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Wang Z, Li F, Zhu M, Lu T, Wen L, Yang S, Zhuang X, Zhang S, Ma Y, Lian J. Prognostic prediction and comparison of three staging programs for patients with advanced (T2-T4) esophageal squamous carcinoma after radical resection. Front Oncol 2024; 14:1376527. [PMID: 38993638 PMCID: PMC11236680 DOI: 10.3389/fonc.2024.1376527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 06/12/2024] [Indexed: 07/13/2024] Open
Abstract
Purpose Lymph node-based staging protocols are frequently employed to evaluate the prognosis of esophageal cancer, yet their accuracy remains contentious. The present study was conducted to assess the prognostic significance of three lymph node staging systems, namely N stage, lymph node rate (LNR), and log odds of positive lymph nodes (LODDS), in patients diagnosed with advanced (T2-T4) esophageal squamous cell carcinoma (ESCC). Methods This cohort comprised 319 eligible patients, with an additional 409 individuals retrieved from the Surveillance, Epidemiology, and End Results (SEER) database, forming the validation cohort. Differences in overall survival (OS) of patients between groups were assessed using the log-rank test. Prognostic independent risk variables were identified, and lymph nodes (LN) prognostic models were built using multivariate Cox regression analysis. Besides, the predictive accuracy of each model was evaluated utilizing the (-2) log-likelihood ratio (-2LLR), the likelihood ratio χ2 score (LRχ2), the Akaike information criterion (AIC), and Harrell's concordance index (C-index). To further evaluate the potential superiority of the model, a nomogram was constructed for comparison with the conventional Tumor Node Metastasis (TNM) staging approach. Results Independent prognostic factors for advanced ESCC include the N stage, LNR, and LODDS. Herein, LODDS presented higher values for C-index and LRχ2, and lower values for AIC and -2LLR in OS compared to the others. Consequently, a nomogram was constructed based on LODDS. Calibration curves exhibited strong agreement, and assessment through C-index, receiver operating characteristic (ROC) curves, and clinical decision curve analysis (DCA) demonstrated promising clinical applicability. Conclusion LODDS emerges as a promising future prognostic indicator. After surgery, the proposed model holds the potential to provide valuable treatment recommendations for patients with advanced ESCC.
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Affiliation(s)
- Zhongshuai Wang
- Cancer Hospital Affiliated to Shanxi Medical University/ Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
- Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, China
| | - Feng Li
- Cancer Hospital Affiliated to Shanxi Medical University/ Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
- Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, China
| | - Mingchuang Zhu
- Cancer Hospital Affiliated to Shanxi Medical University/ Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
- Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, China
| | - Tao Lu
- Cancer Hospital Affiliated to Shanxi Medical University/ Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
- Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, China
| | - Linqi Wen
- Cancer Hospital Affiliated to Shanxi Medical University/ Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
- Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, China
| | - Shengzhao Yang
- Cancer Hospital Affiliated to Shanxi Medical University/ Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
- Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, China
| | - Xiaofei Zhuang
- Cancer Hospital Affiliated to Shanxi Medical University/ Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
- Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, China
| | - Shuangping Zhang
- Cancer Hospital Affiliated to Shanxi Medical University/ Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
- Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, China
| | - Yong Ma
- Cancer Hospital Affiliated to Shanxi Medical University/ Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
- Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, China
| | - Jianhong Lian
- Cancer Hospital Affiliated to Shanxi Medical University/ Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
- Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, China
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Nguyen CL, Tovmassian D, Isaacs A, Falk GL. Risk of lymph node metastasis in T1 esophageal adenocarcinoma: a meta-analysis. Dis Esophagus 2024; 37:doae012. [PMID: 38391209 DOI: 10.1093/dote/doae012] [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: 03/04/2023] [Revised: 06/29/2023] [Accepted: 02/02/2024] [Indexed: 02/24/2024]
Abstract
Patients with early (T1) esophageal adenocarcinoma (EAC) are increasingly having definitive local therapy endoscopically. Endoscopic resection is not able to pathologically stage or treat lymph node metastasis (LNM). Accurate identification of patients having nodal metastasis is critical to select endoscopic therapy over surgery. This study aimed to define the risk of LNM in T1 EAC. A meta-analysis of studies of patients who underwent surgery and lymphadenectomy with assessment of LNM was performed according to PRISMA. Main outcome was probability of LNM in T1a and T1b disease. Secondary outcomes were risk factors for LNM and rate of LNM in submucosal T1b (SM1, SM2, and SM3) disease. Registered with PROSPERO (CRD42022341794). Twenty cohort studies involving 2264 patients with T1 EAC met inclusion criteria: T1a (857 patients) with 36 (4.2%) node positive and T1b (1407 patients) with 327 (23.2%) node positive. Subgroup analysis of T1b lesions was available in 10 studies (405 patients). Node positivity for SM1, SM2, and SM3 was 16.3%, 16.2%, and 29.4%, respectively. T1 substage (odds ratio [OR] 7.72, 95% confidence interval [CI] 4.45-13.38, P < 0.01), tumor differentiation (OR 2.82, 95% CI 2.06-3.87, P < 0.01), and lymphovascular invasion (OR 13.65, 95% CI 6.06-30.73, P < 0.01) were associated with LNM. T1a disease demonstrated a 4.2% nodal metastasis rate and T1b disease a rate of 23.2%. Endoscopic therapy should be reserved for T1a disease and perhaps select T1b disease, which has a moderately high rate of nodal metastasis. There were inadequate data to stratify T1b SM disease into 'low-risk' and 'high-risk' based on tumor differentiation and lymphovascular invasion.
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Affiliation(s)
- Chu Luan Nguyen
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - David Tovmassian
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Anna Isaacs
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Gregory L Falk
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
- Sydney Heartburn Clinic, Lindfield, NSW, Australia
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Ebert MP, Fischbach W, Hollerbach S, Höppner J, Lorenz D, Stahl M, Stuschke M, Pech O, Vanhoefer U, Porschen R. S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:535-642. [PMID: 38599580 DOI: 10.1055/a-2239-9802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Matthias P Ebert
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universitätsmedizin, Universität Heidelberg, Mannheim
- DKFZ-Hector Krebsinstitut an der Universitätsmedizin Mannheim, Mannheim
- Molecular Medicine Partnership Unit, EMBL, Heidelberg
| | - Wolfgang Fischbach
- Deutsche Gesellschaft zur Bekämpfung der Krankheiten von Magen, Darm und Leber sowie von Störungen des Stoffwechsels und der Ernährung (Gastro-Liga) e. V., Giessen
| | | | - Jens Höppner
- Klinik für Allgemeine Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck
| | - Dietmar Lorenz
- Chirurgische Klinik I, Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Darmstadt, Darmstadt
| | - Michael Stahl
- Klinik für Internistische Onkologie und onkologische Palliativmedizin, Evang. Huyssensstiftung, Evang. Kliniken Essen-Mitte, Essen
| | - Martin Stuschke
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Essen, Essen
| | - Oliver Pech
- Klinik für Gastroenterologie und Interventionelle Endoskopie, Krankenhaus Barmherzige Brüder, Regensburg
| | - Udo Vanhoefer
- Klinik für Hämatologie und Onkologie, Katholisches Marienkrankenhaus, Hamburg
| | - Rainer Porschen
- Gastroenterologische Praxis am Kreiskrankenhaus Osterholz, Osterholz-Scharmbeck
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4
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Tankel J, Ijner T, Ferri C, Trottenberg T, Dehghani M, Najmeh S, Fiset PO, Alsaddah S, Cools-Lartigue J, Spicer J, Mueller C, Ferri L. Esophagectomy versus observation following endoscopic submucosal dissection of pT1b esophageal adenocarcinoma. Surg Endosc 2024; 38:1342-1350. [PMID: 38114878 DOI: 10.1007/s00464-023-10623-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Management following endoscopic submucosal dissection (ESD) of pT1b esophageal adenocarcinoma (EAC) remains controversial. This study compared pathological and survival outcomes of patients after endoscopic resection (ER) of pT1b EAC followed by either en bloc esophagectomy or observation. METHODS From 1/12 to 12/22, all patients with pT1b EAC treated with ER were identified from a prospectively maintained departmental database. ESD was curative (all of: Submucosal invasion < 500 μm; G1/2, LVI/PNI-; deep margin-) or non-curative (one or more of Submucosal invasion ≥ 500 μm; G3; LVI/PNI+; deep margin+). Patients were allocated to observation (OBS) or esophagectomy (SURG) based on patient factors/preference and pathological variables. RESULTS 56/171 ERs met the inclusion criteria. ER was curative in 8/56 (14%) and non-curative in 48/56 (86%). OBS was undertaken after 8/27 (30%) curative and 19/27 (70%) non-curative resections. All 29 SURG patients had non-curative ERs and were younger, had lower Charlson comorbidity scores and had more deep margin + lesions than OBS patients. Post-esophagectomy, 15/29 (52%) had no residual disease within the surgical specimen while pT+N-/pT-N+/pT+N+ occurred in 5/3/6 (17%/10%/21%) patients. Of those with residual disease in the surgical specimen, 12/14 (86%) had deep margin + ERs; however, only ESD instead of EMR was independently associated with a lower risk of residual disease (OR 0.431, 95% CI - 0.016 to 1.234, p = 0.045). OBS and SURG patients had equivalent overall survival outcomes and recurrence was low in both groups even following non-curative ER. Follow-up was 28 months (0-102) and 30 months (0-97), respectively. CONCLUSION In select patients, including some of those with a non-curative ESD resection of pT1B EAC, surveillance alone may be appropriate. Alternatives beyond traditional pathological features is needed to direct patient care more accurately.
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Affiliation(s)
- James Tankel
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Tvisha Ijner
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Chiara Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Talia Trottenberg
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Mehrnoush Dehghani
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Sara Najmeh
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Pierre Olivier Fiset
- Department of Pathology, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Saba Alsaddah
- Department of Pathology, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Jonathan Cools-Lartigue
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Jonathan Spicer
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Carmen Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada
| | - Lorenzo Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, Canada.
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5
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Leclercq P, Bisschops R, Bergman JJGHM, Pouw RE. Management of high risk T1 esophageal adenocarcinoma following endoscopic resection. Best Pract Res Clin Gastroenterol 2024; 68:101882. [PMID: 38522880 DOI: 10.1016/j.bpg.2024.101882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/17/2024] [Indexed: 03/26/2024]
Abstract
High-risk T1 esophageal adenocarcinoma (HR-T1 EAC) is defined as T1 cancer, with one or more of the following histological criteria: submucosal invasion, poorly or undifferentiated cancer, and/or presence of lympho-vascular invasion. Esophagectomy has long been the only available treatment for these HR-T1 EACs and was considered necessary because of a presumed high risk of lymph node metastases up to 46%. However, endoscopic submucosal disscection have made it possible to radically remove HR-T1 EAC, irrespective of size, while leaving the esophageal anatomy intact. Parallel to this development, new publications demonstrated that the risk of lymph node metastases for HR-T1 EAC may be even <24%. Therefore, indications for endoscopic treatment of HR-T1 EAC are being reconsidered and current research aims at finding the optimal management strategy for this indication, where watchful waiting may proof to be an acceptable strategy in selected patients. In this review, we will discuss the latest developments in this field.
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Affiliation(s)
- Philippe Leclercq
- Departement of Gastroenterology, Universitair Ziekenhuis Leuven, 49 Herestraat, 3000, LEUVEN, Belgium.
| | - Raf Bisschops
- Departement of Gastroenterology, Universitair Ziekenhuis Leuven, 49 Herestraat, 3000, LEUVEN, Belgium.
| | - Jacques J G H M Bergman
- Dept. of Gastroenterology and Hepatology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, 1081, HV, Netherlands.
| | - Roos E Pouw
- Dept. of Gastroenterology and Hepatology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, 1081, HV, Netherlands.
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6
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Fernandes A, Li C, French D, Ellsmere J. Ten-year follow-up of endoscopic mucosal resection versus esophagectomy for esophageal intramucosal adenocarcinoma in the setting of Barrett's esophagus: a Canadian experience. Surg Endosc 2023; 37:8735-8741. [PMID: 37563345 DOI: 10.1007/s00464-023-10318-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/19/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is an effective treatment for esophageal intramucosal adenocarcinoma (IMC), with similar recurrence and mortality rates versus esophagectomy in up to 5 years of follow-up. Long-term outcomes to 10 years have not been studied. This retrospective study investigates IMC eradication, recurrence, morbidity and mortality at 10 years following EMR versus esophagectomy in a single Canadian institution. METHODS Patients with IMC treated via esophagectomy or EMR from 2006 to 2015 were included. Post-EMR endoscopic follow-up occurred every 3 months for 1 year, every 6 months for 2 years and every 12 months thereafter. Categorical variables were expressed as percentages and continuous variables as mean with standard deviation or median and interquartile range. The student's t-test and Fischer's exact test were used for comparisons. Survival analysis utilized the Kaplan-Meier estimator and log-rank test. RESULTS Twenty-four patients were included. Patient and tumor characteristics were similar between groups. Median follow-up for EMR and esophagectomy were 85.2 months [IQR 64.8] and 126 months [IQR 54] respectively. A mean of 1.3 EMR (SD 1.1) were required for eradication, which was seen in 12 patients (12/14, 86%). No EMR-related complications occurred. Disease progression was seen in two patients (2/14, 14%); local recurrence was seen in 1 patient (1/14, 7%). Esophagectomy eradicated IMC in 10 patients (10/10, 100%); recurrence was seen in 2 (2/10, 20%, metastatic). Major, early esophagectomy-related morbidity affected 3 patients (3/10, 30%), and late morbidity was documented for 9 (9/10, 90%). Esophagectomy and EMR had similar recurrence rates (p = 0.554). Esophagectomy was associated with significantly more procedure-related morbidity (p < 0.001). There was no difference in mortality (p = 0.442) or disease-free survival (p = 0.512) between treatment groups. CONCLUSION EMR and esophagectomy for the treatment of IMC are associated with comparable recurrence rates and disease-free survival in 10-year follow-up. EMR is associated with significantly lower procedure-associated morbidity. EMR can be used to treat T1a distal esophageal adenocarcinoma with minimal procedure-related morbidity, and acceptable oncologic outcomes in long-term follow-up.
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Affiliation(s)
- Alisha Fernandes
- Division of General and Gastrointestinal Surgery, Department of Surgery, Dalhousie University, Room 8-23/4 Victoria Building, QEII-HSC, VG Site, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Chao Li
- Division of General Surgery, Department of Surgery, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Canada
| | - Daniel French
- Division of Thoracic Surgery, Department of Surgery, Dalhousie University, Halifax, Canada
| | - James Ellsmere
- Division of General and Gastrointestinal Surgery, Department of Surgery, Dalhousie University, Room 8-23/4 Victoria Building, QEII-HSC, VG Site, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada.
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7
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S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e209-e307. [PMID: 37285869 DOI: 10.1055/a-1771-6953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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8
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Gambitta P, Fontana P, Fanetti I, Veglia G, Vertemati M, Armellino A, Aseni P. Diagnostic Accuracy of Endoscopic Ultrasonography in Selecting Patients for Endoscopic Submucosal Dissection for Early Gastrointestinal Neoplasms. J Clin Med 2023; 12:jcm12072505. [PMID: 37048589 PMCID: PMC10094822 DOI: 10.3390/jcm12072505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/21/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Tumor invasion depth and lymph node metastasis determine the prognosis of gastrointestinal (GI) neoplasms. GI neoplasms limited to mucosa (m1 or m2) and superficial submucosa (sm1) can be treated effectively with minimally invasive endoscopic therapy, while the deep invasion of the submucosa (sm2 or sm3) is associated with lymph node metastasis, and surgical resection is required. Correct staging is therefore crucial for preoperative evaluation and planning. Endoscopic ultrasonography (EUS) can be used to detect the depth of invasion due to its close proximity to the lesion. The diagnostic accuracy of EUS, when compared to conventional endoscopic staging, is debated as it can under- or overstage the lesion. We aim in this study to determine if EUS can accurately differentiate mucosal from submucosal GI neoplasms to select patients with early GI lesions for endoscopic submucosal dissection (ESD) or surgery. From March 2014 to February 2022, 293 patients with early superficial GI neoplasms were admitted to our endoscopic unit for EUS staging. To evaluate the accuracy of EUS, we compared the preoperative EUS findings with the definitive histopathologic findings on the resected specimen. Overall, 242 of 293 lesions were correctly staged by EUS (82.59%). In the evaluation of submucosal invasion or deeper, EUS understaged 38 of 293 (12.96%) and overstaged 13 of 293 (4.43%) lesions. EUS has excellent accuracy in staging superficial GI neoplasms; its use is highly recommended before ESD since it can also detect lymph node metastases around the lesions, thus changing the indication from ESD to surgery.
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Affiliation(s)
- Pietro Gambitta
- Department of Gastroenterology, Ospedale Civile di Legnano, ASST-Ovest Milanese, 20025 Legnano, Italy
| | - Paola Fontana
- Department of Gastroenterology, Ospedale Civile di Legnano, ASST-Ovest Milanese, 20025 Legnano, Italy
| | - Ilaria Fanetti
- Department of Gastroenterology, Ospedale Civile di Legnano, ASST-Ovest Milanese, 20025 Legnano, Italy
| | - Giulia Veglia
- Department of Gastroenterology, Ospedale Civile di Legnano, ASST-Ovest Milanese, 20025 Legnano, Italy
| | - Maurizio Vertemati
- Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, 20157 Milan, Italy
| | - Antonio Armellino
- Endoscopy Division, Ospedale San Leopoldo Mandic di Merate, ASST Lecco, 23807 Lecco, Italy
| | - Paolo Aseni
- Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, 20157 Milan, Italy
- Department of Emergency, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- Correspondence:
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9
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Yang D, King W, Aihara H, Karasik MS, Ngamruengphong S, Aadam AA, Othman MO, Sharma N, Grimm IS, Rostom A, Elmunzer BJ, Jawaid SA, Perbtani YB, Hoffman BJ, Akki AS, Schlachterman A, Coman RM, Wang AY, Draganov PV. Effect of endoscopic submucosal dissection on histologic diagnosis in Barrett's esophagus visible neoplasia. Gastrointest Endosc 2022; 95:626-633. [PMID: 34906544 DOI: 10.1016/j.gie.2021.11.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/30/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Data are limited on the role of endoscopic submucosal dissection (ESD) as a potential diagnostic and staging tool in Barrett's esophagus (BE) neoplasia. We aimed to evaluate the frequency and factors associated with change of histologic diagnosis by ESD compared with pre-ESD histology. METHODS This was a multicenter, prospective cohort study of patients who underwent ESD for BE visible neoplasia. A change in histologic diagnosis was defined as "upstaged" or "downstaged" if the ESD specimen had a higher or lower degree, respectively, of dysplasia or neoplasia when compared with pre-ESD specimens. RESULTS Two hundred five patients (median age, 69 years; 81% men) with BE visible neoplasia underwent ESD from 2016 to 2021. Baseline histology was obtained using forceps (n = 182) or EMR (n = 23). ESD changed the histologic diagnosis in 55.1% of cases (113/205), of which 68.1% were upstaged and 31.9% downstaged. The frequency of change in diagnosis after ESD was similar whether baseline histology was obtained using forceps (55.5%) or EMR (52.2%) (P = .83). In aggregate, 23.9% of cases (49/205) were upstaged to invasive cancer on ESD histopathology. On multivariate analysis, lesions in the distal esophagus and gastroesophageal junction (odds ratio, 2.1; 95 confidence interval, 1.1-3.9; P = .02) and prior radiofrequency ablation (odds ratio, 2.5; 95% confidence interval, 1.2-5.5; P = .02) were predictors of change in histologic diagnosis. CONCLUSIONS ESD led to a change of diagnosis in more than half of patients with BE visible neoplasia. Selective ESD can serve as a potential diagnostic and staging tool, particularly in those with suspected invasive disease. (Clinical trial registration number: NCT02989818.).
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - William King
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael S Karasik
- Division of Gastroenterology and Hepatology, Hartford Hospital, Hartford, Connecticut, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Abdul Aziz Aadam
- Division of Gastroenterology and Hepatology, Northwestern Medicine Digestive Health Center, Chicago, Illinois, USA
| | - Mohamed O Othman
- Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas, USA
| | - Neil Sharma
- Division of Interventional Endoscopic Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, Indiana, USA
| | - Ian S Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA
| | - Alaa Rostom
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Salmaan A Jawaid
- Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas, USA
| | - Yaseen B Perbtani
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Brenda J Hoffman
- Division of Gastroenterology and Hepatology, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ashwin S Akki
- Department of Pathology Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida, USA
| | - Alexander Schlachterman
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Roxana M Coman
- Division of Hospital Gastroenterology, Atrium/Navicent Health, Mercer University, College of Medicine, Macon, Georgia, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
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10
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Suetsugu T, Tanaka Y, Sato Y, Fukada M, Yasufuku I, Yoshida K. Intraperitoneal perforation through lymph node metastases in a patient with esophageal squamous cell carcinoma during intensive chemotherapy: A case report with literature review. Int J Surg Case Rep 2022; 93:106944. [PMID: 35334369 PMCID: PMC8943425 DOI: 10.1016/j.ijscr.2022.106944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Esophageal fistula after treatment is a critical and fatal complication of esophageal cancer. A fistula forming from lower thoracic esophageal cancer to the peritoneum through lymph node metastases following chemotherapy has not been reported. We report a case of peritonitis due to lymph node perforation through the tumor ulcer after induction of biweekly docetaxel, cisplatin, and 5FU combined chemotherapy (Bi-DCF) for advanced esophageal squamous cell carcinoma (ESCC). Presentation of case A 48-year-old woman was referred to us with a diagnosis of lower thoracic ESCC and thoracoabdominal aortic aneurysm. Esophagogastroduodenoscopy showed a circumferential type 3 tumor with stenosis in the lower thoracic esophagus. Contrast-enhanced computed tomography (CT) showed a thoracoabdominal aortic aneurysm and wall thickening of the lower thoracic esophagus that was suspicious of esophageal cancer. Lymph node metastases dumpling from around the tumor to abdominal cavity were also observed. The initial diagnosis was ESCC T3 N3 M1 (para-aortic lymph nodes and liver) Stage IVB. She was started on Bi-DCF (docetaxel 35 mg/m2 days 1/15, cisplatin 40 mg/m2 days 1/15, 5FU 400 mg/m2 days 1–5, 15–19) as the first-line regimen. The third day after starting chemotherapy, she felt strong abdominal pain, and internal necrosis of lymph nodes around the primary lesion and free air in the abdominal cavity were found. Peritonitis was diagnosed due to a fistula formed from the lower thoracic ESCC to the peritoneum through lymph node metastases. She underwent emergency laparoscopic drainage, omental filling, and jejunostomy. Postoperatively, her general condition and inflammatory findings improved within 10 days, and she could continue intensive chemotherapy as scheduled. Discussion Because of the risk of perforation and fistula in regimens that are expected to cause tumor shrinkage, careful observation may be required after starting chemotherapy. Conclusion We report the first case of peritonitis caused by perforation through lymph node metastasis of thoracic esophageal cancer.
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Affiliation(s)
- Tomonari Suetsugu
- Department of Gastroenterological Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Yoshihiro Tanaka
- Department of Gastroenterological Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan.
| | - Yuta Sato
- Department of Gastroenterological Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Masahiro Fukada
- Department of Gastroenterological Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Itaru Yasufuku
- Department of Gastroenterological Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Kazuhiro Yoshida
- Department of Gastroenterological Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan.
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11
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Gotink AW, van de Ven SEM, Ten Kate FJC, Nieboer D, Suzuki L, Weusten BLAM, Brosens LAA, van Hillegersberg R, Alvarez Herrero L, Seldenrijk CA, Alkhalaf A, Moll FCP, Schoon EJ, van Lijnschoten I, Tang TJ, van der Valk H, Nagengast WB, Kats-Ugurlu G, Plukker JTM, Houben MHMG, van der Laan JS, Pouw RE, Bergman JJGHM, Meijer SL, van Berge Henegouwen MI, Wijnhoven BPL, de Jonge PJF, Doukas M, Bruno MJ, Biermann K, Koch AD. Individual risk calculator to predict lymph node metastases in patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study. Endoscopy 2022; 54:109-117. [PMID: 33626582 DOI: 10.1055/a-1399-4989] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Lymph node metastasis (LNM) is possible after endoscopic resection of early esophageal adenocarcinoma (EAC). This study aimed to develop and internally validate a prediction model that estimates the individual risk of metastases in patients with pT1b EAC. METHODS A nationwide, retrospective, multicenter cohort study was conducted in patients with pT1b EAC treated with endoscopic resection and/or surgery between 1989 and 2016. The primary end point was presence of LNM in surgical resection specimens or detection of metastases during follow-up. All resection specimens were histologically reassessed by specialist gastrointestinal pathologists. Subdistribution hazard regression analysis was used to develop the prediction model. The discriminative ability of this model was assessed using the c-statistic. RESULTS 248 patients with pT1b EAC were included. Metastases were seen in 78 patients, and the 5-year cumulative incidence was 30.9 % (95 % confidence interval [CI] 25.1 %-36.8 %). The risk of metastases increased with submucosal invasion depth (subdistribution hazard ratio [SHR] 1.08, 95 %CI 1.02-1.14, for every increase of 500 μm), lymphovascular invasion (SHR 2.95, 95 %CI 1.95-4.45), and for larger tumors (SHR 1.23, 95 %CI 1.10-1.37, for every increase of 10 mm). The model demonstrated good discriminative ability (c-statistic 0.81, 95 %CI 0.75-0.86). CONCLUSIONS A third of patients with pT1b EAC experienced metastases within 5 years. The probability of developing post-resection metastases was estimated with a personalized predicted risk score incorporating tumor invasion depth, tumor size, and lymphovascular invasion. This model requires external validation before implementation into clinical practice.
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Affiliation(s)
- Annieke W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Fiebo J C Ten Kate
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands.,Department of Pathology, Isala Clinics, Zwolle, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Lucia Suzuki
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Cees A Seldenrijk
- Department of Pathology, Pathology DNA, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Freek C P Moll
- Department of Pathology, Isala Clinics, Zwolle, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Thjon J Tang
- Department of Gastroenterology and Hepatology, Ijsselland Hospital, Capelle aan den Ijssel, the Netherlands
| | - Hans van der Valk
- Department of Pathology, Ijselland Hospital, Capelle aan den Ijssel, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Gursah Kats-Ugurlu
- Department of Pathology, University Medical Center Groningen, Groningen, the Netherlands
| | - John T M Plukker
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | | | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Michael Doukas
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
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12
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van de Ven SEM, Suzuki L, Gotink AW, Ten Kate FJC, Nieboer D, Weusten BLAM, Brosens LAA, van Hillegersberg R, Alvarez Herrero L, Seldenrijk CA, Alkhalaf A, Moll FCP, Curvers W, van Lijnschoten IG, Tang TJ, van der Valk H, Nagengast WB, Kats-Ugurlu G, Plukker JTM, Houben MHMG, van der Laan JS, Pouw RE, Bergman JJGHM, Meijer SL, van Berge Henegouwen MI, Wijnhoven BPL, de Jonge PJF, Doukas M, Bruno MJ, Biermann K, Koch AD. Lymphovascular invasion quantification could improve risk prediction of lymph node metastases in patients with submucosal (T1b) esophageal adenocarcinoma. United European Gastroenterol J 2021; 9:1066-1073. [PMID: 34609076 PMCID: PMC8598963 DOI: 10.1002/ueg2.12151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/16/2021] [Accepted: 08/05/2021] [Indexed: 01/08/2023] Open
Abstract
Aim To quantify lymphovascular invasion (LVI) and to assess the prognostic value in patients with pT1b esophageal adenocarcinoma. Methods In this nationwide, retrospective cohort study, patients were included if they were treated with surgery or endoscopic resection for pT1b esophageal adenocarcinoma. Primary endpoint was the presence of metastases, lymph node metastases, or distant metastases, in surgical resection specimens or during follow‐up. A prediction model to identify risk factors for metastases was developed and internally validated. Results 248 patients were included. LVI was distributed as follows: no LVI (n = 196; 79.0%), 1 LVI focus (n = 16; 6.5%), 2–3 LVI foci (n = 21; 8.5%) and ≥4 LVI foci (n = 15; 6.0%). Seventy‐eight patients had metastases. The risk of metastases was increased for tumors with 2–3 LVI foci [subdistribution hazard ratio (SHR) 3.39, 95% confidence interval (CI) 2.10–5.47] and ≥4 LVI foci (SHR 3.81, 95% CI 2.37–6.10). The prediction model demonstrated a good discriminative ability (c‐statistic 0.81). Conclusion The risk of metastases is higher when more LVI foci are present. Quantification of LVI could be useful for a more precise risk estimation of metastases. This model needs to be externally validated before implementation into clinical practice.
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Affiliation(s)
- Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Lucia Suzuki
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Annieke W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Fiebo J C Ten Kate
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands.,Department of Pathology, Isala Clinics, Zwolle, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Cees A Seldenrijk
- Department of Pathology, Pathology DNA, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands
| | - Freek C P Moll
- Department of Pathology, Isala Clinics, Zwolle, The Netherlands
| | - Wouter Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Thjon J Tang
- Department of Gastroenterology and Hepatology, Ijsselland Hospital, Capelle aan den Ijssel, The Netherlands
| | - Hans van der Valk
- Department of Pathology, Ijselland Hospital, Capelle aan den Ijssel, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Gursah Kats-Ugurlu
- Department of Pathology, University Medical Center Groningen, Groningen, The Netherlands
| | - John T M Plukker
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, The Netherlands
| | | | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Pieter J F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Michael Doukas
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
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13
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Karamchandani DM, Gonzalez RS, Westerhoff M, Westbrook LM, Panarelli NC, Al-Nuaimi M, King T, Arnold CA. Measuring depth of invasion of submucosa - invasive adenocarcinoma in oesophageal endoscopic specimens: how good are we?☆. Histopathology 2021; 80:420-429. [PMID: 34519098 DOI: 10.1111/his.14566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/12/2021] [Indexed: 01/10/2023]
Abstract
AIMS Emerging data support that submucosa-invasive (pT1b) esophageal adenocarcinomas are cured via endoscopic resection, provided that invasion measures ≤500 μm, they lack other histological features predictive of nodal metastasis and have negative margins. Hence, pathologists' measurement of the depth of submucosal invasion in endoscopic resections may dictate further management (i.e. endoscopic follow-up versus oesophagectomy). In this study, we assessed the interobserver agreement in measuring the depth of submucosal invasion in oesophageal endoscopic resections. METHODS AND RESULTS Six subspecialised gastrointestinal (GI) pathologists from five academic centres independently measured the depth of submucosal invasion in μm from the deepest muscularis mucosae on 37 oesophageal endoscopic resection slides (round 1 scoring). A consensus meeting with a systematic approach for measuring and discussion of pitfalls was undertaken and remeasuring (round 2 scoring) was conducted. Interobserver agreement was assessed by the intraclass correlation coefficient (ICC) and Cohen's kappa statistics. A lack of agreement was seen among the six reviewers with a poor ICC for both rounds: 1 [0.40, 95% confidence interval (CI) = 0.26-0.56] and 2 (0.49, 95% CI = 0.34-0.63). When measurements were categorised as < or >500 μm, the overall agreement among the six reviewers was only fair for both rounds: 1 (kappa = 0.37, 95% CI = 0.22-0.53) and 2 (kappa = 0.29, 95% CI = 0.12-0.46). CONCLUSIONS Our study shows a lack of agreement among gastrointestinal pathologists in measuring the depth of submucosal invasion in oesophageal endoscopic resections despite formulating a consensus approach for scoring. If important management decisions continue to be based upon this parameter, more reproducible and concrete guidelines are needed.
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Affiliation(s)
- Dipti M Karamchandani
- Department of Pathology, 1 Penn State Health Milton S. Hershey Medical Center/Penn State College of Medicine, Hershey, PA, USA
| | | | | | | | | | - Mayyadah Al-Nuaimi
- Department of Pathology, 1 Penn State Health Milton S. Hershey Medical Center/Penn State College of Medicine, Hershey, PA, USA
| | - Tonya King
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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14
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Jia R, Xiao W, Zhang H, Yu Z. Comparative study of treatment options and construction nomograms to predict survival for early-stage esophageal cancer: a population-based study. Scand J Gastroenterol 2021; 56:635-646. [PMID: 33872097 DOI: 10.1080/00365521.2021.1910997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to investigate the impact of several common treatment options on the long-term survival of patients with early-stage esophageal cancer and to construct nomograms for survival prediction. METHOD This study was performed using the Surveillance, Epidemiology and End Results (SEER) database (2004-2015) on patients with early-stage (pT1N0M0) esophageal cancer who underwent endoscopic local therapy (ET), radiotherapy (RT), esophagectomy (ES) or neoadjuvant therapy (NT). Multivariate Cox regression was used to explore which factors influenced patient survival, and these factors were then incorporated into propensity sore matching (PSM) and the construction of nomogram plots. Kaplan-Meier analysis was used to compare whether there was a difference in long-term survival between the other three treatments and esophagectomy. RESULT Data from 4184 patients were included in this study. Multivariate Cox regression analysis showed that age, grade, marital status, and treatment method were independent factors affecting survival. After matching, Kaplan-Meier analysis showed that the ET group had better CSS than the ES group, but no difference in OS, while the NT and RT groups had worse OS and CSS than the ES group. In the nomogram prediction model, the c-indexes of the training and validation cohorts were 0.805 and 0.794, respectively. Additionally the ROC curve (5-year AUC = 0.877) and DCA curve showed that the model had a good predictive effect. CONCLUSION For early-stage esophageal cancer, the results of this study showed that ET is not inferior to ES. Based on the independent factors affecting prognosis identified in the study, we constructed and validated a predictive model for predicting long-term survival in patients with early-stage esophageal cancer.
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Affiliation(s)
- Ran Jia
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center of Cancer, Tianjin, China.,Department of Thoracic Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and PeKing Union Medical College, Shenzhen, China
| | - Wanyi Xiao
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center of Cancer, Tianjin, China
| | - Hongdian Zhang
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center of Cancer, Tianjin, China
| | - Zhentao Yu
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center of Cancer, Tianjin, China.,Department of Thoracic Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and PeKing Union Medical College, Shenzhen, China
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15
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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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16
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Kumarasinghe MP, Bourke MJ, Brown I, Draganov PV, McLeod D, Streutker C, Raftopoulos S, Ushiku T, Lauwers GY. Pathological assessment of endoscopic resections of the gastrointestinal tract: a comprehensive clinicopathologic review. Mod Pathol 2020; 33:986-1006. [PMID: 31907377 DOI: 10.1038/s41379-019-0443-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/27/2019] [Accepted: 12/10/2019] [Indexed: 12/13/2022]
Abstract
Endoscopic resection (ER) allows optimal staging with potential cure of early-stage luminal malignancies while maintaining organ preservation. ER and surgery are non-competing but complementary therapeutic options. In addition, histological examination of ER specimens can either confirm or refine the pre-procedure diagnosis. ER is used for the treatment of Barrett's related early carcinomas and dysplasias, early-esophageal squamous cell carcinomas and dysplasias, early gastric carcinomas and dysplasia, as well as low-risk submucosal invasive carcinomas (LR-SMIC) and, large laterally spreading adenomas of the colon. For invasive lesions, histological risk factors predict risk of lymph node metastasis and residual disease at the ER site. Important pathological risk factors predictive of lymph node metastasis are depth of tumor invasion, poor differentiation, and lymphovascular invasion. Complete resection with negative margins is critical to avoid local recurrences. For non-invasive lesions, complete resection is curative. Therefore, a systematic approach for handling and assessing ER specimens is recommended to evaluate all above key prognostic features appropriately. Correct handling starts with pinning the specimen before fixation, meticulous macroscopic assessment with orientation of appropriate margins, systematic sectioning, and microscopic assessment of the entire specimen. Microscopic examination should be thorough for accurate assessment of all pathological risk factors and margin assessment. Site-specific issues such as duplication of muscularis mucosa of the esophagus, challenges of assessing ampullectomy specimens and site-specific differences of staging of early carcinomas throughout the gastrointestinal tract (GI) tract should be given special consideration. Finally, a standard, comprehensive pathology report that allows optimal staging with potential cure of early-stage malignancies or better stratification and guidance for additional treatment should be provided.
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Affiliation(s)
- M Priyanthi Kumarasinghe
- Department of Anatomical Pathology, PathWest, QE II Medical Centre and School of Pathology and Laboratory Medicine, University of Western Australia, Hospital Avenue, Nedlands Perth, WA, 6009, Australia.
| | - Michael J Bourke
- Department of Medicine, University of Sydney, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Ian Brown
- Envoi Pathology,Unit 5, 38 Bishop Street, Kelvin Grove, QLD, 4059, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia
| | - Peter V Draganov
- Department of Medicine, University of Florida, 1329 SW 16th Street, Room # 5251, Gainesville, FL, 32608, USA
| | | | - Catherine Streutker
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Director of Pathology, St Michael's Hospital, Toronto, ON, M5B 1W9, Canada
| | - Spiro Raftopoulos
- Sir Charles Gairdner Hospital, QE II Medical Centre, Hospital Avenue, Nedlands Perth, WA, 6009, Australia
| | - Tetsuo Ushiku
- Department of Pathology, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Gregory Y Lauwers
- H. Lee Moffitt Cancer Center & Research Institute and Departments of Pathology & Cell Biology and Oncologic Sciences, University of South Florida, Tampa, FL, USA
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17
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Bennett C, Green S, DeCaestecker J, Almond M, Barr H, Bhandari P, Ragunath K, Singh R, Jankowski J. Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus. Cochrane Database Syst Rev 2020; 5:CD007334. [PMID: 32442322 PMCID: PMC7390331 DOI: 10.1002/14651858.cd007334.pub5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy). OBJECTIVES We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)). SEARCH METHODS We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012. SELECTION CRITERIA Types of studies: RCTs comparing endotherapies with surgery in the treatment of high-grade dysplasia or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately. TYPES OF PARTICIPANTS patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus. Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent. DATA COLLECTION AND ANALYSIS Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9. MAIN RESULTS We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies. AUTHORS' CONCLUSIONS This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.
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Affiliation(s)
- Cathy Bennett
- Centre for Innovative Research Across the Life Course (CIRAL), Coventry University, Coventry, UK
| | - Susi Green
- Gastroenterology, Portsmouth Hospitals Trust, Cosham, UK
| | | | - Max Almond
- Department of Oesphogastric Surgery, Gloucestershire Royal Hospital, Gloucester, UK
| | - Hugh Barr
- Surgery, Gloucester Royal Hospital, Gloucester, UK
| | - Pradeep Bhandari
- Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Krish Ragunath
- Wolfson Digestive Diseases Centre, Queens Medical Centre, Nottingham University NHS Trust, Nottingham, UK
| | - Rajvinder Singh
- Gastroenterology, The Lyell McEwin Hospital, Elizabeth Vale, Australia
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Clinical Practice Update on the Utility of Endoscopic Submucosal Dissection in T1b Esophageal Cancer: Expert Review. Clin Gastroenterol Hepatol 2019; 17:2161-2166. [PMID: 31401148 DOI: 10.1016/j.cgh.2019.05.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/03/2019] [Accepted: 05/29/2019] [Indexed: 02/07/2023]
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19
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Barrett's adenocarcinoma with esophageal varices successfully treated by endoscopic submucosal dissection with direct varices coagulation. Clin J Gastroenterol 2019; 13:178-181. [PMID: 31559540 DOI: 10.1007/s12328-019-01048-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/17/2019] [Indexed: 12/27/2022]
Abstract
A 67-year-old Japanese man with alcoholic cirrhosis underwent esophagogastroduodenoscopy (EGD), which revealed a 15-mm elevated lesion on the esophagogastric junction (EGJ). Endoscopic findings suggested that the lesion was an intramucosal cancer present on the esophageal varices. The location of the lesion at EGJ caused difficulties in endoscopic injection sclerotherapy and endoscopic variceal ligation for esophageal varices before esophageal endoscopic submucosal dissection (ESD). Direct varices coagulation treatment was therefore selected during ESD. Coagulation of bared varices with hemostatic forceps after mucosal incision enabled performing ESD without serious bleeding. 2 months afterwards, the patient underwent EGD, with no esophageal varices or carcinoma recurrence. Direct varices coagulation was effective for ESD of Barrett adenocarcinoma with esophageal varices.
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20
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Histopathology of Barrett’s Esophagus and Early-Stage Esophageal Adenocarcinoma: An Updated Review. GASTROINTESTINAL DISORDERS 2018. [DOI: 10.3390/gidisord1010011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Esophageal adenocarcinoma carries a very poor prognosis. For this reason, it is critical to have cost-effective surveillance and prevention strategies and early and accurate diagnosis, as well as evidence-based treatment guidelines. Barrett’s esophagus is the most important precursor lesion for esophageal adenocarcinoma, which follows a defined metaplasia–dysplasia–carcinoma sequence. Accurate recognition of dysplasia in Barrett’s esophagus is crucial due to its pivotal prognostic value. For early-stage esophageal adenocarcinoma, depth of submucosal invasion is a key prognostic factor. Our systematic review of all published data demonstrates a “rule of doubling” for the frequency of lymph node metastases: tumor invasion into each progressively deeper third of submucosal layer corresponds with a twofold increase in the risk of nodal metastases (9.9% in the superficial third of submucosa (sm1) group, 22.0% in the middle third of submucosa (sm2) group, and 40.7% in deep third of submucosa (sm3) group). Other important risk factors include lymphovascular invasion, tumor differentiation, and the recently reported tumor budding. In this review, we provide a concise update on the histopathological features, ancillary studies, molecular signatures, and surveillance/management guidelines along the natural history from Barrett’s esophagus to early stage invasive adenocarcinoma for practicing pathologists.
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21
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Mönig S, Chevallay M, Niclauss N, Zilli T, Fang W, Bansal A, Hoeppner J. Early esophageal cancer: the significance of surgery, endoscopy, and chemoradiation. Ann N Y Acad Sci 2018; 1434:115-123. [PMID: 30138532 DOI: 10.1111/nyas.13955] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 07/18/2018] [Accepted: 07/26/2018] [Indexed: 12/22/2022]
Abstract
Early carcinomas of the esophagus are histologically classified as adenocarcinoma or squamous cell carcinoma and microscopically subdivided into mucosal and submucosal carcinomas depending on infiltration depth. The prevalence of lymph node metastasis in mucosal carcinoma remains low. However, lymph node metastases arise frequently from tumors with submucosal infiltration, with increasing prevalence in the deeper submucosal sublayers. According to current German guidelines, endoscopic resection is the recommended treatment in mucosal adenocarcinoma without histologic risk factors (lymphatic invasion 1, vascular invasion 1, >grade 2, R1-margin). In superficial submucosal infiltration without histologic risk factors, endoscopic resection can be considered. In squamous cell carcinoma, endoscopic resection is indicated up to middle layer mucosal carcinoma. Beyond these criteria, surgical resection should be considered. The gold standard is a subtotal transthoracic esophagectomy with two-field lymphadenectomy. Total esophagectomy is performed in cervical esophageal carcinoma and transhiatal extended gastrectomy in carcinoma of the cardia. Minimally invasive procedures show good oncologic results and reduce the morbidity of radical esophagectomy. Reduced morbidity might be an argument for surgical resection in borderline cases between endoscopic and surgical resection. In early squamous cell cancer, the combination of endoscopic resection and adjuvant chemoradiotherapy is a therapeutic option with promising results.
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Affiliation(s)
- Stefan Mönig
- Visceral Surgery Department, Geneva University Hospital, Geneva, Switzerland
| | - Mickael Chevallay
- Visceral Surgery Department, Geneva University Hospital, Geneva, Switzerland
| | - Nadja Niclauss
- Visceral Surgery Department, Geneva University Hospital, Geneva, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.,Faculty of Medicine, Geneva University, Geneva, Switzerland
| | - Wentao Fang
- Department of Thoracic Surgery, Shanghai Chest Hospital Clinical Center for Esophageal Diseases, Shanghai Jiaotong University, Shanghai, China
| | - Ajay Bansal
- Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas.,Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Jens Hoeppner
- Department of General and Visceral Surgery, Faculty of Medicine, University of Freiburg Medical Center, Freiburg, Germany
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22
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Seewald S, Ang TL, Pouw RE, Bannwart F, Bergman JJ. Management of Early-Stage Adenocarcinoma of the Esophagus: Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection. Dig Dis Sci 2018; 63:2146-2154. [PMID: 29934725 DOI: 10.1007/s10620-018-5158-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Barrett's esophagus with high-grade dysplasia and early-stage adenocarcinoma is amenable to curative treatment by endoscopic resection. Histopathological correlation has established that mucosal cancer has minimal risk of nodal metastases and that long-term complete remission can be achieved. Although surgery is the gold-standard treatment once there is submucosal involvement, even T1sm1 (submucosal invasion ≤ 500 μm) cases without additional risk factors for nodal metastases might also be cured with endoscopic resection. Endoscopic resection is foremost an initial diagnostic procedure, and once histopathological assessment confirms that curative criteria are met, it will be considered curative. Endoscopic resection may be achieved by endoscopic mucosal resection, which, although easy to perform with relatively low risk, is limited by an inability to achieve en bloc resection for lesions of size more than 1.5 cm. Conversely, the technique of endoscopic submucosal dissection is more technically demanding with higher risk of complications but is able to achieve en bloc resection for lesions larger than 1.5 cm. Endoscopic submucosal dissection would be particularly important in specific situations such as suspected submucosal invasion and lesion size more than 1.5 cm. In other situations, since endoscopic resection would always be combined with radiofrequency ablation to ablate the remaining Barrett's epithelium, piecemeal endoscopic mucosal resection would suffice since any remnant superficial invisible dysplasia would be ablated.
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Affiliation(s)
- Stefan Seewald
- Centre of Gastroenterology, Klinik Hirslanden, Witellikerstrasse 40, 8008, Zurich, Switzerland.
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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23
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Qumseya BJ, Bartel MJ, Gendy S, Bain P, Qumseya A, Wolfsen H. High rate of over-staging of Barrett's neoplasia with endoscopic ultrasound: Systemic review and meta-analysis. Dig Liver Dis 2018; 50:438-445. [PMID: 29573963 DOI: 10.1016/j.dld.2018.02.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 12/07/2017] [Accepted: 02/06/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The use of endoscopic ultrasound (EUS) to stage patients with Barrett's esophagus (BE) with suspected neoplasia is controversial due to high rates of over-staging. However, this rate of over-staging has not been adequately investigated or quantified. AIM To determine the rate of over-staging related EUS in this population. METHODS Search included Medline, Embase, Web of Science, and Cochrane Central ending on 9/30/2016. The primary effect-estimate of interest was the false positive rate of advanced disease on EUS at the tumor level (T1a vs. T1b). Secondary outcomes included false detection rate, false negative rate, accuracy, sensitivity, and specificity. Study heterogeneity was assessed using the I2 and Cochrane's Q. RESULTS Of 1872 studies, 11 met our inclusion criteria totaling 895 patients. Based on random effects models, the pooled FPR for advanced disease was 9.1% ([6.5-12.5%], p<0.001). Tests of heterogeneity showed no significant heterogeneity for this outcome. The pooled false negative rate was 9.2% [95%CI: 4.7-17.3%], p<0.01. Overall, the pooled accuracy of EUS results in BE neoplasia patients was low at 74.6% [58.7-85.8%], p=0.004. CONCLUSIONS The use of EUS in BE patients with dysplasia and early neoplasia results in a large proportion of patients falsely over-staged and under-staged.
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Affiliation(s)
- Bashar J Qumseya
- Division of Gastroenterology and Hepatology, Archbold Medical Group/Florida State University, United States.
| | - Michael J Bartel
- Division of Gastroenterology, Fox Chase Cancer Center, Philadelphia, PA, United States
| | - Sherif Gendy
- Florida A&M University, Tallahassee, FL, United States
| | - Paul Bain
- Harvard Medical School, Boston, MA, United States
| | - Amira Qumseya
- Evidence-Based Research Institute, Tallahassee, FL, United States
| | - Herbert Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, United States
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24
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Boisen ML, Sardesai MP, Kolarczyk L, Rao VK, Owsiak CP, Gelzinis TA. The Year in Thoracic Anesthesia: Selected Highlights From 2017. J Cardiothorac Vasc Anesth 2018; 32:1556-1569. [PMID: 29655515 DOI: 10.1053/j.jvca.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Michael L Boisen
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA
| | - Mahesh P Sardesai
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
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25
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Endoscopic submucosal dissection compared to endoscopic mucosal resection for early Barrett esophagus neoplasia. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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26
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Trindade AJ, Benias PC, Inamdar S, Fan C, Sethi A, Fukami N, Kahn A, Kahaleh M, Andalib I, Sejpal DV, Rishi A. Use of volumetric laser endomicroscopy for determining candidates for endoscopic therapy in superficial esophageal squamous cell carcinoma. United European Gastroenterol J 2018; 6:838-845. [PMID: 30023061 DOI: 10.1177/2050640618761701] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 02/06/2018] [Indexed: 12/17/2022] Open
Abstract
Background Accurate staging of superficial esophageal squamous cell cancer (ESCC) for endoscopic therapy is challenging. Optical coherence tomography (OCT) has been shown to be superior to high-resolution endoscopic ultrasound (EUS). Volumetric Laser Endomicroscopy (VLE), a second-generation OCT, has recently become commercially available. Objective To assess if VLE can determine which patients with superficial ESSC can undergo endoscopic therapy. Methods This is a multi-center retrospective study. Patients were included if (a) they had visible ESCC, (b) they underwent VLE and EUS for staging, and c) if superficial disease was suspected then endoscopic resection had to be performed to have accurate histology to compare the VLE scan to. VLE scans were then compared to the gold standard: histology for superficial disease and EUS for disease T1b and greater. Results Seventeen patients were included with the following disease: squamous intraepithelial neoplasia (4 patients), T1a disease (6 patients), T1b (2 patients), T2 disease (2 patients) and T3 disease (3 patients). VLE was able to distinguish superficial disease, defined as disease limited up to the lamina propria, from non-superficial disease in all cases. Conclusions VLE may be able to determine which ESCC patients are candidates for endoscopic therapy. Prospective studies are needed to confirm this.
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Affiliation(s)
- Arvind J Trindade
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Petros C Benias
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Sumant Inamdar
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Cathy Fan
- Department of Pathology, Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Amrita Sethi
- Columbia University Medical Center, Division of Gastroenterology, New York, NY, USA
| | - Norio Fukami
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Allon Kahn
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Michel Kahaleh
- Department of Gastroenterology, Weill Cornell Medical College, New York, NY, USA
| | - Iman Andalib
- Department of Gastroenterology, Weill Cornell Medical College, New York, NY, USA
| | - Divyesh V Sejpal
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Arvind Rishi
- Department of Pathology, Long Island Jewish Medical Center, New Hyde Park, NY, USA
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27
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Niclauss N, Chevallay M, Frossard JL, Mönig SP. [Surgical strategy for early stage carcinoma of the esophagus]. Chirurg 2018; 89:339-346. [PMID: 29392342 DOI: 10.1007/s00104-018-0589-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Early stage carcinomas of the esophagus are histologically differentiated into adenocarcinomas and squamous cell carcinomas and subdivided into mucosal (m1-3) and submucosal (sm1-3) carcinomas depending on the infiltration depth. While the prevalence of lymph node metastases in mucosal carcinomas is very low, the probability of lymph node metastases increases from submucosal infiltration with increasing depth. According to the current German S3 guidelines endoscopic resection is the recommended treatment strategy for mucosal adenocarcinoma without histological risk factors (lymphatic invasion [L1], venous invasion [V1], poorly differentiated [>G2], microscopic residual disease [R1] at the deep resection margin). For superficial submucosal infiltration (sm1) without histological risk factors endoscopic resection can also be carried out, whereby in this case the guidelines make a stronger recommendation for esophagectomy. For squamous cell carcinoma endoscopic resection is indicated for an infiltration depth up to middle layer mucosal carcinoma (m2) without histological risk factors. Outside of these criteria an esophageal resection should always be carried out. The surgical gold standard is a subtotal abdominothoracic esophagectomy with two-field lymphadenectomy. Alternative procedures are total esophagectomy in proximal esophageal carcinoma and transhiatal extended gastrectomy for carcinoma of the cardia. Limited proximal or distal esophageal resections can be performed in proximal or distal mucosal carcinoma without the possibility of endoscopic resection; however, partial resections are not superior in terms of functional results and are not oncologically equivalent due to limited lymphadenectomy. Minimally invasive procedures show good oncological results and reduce the morbidity of radical esophagectomy. Reduced morbidity might be an argument for surgical resection in borderline cases between endoscopic and surgical resection.
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Affiliation(s)
- N Niclauss
- Service de chirurgie viscérale, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, 1205, Genf, Schweiz
| | - M Chevallay
- Service de chirurgie viscérale, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, 1205, Genf, Schweiz
| | - J L Frossard
- Service de gastroentérologie et hépatologie, Hôpitaux Universitaires de Genève, Genf, Schweiz
| | - S P Mönig
- Service de chirurgie viscérale, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, 1205, Genf, Schweiz.
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McLaren PJ, Dolan JP. Surgical Treatment of High-Grade Dysplasia and Early Esophageal Cancer. World J Surg 2018; 41:1712-1718. [PMID: 28258451 DOI: 10.1007/s00268-017-3958-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The treatment of early-stage esophageal cancer and high-grade dysplasia of the esophagus has changed significantly in recent years. Many early tumors that were traditionally treated with esophagectomy can now be resected with endoscopic therapy alone. These new endoscopic modalities can offer similar survival outcomes without the associated morbidity of a major operation. However, a number of these cases may still require surgical intervention as the best treatment option. METHODS The current scientific literature, national and international guidelines were reviewed for recommendations regarding optimal treatment of early esophageal malignancy. RESULTS The primary advantage of surgery over endoscopic treatment lies in the reduced risk of recurrence as well as the ability to assess harvested lymph nodes for regional disease. We recommend that esophageal tumors that have invaded into the submucosa (T1b) or beyond should be treated with an esophagectomy. In addition, dysplastic lesions and cancers that demonstrate poorly differentiated pathology or lymphovascular or perineural invasion should be surgically resected. Finally, large tumors, multifocal lesions, tumors within a long segment of Barrett's esophagus, tumors adjacent to a hiatal hernia, tumors that cannot be resected enbloc with endoscopic techniques should also be treated with an esophagectomy. CONCLUSIONS When performed at high-volume centers in experienced hands, esophagectomy can have consistently good outcomes for high-grade dysplasia and early esophageal cancers, and should be considered as a treatment option.
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Affiliation(s)
- Patrick J McLaren
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd., Portland, OR, 97239, USA
| | - James P Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd., Portland, OR, 97239, USA.
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29
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Newton AD, Predina JD, Xia L, Roses RE, Karakousis GC, Dempsey DT, Williams NN, Kucharczuk JC, Singhal S. Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk. Ann Surg Oncol 2017; 25:318-325. [PMID: 29147928 DOI: 10.1245/s10434-017-6238-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND In early-stage esophageal adenocarcinoma (EAC), esophagectomy improves staging but also increases mortality compared with endoscopic resection. Our objective was to quantify esophagectomy mortality and lymph node metastasis (LNM) risk in early-stage EAC to improve surgical treatment allocation. METHODS We identified National Cancer Database (2004-2014) patients with nonmetastatic, Tis, T1a, or T1b EAC who had primary surgical resection and microscopic examination of at least 15 lymph nodes. Univariate and multivariable logistic regression identified predictors of LNM. Cox regression identified predictors of death. The Kaplan-Meier method predicted overall survival (OS). RESULTS In 782 patients, LNM rates were: all patients 13.8%, Tis 0%, T1a 3.6%, T1b 23.4%. Independent predictors of LNM were submucosal invasion, lymphovascular invasion (LVI), decreasing differentiation, and tumor size ≥ 2 cm (P < 0.05). For T1a tumors with poor differentiation or size ≥ 2 cm, LNM rates were 10.2 and 6.7%, respectively; 90-day mortality was 3.1%. The LNM rate in well differentiated T1b tumors < 2 cm was 4.2%; 90-day mortality was 6.0%. Estimated 5-year OS was 80.2% versus 64.4% (T1a vs. T1b). LNM increased risk of death for T1a (hazard ratio [HR] 8.52, 95% confidence interval [CI] 3.13-23.22, P < 0.001) and T1b tumors (HR 2.52, 95% CI 1.59-4.00, P < 0.001). CONCLUSIONS In T1a EAC with poor differentiation or size ≥ 2 cm, esophagectomy should be considered, whereas in T1b EAC with low-risk features (well-differentiated T1b EAC < 2 cm without LVI), endoscopic resection may be sufficient. Treatment guidelines for early-stage EAC should include all high-risk tumor features for LNM and stage-specific esophagectomy mortality.
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Affiliation(s)
- Andrew D Newton
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.
| | - Jarrod D Predina
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Leilei Xia
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Daniel T Dempsey
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Noel N Williams
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
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30
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Upchurch E, Griffiths S, Lloyd GR, Isabelle M, Kendall C, Barr H. Developments in optical imaging for gastrointestinal surgery. Future Oncol 2017; 13:2363-2382. [PMID: 29121775 DOI: 10.2217/fon-2017-0181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
To improve outcomes for patients with cancer, in terms of both survival and a reduction in the morbidity and mortality that results from surgical resection and treatment, there are two main areas that require improvement. Accurate early diagnosis of the cancer, at a stage where curative and, ideally, minimally invasive treatment is achievable, is desired as well as identification of tumor margins, lymphatic and distant disease, enabling complete, but not unnecessarily extensive, resection. Optical imaging is making progress in achieving these aims. This review discusses the principles of optical imaging, focusing on fluorescence and spectroscopy, and the current research that is underway in GI tract carcinomas.
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Affiliation(s)
- Emma Upchurch
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN.,Department of Upper GI Surgery, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
| | - Shelly Griffiths
- Department of Upper GI Surgery, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
| | - Gavin-Rhys Lloyd
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
| | - Martin Isabelle
- Renishaw plc, New Mills, Wotton-under-Edge, Gloucestershire, UK, GL12 8JR
| | - Catherine Kendall
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
| | - Hugh Barr
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN.,Department of Upper GI Surgery, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
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Chen L, Wang YH, Cheng YQ, Du MZ, Shi J, Fan XS, Zhou XL, Zhang YF, Guo LC, Xu GF, He YM, Zhou D, Zou XP, Huang Q, Team TJPEGCMS. Risk factors of lymph node metastasis in 1620 early gastric carcinoma radical resections in Jiangsu Province in China: A multicenter clinicopathological study. J Dig Dis 2017; 18:556-565. [PMID: 28949436 DOI: 10.1111/1751-2980.12545] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 09/22/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate risk factors of lymph node metastasis (LNM) in early gastric carcinoma (EGC) in four tertiary medical centers in Jiangsu Province, China. METHODS Among 10 097 consecutive combined gastric cancer radical resections, 1903 EGC were identified and reviewed, 283 excluded and 1620 included in the study. All pathological and some endoscopic reports were reviewed for patients' characteristics, tumor location, gross features, and the number of lymph nodes retrieved and involved. Two pathologists independently investigated the pathological features of tumor type, differentiation, invasion depth, lymphovascular invasion (LVI), and perineural invasion. The data were statistically analyzed to identify risk factors for LNM. RESULTS The average number of lymph nodes retrieved was 17.5 per patient. LNM was diagnosed in 15.5%. By univariate analysis, significant risk factors for LNM included age ≥ 41 years, female sex, size over 1 cm, submucosal invasion, poor differentiation, poorly cohesive carcinoma, micropapillary adenocarcinoma, adenocarcinoma mixed with signet-ring cell carcinoma, LVI, perineural invasion, and distal gastric location. By multivariate analysis, independent risk factors for LNM were size ≥ 3 cm (odds ratio [OR] 1.9), poor differentiation (OR 2.5), adenocarcinoma mixed with signet-ring cell carcinoma (OR 1.7), LVI (OR 5.8) and submucosal invasion (OR 2.9). In contrast, size < 3 cm and ulcer were not significant risk factors. Early cardiac carcinoma (OR 0.4) had significantly lower risk. CONCLUSIONS Independent risk factors for LNM in EGC in Chinese patients included tumor size ≥ 3 cm, poor differentiation, submucosal invasion, adenocarcinoma mixed with signet-ring cell carcinoma and LVI. Early cardiac carcinoma had a significantly lower risk for LNM.
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Affiliation(s)
- Ling Chen
- Department of Pathology, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, China
| | - Yao Hui Wang
- Department of Pathology, Jiangsu Provincial Hospital of Traditional Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Yu Qing Cheng
- Department of Pathology, Changzhou Second Hospital, Changzhou, Jiangsu Province, China
| | - Ming Zhan Du
- Department of Pathology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jiong Shi
- Department of Pathology, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, China
| | - Xiang Shan Fan
- Department of Pathology, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, China
| | - Xiao Li Zhou
- Department of Pathology, Changzhou Second Hospital, Changzhou, Jiangsu Province, China
| | - Yi Fen Zhang
- Department of Pathology, Jiangsu Provincial Hospital of Traditional Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Ling Chuan Guo
- Department of Pathology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Gui Fang Xu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, China
| | - Ya Min He
- Department of Pathology, Jiangsu Provincial Hospital of Traditional Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Dan Zhou
- Quality Care Medical Consulting, LLC, Lexington, Massachusetts, USA
| | - Xiao Ping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, China
| | - Qin Huang
- Department of Pathology, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, China.,Department of Pathology and Laboratory Medicine, Boston VA Healthcare System, Harvard Medical School, West Roxbury, Massachusetts, USA
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Weksler B, Kennedy KF, Sullivan JL. Using the National Cancer Database to create a scoring system that identifies patients with early-stage esophageal cancer at risk for nodal metastases. J Thorac Cardiovasc Surg 2017; 154:1787-1793. [PMID: 28867381 DOI: 10.1016/j.jtcvs.2017.07.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/08/2017] [Accepted: 07/16/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Endoscopic resection is gaining popularity as a treatment for early-stage esophageal adenocarcinoma, particularly for T1a tumors. The goal of this study was to create a scoring system to reflect the risk of nodal metastases in early-stage esophageal adenocarcinoma to be used after endoscopic resection to better individualize treatment. METHODS The National Cancer Database was queried for patients with T1a or T1b esophageal adenocarcinoma who underwent esophagectomy. We identified variables affecting nodal metastases using multivariable logistic regression, which we then used to create a scoring system. We stratified the model for T1a or T1b tumors, tested model discrimination, and validated the models by refitting in 1000 bootstrap samples. C-statistics greater than 0.7 were considered relevant. RESULTS We identified 1283 patients with T1a or T1b tumors; 146 had nodal metastases (11.4%). Tumor category (pT1a vs pT1b), grade, and size and the presence of angiolymphatic invasion significantly affected the risk of nodal metastases. We assigned points to each variable and added them to get a risk score. In patients with T1a tumors, less than 3% of patients with a risk score of 3 or less had nodal metastases, whereas 16.1% of patients with a risk score of 5 or greater had nodal metastases. In patients with T1b tumors, less than 5% of patients with a risk score of 2 or less had nodal metastases, whereas 41% of patients with a score of 6 or greater had nodal metastases (c-statistic = 0.805). CONCLUSIONS The proposed scoring system seems to be useful in discriminating risk of nodal metastases in patients with T1a or T1b esophageal adenocarcinoma and may be useful in directing patients who received endoscopic resection to esophagectomy or careful follow-up.
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Affiliation(s)
- Benny Weksler
- Division of Thoracic Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tenn.
| | - Kevin F Kennedy
- Department of Biostatistics, St Lukes Health System, Mid America Heart Institute, Kansas City, Mo
| | - Jennifer L Sullivan
- Division of Thoracic Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tenn
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Abstract
Endoscopic therapies have become the standard of care for most cases of Barrett's esophagus with high-grade dysplasia or intramucosal adenocarcinoma. Despite a rapid and dramatic evolution in treatment paradigms, esophagectomy continues to occupy a place in the therapeutic armamentarium for superficial esophageal neoplasia. The managing physician must remain cognizant of the limitations of endoscopic approaches and consider surgical resection when they are exceeded. Esophagectomy, performed at experienced centers for appropriately selected patients with early-stage disease can be undertaken with the expectation of cure as well as low mortality, acceptable morbidity, and good long-term quality of life.
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Affiliation(s)
- Thomas J Watson
- Division of Thoracic and Esophageal Surgery, Department of Surgery, MedStar Washington, Georgetown University School of Medicine, 3800 Reservoir Road Northwest, 4PHC, Washington, DC 20007, USA.
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Qumseya BJ, Wolfsen HC. The Role of Endoscopic Ultrasound in the Management of Patients with Barrett's Esophagus and Superficial Neoplasia. Gastrointest Endosc Clin N Am 2017; 27:471-480. [PMID: 28577768 DOI: 10.1016/j.giec.2017.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic ultrasound (EUS) is a minimally invasive advanced imaging procedure using high-frequency sound waves to produce detailed images of the esophageal wall with fine-needle aspiration to biopsy adjacent lymph nodes. The role of EUS is well established in patients with locally advanced Barrett esophagus neoplasia. The utility of EUS in the evaluation of Barrett esophagus patients is controversial. This is a review of the evidence using EUS in BE patients. The assessment is that EUS may be a powerful tool in managing patients with BE neoplasia.
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Affiliation(s)
- Bashar J Qumseya
- Division of Gastroenterology and Hepatology, Archbold Medical Group, Florida State University, 112 Mimosa Drive, Thomasville, GA 31792, USA
| | - Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Endoscopic mucosal resection versus esophagectomy for intramucosal adenocarcinoma in the setting of barrett's esophagus. Surg Endosc 2017; 31:4211-4216. [PMID: 28342132 DOI: 10.1007/s00464-017-5479-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 02/16/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Esophagectomy has been the standard of care for patients with intramucosal adenocarcinoma (IMC) in the setting of Barrett's esophagus. It is, however, associated with significant post-operative morbidity and mortality. Endoscopic mucosal resection (EMR) offers a minimally invasive approach with lesser morbidity. This study investigates the transition from esophagectomy to EMR for IMC with respect to eradication rates, post-operative morbidity, and long-term survival. METHODS Patients diagnosed with IMC from 2005 to 2013 were identified retrospectively. Beginning in 2009, preferred initial therapy for IMC transitioned from esophagectomy to EMR. Esophagectomy was performed either through a transthoracic or transhiatal technique. EMR was repeated until resolution of IMC on pathology or progression of disease. Continuous data are expressed as mean (SD) and analyzed using Student's t test. Categorical data are presented as number (%) and analyzed using Fisher's exact test. RESULTS We identified 23 patients; 12 patients underwent esophagectomy and 11 patients underwent EMR as initial therapy. Patients were similar with respects to age, gender, and comorbidity index. Most tumors arose from short segment (vs long segment) Barrett's (esophagectomy: 9 (75%) vs. EMR: 10 (91%), p = 0.59) and one patient in each group had superficial invasion into the submucosa (T1sm1), the remainder having mucosal disease. Esophagectomy was associated with 7 (58%) minor complications and 2 (17%) major complications (respiratory failure, anastomotic leak), whereas there were no complications related to EMR (p < 0.01). EMR successfully eradicated IMC in 10 patients (91%) with one progressing to esophagectomy. Patients required 2 (1) endoscopies to achieve eradication. There was one mortality in each group on long-term follow-up (log-rank test, p = 0.62). CONCLUSIONS EMR was successful in eradicating IMC in 10/11 patients with similar long-term recurrence and mortality to esophagectomy patients. Patients with IMC may benefit from EMR as initial therapy by obviating the need for a complex and morbid operation.
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Abstract
Barrett esophagus (BE) is a precursor lesion for esophageal adenocarcinoma (EAC). Developments in imaging and molecular markers, and endoscopic eradication therapy, are available to curb the increase of EAC. Endoscopic surveillance is recommended, despite lack of data. The cancer risk gets progressively downgraded, raising questions about the understanding of risk factors and molecular biology involved. Recent data point to at least 2 carcinogenic pathways operating in EAC. The use of p53 overexpression and high-risk human papillomavirus may represent the best chance to detect progressors. Genome-wide technology may provide molecular signatures to aid diagnosis and risk stratification in BE.
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37
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Manner H, Wetzka J, May A, Pauthner M, Pech O, Fisseler-Eckhoff A, Stolte M, Vieth M, Lorenz D, Ell C. Early-stage adenocarcinoma of the esophagus with mid to deep submucosal invasion (pT1b sm2-3): the frequency of lymph-node metastasis depends on macroscopic and histological risk patterns. Dis Esophagus 2017; 30:1-11. [PMID: 26952572 DOI: 10.1111/dote.12462] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The rate of lymph-node (LN) metastasis in early adenocarcinoma (EAC) of the esophagus with mid to deep submucosal invasion (pT1b sm2/3) has not yet been precisely defined. The aim of the this study was to evaluate the rate of LN metastasis in pT1b sm2/3 EAC depending on macroscopic and histological risk patterns to find out whether there may also be options for endoscopic therapy as in cancers limited to the mucosa and the upper third of the submucosa. A total of 1.718 pt with suspicion of EAC were referred for endoscopic treatment (ET) to the Dept. of Internal Medicine II at HSK Wiesbaden 1996-2010. In 230/1.718 pt, the suspicion (endoscopic ultrasound, EUS) or definitive diagnosis of pT1b EAC (ER/surgery) was made. Of these, 38 pt had sm2 lesions, and 69 sm3. Rate of LN metastasis was analyzed depending on risk patterns: histologically low-risk (hisLR): G1-2, L0, V0; histologically high-risk (hisHR): ≥1 criterion not fulfilled; macroscopically low-risk (macLR): gross tumor type I-II, tumor size ≤2 cm; macroscopically high-risk (macHR): ≥1 criterion not fulfilled; combined low-risk (combLR): hisLR+macLR; combined high-risk (combHR): at least 1 risk factor. LN rate was only evaluated in pt who had proven maximum invasion depth of sm2/sm3, and who in case of ET had a follow-up (FU) by EUS of at least 24 months. 23/38 pt with pT1b sm2 lesions and 39/69 pt with sm3 lesions fulfilled our inclusion criteria. In the pT1b sm2 group, rate of LN metastasis in the hisLR, hisHR, combLR, and combHR groups were 8.3% (1/12), 36.3% (4/11), 0% (0/5), and 27.8% (5/18). In the pT1b sm3 group, rate of LN metastasis in the hisLR, hisHR, combLR and combHR groups were 28.6% (2/7), 37.5% (12/32), 25% (1/4), and 37.1% (13/35). 30-day mortality of surgery was 1.7% (1/58 pt). In EAC with pT1b sm2/3 invasion, the frequency of LN metastasis depends on macroscopic and histological risk patterns. Surgery remains the standard treatment, because the rate of LN metastasis appears to be higher than the mortality risk of surgery. Whether a highly selected group of pT1b sm2 patients with a favourable risk pattern may be candidates for endoscopic therapy cannot be decided until the results of larger case volumes are available.
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Affiliation(s)
- H Manner
- Department of Internal Medicine II, HSK Hospital, Teaching Hospital of the University Medicine of Mainz, Wiesbaden, Germany
| | - J Wetzka
- Department of Internal Medicine II/IV, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
| | - A May
- Department of Internal Medicine II/IV, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
| | - M Pauthner
- Department of General and Visceral Surgery, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
| | - O Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | | | - M Stolte
- Institute of Pathology, Kulmbach Hospital, Germany
| | - M Vieth
- Institute of Pathology, Bayreuth Hospital, Germany
| | - D Lorenz
- Department of General and Visceral Surgery, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
| | - C Ell
- Department of Internal Medicine II/IV, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
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38
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Old OJ, Isabelle M, Barr H. Staging Early Esophageal Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 908:161-81. [PMID: 27573772 DOI: 10.1007/978-3-319-41388-4_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Staging esophageal cancer provides a standardized measure of the extent of disease that can be used to inform decisions about therapy and guide prognosis. For esophageal cancer, the treatment pathways vary greatly depending on stage of disease, and accurate staging is therefore crucial in ensuring the optimal therapy for each patient. For early esophageal cancer (T1 lesions), endoscopic resection can be curative and simultaneously gives accurate staging of depth of invasion. For tumors invading the submucosa or more advanced disease, comprehensive investigation is required to accurately stage the tumor and assess suitability for curative resection. A combined imaging approach of computed tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS) offers complementary diagnostic information and gives the greatest chance of accurate staging. Staging laparoscopy can identify peritoneal disease and small superficial liver lesions that could be missed on CT or PET, and alters management in up to 20 % of patients. Optical diagnostic techniques offer the prospect of further extending the possibilities of endoscopic staging in real time. Optical coherence tomography can image superficial lesions and could provide information on depth of invasion for these lesions. Real-time lymph node analysis using optical diagnostics such as Raman spectroscopy could be used to support immediate endoscopic therapy without waiting for results of cytology or further investigations.
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Affiliation(s)
- O J Old
- Upper GI Surgery Department, Gloucestershire Royal Hospital, Gloucester, UK. .,Biophotonics Research Unit, Gloucestershire Royal Hospital, Gloucester, UK.
| | - M Isabelle
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Gloucester, UK
| | - H Barr
- Upper GI Surgery Department, Gloucestershire Royal Hospital, Gloucester, UK
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39
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Standardised reporting protocol for endoscopic resection for Barrett oesophagus associated neoplasia: expert consensus recommendations. Pathology 2016; 46:473-80. [PMID: 25158823 DOI: 10.1097/pat.0000000000000160] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Endoscopic resection (ER) is considered the therapy of choice for intraepithelial neoplasia associated with visible lesions and T1a adenocarcinoma. Pathologists are bound to encounter specimens collected via these techniques more frequently in their practice. A standardised protocol for handling, grossing, and assessing ER specimens should be adopted to ensure that all prognostic information and characteristics influencing treatment are included in reports (see Supplementary Video Abstract, http://links.lww.com/PAT/A22). The entire specimen should be appropriately oriented, processed and assessed. An ER specimen will commonly show intraepithelial neoplasia or invasive carcinoma. There are essential features that should be recorded if invasive carcinoma is found as they dictate further management and follow-up. These features are the margin status, depth of invasion, degree of differentiation and presence or absence of lymphovascular invasion. Important features such as duplication of muscularis mucosae should be recognised to avoid misinterpretation of depth of invasion. Key diagnostic and prognostic elements that are essential for optimal clinical decisions have been included in the reporting format proposed by the Structured Pathology Reporting committee of the Royal College of Pathologists of Australasia (RCPA).
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40
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Abstract
Incidence of oesophageal adenocarcinoma has increased exponentially in the West over the past few decades. Following detection of advanced cancers, 5-year survival rates remain bleak, making identification of early neoplasia, which has a better outcome, important. Detection of subtle oesophageal lesions during endoscopy can be challenging, and advanced imaging techniques might improve their detection. High-definition endoscopy has become a standard in most endoscopy centres, and this technology probably provides better delineation of mucosal features than standard-definition endoscopy. Various image enhancement techniques are now available with the development of new electronics and software systems. Image enhancement with chromoendoscopy using dyes has been a cost-effective option for many years, yet these techniques have been replaced in some contexts by electronic chromoendoscopy, which can be used with the press of a button. However, Lugol's chromoendoscopy remains the gold standard to identify squamous dysplasia. Identification and characterization of subtle neoplastic lesions could help to target biopsies and perform endoscopic resection for better local staging and definitive therapy. In vivo histology with techniques such as confocal endomicroscopy could make endotherapy feasible within a shorter timescale than when relying on histology on tissue samples. Once early neoplasia is identified, treatments include endoscopic resection, endoscopic submucosal dissection or various ablative techniques. Endotherapy has the advantage of being a less invasive technique than oesophagectomy, and is associated with lower mortality and morbidity. Endoscopic ablation therapies have evolved over the past few years, with radiofrequency ablation showing the best results in terms of success rates and complications in Barrett dysplasia.
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Aho JM, Nenadic IZ, Aristizabal S, Wigle DA, Tschumperlin DJ, Urban MW. Use of Shear Wave Ultrasound Vibrometry for Detection of Simulated Esophageal Malignancy in Ex Vivo Porcine Esophagi. Biomed Phys Eng Express 2016; 2:065002. [PMID: 28948043 PMCID: PMC5609727 DOI: 10.1088/2057-1976/2/6/065002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Esophageal cancer is a malignant neoplasm with poor outcomes. Determination of local disease progression is a major determining factor in treatment modality, radiation dose, radiation field and subsequent surgical therapy. Discrimination of true tumor extent is difficult given the similarity of soft tissues of the malignancy compared to non-malignant tissues using current imaging modalities. A possible method to discriminate between these tissues may be to exploit mechanical properties to diagnostic advantage, as malignant tissues tend to be stiffer relative to normal adjacent tissue. Shear waves propagate faster in stiffer tissues relative to softer tissues. This may be measured by using ultrasound based shear wave vibrometry. In this method, acoustic radiation force is used to create a shear wave in the tissue of interest and ultrafast ultrasound imaging is used to track the propagating wave to measure the wave velocity and estimate the shear moduli. In this study we created simulated malignant lesions (1.5 cm length) using radiofrequency ablation in ex vivo esophageal samples with varied progression (partial thickness n = 4, and full thickness n = 5) and used normal regions of the same esophageal specimen as controls. Shear wave vibrometry was used to measure shear wave group velocity and shear wave phase velocity in the ex vivo specimens. These values were used to estimate shear moduli using an elastic shear wave model and elastic and viscoelastic Lamb wave models. Our results show that the group and phase velocities increase due to both full and mucosal ablation, and that discrimination may be provided by higher order analysis using viscoelastic Lamb wave fitting. This technique may have application for determination of extent of early esophageal malignancy and warrants further investigation using in vivo approaches to determine performance compared to current imaging modalities.
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Affiliation(s)
- Johnathon M. Aho
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN 55905
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, MN 55905
| | - Ivan Z. Nenadic
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, MN 55905
| | - Sara Aristizabal
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, MN 55905
| | - Dennis A. Wigle
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN 55905
| | - Daniel J. Tschumperlin
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, MN 55905
| | - Matthew W. Urban
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, MN 55905
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN 55905
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42
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Oguma J, Ozawa S, Kazuno A, Nitta M, Ninomiya Y, Tomita S. Two-year follow-up period showing the natural history of a superficial esophageal adenocarcinoma arising in a long segment of Barrett's esophagus. Clin J Gastroenterol 2016; 9:289-92. [PMID: 27590624 DOI: 10.1007/s12328-016-0681-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 08/25/2016] [Indexed: 11/28/2022]
Abstract
A 55-year-old woman experienced gastrointestinal dysfunction caused by scleroderma. An initial endoscopy revealed an erosive lesion in a long segment of Barrett's esophagus, and a biopsy led to a diagnosis of ectopic gastric mucosa. Two years later, an irregular, elevated tumor developed at the same site. This tumor was suspected of having invaded the submucosal layer. A second biopsy led to a diagnosis of adenocarcinoma. The patient subsequently underwent a thoracoscopic esophagectomy. The resected specimen revealed an invasive tumor front that had invaded the deep layer of a duplicated muscularis mucosae. Intraepithelial neoplasia partially surrounded the tumor. This lesion was thought to have developed into an adenocarcinoma according to the orderly sequence of metaplasia, intraepithelial neoplasia and finally adenocarcinoma over a 2-year period. The present case suggests that erosive lesions in Barrett's esophagus should be strictly followed up by endoscopy, even if a biopsy does not reveal any neoplastic findings.
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Affiliation(s)
- Junya Oguma
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Akihito Kazuno
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Nitta
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Sakura Tomita
- Department of Pathology, Tokai University School of Medicine, Kanagawa, Japan
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43
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Oh D, Noh JM, Nam H, Lee H, Kim TG, Ahn YC. High-dose radiation therapy alone by moderate hypofractionation for patients with thoracic esophageal squamous cell carcinoma. Medicine (Baltimore) 2016; 95:e4591. [PMID: 27537591 PMCID: PMC5370817 DOI: 10.1097/md.0000000000004591] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
We conducted retrospective analyses to investigate the clinical outcome of thoracic esophageal cancer patients who were treated with high-dose radiation therapy (RT) alone by moderate hypofractionation due to medical unfitness or refusal to receive either surgery or chemo-radiotherapy.Between May 2003 and April 2013, 70 patients were treated with high-dose RT alone with curative aim. The planned total RT dose was 60 Gy in daily 3.0 Gy per fraction. We evaluated the survival outcome, toxicities, and prognostic factors affecting patients' survival.At the time of analysis, 32 patients experienced disease progression. The 2-year overall survival (OS), cancer-specific survival (CSS) and local control (LC) rates were 52.1%, 57.8%, and 68.2%, respectively. Among them, 25 patients had superficial (cT1a-b) esophageal cancers, and the 2-year OS, CSS, and LC rates were 80.0%, 87.3%, and 81.6%, respectively. Multivariate analysis revealed that cT disease (P < 0.001) and tumor location (P = 0.022) were the significant factors for OS. The incidence of grade 3 or higher toxicities were 9.9%, including grade 3 esophagitis (2 patients, 2.8%) and grade 4 or 5 trachea-esophageal fistula (5 patients, 7.1%).High-dose RT alone by moderate hypofractionation had led to reasonable clinical outcomes at acceptable toxicity risk in thoracic esophageal cancer patients who are medically unfit or refuse surgery or chemotherapy, especially for the patients having superficial lesion.
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Affiliation(s)
- Dongryul Oh
- Department of Radiation Oncology, Samsung Medical Center
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center
| | | | | | - Tae Gyu Kim
- Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Chan Ahn
- Department of Radiation Oncology, Samsung Medical Center
- Correspondence: Yong Chan Ahn, Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135–710, Korea (e-mail: ; )
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44
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Goense L, van Rossum PSN, Kandioler D, Ruurda JP, Goh KL, Luyer MD, Krasna MJ, van Hillegersberg R. Stage-directed individualized therapy in esophageal cancer. Ann N Y Acad Sci 2016; 1381:50-65. [PMID: 27384385 DOI: 10.1111/nyas.13113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/05/2016] [Indexed: 12/16/2022]
Abstract
Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.
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Affiliation(s)
- Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter S N van Rossum
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daniela Kandioler
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Khean-Lee Goh
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Mark J Krasna
- Meridian Cancer Care, Jersey Shore University Medical Center, Neptune, New Jersey
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Gamboa AM, Kim S, Force SD, Staley CA, Woods KE, Kooby DA, Maithel SK, Luke JA, Shaffer KM, Dacha S, Saba NF, Keilin SA, Cai Q, El-Rayes BF, Chen Z, Willingham FF. Treatment allocation in patients with early-stage esophageal adenocarcinoma: Prevalence and predictors of lymph node involvement. Cancer 2016; 122:2150-7. [PMID: 27142247 DOI: 10.1002/cncr.30040] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/15/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND In considering treatment allocation for patients with early esophageal adenocarcinoma, the incidence of lymph node metastasis is a critical determinant; however, this has not been well defined or stratified by the relevant clinical predictors of lymph node spread. METHODS Data from the Surveillance, Epidemiology, and End Results database of the National Cancer Institute were abstracted from 2004 to 2010 for patients with early-stage esophageal adenocarcinoma. The incidence of lymph node involvement for patients with Tis, T1a, and T1b tumors was examined and was stratified by predictors of spread. RESULTS A total of 13,996 patients with esophageal adenocarcinoma were evaluated. Excluding those with advanced, metastatic, and/or invasive (T2-T4) disease, 715 patients with Tis, T1a, and T1b tumors were included. On multivariate analysis, tumor grade (odds ratio [OR], 2.76; 95% confidence interval [95% CI], 1.58-4.82 [P<.001]), T classification (OR, 0.47; 95% CI, 0.24-0.91 [P =.025]), and tumor size (OR, 2.68; 95% CI, 1.48-4.85 [P = .001]) were found to be independently associated with lymph node metastases. There was no lymph node spread noted with Tis tumors. For patients with low-grade (well or moderately differentiated) tumors measuring <2 cm in size, the risk of lymph node metastasis was 1.7% for T1a (P<.001) and 8.6% for T1b (P = .001) tumors. CONCLUSIONS For patients with low-grade Tis or T1 tumors measuring ≤2 cm in size, the incidence of lymph node metastasis appears to be comparable to the mortality rate associated with esophagectomy. For highly selected patients with early esophageal adenocarcinomas, the results of the current study support the recommendation that local endoscopic resection can be considered as an alternative to surgical management when followed by rigorous endoscopic and radiographic surveillance. Cancer 2016;122:2150-7. © 2016 American Cancer Society.
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Affiliation(s)
- Anthony M Gamboa
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sungjin Kim
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Seth D Force
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kevin E Woods
- Interventional Endoscopy, Gastroenterology and Nutrition, Cancer Treatment Centers of America, Newnan, Georgia
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jennifer A Luke
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Katherine M Shaffer
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sunil Dacha
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nabil F Saba
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Steven A Keilin
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Qiang Cai
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bassel F El-Rayes
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Zhengjia Chen
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Abstract
CONTEXT Esophageal cancer continues to be one of the most lethal of all gastrointestinal malignancies. Its prognostic parameters are based on the gross and histopathologic examination of resected specimens by pathologists. OBJECTIVE To describe the implications of appropriate handling and examination of endomucosal resection and esophagectomy specimens from patients with esophageal carcinoma while considering the implications of the surgical techniques used to obtain such specimens. Parameters include histopathologic findings necessary for accurate staging, differences in the assessment of margins, residual malignancy, and criteria to evaluate for tumor regression after chemoradiation therapy as well as the role of immunohistochemistry and the judicious use of frozen sections. DATA SOURCES Sources were a review of the literature and the authors' experience handling these types of specimens. CONCLUSIONS Examining surgical specimens of the esophagus is critical in the management of patients with esophageal carcinoma, and it requires careful consideration of the diagnostic pitfalls, staging-related parameters, and results of molecular tests.
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Affiliation(s)
| | - Mariana Berho
- From the Department of Pathology, Cleveland Clinic Florida, Weston
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47
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Nason KS. Minimal or maximal surgery for esophageal cancer? J Thorac Cardiovasc Surg 2016; 151:633-635. [DOI: 10.1016/j.jtcvs.2015.09.118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 02/07/2023]
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48
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What Makes an Expert Barrett’s Histopathologist? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 908:137-59. [DOI: 10.1007/978-3-319-41388-4_8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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49
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Boys JA, Worrell SG, Chandrasoma P, Vallone JG, Maru DM, Zhang L, Blackmon SH, Dickinson KJ, Dunst CM, Hofstetter WL, Lada MJ, Louie BE, Molena D, Watson TJ, DeMeester SR. Can the Risk of Lymph Node Metastases Be Gauged in Endoscopically Resected Submucosal Esophageal Adenocarcinomas? A Multi-Center Study. J Gastrointest Surg 2016; 20:6-12; discussion 12. [PMID: 26408330 DOI: 10.1007/s11605-015-2950-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/14/2015] [Indexed: 02/07/2023]
Abstract
Endoscopic resection (ER) allows for local therapy of superficial esophageal cancers. Factors reported to be associated with an increased risk of lymph node metastases in patients with adenocarcinoma are poor differentiation, lymphovascular invasion (LVI), and submucosal invasion >500 μ. The aim of this study was to determine whether depth of invasion and tumor characteristics in an ER specimen can be used to gauge the risk of lymph node metastases in patients with superficial esophageal adenocarcinoma. Patients from seven US centers that had ER of an adenocarcinoma followed by an esophagectomy were identified. The ER pathology slides were rereviewed by three experienced GI pathologists for depth of invasion, presence of LVI, and tumor differentiation. The findings from the ER specimen were correlated with the presence and number of lymph node metastases in the final esophagectomy specimen. There were 19 T1a and 23 T1b tumors. A median of 24 nodes were resected per patient. None of the T1a tumors had involved lymph nodes despite the presence of LVI in 5% and poor differentiation in 21% of patients. In contrast, 26% of T1b tumors had involved nodes. None of the four patients with submucosal invasion ≤500 μ, no LVI, and no poor differentiation had involved nodes. However, with an increasing number of risk factors, the likelihood of involved lymph nodes increased, reaching 50% when all three factors were present. Endoscopic therapy appears appropriate for intramucosal tumors and may be an option for low-risk T1b tumors. Esophagectomy is preferred for patients with submucosal invasion and one or more risk factors.
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Affiliation(s)
- Joshua A Boys
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | - Stephanie G Worrell
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | - Parakrama Chandrasoma
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John G Vallone
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Dipen M Maru
- Department of Pathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Lizhi Zhang
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Wayne L Hofstetter
- Department of Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Michael J Lada
- Department of Surgery, University of Rochester, New York, NY, USA
| | - Brian E Louie
- Department of Surgery, Swedish Cancer Institute, Seattle, WA, USA
| | - Daniela Molena
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Thomas J Watson
- Department of Surgery, University of Rochester, New York, NY, USA
| | - Steven R DeMeester
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA.
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50
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Fotis D, Doukas M, Wijnhoven BP, Didden P, Biermann K, Bruno MJ, Koch AD. Submucosal invasion and risk of lymph node invasion in early Barrett's cancer: potential impact of different classification systems on patient management. United European Gastroenterol J 2015; 3:505-13. [PMID: 26668743 DOI: 10.1177/2050640615581965] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Due to the high mortality and morbidity rates of esophagectomy, endoscopic mucosal resection (EMR) is increasingly used for the curative treatment of early low risk Barrett's adenocarcinoma. OBJECTIVE This retrospective cohort study aimed to assess the prevalence of lymph node metastases (LNM) in submucosal (T1b) esophageal adenocarcinomas (EAC) in relation to the absolute depth of submucosal tumor invasion and demonstrate the efficacy of EMR for low risk (well and moderately differentiated without lymphovascular invasion) EAC with sm1 invasion (submucosal invasion ≤500 µm) according to the Paris classification. METHODS The pathology reports of patients undergoing endoscopic resection and surgery from January 1994 until December 2013 at one center were reviewed and 54 patients with submucosal invasion were included. LNM were evaluated in surgical specimens and by follow up examinations in case of EMR. RESULTS No LNM were observed in 10 patients with sm1 adenocarcinomas that underwent endoscopic resection. Three of them underwent supplementary endoscopic eradication therapy with a median follow up of 27 months for patients with sm1 tumors. In the surgical series two patients (29%) with sm1 invasion according to the pragmatic classification (subdivision of the submucosa into three equal thirds), staged as sm2-3 in the Paris classification, had LNM. The rate of LNM for surgical patients with low risk sm1 tumors was 10% according to the pragmatic classification and 0% according to Paris classification. CONCLUSION Different classifications of the tumor invasion depth lead to different LNM risks and treatment strategies for sm1 adenocarcinomas. Patients with low risk sm1 adenocarcinomas appear to be suitable candidates for EMR.
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Affiliation(s)
- Dimitrios Fotis
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Michael Doukas
- Department of Pathology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Bas Pl Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
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