Tumor cell dissociation score highly correlates with lymph node metastasis in superficial esophageal carcinoma

Long-term outcomes of endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma in Taiwan

Background

Endoscopic submucosal dissection (ESD) is gradually turning into the standard treatment for superficial esophageal squamous cell carcinoma (SESCC), however, the long-term outcomes have hardly ever been reported outside Japan.

Method

We consecutively recruited patients with SESCC who had received ESD treatment at E-Da Hospital. The demographics, pathological characteristics, and Lugol staining background pattern (type A or B: none or < 10 small Lugol-voiding lesions [LVLs]; type C or D: > 10 small or multiform LVLs) were collected, and then correlated to outcomes and survival.

Results

Total of 229 lesions were enrolled and the mean lesion size was 3.28 ± 1.69 (range 1–10) cm. 72% of the lesions had a type C-D Lugol staining background pattern. After ESD, the en bloc and R0 resection rates were 93.9% and 83.5%, respectively. Forty-nine subjects developed complications, including six (2.6%) with major bleeding, two (0.9%) with perforation, and 41 (17.9%) with strictures. Pathological staging showed that 19 cases had deep submucosal cancer invasion and subsequently received adjuvant therapies. During a mean follow-up period of 52.6 (range 3–146) months, 41 patients developed metachronous recurrence. The patients with a type C-D Lugol staining background pattern were associated with a higher risk of recurrence than those with few LVLs (log-rank P = 0.019). The 10-year survival rate was more than 90%, and only eight patients died of ESCC.

Conclusion

ESD has excellent long-term outcomes but a high risk of metachronous recurrence. The Lugol staining pattern over the background mucosa could offer the risk stratification of metachronous recurrence.

S100A4 silencing blocks invasive ability of esophageal squamous cell carcinoma cells

AIM: To investigate a potential role of S100A4 in esophagus squamous cell carcinoma metastasis (ESCCs).

METHODS: Expression of S100A4 and E-cadherin were analyzed in frozen sections from ESCCs (metastasis, n = 28; non-metastasis, n = 20) by reverse transcription-polymerase chain reaction, quantitative polymerase chain reaction and immunohistochemistry. To explore the influence of S100A4 on esophageal cancer invasion and metastasis, S100A4 was overexpressed or silenced by S100A4 siRNA in TE-13 or Eca-109 cells in vitro and in vivo.

RESULTS: We found the mRNA and protein levels of S100A4 expression in ESCCs was significantly upregulated, and more importantly, that expression of S100A4 and E cadherin are strongly negatively correlated in patients who had metastasis. It was indicated that overexpression of S100A4 in TE-13 and Eca-109 cells downregulates the expression of E-cadherin, leading to increased cell migration in vitro, whereas knockdown of S100A4 inhibited cell migration and upregulation of E-cadherin expression. Moreover, the loss of cell metastatic potential was rescued by overexpression of E-cadherin completely. In addition, nude mice inoculated with S100A4 siRNA-transfected cells exhibited a significantly decreased invasion ability in vivo.

CONCLUSION: S100A4 may be involved in ESCC progression by regulate E-cadherin expression, vector-based RNA interference targeting S100A4 is a potential therapeutic method for human ESCC.

The Use of Neural Networks in Identifying Risk Factors for Lymph Node Metastasis and Recommending Management of T1b Esophageal Cancer

The objective of this study was to establish a prediction model of lymph node status in T1b esophageal carcinoma and define the best squamous and adenocarcinoma predictors. The literature lacks a satisfactory level of evidence of T1b esophageal cancer management. We performed an analysis pooling the effects of outcomes of 2098 patients enrolled into 37 retrospective studies using “neural networks” as data mining techniques. The percentages for lymph node, lymphatic (L1), and vascular (V1) invasion in Sm1 esophageal cancers were 24, 46, and 20 per cent, respectively. The same parameters apply to Sm2 with 34, 63, and 38 per cent as opposed to Sm3 with 51, 69, and 47 per cent. The respective number of patients with well, moderate, and poor histologic differentiation totaled 267, 752, and 582. The rank order of the predictors of lymph node positivity was, respectively: Grade III, (L1), (V1), Sm3 invasion, Sm2 invasion, and Sm1 invasion. Histologic-type squamous and adenocarcinoma (ADC/SCC) was not included in the model. The best predictors for SCC lymph node positivity were sm3 invasion and (V1). As concerns ADC, the most important predictor was (L1). Submucosal esophageal cancer should be managed with surgical resection. However, this is subject to the histologic type and presence of specific predictors that could well alter the perspective of multimodality management.

Prognostic impact of upper, middle, and lower third mucosal or submucosal infiltration in early esophageal cancer

OBJECTIVE

To identify differences in survival of patients with pT1 esophageal cancer relating to depth of wall infiltration.

BACKGROUND DATA

Histologic analysis of mucosal and submucosal infiltration in thirds has shown an increasing rate of lymph node metastases (LNM) according to the depth of wall infiltration in pT1 esophageal cancer.

METHODS

One hundred seventy-one patients had transthoracic en bloc (n = 161) or transhiatal esophagectomy (n = 10) for pT1 esophageal cancer [121 adenocarcinomas (AC), 50 squamous cell carcinomas (SCC)]. The histologic analysis of the specimen comprised depth of wall penetration of the carcinoma in thirds of pT1a = mucosa (m1, m2, m3) or pT1b = submucosa (sm1, sm2, sm3) and number and infiltration of the resected lymph nodes.

RESULTS

The rate of LNM was 0% for 70 mucosal carcinomas and 34% for 101 submucosal carcinomas (P = 0.001). For sm1, this rate was 13%, for sm2 19% and for sm3 56%. The 5-year survival rate (5Y-SR) was 82% for pN0 and 45% for pN+ patients (P < 0.001). There was no significant prognostic difference between AC and SCC (5Y-SR: 74% vs 71%). The 5Y-SR of the pT1a group was 87% compared with 66% for pT1b (P = 0.046). The 5-year survival rate for sm1 and sm2 were similar; sm1 + sm2 were together significantly better (80%) than sm3 (46%) (P = 0.008). In multivariate analysis, only sm3 was an independent prognostic factor (P = 0.01).

CONCLUSIONS

After esophagectomy, the prognosis of patients with sm1/sm2 infiltration is as good as for patients with mucosal carcinoma. Sm3 infiltration is the worst prognostic factor in pT1 esophageal cancer.

Risk of lymph node metastasis in submucosal esophageal cancer: a review of surgically resected patients

OBJECTIVES

Endoscopic local procedures are increasingly applied in patients with superficial esophageal cancer as an alternative to radical oncologic resection. The objective of this article is to determine the risk of nodal metastases in submucosal (sm) esophageal cancer, comparing the two predominating histologic tumor types, squamous cell cancer (SCC) and adenocarcinoma (ADC).

METHODS

A query of PubMed, MEDLINE, Embase and Cochrane Library (1980-2009) using predetermined search terms revealed 675 abstracts, of which 485 full-text articles were reviewed. A total of 105 articles met the selection criteria. A review of article references and consultation with experts revealed additional articles for inclusion. Studies that enrolled patients with submucosal esophageal cancer and provided adequate extractable data were included.

RESULTS

The pooled outcomes of 7645 patients with esophageal cancer involving the sm level of infiltration were included in the analysis. Overall, the percentage of lymph node metastasis in submucosal cancer was 37%. Lymph node (N), lymphatic (L) and vascular (V) invasion in sm1 esophageal cancers was 27, 46 and 22%, respectively. Within sm2 lesions, N, L and V invasion were involved in 38, 63 and 38% of patients, respectively. Finally, N, L and V involvement in patients with sm3 lesions was 54, 69 and 47%, respectively. The rates of lymph node metastasis for sm1 and sm2 were higher in SCC compared with ADC, whereas the lymph node metastasis for sm3 was comparable, with >50% involvement in both histologic subtypes. SCC revealed an overall more aggressive behavior compared with ADC (N+: 45 vs 26%; L+: 57 vs 37%; V+: 40 vs 18%).

DISCUSSION

While endoscopic therapy may be adequate in selected patients with 'low-risk' sm1 ADC, submucosal SCC necessitates esophageal resection and systematic lymphadenectomy because of its aggressive nature and tendency for early metastasis.

Endoscopic submucosal dissection is superior to conventional endoscopic resection as a curative treatment for early squamous cell carcinoma of the esophagus (with video)

BACKGROUND

Endoscopic submucosal dissection (ESD) was originally developed in Japan for en bloc resection of gastric neoplasms.

OBJECTIVE

To clarify whether the novel ESD procedure is feasible and gives results that justify the pursuit of integrated minimally invasive procedures aimed at curing early squamous cell carcinoma of the esophagus (SCCE).

DESIGN

Retrospective cohort study.

SETTING

A single-institution trial by experienced endoscopists.

PATIENTS

This study involved 300 consecutively enrolled patients with SCCE (Tumor, Nodes, Metastasis classification T1, N0) who underwent either EMR (n = 184) or ESD (n = 116) from March 1994 to July 2007.

INTERVENTION

The patients underwent endoscopic resection and then were followed by periodic endoscopy for 8 to 174 months (mean 65 months).

MAIN OUTCOME MEASUREMENTS

Resectability, cure rates, complications, disease-free survival of the two groups, and risk factors for local recurrence were explored.

RESULTS

En bloc resection and the local recurrence rate were significantly better in the ESD group (P = .0009 and .065, respectively). The frequency of perforation was not significantly different between the two groups (P = .68). Four independent risk factors for local recurrence were identified by the Cox regression model: EMR, deep cancer invasion, upper esophagus location, and family history of esophageal cancer. Radical cure is mostly obtained by successful endoscopic retreatment of local recurrence after previous endoscopic resection. Disease-free survival was significantly better with ESD.

LIMITATIONS

The study's retrospective nature prevents definitive conclusions.

CONCLUSIONS

We provide evidence that ESD gives a higher cure rate and is safer than conventional endoscopic resection when applied to early SCCE. ESD warrants prospective comparative studies with conventional endoscopic resection.

Independent histological risk factors for lymph node metastasis of superficial esophageal squamous cell carcinoma; implication of claudin-5 immunohistochemistry for expanding the indications of endoscopic resection

Endoscopic resection is curative for superficial esophageal squamous cell carcinoma (ESCC) limited to the lamina propria. Endoscopic resection is not recommended for superficial ESCC invading muscularis mucosa or submucosa, however, because of the high frequency of lymph node metastasis (LNM) in such patients. Methods to more accurately predict LNM by analysis of endoscopically resected specimens are needed. Patients with superficial ESCC who underwent surgery without prior chemoradiotherapy (n= 110) were retrospectively examined to determine whether LNM correlated with immunohistochemical parameters and conventional histological parameters, including depth of invasion and vascular permeation. Cancer cell expression of claudins-1, 5, and 7, E-cadherin, beta-catenin, and matrix metalloproteinase 7 was evaluated. Univariate analysis revealed that LNM correlated with claudin-5 expression, but not any other immunohistochemical parameter examined. Multivariate analysis revealed three independent risk factors for LNM: aberrant claudin-5 expression in cancer cells (odds ratio; OR [95% confidence interval]= 4.61[1.44-14.77]), depth of submucosal invasion greater than 200 microm (3.55 [1.02-13.17]), and positive lymphatic permeation (3.34 [1.22-9.15]). LNM was found in one of 29 (3.4%) patients with none of these three risk factors, and in 32 of 81 (39.5%) patients with one or more of these risk factors. In superficial ESCC, routine analysis of claudin-5 expression in cancer cells together with depth of invasion and lymphatic permeation may be useful for predicting LNM and thereby reducing the number of patients undergoing additional surgery after successful endoscopic resection.

Prediction model of lymph node metastasis in superficial esophageal adenocarcinoma and squamous cell cancer including D2-40 immunostaining

BACKGROUND

It was the aim of our study to establish a model for prediction of lymph node metastases in superficial esophageal cancer.

METHODS

We analyzed the clinical and histopathological data of 50 consecutive patients with pT1-esophageal cancer who underwent oncological resection. Submucosal carcinomas (pT1b) were classified according to sm levels 1-3. D2-40 immunostaining was investigated using the ABC technique. In a first step, we performed univariate analysis (One-way ANOVA: Sigma restricted parameterization; test of SS whole vs. SS predicted) to test the predictive value of the following categorical parameters for lymph node status (positive/negative): sex, histologic tumor type, localization, surgical technique (transhiatal/transthoracic), grading, pT1-subclassification (pT1a, pT1b sm 1-3), pL-, pV-status, and D2-40 labeling. Simple regression was applied for the following continuous predictors: age and tumor size. All significant variables of univariate analysis were included in the multivariate analysis. For this purpose, we used the General Liner Models's analysis (forward stepwise). In a third step, the Kruskal-Wallis test with post hoc comparisons was intended to define the cut-off value of parameters tested.

RESULTS

Only the following variables gained statistical significance in univariate analysis: sex, histological tumor type, grading, pT1-subclassification, lymphatic infiltration, microvascular infiltration, D2-40 immunostaining, and tumor size (P < 0.05). Variables reaching significance in multivariate analysis were tumor size (P = 0.017) and pV-status (P = 0.037). In the Kruskal-Wallis test with post hoc comparisons, the cut-off value of tumor size was 2 cm (model P = 0.002) and between the categories (P < 0.05).

CONCLUSIONS

Lymph node positivity and lymphatic vessel infiltration did not linearly increase with sm tumor infiltration depth. The risk category of lymph node involvement in superficial esophageal cancer exists according to our prediction model on the basis of tumor size of >2 cm and microvascular infiltration. The hitherto common sm levels 1-3 classification of submucosal cancers appears to display a lesser impact than previously assumed with regard to prediction of potential lymph node metastases and consequently the indication for endoscopic or surgical therapy.

Reflux esophagitis, high-grade neoplasia, and early Barrett's carcinoma-what is the place of the Merendino procedure?

INTRODUCTION

Because of the increasing frequency of Barrett's cancer in Western industrialized countries, the management of reflux disease with the potential development of Barrett's esophagus, neoplasia, and early carcinoma is very important. In case of established Barrett's esophagus, the malignant degeneration of the specialized epithelium cannot definitely be prevented by antireflux surgery or continuous medication. Mucosal adenocarcinomas nearly never develop lymph node metastasis and can mostly be treated by endoscopic mucosectomy. The deeper the submucosa is infiltrated, the higher is the rate of lymph node metastasis which is, on the average, 30% for submucosal carcinoma.

CONCLUSIONS

Therefore, radical subtotal esophagectomy is the treatment of choice for submucosal carcinoma, whereas distal esophageal resection with limited lymph node dissection is only indicated in mucosal carcinoma which cannot be completely removed by interventional endoscopy.

Endoscopic mucosal resection of early esophageal carcinoma--experience of 9 cases

BACKGROUND

Early esophageal mucosal carcinoma (M1 and M2) can be treated by ablation, or by endoscopic resection such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection. Endoscopic resection enables pathologic examination of resected specimens. We hereby report our experiences with early esophageal cancer and its endoscopically observed types, chromoendoscopy with Lugol's iodine and EMR results.

METHODS

Between May 2003 and July 2007, 9 patients with early esophageal carcinoma underwent EMR. The diagnosis was made by conventional endoscopy (waiting for the relaxed phase during esophageal peristalsis) followed by chromoendoscopy using 3% Lugol's iodine to stain suspected early lesions or in high-risks patients. Miniprobe endoscopic ultrasound examinations were performed in all cases except 1. EMRs were carried out with a cap-fitted endoscope (EMRC).

RESULTS

There were 6 male and 3 female patients, with a median age of 53 years (range, 44-83 years). Six of the 9 cases had a history of smoking, 5 had a history of drinking, and 4 had a history of betel nut chewing. The endoscopic pictures of the early cancers were type 0-IIa (1 case), type 0-IIb (2 cases), and type 0-IIc (6 cases). One patient had double 0-IIc lesions. Two 0-IIb cases were detected only by chromoendoscopy using Lugol's iodine staining. The median size of the lesions was 0.85 cm (range, 0.7-2.0 cm). The final pathology reports of the endoscopically resected specimens were well-differentiated squamous cell carcinoma with free vertical and lateral margins, and no vascular or lymphatic invasion. The depths of tumor invasion were mucosal layer M1 in 7 cases, M2 in 1 case, and submucosal layer SM1 in the remaining case. There were no perforation or bleeding complications. The mean follow-up period was 13.1 months (range, 4-46 months). A M2 early esophageal cancer measuring 2 cm in diameter recurred 6 months after piecemeal EMRC. No additional adjuvant therapy was given to the SM1 case owing to her old age and bedridden condition.

CONCLUSION

Early esophageal cancer can be diagnosed by meticulous examination of the esophageal mucosa with conventional endoscopy, facilitated by Lugol's iodine staining, and can be treated by EMR, which is safe. Recurrence can occur after piecemeal EMR.

Are squamous and adenocarcinomas of the esophagus the same disease?

Esophageal cancer can be divided in squamous-cell cancer (SCC) and adenocarcinoma (Barrett cancer: AEG I) by histopathology. However, most studies do not differentiate between these two tumor entities. SCC is associated with a lower socioeconomic level with nicotine and alcohol abuse resulting in comorbidities like liver cirrhosis and reduced pulmonary function; in contrast, AEG I is associated with a high socioeconomic level and cardiovascular risk factors. The median age of patients with SCC is 10 years younger than with AEG I. The localization of AEG I is in 94% below the tracheal bifurcation, whereas SCC has contact to the tracheal bronchial tree in 75%. Furthermore, SCC shows an earlier lymphatic spread and a worse prognosis compared to AEG I. The different localization and different comorbidities require different therapeutic strategies. The preoperative induction therapy consists of combined chemoradiotherapy for locally advanced SCC and of chemotherapy for AEG I in our department. Due to the favorable position of AEG I a classic Ivor-Lewis procedure ending with an intrathoracic anastomosis is possible, in contrast, SCC frequently requires a subtotal esophagectomy with cervical anastomosis (in a two step strategy). Therefore, at the moment there is no doubt that SCC and AEG I are two different diseases with different pathogenesis, epidemiology, tumor biology and prognosis requiring different therapeutic strategies. We suggest that the two different tumor entities should be analyzed and reported separately to provide comparable results in the future.