NUMBER UMIN000002047.).
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Affiliation(s)
- Katsuhiko Higuchi
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
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Prevalence of lymph node metastases in superficial esophageal squamous cell carcinoma. J Thorac Cardiovasc Surg 2013; 146:1198-203. [PMID: 23988285 DOI: 10.1016/j.jtcvs.2013.07.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 04/26/2013] [Accepted: 07/09/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Endoscopic treatment of superficial esophageal carcinoma has been increasingly conducted around the world. Because no lymph nodes are removed in such a procedure, the risk of lymph node metastases (LNMs) should be clearly understood. The aim of the present study was to accurately clarify the pattern of lymphatic spread in patients with superficial esophageal squamous cell carcinoma and analyze the factors potentially related to LNMs. METHODS The pattern of lymphatic spread was studied in 189 patients who had undergone radical lymphadenectomy from 2006 to 2011. The risk factors associated with LNMs were determined by multivariate logistic regression analysis. According to the depth of tumor invasion, mucosal tumors were classified as M1, M2, and M3 and submucosal tumors as SM1, SM2, and SM3. RESULTS A total of 4252 lymph nodes were resected (average, 23 ± 9; range, 12-68). LNMs occurred in 49 patients (25.9%). The frequency of LNMs was 4.3% in those with mucosal and 33.1% in those with submucosal cancer. LNMs were found in 0%, 0%, 11.8%, 24.0%, 20.5%, and 43.8% of the M1, M2, M3, SM1, SM2, and SM3 cancer, respectively. For submucosal cancer, SM3 cancer (P = .006) and lymphovascular invasion (P = .001) were significant independent risk factors for LNMs. Paratracheal nodes were the most frequently involved. "Skip" metastases occurred in 20 of 49 patients (40.8%). CONCLUSIONS Endoscopic treatment can be attempted when the tumor is limited to the lamina propria mucosa. However, 2-field radical lymphadenectomy with careful upper mediastinal lymph node resection should be conducted for submucosal squamous cell carcinoma.
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Sgourakis G, Gockel I, Lang H. Endoscopic and surgical resection of T1a/T1b esophageal neoplasms: A systematic review. World J Gastroenterol 2013; 19:1424-37. [PMID: 23539431 PMCID: PMC3602502 DOI: 10.3748/wjg.v19.i9.1424] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Revised: 08/22/2012] [Accepted: 08/25/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/T1b esophageal neoplasms.
METHODS: A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane Library, from 1997 up to January 2011 was performed. An analysis was carried out, pooling the effects of outcomes of 4241 patients enrolled in 80 retrospective studies. For comparisons across studies, each reporting on only one endoscopic method, we used a random effects meta-regression of the log-odds of the outcome of treatment in each study. “Neural networks” as a data mining technique was employed in order to establish a prediction model of lymph node status in superficial submucosal esophageal carcinoma. Another data mining technique, the “feature selection and root cause analysis”, was used to identify the most important predictors of local recurrence and metachronous cancer development in endoscopically resected patients, and lymph node positivity in squamous carcinoma (SCC) and adenocarcinoma (ADC) separately in surgically resected patients.
RESULTS: Endoscopically resected patients: Low grade dysplasia was observed in 4% of patients, high grade dysplasia in 14.6%, carcinoma in situ in 19%, mucosal cancer in 54%, and submucosal cancer in 16% of patients. There were no significant differences between endoscopic mucosal resection and endoscopic submucosal dissection (ESD) for the following parameters: complications, patients submitted to surgery, positive margins, lymph node positivity, local recurrence and metachronous cancer. With regard to piecemeal resection, ESD performed better since the number of cases was significantly less [coefficient: -7.709438, 95%CI: (-11.03803, -4.380844), P < 0.001]; hence local recurrence rates were significantly lower [coefficient: -4.033528, 95%CI: (-6.151498, -1.915559), P < 0.01]. A higher rate of esophageal stenosis was observed following ESD [coefficient: 7.322266, 95%CI: (3.810146, 10.83439), P < 0.001]. A significantly greater number of SCC patients were submitted to surgery (log-odds, ADC: -2.1206 ± 0.6249 vs SCC: 4.1356 ± 0.4038, P < 0.05). The odds for re-classification of tumor stage after endoscopic resection were 53% and 39% for ADC and SCC, respectively. Local tumor recurrence was best predicted by grade 3 differentiation and piecemeal resection, metachronous cancer development by the carcinoma in situ component, and lymph node positivity by lymphovascular invasion. With regard to surgically resected patients: Significant differences in patients with positive lymph nodes were observed between ADC and SCC [coefficient: 1.889569, 95%CI: (0.3945146, 3.384624), P < 0.01). In contrast, lymphovascular and microvascular invasion and grade 3 patients between histologic types were comparable, the respective rank order of the predictors of lymph node positivity was: Grade 3, lymphovascular invasion (L+), microvascular invasion (V+), submucosal (Sm) 3 invasion, Sm2 invasion and Sm1 invasion. Histologic type (ADC/SCC) was not included in the model. The best predictors for SCC lymph node positivity were Sm3 invasion and (V+). For ADC, the most important predictor was (L+).
CONCLUSION: Local tumor recurrence is predicted by grade 3, metachronous cancer by the carcinoma in-situ component, and lymph node positivity by L+. T1b cancer should be treated with surgical resection.
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Endoscopic submucosal dissection for early esophageal neoplasia: a single center experience in South Taiwan. J Formos Med Assoc 2012; 111:132-9. [PMID: 22423666 DOI: 10.1016/j.jfma.2010.12.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 11/25/2010] [Accepted: 12/24/2010] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/PURPOSE Endoscopic submucosal dissection (ESD) is an advanced endoscopic procedure to resect early gastrointestinal neoplasm. It is technically more difficult and risky when used to treat early esophageal tumors. We report our experiences related to performing ESD for early esophageal neoplasia. The efficacy, complications, and outcome were also analyzed. METHODS From December 2007 to April 2010, 22 patients with documented early esophageal neoplasm underwent ESD. All patients completed a meticulous endoscopic examination using conventional endoscopy followed by narrow-band imaging. Lugol's staining was performed to identify the margin of the suspicious lesion. Insulation-tipped diathermic knife 2 was used for ESD. RESULTS A total of 26 neoplastic lesions (including 13 tumors with high-grade dysplasia, 12 tumors with squamous cell carcinoma, and one tumor with adenocarcinoma) in 22 patients were enrolled. All patients were men. The mean age was 47.6 ± 8.6 years (range, 30-68 years). The mean size of tumors was 33.7 ± 21.7 mm (range, 8-80 mm). ESD was performed for 24 lesions in 20 patients. The mean size of resected specimens was 43.1 ± 19.2 mm (range, 15-90 mm). The mean operation time was 92.7 ± 69 minutes (range, 30-310 minutes). There were three ESD-related complications, including one with delayed bleeding, one with subcutaneous emphysema, and one with perforation. Two patients received additional operations after ESD due to deep submucosal invasion by cancer. Three lesions in two patients (12.5%) developed post-ESD esophageal stricture that needed repeated endoscopic bougination. There was no procedure-related mortality. No local recurrence was found during the follow-up period. CONCLUSION ESD is a promising local curative treatment option for early esophageal neoplasia in Taiwan. However, this procedure may result in complications that are worth noting, especially post-ESD esophageal stricture. Education regarding this procedure and more hands-on training will facilitate endoscopists to improve the outcomes of patients undergoing this procedure.
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Sgourakis G, Gockel I, Lyros O, Lanitis S, Dedemadi G, Polotzek U, Karaliotas C, Lang H. The Use of Neural Networks in Identifying Risk Factors for Lymph Node Metastasis and Recommending Management of T1b Esophageal Cancer. Am Surg 2012. [DOI: 10.1177/000313481207800238] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The objective of this study was to establish a prediction model of lymph node status in T1b esophageal carcinoma and define the best squamous and adenocarcinoma predictors. The literature lacks a satisfactory level of evidence of T1b esophageal cancer management. We performed an analysis pooling the effects of outcomes of 2098 patients enrolled into 37 retrospective studies using “neural networks” as data mining techniques. The percentages for lymph node, lymphatic (L1), and vascular (V1) invasion in Sm1 esophageal cancers were 24, 46, and 20 per cent, respectively. The same parameters apply to Sm2 with 34, 63, and 38 per cent as opposed to Sm3 with 51, 69, and 47 per cent. The respective number of patients with well, moderate, and poor histologic differentiation totaled 267, 752, and 582. The rank order of the predictors of lymph node positivity was, respectively: Grade III, (L1), (V1), Sm3 invasion, Sm2 invasion, and Sm1 invasion. Histologic-type squamous and adenocarcinoma (ADC/SCC) was not included in the model. The best predictors for SCC lymph node positivity were sm3 invasion and (V1). As concerns ADC, the most important predictor was (L1). Submucosal esophageal cancer should be managed with surgical resection. However, this is subject to the histologic type and presence of specific predictors that could well alter the perspective of multimodality management.
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Affiliation(s)
- George Sgourakis
- Department of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Mainz, Germany, and the, Athens, Greece
- 2nd Surgical Department and Surgical Oncology Unit of “Korgialenio–Benakio,” Red Cross Hospital, Athens, Greece
| | - Ines Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Mainz, Germany, and the, Athens, Greece
| | - Orestis Lyros
- Department of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Mainz, Germany, and the, Athens, Greece
| | - Sophocles Lanitis
- 2nd Surgical Department and Surgical Oncology Unit of “Korgialenio–Benakio,” Red Cross Hospital, Athens, Greece
| | - Georgia Dedemadi
- 2nd Surgical Department and Surgical Oncology Unit of “Korgialenio–Benakio,” Red Cross Hospital, Athens, Greece
| | - Ursula Polotzek
- Department of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Mainz, Germany, and the, Athens, Greece
| | - Constantine Karaliotas
- 2nd Surgical Department and Surgical Oncology Unit of “Korgialenio–Benakio,” Red Cross Hospital, Athens, Greece
| | - Hauke Lang
- Department of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Mainz, Germany, and the, Athens, Greece
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Prognostic impact of upper, middle, and lower third mucosal or submucosal infiltration in early esophageal cancer. Ann Surg 2012; 254:802-7; discussion 807-8. [PMID: 22042472 DOI: 10.1097/sla.0b013e3182369128] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To identify differences in survival of patients with pT1 esophageal cancer relating to depth of wall infiltration. BACKGROUND DATA Histologic analysis of mucosal and submucosal infiltration in thirds has shown an increasing rate of lymph node metastases (LNM) according to the depth of wall infiltration in pT1 esophageal cancer. METHODS One hundred seventy-one patients had transthoracic en bloc (n = 161) or transhiatal esophagectomy (n = 10) for pT1 esophageal cancer [121 adenocarcinomas (AC), 50 squamous cell carcinomas (SCC)]. The histologic analysis of the specimen comprised depth of wall penetration of the carcinoma in thirds of pT1a = mucosa (m1, m2, m3) or pT1b = submucosa (sm1, sm2, sm3) and number and infiltration of the resected lymph nodes. RESULTS The rate of LNM was 0% for 70 mucosal carcinomas and 34% for 101 submucosal carcinomas (P = 0.001). For sm1, this rate was 13%, for sm2 19% and for sm3 56%. The 5-year survival rate (5Y-SR) was 82% for pN0 and 45% for pN+ patients (P < 0.001). There was no significant prognostic difference between AC and SCC (5Y-SR: 74% vs 71%). The 5Y-SR of the pT1a group was 87% compared with 66% for pT1b (P = 0.046). The 5-year survival rate for sm1 and sm2 were similar; sm1 + sm2 were together significantly better (80%) than sm3 (46%) (P = 0.008). In multivariate analysis, only sm3 was an independent prognostic factor (P = 0.01). CONCLUSIONS After esophagectomy, the prognosis of patients with sm1/sm2 infiltration is as good as for patients with mucosal carcinoma. Sm3 infiltration is the worst prognostic factor in pT1 esophageal cancer.
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Tanaka S, Morita Y, Fujita T, Wakahara C, Ikeda A, Toyonaga T, Azuma T. Ex vivo pig training model for esophageal endoscopic submucosal dissection (ESD) for endoscopists with experience in gastric ESD. Surg Endosc 2012; 26:1579-86. [PMID: 22223113 DOI: 10.1007/s00464-011-2074-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 11/09/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Esophageal endoscopic submucosal dissection (ESD) has developed in recent years because of its high rate of en bloc resection. However, for many endoscopists, technical difficulty and risks of complications are great barriers to performing esophageal ESD. In this study, we developed an original training model for esophageal ESD using isolated pig esophagus and assessed this ex vivo model in endoscopists with experience in gastric ESD. METHODS Three endoscopists without experience in esophageal ESD but with some experience in gastric ESD performed esophageal ESD of artificial lesions in 10 consecutive sessions using this ex vivo model. The en bloc resection rate, operation time, number of muscularis propria layer injuries, and presence of perforation were recorded. We evaluated the effectiveness of this training in the three endoscopists by comparing results from the first five sessions (former period) with those from the last five sessions (latter period). RESULTS All three endoscopists achieved en bloc resections in all trials. In the former period, injury to the muscularis propria layer for each of the three endoscopists occurred a mean of 2.2 (1-3), 0.6 (0-1), and 3.2 (1-6) times, respectively. Perforation occurred in one session performed by one endoscopist. In the latter period, the mean number of muscularis propria layer injuries for each of the three endoscopists decreased to 0.2 (0-1), 0.2 (0-1), and 0.8 (0-2), respectively. The time of operation shortened from 35.0 (25-40), 36.4 (30-50), and 29.8 (23-43) min to 23.0 (16-31), 25.6 (23-28), and 29.2 (21-37) min, respectively. CONCLUSIONS This original ex vivo training model was helpful to endoscopists with experience in gastric ESD in acquiring the basic skills for performing esophageal ESD.
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Affiliation(s)
- Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, 7-5-1 Chu-o-ku, Kusunoki-Cho, Kobe, Hyogo 650-0017, Japan.
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Green S, Bhandari P, DeCaestecker J, Barr H, Ragunath K, Jankowski J, Singh R, Longcroft-Wheaton G, Bennett C. Endoscopic therapies for the prevention and treatment of early esophageal neoplasia. Expert Rev Gastroenterol Hepatol 2011; 5:731-43. [PMID: 22017700 DOI: 10.1586/egh.11.80] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Esophageal cancers have traditionally been diagnosed late and prognosis has been dire. For many years the only real treatment option was esophagectomy with substantial morbidity and mortality. This situation has now changed dramatically. Improvements have been achieved in surgical outcomes and there is an array of new effective treatment options now available, particularly for the increasing proportion diagnosed with early-stage disease. Minimally invasive endoscopic therapies can now prevent, cure or palliate esophageal cancers. This article aims to investigate the role and evidence base for these new therapeutic options.
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Affiliation(s)
- Susi Green
- St Mark's Hospital, Northwick Park, Watford Road, Harrow, Middlesex, HA1 3UJ, UK.
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Gockel I, Sgourakis G, Lyros O, Polotzek U, Schimanski CC, Lang H, Hoppo T, Jobe BA. Risk of lymph node metastasis in submucosal esophageal cancer: a review of surgically resected patients. Expert Rev Gastroenterol Hepatol 2011; 5:371-84. [PMID: 21651355 DOI: 10.1586/egh.11.33] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Endoscopic local procedures are increasingly applied in patients with superficial esophageal cancer as an alternative to radical oncologic resection. The objective of this article is to determine the risk of nodal metastases in submucosal (sm) esophageal cancer, comparing the two predominating histologic tumor types, squamous cell cancer (SCC) and adenocarcinoma (ADC). METHODS A query of PubMed, MEDLINE, Embase and Cochrane Library (1980-2009) using predetermined search terms revealed 675 abstracts, of which 485 full-text articles were reviewed. A total of 105 articles met the selection criteria. A review of article references and consultation with experts revealed additional articles for inclusion. Studies that enrolled patients with submucosal esophageal cancer and provided adequate extractable data were included. RESULTS The pooled outcomes of 7645 patients with esophageal cancer involving the sm level of infiltration were included in the analysis. Overall, the percentage of lymph node metastasis in submucosal cancer was 37%. Lymph node (N), lymphatic (L) and vascular (V) invasion in sm1 esophageal cancers was 27, 46 and 22%, respectively. Within sm2 lesions, N, L and V invasion were involved in 38, 63 and 38% of patients, respectively. Finally, N, L and V involvement in patients with sm3 lesions was 54, 69 and 47%, respectively. The rates of lymph node metastasis for sm1 and sm2 were higher in SCC compared with ADC, whereas the lymph node metastasis for sm3 was comparable, with >50% involvement in both histologic subtypes. SCC revealed an overall more aggressive behavior compared with ADC (N+: 45 vs 26%; L+: 57 vs 37%; V+: 40 vs 18%). DISCUSSION While endoscopic therapy may be adequate in selected patients with 'low-risk' sm1 ADC, submucosal SCC necessitates esophageal resection and systematic lymphadenectomy because of its aggressive nature and tendency for early metastasis.
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Affiliation(s)
- Ines Gockel
- Johannes Gutenberg-University of Mainz, Mainz, Germany.
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Choi JY, Park YS, Jung HY, Ahn JY, Kim MY, Lee JH, Choi KS, Kim DH, Choi KD, Song HJ, Lee GH, Cho KJ, Kim JH. Feasibility of endoscopic resection in superficial esophageal squamous carcinoma. Gastrointest Endosc 2011; 73:881-9, 889.e1-2. [PMID: 21392755 DOI: 10.1016/j.gie.2010.12.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 12/18/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND Endoscopic resection in patients with superficial esophageal squamous carcinoma (SESC) is limited by the presence of lymph node metastasis (LNM), highlighting the importance of determining which patients have virtually no risk of LNM. OBJECTIVE To investigate the clinicopathological parameters predicting LNM in patients who underwent esophagectomy for SESCs and to identify the best candidate patients for endoscopic resection. DESIGN Retrospective, single-center study. SETTING Tertiary-care center. PATIENTS A total of 190 patients who underwent esophagectomy for SESCs between 1991 and 2009. INTERVENTIONS Esophagectomy with lymph node dissection. MAIN OUTCOME MEASUREMENTS LNM. RESULTS Of 190 patients, 39 (20.5%) had LNM. The rates of LNM in patients with m1, m2, m3, sm1, sm2, and sm3 lesions were 0.0% (0/18), 8.7% (4/46), 25.0% (6/24), 15.0% (3/20), 26.0% (7/27), and 37.3% (19/51), respectively. On multivariate analysis, lymphovascular invasion (LVI) (P<.001), superficial tumor size (P=.004), and lower LMM (lamina muscularis mucosae) invasion width (P<.001) were independent predictors of LNM in patients with SESC invading the LMM. Among 63 patients with mucosal or sm1 cancer 3 cm or smaller, only 1 had LNM without LVI showing a lower LMM invasion width greater than 3.0 mm. LIMITATIONS Retrospective analysis. CONCLUSIONS Endoscopic resection should be performed for mucosal cancer of 3 cm or less without positive lymph nodes. Moreover, if pathological examination of the endoscopically resected specimens shows invasion of the sm1 layer and a lower LMM invasion width of 3.0 mm or less, indicating an absence of LVI, the patient can be carefully observed without additional treatment.
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Affiliation(s)
- Ji Young Choi
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, South Korea
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The safety and effectiveness of endoscopic and non-endoscopic approaches to the management of early esophageal cancer: a systematic review. Cancer Treat Rev 2010; 37:11-62. [PMID: 20570442 DOI: 10.1016/j.ctrv.2010.04.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 04/13/2010] [Accepted: 04/25/2010] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Traditionally, management of early cancer (stages 0-IIA) has comprised esophagectomy, either alone or in combination with chemotherapy and/or radiotherapy. Recent efforts to improve outcomes and minimize side-effects have focussed on minimally invasive, endoscopic treatments that remove lesions while sparing healthy tissue. This review assesses their safety and efficacy/effectiveness relative to traditional, non-endoscopic treatments for early esophageal cancer. METHODS A systematic review of peer-reviewed studies was performed using Cochrane guidelines. Bibliographic databases searched to identify relevant English language studies published in the last 3 years included: PubMed (i.e., MEDLINE and additional sources), EMBASE, CINAHL, The Cochrane Library, the UK Centre for Reviews and Dissemination (NHS EED, DARE and HTA) databases, EconLit and Web of Science. Web sites of professional associations, relevant cancer organizations, clinical practice guidelines, and clinical trials were also searched. Two independent reviewers selected, critically appraised, and extracted information from studies. RESULTS The review included 75 studies spanning 3124 patients and 10 forms of treatment. Most studies were of short term duration and non-comparative. Adverse events reported across studies of endoscopic techniques were similar and less significant compared to those in the studies of non-endoscopic techniques. Complete response rates were slightly lower for photodynamic therapy (PDT) relative to the other endoscopic techniques, possibly due to differences in patient populations across studies. No studies compared overall or cause-specific survival in patients who received endoscopic treatments vs. those who received non-endoscopic treatments. DISCUSSION Based on findings from this review, there is no single "best practice" approach to the treatment of early esophageal cancer.
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Lauwers GY, Badizadegan K. New Endoscopic Techniques: Challenges and Opportunities for Surgical Pathologists. Surg Pathol Clin 2010; 3:411-28. [PMID: 26839138 DOI: 10.1016/j.path.2010.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In recent years, significant clinical and technological advances have been made in endoscopic methods for diagnosis and treatment of early gastrointestinal neoplasms. However, essential information related to these novel techniques and their implications for practicing surgical pathologists have largely been missing in the general pathology literature. This article provides a general introduction to these novel therapeutic and diagnostic methods, and discusses their indications, contraindications, and potential limitations. The article aims to enable surgical pathologists to interact more efficiently with basic scientists and clinical colleagues to help implement and improve the existing clinical methods and to advance the new technologies.
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Affiliation(s)
- Gregory Y Lauwers
- Gastrointestinal Pathology Service, James Homer Wright Pathology Laboratories, 55 Fruit Street, WRN 219, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Pathology, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Kamran Badizadegan
- Gastrointestinal Pathology Service, James Homer Wright Pathology Laboratories, 55 Fruit Street, WRN 219, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Pathology, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Harvard-MIT Division of Health Sciences and Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA
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OGUMA JUNYA, OZAWA SOJI, SAIKAWA YOSHIRO, KITAGAWA YUKO. Surgical treatments for squamous cell carcinoma of the esophagus reaching to the muscularis mucosa or the upper third of the submucosal layer. Oncol Lett 2010; 1:521-525. [PMID: 22966336 PMCID: PMC3436346 DOI: 10.3892/ol_00000092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Accepted: 03/19/2010] [Indexed: 01/14/2023] Open
Abstract
We studied the surgical treatments of patients with either esophageal cancer reaching to the muscularis mucosae (m3) or with a slight invasion of the submucosa (sm1). We reviewed the records and examined the clinicopathological features of 29 patients with m3 or sm1 esophageal squamous cell carcinoma who had undergone surgery. Lymph node metastasis was noted in 6.3% (1 patient) of patients with m3 cancers and in 38.5% (5 patients) of those with sm1 cancers. The incidence of lymph node metastasis was higher in the sm1 than in the m3 group, but the difference was not significant. Lymphatic invasion (ly) was noted in 12.3% (2 patients) of patients with m3 cancers and in 53.8% (7 patients) of those with sm1 cancers. The incidence of ly was significantly higher in the sm1 group than in the m3 group (P<0.05). In a multivariate analysis of factors for predicting lymph node metastasis, the presence of ly was the only significant predictor (P<0.05). The preoperative diagnostic accuracies of endoscopic ultrasonography (EUS), esophagogastroduodenoscopy (EGD) and an upper gastrointestinal series (UGS) for predicting depth of invasion were 27.8, 31.0 and 41.4%, respectively, with the majority of the misdiagnoses being overestimations. In conclusion, we suggested that ly is associated with lymph node metastasis in m3 or sm1 esophageal cancer. This association is significant for treatment-related decision making.
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Affiliation(s)
- JUNYA OGUMA
- Department of Surgery, School of Medicine, Keio University, Tokyo 160-8582
| | - SOJI OZAWA
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Kanagawa 259-1193, Japan
| | - YOSHIRO SAIKAWA
- Department of Surgery, School of Medicine, Keio University, Tokyo 160-8582
| | - YUKO KITAGAWA
- Department of Surgery, School of Medicine, Keio University, Tokyo 160-8582
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Repici A, Hassan C, Carlino A, Pagano N, Zullo A, Rando G, Strangio G, Romeo F, Nicita R, Rosati R, Malesci A. Endoscopic submucosal dissection in patients with early esophageal squamous cell carcinoma: results from a prospective Western series. Gastrointest Endosc 2010; 71:715-21. [PMID: 20363414 DOI: 10.1016/j.gie.2009.11.020] [Citation(s) in RCA: 133] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 11/10/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although endoscopic submucosal dissection (ESD) is becoming accepted as an established treatment for superficial esophageal squamous cell neoplasia, the majority of data on this endoscopic modality has been provided by Japanese series. OBJECTIVE To assess the efficacy and safety of ESD for esophageal squamous cell neoplasia in a consecutive series of patients treated in a Western setting. DESIGN AND SETTING Single-center, prospective observational study. PATIENTS AND INTERVENTION From January 2005 to July 2008, 20 patients with superficial esophageal squamous cell neoplasia were treated by ESD. MAIN OUTCOME MEASUREMENTS Rates of en bloc resection, complete resection, and complications were evaluated as short-term outcomes. Overall survival, local or distant recurrence, and postoperative stricture rates were evaluated as long-term outcomes. RESULTS ESD was performed in 20 patients (mean age 64 years, range 46-81 years; 16 men). The mean size of the lesion was 32 mm (range 15-60 mm); it was 30 mm or larger in 14 patients (70%). The mean time of ESD was 89 minutes (range 58-180 minutes). En bloc resection with resection-free margins was achieved in 18 patients (90%), whereas 2 patients presented with incomplete or indeterminate resection. Two cases (10%) of mediastinal emphysema without overt perforation and 1 case (5%) of post-ESD symptomatic stricture were reported. No local or distant post-ESD recurrence occurred in those with resection-free margins at a median follow-up of 18 months. LIMITATIONS Small number of patients and limited follow-up. CONCLUSION This Western series study confirms that ESD is a potentially curative treatment for superficial esophageal squamous cell neoplasia. Early and late complication rates were comparable to those of Japanese series. ESD should be probably considered as the treatment of choice in all large lesions amenable to endoscopic treatment.
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Affiliation(s)
- Alessandro Repici
- Gastroenterology Department, IRCCS Istituto Clinico Humanitas, Milan, Italy
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Chaves DM, Maluf Filho F, de Moura EGH, dos Santos MEL, Arrais LRG, Kawaguti F, Sakai P. Endoscopic submucosal dissection for the treatment of early esophageal and gastric cancer--initial experience of a western center. Clinics (Sao Paulo) 2010; 65:377-82. [PMID: 20454494 PMCID: PMC2862673 DOI: 10.1590/s1807-59322010000400005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Revised: 12/01/2009] [Accepted: 01/19/2010] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Endoscopic submucosal dissection is a new Japanese technique characterized by en-bloc resection of the entire lesion irrespective of size, with lower local recurrence when compared to endoscopic mucosal resection. OBJECTIVE To evaluate the feasibility, early results and complications of the endoscopic submucosal dissection technique for treating early gastric and esophageal cancer at the Endoscopic Unit of Clinics Hospital and Cancer Institute of the São Paulo University. MATERIALS AND METHODS Twenty patients underwent endoscopic resection using the endoscopic submucosal dissection technique for early gastric or esophageal cancer. The patients were evaluated prospectively as to the executability of the technique, the short-term results of the procedure and complications. RESULTS Sixteen gastric adenocarcinoma lesions and six esophageal squamous carcinoma lesions were resected. In the stomach, the mean diameter of the lesions was 16.2 mm (0.6-3.5 mm). Eight lesions were type IIa + IIc, four were type IIa and four IIc, with thirteen being well differentiated and three undifferentiated. Regarding the degree of invasion, five were M2, seven were M3, two were Sm1 and one was Sm2. The mean duration of the procedures was 85 min (20-160 min). In the esophagus, all of the lesions were type IIb, with a mean diameter of 17.8 mm (6-30 mm). Regarding the degree of invasion, three were M1, one was M2, one was M3 and one was Sm1. All had free lateral and deep margins. The mean time of the procedure was 78 min (20-150 min) CONCLUSION The endoscopic submucosal dissection technique was feasible in our service with a high success rate.
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Affiliation(s)
- Dalton Marques Chaves
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
| | - Fauze Maluf Filho
- Cancer Institute of São Paulo - São Paulo/SP, Brazil., Tel.: 55 11 3069.6221,
| | - Eduardo G. H. de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
| | - Marcos Eduardo Lera dos Santos
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
| | - Livia Ronise Garcia Arrais
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
| | - Fabio Kawaguti
- Cancer Institute of São Paulo - São Paulo/SP, Brazil., Tel.: 55 11 3069.6221,
| | - Paulo Sakai
- Cancer Institute of São Paulo - São Paulo/SP, Brazil., Tel.: 55 11 3069.6221,
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Ishii N, Uchida S, Itoh T, Horiki N, Matsuda M, Setoyama T, Suzuki S, Uemura M, Iizuka Y, Fukuda K, Suzuki K, Fujita Y. Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for superficial esophageal neoplasia. Is it safe for elderly patients? Surg Endosc 2010; 24:2110-9. [PMID: 20169365 DOI: 10.1007/s00464-010-0907-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 01/14/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Safety and efficacy of endoscopic submucosal dissection (ESD) for esophageal neoplasias have not been adequately investigated in elderly patients. This study was designed to evaluate the safety and efficacy of ESD for esophageal neoplasias in elderly patients. METHODS Fifty-three superficial esophageal neoplasias treated with ESD using a combination of small-caliber-tip transparent hood and flex knife from May 2006 to June 2009 were divided into elderly group (aged 70 years or older: 25 lesions in 23 patients) and nonelderly group (younger than aged 70 years: 28 lesions in 25 patients). Therapeutic efficacy, complications, and follow-up results were evaluated retrospectively. RESULTS The history of cerebral infarction or cardiopulmonary disease and the usage of antiplatelet agents or anticoagulants were significantly higher in elderly group (p 0.0050 and p 0.0013, respectively). Median procedural times in the elderly group and the nonelderly group were 93 ± 53 (range, 42-235) min and 95 ± 55 (range, 40-230) min (p 0.73), respectively. Median sizes of the neoplasias and the resected specimens were 14 ± 11 (range, 5-45) mm and 15 ± 17 (range, 5-83) mm (p 0.56), and 35 ± 12 (range, 18-60) mm and 38 ± 17 (range, 18-90) mm (p 0.38), respectively. En bloc resection rate was 100% in each group. Body temperature and white blood cell counts of the next day after ESD were significantly higher in the nonelderly group than in the elderly group (p 0.0087 and p 0.0043, respectively). There were no complications, such as postoperative bleeding or perforation, in each group. The median follow-up period of 23 ± 10 (range, 4-35) months in the elderly group revealed no local or distant metastasis. CONCLUSIONS ESD with a combination of small-caliber-tip transparent hood and flex knife is a safe and effective treatment for superficial esophageal neoplasia in elderly and nonelderly patients.
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Affiliation(s)
- Naoki Ishii
- Department of Gastroenterology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan.
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Gockel I, Domeyer M, Sgourakis GG, Schimanski CC, Moehler M, Kirkpatrick CJ, Lang H, Junginger T, Hansen T. Prediction model of lymph node metastasis in superficial esophageal adenocarcinoma and squamous cell cancer including D2-40 immunostaining. J Surg Oncol 2009; 100:191-8. [PMID: 19548259 DOI: 10.1002/jso.21336] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND It was the aim of our study to establish a model for prediction of lymph node metastases in superficial esophageal cancer. METHODS We analyzed the clinical and histopathological data of 50 consecutive patients with pT1-esophageal cancer who underwent oncological resection. Submucosal carcinomas (pT1b) were classified according to sm levels 1-3. D2-40 immunostaining was investigated using the ABC technique. In a first step, we performed univariate analysis (One-way ANOVA: Sigma restricted parameterization; test of SS whole vs. SS predicted) to test the predictive value of the following categorical parameters for lymph node status (positive/negative): sex, histologic tumor type, localization, surgical technique (transhiatal/transthoracic), grading, pT1-subclassification (pT1a, pT1b sm 1-3), pL-, pV-status, and D2-40 labeling. Simple regression was applied for the following continuous predictors: age and tumor size. All significant variables of univariate analysis were included in the multivariate analysis. For this purpose, we used the General Liner Models's analysis (forward stepwise). In a third step, the Kruskal-Wallis test with post hoc comparisons was intended to define the cut-off value of parameters tested. RESULTS Only the following variables gained statistical significance in univariate analysis: sex, histological tumor type, grading, pT1-subclassification, lymphatic infiltration, microvascular infiltration, D2-40 immunostaining, and tumor size (P < 0.05). Variables reaching significance in multivariate analysis were tumor size (P = 0.017) and pV-status (P = 0.037). In the Kruskal-Wallis test with post hoc comparisons, the cut-off value of tumor size was 2 cm (model P = 0.002) and between the categories (P < 0.05). CONCLUSIONS Lymph node positivity and lymphatic vessel infiltration did not linearly increase with sm tumor infiltration depth. The risk category of lymph node involvement in superficial esophageal cancer exists according to our prediction model on the basis of tumor size of >2 cm and microvascular infiltration. The hitherto common sm levels 1-3 classification of submucosal cancers appears to display a lesser impact than previously assumed with regard to prediction of potential lymph node metastases and consequently the indication for endoscopic or surgical therapy.
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Affiliation(s)
- I Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg University of Mainz, Langenbeckstr. 1, Mainz D-55131, Germany.
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Ishii N, Horiki N, Itoh T, Uemura M, Maruyama M, Suzuki S, Uchida S, Izuka Y, Fukuda K, Fujita Y. Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife is a safe and effective treatment for superficial esophageal neoplasias. Surg Endosc 2009; 24:335-42. [PMID: 19517169 DOI: 10.1007/s00464-009-0560-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Revised: 04/30/2009] [Accepted: 05/14/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Superficial esophageal neoplasias resected in piecemeal manner with endoscopic mucosal resection (EMR) sometimes recur locally, and additional treatments need to be developed. Efficacy and safety of endoscopic submucosal dissection (ESD) for esophageal neoplasias are not sufficiently demonstrated, so we conducted a retrospective study to evaluate the efficacy and safety of ESD for superficial esophageal neoplasias. METHODS Thirty-seven superficial esophageal neoplasias consisted of 34 squamous cell neoplasias and 3 columnar neoplasias in 35 patients were treated with ESD from May 2006 to July 2008. Patients were regularly followed up with endoscopy every 6 months, and with echoendoscope and computed tomography every year. Therapeutic efficacy, complications, and follow-up results were evaluated. RESULTS The mean size of the resected neoplasias and that of the resected specimens were 22 mm (range 10-83 mm) and 41 mm (range 18-90 mm), respectively. The mean duration of the ESD procedures was 117 min (range 40-235 min). The overall rates of en bloc resection and of free margin resection were 100% (37/37) and 95% (35/37), respectively. The mean follow-up period of 19 months (range 7-32 months) revealed no local or distant recurrence. There were no complications such as bleeding or perforation in any case. In all nine cases, the strictures were successfully managed with prophylactic endoscopic balloon dilation. CONCLUSIONS ESD with a combination of small-caliber-tip transparent hood and flex knife is a safe endoscopic treatment for superficial esophageal neoplasias and enables large en bloc resection.
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Affiliation(s)
- Naoki Ishii
- Department of Gastroenterology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan.
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Ishii N, Horiki N, Itoh T, Uemura M, Maruyama M, Suzuki S, Uchida S, Izuka Y, Fukuda K, Fujita Y. Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife is a safe and effective treatment for superficial esophageal neoplasias. Surg Endosc 2009. [PMID: 19517169 DOI: 10.1007/s00464-009-0560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Superficial esophageal neoplasias resected in piecemeal manner with endoscopic mucosal resection (EMR) sometimes recur locally, and additional treatments need to be developed. Efficacy and safety of endoscopic submucosal dissection (ESD) for esophageal neoplasias are not sufficiently demonstrated, so we conducted a retrospective study to evaluate the efficacy and safety of ESD for superficial esophageal neoplasias. METHODS Thirty-seven superficial esophageal neoplasias consisted of 34 squamous cell neoplasias and 3 columnar neoplasias in 35 patients were treated with ESD from May 2006 to July 2008. Patients were regularly followed up with endoscopy every 6 months, and with echoendoscope and computed tomography every year. Therapeutic efficacy, complications, and follow-up results were evaluated. RESULTS The mean size of the resected neoplasias and that of the resected specimens were 22 mm (range 10-83 mm) and 41 mm (range 18-90 mm), respectively. The mean duration of the ESD procedures was 117 min (range 40-235 min). The overall rates of en bloc resection and of free margin resection were 100% (37/37) and 95% (35/37), respectively. The mean follow-up period of 19 months (range 7-32 months) revealed no local or distant recurrence. There were no complications such as bleeding or perforation in any case. In all nine cases, the strictures were successfully managed with prophylactic endoscopic balloon dilation. CONCLUSIONS ESD with a combination of small-caliber-tip transparent hood and flex knife is a safe endoscopic treatment for superficial esophageal neoplasias and enables large en bloc resection.
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Affiliation(s)
- Naoki Ishii
- Department of Gastroenterology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan.
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Abstract
Therapeutic endoscopy plays a major role in the management of gastrointestinal (GI) neoplasia. Its indications can be generalized into four broad categories; to remove or obliterate neoplastic lesion, to palliate malignant obstruction, or to treat bleeding. Only endoscopic resection allows complete histological staging of the cancer, which is critical as it allows stratification and refinement for further treatment. Although other endoscopic techniques, such as ablation therapy, may also cure early GI cancer, they can not provide a definitive pathological specimen. Early stage lesions reveal low frequency of lymph node metastasis which allows for less invasive treatments and thereby improving the quality of life when compared to surgery. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are now accepted worldwide as treatment modalities for early cancers of the GI tract.
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Affiliation(s)
- Giovannini Marc
- Endoscopic Unit, Paoli-Calmettes Institute, 232 Bd. St-Marguerite, Cedex 13273, France.
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