Endoscopic and surgical resection of T1a/T1b esophageal neoplasms: A systematic review

Successful endoscopic treatment of superficial esophageal cancer in a patient with esophageal variceal bleeding: A case report

BACKGROUND

The coexistence of esophageal variceal bleeding and superficial esophageal cancer (SEC) is relatively rare in clinical practice. Moreover, there have been few reports of SEC overlying esophageal varices (EVs). Herein, we report our successful use of endoscopic submucosal dissection (ESD), esophageal solitary venous dilatation (ESVD), and endoscopic injection sclerotherapy (EIS) to treat a 75-year-old man who was diagnosed with SEC coexisting with esophageal variceal bleeding.

CASE SUMMARY

A 75-year-old man was admitted to the hospital due to black stool for 4 days. The patient had a history of liver cancer, cirrhosis, and portal hypertension. Endoscopic examination revealed esophageal and gastric varicose veins, as well as esophageal carcinoma in situ. We first treated esophageal variceal bleeding by ESVD and EIS. One week later, ESD treatment was done, and the complete resection of early esophageal cancer was successfully completed via endoscopy. There were no postoperative complications, such as bleeding, infection, or perforation.

CONCLUSION

The sequential treatment of ESVD, EIS, and ESD is an effective method for treating EVs with early esophageal cancer.

Advances in diagnosis and management of cancer of the esophagus

Esophageal cancer is the seventh most common malignancy worldwide, with over 470 000 new cases diagnosed each year. Two distinct histological subtypes predominate, and should be considered biologically separate disease entities.1 These subtypes are esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC). Outcomes remain poor regardless of subtype, with most patients presenting with late stage disease.2 Novel strategies to improve early detection of the respective precursor lesions, squamous dysplasia, and Barrett's esophagus offer the potential to improve outcomes. The introduction of a limited number of biologic agents, as well as immune checkpoint inhibitors, is resulting in improvements in the systemic treatment of locally advanced and metastatic esophageal cancer. These developments, coupled with improvements in minimally invasive surgical and endoscopic treatment approaches, as well as adaptive and precision radiotherapy technologies, offer the potential to improve outcomes still further. This review summarizes the latest advances in the diagnosis and management of esophageal cancer, and the developments in understanding of the biology of this disease.

Management of early oesophageal cancer: An overview

The incidence of esophageal cancer, namely the adenocarcinoma subtype, continues to increase exponentially on an annual basis. The indolent nature of the disease renders a significant proportion inoperable at first presentation, however, with the increased utilisation of endoscopy, many early lesions are now being identified which are suitable for endotherapeutic approaches. This article details the options available for dealing with early esophageal cancer by endoscopic mean obviating the need for surgery thereby avoiding the potential morbidity and mortality of such intervention.

Defining Pathologic Upstaging in cT1b Esophageal Cancer: Should We Consider Neoadjuvant Therapy?

INTRODUCTION

Neoadjuvant chemoradiation therapy (NCRT) for cT1b esophageal cancer is not recommended despite the risk of pathologic upstaging with increased depth of penetration. We aimed to (1) define the rate of and factors associated with pathologic upstaging, (2) describe current trends in treatments, and (3) compare overall survival (OS) with and without NCRT for surgically resected cT1b lesions.

METHODS

We used the 2020 National Cancer Database to identify patients with cT1b N0 esophageal cancer with or without pathologic upstaging who underwent removal of their tumor. We built multivariable logistic regression models to assess factors associated with pathologic upstaging. Survival was compared using log-rank analysis and modeled using multivariable Cox proportional hazards regressions.

RESULTS

Out of 1106 patients with cT1b esophageal cancer, 17.3% (N = 191) had pathologic upstaging. A higher tumor grade (P = 0.002), greater tumor size (P < 0.001), and presence of lympho-vascular invasion (P < 0.001) were associated with pathologic upstaging. 8.0% (N = 114) of patients were treated with NCRT. Five-y OS was 49.4% for patients who received NCRT compared to 67.2% for upfront esophagectomy (P < 0.05). Pathologic upstaging was associated with decreased OS (pathologic upstaging 43.7% versus no pathologic upstaging 67.7%) (hazard ratio 2.12 [95% confidence interval, 1.70-2.65; P < 0.001]). Compared to esophagectomy, endoscopic local tumor excision was associated with a decreased OS (hazard ratio 1.50 [95% confidence interval, 1.19-1.89; P = 0.001]).

CONCLUSIONS

Pathologic upstaging of cT1b lesions is associated with decreased OS. Esophagectomy is associated with a survival benefit over endoscopic local tumor excision for these lesions. NCRT is not associated with an increase in OS in cT1b lesions compared to upfront esophagectomy.

Endoscopic Submucosal Dissection in the Upper Gastrointestinal Tract and the Need for Rescue Surgery-A Multicenter Analysis

Endoscopic submucosal dissection (ESD) has become the standard treatment for early malignant lesions in the upper gastrointestinal (GI) tract. Its clinical results have been reported to be as good as surgery. The outcomes of rescue surgery after non-curative ESD have been reported to be as good as first-line surgery. The aim of this study was to evaluate the outcomes of ESD in the upper GI tract and the outcomes of rescue surgery after non-curative ESD performed in Linz, Austria, between 2009 and January 2023. A total of 193 ESDs were included and divided into 104 esophageal ESD and 89 gastric ESD procedures. The criteria for curative ESD were in line with established guidelines' recommendations. For esophageal lesions, the mean lesion size was 40.3 mm and the rate of curative ESD was 56.7%. In the non-curative ESD, the rate of technical failure as the reason for non-curative ESD was 13.3% and the oncological failure rate was 86.7%. Only 48.7% of indicated rescue surgeries were performed. The main reason for not performing surgery was interdisciplinary consensus due to comorbidity. Perioperative complications Dindo-Clavien ≥ 3 occurred in 22.2% of cases with an in-hospital mortality rate of 0. In gastric lesions, the mean size was 39 mm and the rate of curative ESD was 69.7%. The rate of technical failure as a reason for non-curative ESD was 25.9% and the oncological failure rate was 74.1% for non-curative ESD. Rescue surgery was performed in 48.2% of indicated cases. The perioperative rate for major complications was 0. The outcome of ESD in the upper GI tract is in line with the published literature, and non-curative ESD does not worsen surgical outcomes. The available follow-up data are in line with the international published literature, showing a low rate of residual malignancy in surgical resection specimens. Therefore, the indication of rescue surgery for oncological failure remains challenging. Furthermore, the learning curve of ESD has shown a trend towards improving outcomes over time.

Ten-year follow-up of endoscopic mucosal resection versus esophagectomy for esophageal intramucosal adenocarcinoma in the setting of Barrett's esophagus: a Canadian experience

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.

Management of esophageal neoplasms by endoscopic submucosal dissection: experience over 100 consecutive procedures

BACKGROUND/AIMS

Endoscopic submucosal dissection (ESD) is currently considered the first-line treatment for the eradication of superficial neoplasms of the esophagus in Eastern countries. However, in the West, particularly in Latin America, the experience with esophageal ESD is still limited because of the high technical complexity required for its execution. This study aimed to present the results of the clinical application of ESD to manage superficial esophageal neoplasms in a Latin American center in over 100 consecutive cases.

METHODS

This retrospective study included consecutive patients who underwent endoscopic ESD for superficial esophageal neoplasms between 2009 and 2022. The following clinical outcomes were assessed: en bloc, complete, and curative resection rates, local recurrence, adverse events, and procedure-related mortality.

RESULTS

Esophageal ESD was performed mainly for squamous cell carcinoma (66.6%), high-grade intraepithelial neoplasia (17.1%), and adenocarcinoma (11.4%). En bloc and complete resection rates were 96.2% and 81.0%, respectively. The curative resection rate was 64.8%. Adverse events occurred in six cases (5.7%). Endoscopic follow-up was performed for an average period of 29.7 months.

CONCLUSION

ESD performed by trained operators is feasible, safe, and clinically effective for managing superficial neoplastic lesions of the esophagus in Latin America.

Endoscopic resection of early esophageal tumors in patients with cirrhosis or portal hypertension: a multicenter observational study

BACKGROUND

Liver cirrhosis and esophageal cancer share several risk factors, such as alcohol intake and excess weight. Endoscopic resection is the gold standard treatment for superficial tumors. Portal hypertension and coagulopathy may increase the bleeding risk in these patients. This study aimed to assess the safety and efficacy of endoscopic resection for early esophageal neoplasia in patients with cirrhosis or portal hypertension.

METHODS

This retrospective multicenter international study included consecutive patients with cirrhosis or portal hypertension who underwent endoscopic resection in the esophagus from January 2005 to March 2021.

RESULTS

134 lesions in 112 patients were treated, including by endoscopic submucosal dissection in 101 cases (75 %). Most lesions (128/134, 96 %) were in patients with liver cirrhosis, with esophageal varices in 71 procedures. To prevent bleeding, 7 patients received a transjugular intrahepatic portosystemic shunt, 8 underwent endoscopic band ligation (EBL) before resection, 15 received vasoactive drugs, 8 received platelet transfusion, and 9 underwent EBL during the resection procedure. Rates of complete macroscopic resection, en bloc resection, and curative resection were 92 %, 86 %, and 63 %, respectively. Adverse events included 3 perforations, 8 delayed bleedings, 8 sepsis, 6 cirrhosis decompensations within 30 days, and 22 esophageal strictures; none required surgery. In univariate analysis, cap-assisted endoscopic mucosal resection was associated with delayed bleeding (P = 0.01).

CONCLUSIONS

In patients with liver cirrhosis or portal hypertension, endoscopic resection of early esophageal neoplasia appeared to be effective and should be considered in expert centers with choice of resection technique, following European Society of Gastrointestinal Endoscopy guidelines to avoid undertreatment.

Miniature side-view dual axes confocal endomicroscope for repetitive in vivo imaging

A side-view dual axes confocal endomicroscope is demonstrated that can be inserted repetitively in hollow organs of genetically engineered mice for in vivo real-time imaging in horizontal and vertical planes. Near infrared (NIR) excitation at λex = 785 nm was used. A monolithic 3-axis parametric resonance scan mirror was fabricated using micro-electro-mechanical systems (MEMS) technology to perform post-objective scanning in the distal end of a 4.19 mm diameter instrument. Torsional and serpentine springs were designed to "switch" the mode of imaging between vertical and horizontal planes by tuning the actuation frequency. This system demonstrated real-time in-vivo images in horizontal and vertical planes with 310 µm depth and 1.75 and 7.5 µm lateral and axial resolution. Individual cells and discrete mucosal structures could be identified.

Radiotherapy Improves Survival of Patients With Lymphovascular Invasion in pT1b Esophageal Squamous Cell Cancer After Endoscopic Submucosal Dissection

INTRODUCTION

Adjuvant radiotherapy is recommended for pT1b esophageal squamous cell cancer (ESCC) after endoscopic submucosal dissection (ESD). However, it is unclear whether additional radiotherapy can improve patient survival. This study aimed to evaluate the efficacy of adjuvant radiotherapy after ESD for pT1b ESCC.

METHODS

This was a multicenter, cross-sectional study involving 11 hospitals in China. Between January 2010 and December 2019, patients with T1bN0M0 ESCC treated with or without adjuvant radiotherapy after ESD were included. Survival between groups was compared.

RESULTS

Overall, 774 patients were screened, and 161 patients were included. Forty-seven patients (29.2%) received adjuvant radiotherapy after ESD (RT group) and 114 (70.8%) underwent ESD alone (non-RT group). There were no significant differences in overall survival (OS) and disease-free survival (DFS) between the RT and non-RT groups. Lymphovascular invasion (LVI) was the only prognostic factor. In the LVI+ group, adjuvant radiotherapy significantly improved survival (5-year OS: 91.7% vs 59.5%, P = 0.050; 5-year DFS: 92.9% vs 42.6%, P = 0.010). In the LVI- group, adjuvant radiotherapy did not improve survival (5-year OS: 83.5% vs 93.9%, P = 0.148; 5-year DFS: 84.2% vs 84.7%, P = 0.907). The standardized mortality ratios were 1.52 (95% confidence interval 0.04-8.45) in the LVI+ group with radiotherapy and 0.55 (95% confidence interval 0.15-1.42) in the LVI- group without radiotherapy.

DISCUSSION

Adjuvant radiotherapy could improve survival in pT1b ESCC with LVI+ other than LVI- after ESD. Selective adjuvant radiotherapy based on LVI status achieved survival rates similar to those of the general population.

Utilization Trends and Volume-outcomes Relationship of Endoscopic Resection for Early Stage Esophageal Cancer

OBJECTIVES

We describe utilization trends and center volume-outcomes relationship of ER of early stage esophageal cancer using a large hospitalbased registry.

SUMMARY OF BACKGROUND DATA

ER is increasingly accepted as the preferred treatment for early stage esophageal cancer, however its utilization and the center volume-outcomes relationship in the United States is unknown.

METHODS

The National Cancer Database was used to identify patients with cT1N0M0 esophageal cancer treated with ER or esophagectomy between 2004 and 2015. Relative frequencies were plotted over time. Restricted cubic splines and maximally selected rank statistics were used to identify an inflection point of center volume and survival.

RESULTS

A total of 1136 patients underwent ER and 2829 patients underwent esophagectomy during the study period. Overall utilization of ER, and relative use compared to esophagectomy, increased throughout the study period. Median annualized center ER volume was 1.9 cases per year (interquartile range 0.5-5.8). Multivariable Cox regression showed increasing annualized center volume by 1 case per year was associated with improved survival. Postoperative 30- or 90-day mortality, 30-day readmission, and pathologic T upstaging rates were similar irrespective of center volume.

CONCLUSIONS

Utilization of ER compared to esophagectomy for stage I esophageal cancer has increased over the past decade, though many individual centers perform fewer than 1 case annually. increasing annualized center volume by one procedure per year was associated with improved survival. increased volume beyond this was not associated with survival benefit. Referral to higher volume centers for treatment of superficial esophageal cancer should be considered.

Associated risk factor analysis and the prognostic impact of positive resection margins after endoscopic resection in early esophageal squamous cell carcinoma

Endoscopic resection for early esophageal cancer has a risk of residual margins. The risk these residual margins pose have not been fully evaluated. The present study aimed to investigate the associated risk factors and prognosis of residual margins following the endoscopic resection of early esophageal squamous cell carcinoma. In total, 369 patients (381 lesions) with early esophageal squamous cell carcinoma treated in the Fourth Hospital of Hebei Medical University (Shijiazhuang, China) with endoscopic resection were retrospectively analyzed. Sex, age, location, tumor diameter, depth of tumor invasion, endoscopic treatment, endoscopic ultrasonography (EUS) before resection, work experience of endoscopists and the degree of tumor differentiation were all evaluated as potential risk factors. In addition, the prognosis of patients with positive margins were analyzed. A total of 73 patients (73/381, 19.2%) had positive margins after endoscopic resection. Amongst the 65 patients who were successfully followed up, five patients succumbed to cardiovascular and cerebrovascular diseases, one patient received radiotherapy, two patients received radiotherapy and chemotherapy whilst one patient received chemotherapy. By contrast, 12 patients received surgery and 20 patients received additional endoscopic mucosal resection or endoscopic submucosal dissection. The other 29 patients were followed up regularly and no recurrence could be found. Univariate analysis revealed that tumor diameter, endoscopic treatment, depth of invasion, EUS before resection, degree of tumor differentiation and direction of invasion were all associated with the positive margin. Multivariate logistic regression analysis then found that EUS before resection, degree of tumor differentiation and depth of tumor invasion are independent risk factors for positive margins after endoscopic resection. These results suggest that poorly differentiated lesions and deeper invasion depth can increase the risk of positive margin after endoscopic resection. As a result, EUS evaluation before resection may reduce the risk of invasion depth. In addition, for poorly differentiated lesions, more aggressive treatment regimens may be recommended for preventing recurrence.

Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022

ESGE recommends that the evaluation of superficial gastrointestinal (GI) lesions should be made by an experienced endoscopist, using high definition white-light and chromoendoscopy (virtual or dye-based).ESGE does not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection.ESGE recommends endoscopic submucosal dissection (ESD) as the treatment of choice for most superficial esophageal squamous cell and superficial gastric lesions.For Barrett's esophagus (BE)-associated lesions, ESGE suggests the use of ESD for lesions suspicious of submucosal invasion (Paris type 0-Is, 0-IIc), for malignant lesions > 20 mm, and for lesions in scarred/fibrotic areas.ESGE does not recommend routine use of ESD for duodenal or small-bowel lesions.ESGE suggests that ESD should be considered for en bloc resection of colorectal (but particularly rectal) lesions with suspicion of limited submucosal invasion (demarcated depressed area with irregular surface pattern or a large protruding or bulky component, particularly if the lesions are larger than 20 mm) or for lesions that otherwise cannot be completely removed by snare-based techniques.ESGE recommends that an en bloc R0 resection of a superficial GI lesion with histology no more advanced than intramucosal cancer (no more than m2 in esophageal squamous cell carcinoma), well to moderately differentiated, with no lymphovascular invasion or ulceration, should be considered a very low risk (curative) resection, and no further staging procedure or treatment is generally recommended.ESGE recommends that the following should be considered to be a low risk (curative) resection and no further treatment is generally recommended: an en bloc R0 resection of a superficial GI lesion with superficial submucosal invasion (sm1), that is well to moderately differentiated, with no lymphovascular invasion, of size ≤ 20 mm for an esophageal squamous cell carcinoma or ≤ 30 mm for a stomach lesion or of any size for a BE-related or colorectal lesion, and with no lymphovascular invasion, and no budding grade 2 or 3 for colorectal lesions.ESGE recommends that, after an endoscopically complete resection, if there is a positive horizontal margin or if resection is piecemeal, but there is no submucosal invasion and no other high risk criteria are met, this should be considered a local-risk resection and endoscopic surveillance or re-treatment is recommended rather than surgery or other additional treatment.ESGE recommends that when there is a diagnosis of lymphovascular invasion, or deeper infiltration than sm1, or positive vertical margins, or undifferentiated tumor, or, for colorectal lesions, budding grade 2 or 3, this should be considered a high risk (noncurative) resection, and complete staging and strong consideration for additional treatments should be considered on an individual basis in a multidisciplinary discussion.ESGE recommends scheduled endoscopic surveillance with high definition white-light and chromoendoscopy (virtual or dye-based) with biopsies of only the suspicious areas after a curative ESD.

Transition from esophagectomy to endoscopic therapy for early esophageal cancer

BACKGROUND

To assess the outcomes of patients with early esophageal cancer and high-grade dysplasia comparing esophagectomy, the historical treatment of choice, to endoscopic eradication therapy (EET).

METHODS

Retrospective cohort study of consecutive patients with early esophageal cancer/high-grade dysplasia, treated between 2000 and 2018 at a tertiary center. Primary outcomes were all-cause and disease-specific mortality assessed by multivariable Cox regression and a propensity score matching sub analysis, providing hazard ratios (HR) with 95% confidence intervals (CI) adjusted for age, tumor grade (G1/2 vs. G3), tumor stage, and lymphovascular invasion. Secondary outcomes included complications, hospital stay, and overall costs.

RESULTS

Among 269 patients, 133 underwent esophagectomy and 136 received EET. Adjusted survival analysis showed no difference between groups regarding all-cause mortality (HR 1.85, 95% CI 0.73, 4.72) and disease-specific mortality (HR 1.10, 95% CI 0.26, 4.65). In-hospital and 30-day mortality was 0% in both groups. The surgical group had a significantly higher rate of complications (Clavien-Dindo ≥3 26.3% vs. endoscopic therapy 0.74%), longer in-patient stay (median 14 vs. 0 days endoscopic therapy) and higher hospital costs(£16 360 vs. £8786 per patient).

CONCLUSION

This series of patients treated during a transition period from surgery to EET, demonstrates a primary endoscopic approach does not compromise oncological outcomes with the benefit of fewer complications, shorter hospital stays, and lower costs compared to surgery. It should be available as the gold standard treatment for patients with early esophageal cancer. Those with adverse prognostic features may still benefit from esophagectomy.

cT1N0M0 Esophageal Squamous Cell Carcinoma Invades the Muscularis Mucosa or Submucosa: Comparison of the Results of Endoscopic Submucosal Dissection and Esophagectomy

Simple Summary

Esophagectomy has been the standard treatment for superficial esophageal squamous cell carcinoma (SESCC) that invades the muscularis mucosa or submucosa. This retrospective study aimed to assess the effects of endoscopic submucosal dissection (ESD) combined with selective adjuvant chemoradiotherapy on these SESCCs by comparing the results of esophagectomy. We found no significant differences in overall survival, disease-specific survival, and progression-free survival between the two groups. In the ESD group, the procedure time, overall complication rates, and length of hospital stay were significantly reduced, but the rate of metachronous tumor recurrence was significantly increased. Therefore, ESD combined with selective adjuvant chemoradiotherapy can be an alternative treatment to esophagectomy for SESCC invading the muscularis mucosa or submucosa.

Abstract

Background: Endoscopic submucosal dissection (ESD) combined with selective adjuvant chemoradiotherapy may be a new treatment option for cT1N0M0 esophageal squamous cell carcinoma (ESCC) invading muscularis mucosa or submucosa (pT1a-M3/pT1b). We aim to report the effectiveness of this treatment by comparing the results of esophagectomy. Methods: This retrospective single-center study included 72 patients with pT1a-M3/pT1b ESCC who received ESD combined with selective adjuvant chemoradiotherapy (n = 40) and esophagectomy (n = 32). The main outcome comparison was overall survival (OS). The secondary outcomes were treatment-related events, including operation time, complication rate, and length of hospital stay. Disease-specific survival (DSS) and progression-free survival (PFS) were also evaluated. Results: There were no significant differences in the rates of OS, DSS, and PFS between the two groups (median follow-up time: 49.2 months vs. 50.9 months); these were also the same in the subgroup analysis of pT1b ESCC patients. In the ESD group, the procedure time, overall complication rates, and length of hospital stay were significantly reduced. However, the metachronous recurrence rate was significantly higher. In a multivariate analysis, tumor depth and R0 resection were the independent factors associated with OS. Conclusions: ESD combined with selective adjuvant chemoradiotherapy can be an alternative treatment to esophagectomy for cT1N0M0 ESCC invading muscularis mucosa or submucosa.

Early Esophageal Cancer: What the Gastroenterologist Needs to Know

Endoscopic findings in early esophageal cancer are often subtle and require careful inspection and meticulous endoscopic examination. When dysplasia is suspected, we recommend performing 1 or 2 targeted biopsies of the abnormal area and review with a pathologist specialized in evaluating gastrointestinal diseases. In the case of adenocarcinoma, after resection of any visible cancer, residual Barrett's can be treated by ablation. Endoscopic resection can offer the opportunity for patients to avoid surgery. Further studies are needed to evaluate the optimal management of circumferential and near-circumferential lesions as well as tools and techniques to facilitate the performance of endoscopic submucosal dissection and endoscopic mucosal resection.

The Influence of Different Treatment Strategies on the Long-Term Prognosis of T1 Stage Esophageal Cancer Patients

Objective

To compare the long-term prognosis effects of non-esophagectomy and esophagectomy on patients with T1 stage esophageal cancer.

Methods

All esophageal cancer patients in the study were included from the National Surveillance Epidemiology and End Results (SEER) database between 2005-2015. These patients were classified into non-esophagectomy group and esophagectomy group according to therapy methods and were compared in terms of esophagus cancer specific survival (ECSS) and overall survival (OS) rates.

Results

A total of 591 patients with T1 stage esophageal cancer were enrolled in this study, including 212 non-esophagectomy patients and 111 esophagectomy patients in the T1a subgroup and 37 non-esophagectomy patients and 140 esophagectomy patients in the T1b subgroup. In all T1 stage esophageal cancer patients, there was no difference in the effect of non-esophagectomy and esophagectomy on postoperative OS, but postoperative ECSS in patients treated with non-esophagectomy was significantly better than those treated with esophagectomy. Cox proportional hazards regression model analysis showed that the risk factors affecting ECSS included race, primary site, tumor size, grade, and AJCC stage but factors affecting OS only include tumor size, grade, and AJCC stage in T1 stage patients. In the subgroup analysis, there was no difference in either ECSS or OS between the non-esophagectomy group and the esophagectomy group in T1a patients. However, in T1b patients, the OS after esophagectomy was considerably better than that of non-esophagectomy.

Conclusions

Non-esophagectomy, including a variety of non-invasive procedures, is a safe and available option for patients with T1a stage esophageal cancer. For some T1b esophageal cancer patients, esophagectomy cannot be replaced at present due to its diagnostic and therapeutic effect on lymph node metastasis.

Modeling the impact of delaying surgery for early esophageal cancer in the era of COVID-19

BACKGROUND

Surgical society guidelines have recommended changing the treatment strategy for early esophageal cancer during the novel coronavirus (COVID-19) pandemic. Delaying resection can allow for interim disease progression, but the impact of this delay on mortality is unknown. The COVID-19 infection rate at which immediate operative risk exceeds benefit is unknown. We sought to model immediate versus delayed surgical resection in a T1b esophageal adenocarcinoma.

METHODS

A decision analysis model was developed, and sensitivity analyses performed. The base case was a 65-year-old male smoker presenting with cT1b esophageal adenocarcinoma scheduled for esophagectomy during the COVID-19 pandemic. We compared immediate surgical resection to delayed resection after 3 months. The likelihood of key outcomes was derived from the literature where available. The outcome was 5-year overall survival.

RESULTS

Proceeding with immediate esophagectomy for the base case scenario resulted in slightly improved 5-year overall survival when compared to delaying surgery by 3 months (5-year overall survival 0.74 for immediate and 0.73 for delayed resection). In sensitivity analyses, a delayed approach became preferred when the probability of perioperative COVID-19 infection increased above 7%.

CONCLUSIONS

Immediate resection of early esophageal cancer during the COVID-19 pandemic did not decrease 5-year survival when compared to resection after 3 months for the base case scenario. However, as the risk of perioperative COVID-19 infection increases above 7%, a delayed approach has improved 5-year survival. This balance should be frequently re-examined by surgeons as infection risk changes in each hospital and community throughout the COVID-19 pandemic.

Lymph Node Involvement in Oesophageal Carcinoma: A Single-Centre Observational Study From Western India

Introduction

Lymph node involvement is the most important predictor of prognosis in oesophageal cancer. The present study describes our single-centre experience of lymphadenopathy in oesophageal carcinoma cases at a tertiary care centre in the Marathwada region of Maharashtra state in western India.

Methods

This descriptive study included 31 patients who were operated for oesophageal carcinoma at the State Cancer Hospital in Marathwada from August 2015 to September 2017. Thirty patients underwent three-field lymph node dissections, and one patient underwent Ivor Lewis surgery with two-field lymph node dissections. Three-field lymph node dissections were through a thoracotomy, followed by laparotomy and left cervical incision. The lymphatic metastases were categorised as (a) adjacent node metastases, (b) multiple levels of lymph node metastases, and (c) skip node metastases. The histopathological assessment of the removed specimen and lymph nodes was done. Pathologists evaluated the character and depth of the primary tumour and its invasion and node involvement. The location and numbers of positive and negative nodes were recorded.

Results

A total of 31 patients were included in the study, of which 17 had lymph node involvement. A total of 946 lymph nodes were dissected and examined, and the average number of lymph nodes removed per patient was 30.51. Among the 28 squamous cell carcinoma cases, lymph node involvement was found in 14 cases (50%) whereas, in adenocarcinoma, all the three cases showed lymph node involvement. In 11 cases of squamous cell carcinoma, thoracic lymph nodes were involved, whereas abdominal lymph nodes were involved in nine and cervical lymph nodes in two cases. Thoracic lymph nodes were involved in two cases of adenocarcinoma and abdominal lymph nodes were involved in one case of adenocarcinoma.

Conclusions

Squamous cell carcinoma was the predominant type, and lymph node metastasis was observed in 50% of these cases. Thoracic lymph nodes were more commonly involved. Tumour staging T2 and T3 had an increasing percentage of lymph nodes involved. Lymph node involvement was more in moderately differentiated and undifferentiated oesophageal cancers.

Measuring depth of invasion of submucosa - invasive adenocarcinoma in oesophageal endoscopic specimens: how good are we?☆

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.

Risk factors of refractory post-endoscopic submucosal dissection esophageal strictures

INTRODUCTION

To comparatively assess the treatment outcomes of endoscopic dilatation in Barrett's neoplasia and squamous cell carcinoma (SCC) post- endoscopic submucosal dissection (ESD) strictures and to determine the risk or factors associated to refractory strictures Methods: Observational study. All consecutive patients presenting with a post-ESD stricture in 2007-2016 who underwent dilation therapy were included. Clinical, morphological and technical features were assessed to determine the risk factors of refractory strictures.

RESULTS

Of 414 consecutive patients treated by ESD, 83 (mean age: 65±10 years, 76% men) with 254 dilations (median: 3, range: 1-27) were considered. Barrett's neoplasia and SCC were the indications in 58 (69.9%) in 25 (30.1%) cases. Clinical success was achieved in 84.3% with a median of 3 sessions (range: 1-22). Circumferential resection in one-single procedure (13.2%) was associated to the need for a higher number of dilation sessions. By multivariable analysis, upper-esophageal location (OR: 11.479 [95%CI: 2.058-64.043], p=0.005), recurrent strictures (OR: 17.252 [95%CI: 2.833-105.069], p=0.002), and dilation-related complications (OR: 26.420 [95%CI: 1.736-401.966], p=0.018) were risk factors of refractory stenosis.

CONCLUSION

Preventive strategies, concomitant treatment, and careful dilatation protocols should be considered and undertaken in patients presenting with SCC located in the upper superior esophagus, intra-procedural perforation, and recurrent strictures.

Pathology and Prognosis of Colonic Adenocarcinomas With Intermediate Primary Tumor Stage Between pT2 and pT3

CONTEXT.—

Primary tumor stage (pT) is an important prognostic indicator in colonic adenocarcinomas; however, cases that have no muscle fibers beyond the advancing tumor edge but also show no extension beyond the apparent outer border of muscularis propria (termed pT2int), have not been previously studied.

OBJECTIVE.—

To address the clinicopathologic characteristics and prognosis of pT2int tumors.

DESIGN.—

We recharacterized 168 colon carcinomas and compared pT2int cases to bona fide pT2 and pT3 tumors.

RESULTS.—

In side-by-side analysis, 21 pT2int cases diverged from 29 pT2 tumors only in terms of larger size (P = .03), but they were less likely to show high-grade (P = .03), lymphovascular (P < .001), and extramural venous invasion (P = .04); discontinuous tumor deposits (P = .02); lymph node involvement (P = .001); and advanced stage (P = .001), compared with 118 pT3 tumors. Combining pT2int with pT2 cases (versus pT3) was a better independent predictor of negative lymph nodes in multivariate analysis (P = .04; odds ratio [OR], 3.96; CI, 1.09-14.42) and absent distant metastasis in univariate analysis (P = .04), compared with sorting pT2int with pT3 cases (versus pT2). Proportional hazards regression showed that pT2 and pT2int cases together were associated with better disease-free survival compared with pT3 tumors (P = .04; OR, 3.65; CI, 1.05-12.70). Kaplan-Meier analysis demonstrated that when pT2int were grouped with pT2 tumors, they were significantly less likely to show disease progression compared with pT3 (P = .002; log-rank test) and showed a trend toward better disease-specific survival (P = .06), during a mean patient follow-up of 44.9 months.

CONCLUSIONS.—

These data support the conclusion that pT2int carcinomas have clinicopathologic characteristics and are associated with patient outcomes more closely aligned with pT2 rather than pT3 tumors.

Additional Esophagectomy Following Noncurative Endoscopic Resection for Early Esophageal Squamous Cell Carcinoma: A Multicenter Retrospective Study

BACKGROUND

Esophagectomy is recommended after endoscopic resection (ER) for early esophageal squamous cell carcinoma (ESCC) when histopathological factors indicate a risk of nodal metastasis and incomplete resection. We aimed to analyze the outcomes of surgery management in this clinical setting and evaluate risk factors for residual disease after ER.

PATIENTS AND METHODS

We conducted a retrospective review of cT1N0M0 ESCC patients with noncurative ER and additional esophagectomy (2009-2019, eight centers). Noncurative ER was defined as positive resected margins on pathology, lymphovascular invasion (LVI), poor differentiation, or submucosal invasion. The pathology after ER and esophagectomy was analyzed to identify predictors of nodal metastasis and residual tumor.

RESULTS

The study enrolled 128 patients. Primary residual tumor and nodal metastasis were confirmed in 25 (19.5%) and 15 (11.7%) patients, respectively. On multivariate analysis, nodal metastasis was independently associated with submucosal invasion [odds ratio (OR), 9.9; 95% CI, 1.1-96.1], LVI (OR, 20.9; 95% CI, 2.9-150.5), and tumor size ≥ 2 cm (OR, 8.1; 95% CI, 1.4-48.2) (all P < 0.05), but not with poor differentiation (P = 0.613). Regarding residual primary tumor, only positive vertical margin was significant factor (OR, 147; 95% CI, 18 to > 999; P < 0.001).

CONCLUSIONS

Additional esophagectomy after noncurative ER allowed the resection of residual tumor and nodal metastasis, with favorable outcomes. Close follow-up may be feasible for a positive horizontal margin alone or poor differentiation alone, whereas intensive treatment should be considered for patients with submucosal invasion, LVI, and a positive vertical margin, especially when combined with tumor size ≥ 2 cm. Prospective research is needed to confirm the optimal management after ER.

Surveillance Following Treatment of Esophageal Cancer

We describe the surveillance strategies after esophageal cancer treatment, whether local therapy, induction chemoradiation, or other definitive treatment such as trimodality therapy. We discuss the shortcomings of the different invasive and imaging studies, and the recommended stage-specific surveillance after local and organ-sparing approaches to esophageal cancer treatment.

Endoscopic resection with adjuvant treatment versus esophagectomy for early-stage esophageal cancer

Objective

To evaluate the outcome following the strategy of endoscopic R0 resection (ER) plus adjuvant treatment (AT) versus esophagectomy for esophageal squamous cell cancer in T1a invading muscularis mucosa (M3)-T1b stage.

Methods

We evaluated the outcomes of 46 esophageal squamous cell cancer (ESCC) patients with T1aM3-T1b stage who underwent ER + AT from the Esophageal Cancer Endoscopic Therapy Consortium (ECETC) and compared these outcomes to 92 patients who underwent esophagectomy. Propensity score matching (1:2) was used, with overall survival (OS) and relapse-free survival (RFS) being compared between the two groups.

Results

During a median follow-up of 32 months, there were no statistical differences (P = 0.226) in OS between the two groups. The 1-, 2-, and 3-year overall survival in the esophagectomy group was 95%, 91%, and 84%, respectively. There were no mortalities within three years in the ER + AT group. The RFS between the two groups was also not significantly different (P = 0.938). The 1-, 2-, and 3-year RFS of patients in the esophagectomy group was 90%, 90%, and 83%, respectively, while it was 97%, 94%, and 74% in the ER + AT group, respectively. The local recurrence rates between the two groups were not significantly different (P = 0.277).

Conclusions

This first multicenter analysis showed similar outcomes were found regarding OS and RFS between the two groups in T1aM3-T1b stage patients. ER + AT may be considered in high-risk patients or for those who refuse esophagectomy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08466-2.

Epidemiology, Diagnosis, Staging and Multimodal Therapy of Esophageal and Gastric Tumors

Gastric and esophageal tumors are diverse neoplasms that involve mucosal and submucosal tissue layers and include squamous cell carcinomas, adenocarcinomas, spindle cell neoplasms, neuroendocrine tumors, marginal B cell lymphomas, along with less common tumors. The worldwide burden of esophageal and gastric malignancies is significant, with esophageal and gastric cancer representing the ninth and fifth most common cancers, respectively. The approach to diagnosis and staging of these lesions is multimodal and includes a combination of gastrointestinal endoscopy, endoscopic ultrasound, and cross-sectional imaging. Likewise, therapy is multidisciplinary and combines therapeutic endoscopy, surgery, radiotherapy, and systemic chemotherapeutic tools. Future directions for diagnosis of esophageal and gastric malignancies are evolving rapidly and will involve advances in endoscopic and endosonographic techniques including tethered capsules, optical coherence tomography, along with targeted cytologic and serological analyses.

Long-term Outcomes and Factors Affecting the Survival of Patients with Mucosal Esophageal Squamous Cell Carcinoma

Background/Aims

Data regarding the prognosis of early esophageal cancer are lacking. This study investigated the long-term outcomes and factors affecting the survival of patients with mucosal esophageal squamous cell carcinoma (T1aESCC).

Methods

We analyzed the clinical and tumor-specific parameters of 263 patients who received surgical resection (SR; n=63) or endoscopic resection (ER; n=200) for T1aESCC. Underlying comorbidities were scored using the Charlson Comorbidity Index (CCI). Overall survival (OS) was the primary outcome, and multivariate regression analysis was performed to predict factors for OS.

Results

Of the study patients (age, 64.5±8.0 years), the CCI was 1.0±1.4 in the ER group and 0.6±0.9 in the SR group (p=0.107). The 5-year OS rate during follow-up (54.4±20.4 months) was 85.7% (ER group, 86.8%; SR group, 82.4%; p=0.631). The cumulative 5-year incidence of esophageal cancer recurrence was 10.5% in the ER group (vs 0% in the SR group). The overall mortality rate was 12.9% (12.0% in the ER group and 15.9% in the SR group; p=0.399). The most common cause of mortality was second primary cancers in the ER group (75%) and organ dysfunction or postoperative complications in the SR group (70%). According to multivariate analysis, only CCI was significantly associated with OS (p<0.001). The 5-year OS rate in patients with a CCI >2 and in those with a CCI ≤2 was 60.2% and 88.2%, respectively (p<0.001). The treatment method (ER vs SR) was not a significant affecting factor (p=0.238).

Conclusions

The long-term prognosis of patients with T1aESCC was significantly associated with underlying comorbidities.

Comparison of Outcomes Between Additional Esophagectomy After Noncurative Endoscopic Resection and Upfront Esophagectomy for T1N0 Esophageal Squamous Cell Carcinoma

BACKGROUND

Esophagectomy with lymph node dissection is a choice of additional treatment after noncurative endoscopic resection (ER) of T1N0 esophageal squamous cell carcinoma (ESCC). The efficacy and safety of esophagectomy in this situation remain unclear when compared with upfront esophagectomy.

METHODS

We investigated the short- and long-term outcomes of 321 patients with clinical T1N0M0 ESCC who underwent curative esophagectomy, and compared the status of lymph node metastasis, surgical results, and the prognosis between the ER and non-ER groups.

RESULTS

The ER group consisted of 57 patients (17.8%), while the non-ER group consisted of 264 patients (82.2%). The incidence of lymph node metastasis was not significantly different between the ER (24.6%) and non-ER groups (30.7%), and there was no significant difference in surgical outcomes between the groups. The distribution of metastatic lymph nodes was very similar between the groups. However, 13 of 14 patients (93%) with lymph node metastasis in the ER group and 63 of 82 patients (77%) with lymph node metastasis in the non-ER group had pN1 disease, while the remaining 18 patients (23%) with lymph node metastasis in the non-ER group had pN2 or N3 disease. Overall and relapse-free survival rates were significantly better in the ER group than in the non-ER group (p < 0.05 and p < 0.01, respectively). To date, no patients in the ER group experienced disease recurrence.

CONCLUSIONS

Additional esophagectomy is a safe and effective treatment modality for patients after noncurative ER.

The modern management of Barrett's oesophagus and related neoplasia: role of pathology

Modern management of Barrett's oesophagus and related neoplasia essentially focuses upon surveillance to detect early low-risk neoplastic lesions and offering organ-preserving advanced endoscopic therapies, while traditional surgical treatments of oesophagectomy and lymph node clearance with or without chemoradiation are preserved only for high-risk and advanced carcinomas. With this evolution towards figless invasive therapy, the choice of therapy hinges upon the pathological assessment for risk stratifying patients into those with low risk for nodal metastasis who can continue with less invasive endoscopic therapies and others with high risk for nodal metastasis for which surgery or other forms of treatment are indicated. Detection and confirmation of neoplasia in the first instance depends upon endoscopic and pathological assessment. Endoscopic examination and biopsy sampling should be performed according to the recommended protocols, and endoscopic biopsy interpretation should be performed applying standard criteria using appropriate ancillary studies by histopathologists experienced in the pathology of Barrett's disease. Endoscopic resections (ERs) are both diagnostic and curative and should be performed by clinicians who are skilled with advanced endoscopic techniques. Proper preparation and handling of ERs are essential to assess histological parameters that dictate the curative nature of the procedure. Those parameters are adequacy of resection and risk of lymph node metastasis. The risk of lymph node metastasis is determined by depth invasion and presence of poor differentiation and lymphovascular invasion. Those adenocarcinomas with invasion up to muscularis mucosae (pT1a) and those with superficial submucosal invasion (pT1b) up to 500 µ with no poor differentiation and lymphovascular invasion and negative margins may be considered cured by endoscopic resections.

Endoscopic Submucosal Dissection for Upper Gastrointestinal Neoplasia-a North American Perspective

OBJECTIVES

Organ-sparing endoscopic submucosal dissection (ESD) is an acceptable treatment strategy for superficial neoplastic lesions of the esophagus and stomach. The adoption of this technique has lagged in North America compared with Asia, and we sought to report on our experiences with ESD for upper GI neoplasia.

METHODS

A prospectively entered database of all patients undergoing endoscopic resection of esophageal and gastric neoplasia at McGill University from 2009 to 2019 was queried for those who received ESD.

RESULTS

A total of 103 consecutive ESDs were identified from 2009 to 2019. Seventy-one (69%) patients were male and the median age was 72 (range: 38-90). Sixty-one (59%) cases were esophageal and 42 (41%) gastric. Forty-nine (48%) were performed in the endoscopy suite under local sedation only. Perforation occurred in 9 patients (7 esophageal and 2 stomach), of which 3 required operative repair. Histology was principally invasive carcinoma (79, 77%), with 17 (16%) dysplastic lesions (e.g., HGD), 1 (1%) neuroendocrine tumor, and 7 (7%) benign lesions. En bloc resection was achieved in 90 (87%), and the complete resection rate was 74 (72%), with 51 (50%) of procedures fulfilling the criteria for curative resection. At medium of 23-month (2-199) follow-up of these 51 curative resections, one case of recurrent carcinoma was found at follow-up and was managed with repeat endoscopic resection. Non-curative ESDs were found 45 (R1 resection = 29: risk of lymph node metastasis = 16), 21 had active surveillance, and 24 were resected.

CONCLUSION

ESD is a viable, effective, and safe therapeutic and staging modality for superficial lesions of the stomach and esophagus.

Multi-institutional Evaluation of Curative Intent Chemoradiotherapy for Patients With Clinical T1N0 Esophageal Adenocarcinoma

Purpose

To evaluate the safety and efficacy of definitive chemoradiotherapy (CRT) for patients with clinical T1N0M0 esophageal adenocarcinoma.

Methods and Materials

This was a retrospective study of patients with clinical T1N0 adenocarcinoma of the esophagus treated with curative-intent CRT between 2004 and 2017 at 2 tertiary care centers. Patients received CRT instead of esophagectomy owing to medical comorbidities or patient preference. Toxicities were evaluated according to Common Terminology Criteria for Adverse Events version 4.03. The Kaplan-Meier method was used to estimate overall, progression-free, and disease-specific survivals.

Results

Twenty-eight patients were included for analysis. Median age was 76 years (range 55-90). The majority of patients were male (93%) and had a history of Barrett’s esophagus (71%). Tumor characteristics included distal esophagus location (93%), clinical stage T1b (86%), and median length of 2 cm (range, 1-9). Prior endoscopic resection was performed in 57%.

The median follow-up was 44 months (range, 4-146). The acute grade 3 adverse events were observed in 7 patients (25%). One patient died of complications potentially related to chemoradiation. Eight patients (29%) had disease progression at a median of 7.6 months after CRT. First site of progression was local only (14%), local and regional (11%), or distant (4%). Salvage locally directed treatment was performed in 3 of 4 patients with local-only recurrence. The 3-year overall survival, progression-free, and disease-specific rates were 78%, 62%, and 81%, respectively.

Conclusion

CRT is a safe and effective curative treatment strategy for select patients with clinical T1N0M0 esophageal adenocarcinoma.

Modeling the Cost-effectiveness of Esophageal Cancer Screening in China

BACKGROUND

This study aimed to examine the cost-effectiveness of one-time standard endoscopic screening with Lugol's iodine staining for esophageal cancer (EC) in China.

METHODS

A Markov decision analysis model with eleven states was built. Individuals aged 40 to 69 years were classified into six age groups in five-year intervals. Three different strategies were adopted for each cohort: (1) no screening; (2) one-time endoscopic screening with Lugol's iodine staining with an annual follow-up for low-grade intraepithelial neoplasia (LGIN); and (3) one-time endoscopic screening with Lugol's iodine staining without follow-up. Quality-adjusted life-years (QALYs) indicated the effectiveness of the model. The incremental cost-effectiveness ratio (ICER) was used as the evaluation indicator. Sensitivity analysis was performed to assess the robustness of the model.

RESULTS

One-time screening with follow-up was the undominated strategy for individuals aged 40-44 and 45-49 years, which saved USD 10,942.57 and USD 6611.73 per QALY gained compared to nonscreening strategy. For those aged 50-69 years, the nonscreening scenarios were undominated. One-time screening without follow-up was the extended dominated strategy. Compared to screening strategies without follow-up, all the screening strategies with follow-up were more cost-effective, with the ICER increasing from 299.57 USD/QALY for individuals aged 40-44 years to 1617.72 USD/QALY for individuals aged 65-69 years. Probabilistic sensitivity analysis (PSA) supported the results of the base case analysis.

CONCLUSIONS

One-time EC screening with follow-up targeting individuals aged 40-49 years was the most cost-effective strategy.

The management and long-term outcomes of endoscopic and surgical treatment of early esophageal adenocarcinoma

Endoscopic resection (ER) for early (pT1) esophageal adenocarcinoma can be justified if the rate of coexisting lymph node (LN) metastasis is less than the mortality rate from esophagectomy. This study examines endoscopic and surgical outcomes, histological assessment of submucosal (sm) disease, factors influencing LN metastasis, and the safety of treating pT1b disease endoscopically. Histopathological reexamination recorded thickness, width and depth of sm invasion, grade, presence of lymphovascular invasion (LVI), resection margin status and tumor stage. Multivariate analysis was employed to evaluate the factors influencing survival and LN metastasis. Rate of LN metastasis for pT1 low-risk (LR: sm invasion < 500 μm, G1-2, no LVI) or high-risk (HR: sm invasion >500 μm, G3-4 or LVI) disease were analyzed. Ninety three patients underwent ER and 96 underwent esophagectomy. We demonstrate conflicting histological methods of sm disease reporting, which may explain the difference in LN metastasis rate between reported surgical & endoscopic series. Multivariate analysis confirmed age, T stage, and presence of LN metastases were the independent factors predicting poor prognosis. Tumor thickness as well as grade, T stage, LVI were predictors of LN metastasis. Rates of LN metastasis are <2% in LR sm1 disease, and >15% in HR sm1 disease. Pathological reporting of sm invasion should be updated for uniform analysis of endoscopic and surgical specimens. Following rigorous histopathological examination and within a close endoscopic follow-up regimen, pT1a and pT1b LRsm1 disease may be treated with curative intent endoscopically, whereas pT1b HRsm1-sm3 disease should be offered surgery.

Risk factors of metachronous recurrence after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma

Esophageal endoscopic submucosal dissection (ESD) can be a curative treatment for superficial esophageal squamous cell carcinoma (SESCC). However, it is unclear whether the development of metachronous recurrence after ESD may be explained based on several risk factors. This study aimed to assess the incidence and the risk factors of metachronous recurrence of SESCC after ESD. This retrospective analysis was conducted at Samsung Medical Center, Seoul, Korea, from April 2007 to May 2018. Two hundred and fifty-three SESCC patients treated with ESD were followed using surveillance endoscopy after the procedure. Risk factors for metachronous esophageal SCC were analyzed using the Kaplan-Meier method and Cox's proportional hazards model. Metachronous esophageal SCCs were found in 21 (8.3%) of the 253 patients. Six patients (2.4%) with extraesophageal recurrence such as lymph node metastasis confirmed by imaging were excluded from patients with metachronous recurrence and data were censored from the recurrence date. Univariate analysis revealed that the presence of many (>10) irregularly shaped multiform Lugol-voiding lesions (LVLs) around the main lesion, margin of the main LVL, and tumor differentiation were risk factors for the development of metachronous cancer. Multivariate analysis also revealed that many (>10) LVLs (hazard ratio [HR], 6.32; 95% confidence interval [CI], 1.62-24.72; p = 0.047) and unclear or spiculated margin of the main LVL (HR, 6.51; 95% CI, 1.44-29.42; p = 0.029) were associated with the risk of metachronous recurrence. Metachronous esophageal SCC develops in patients treated with ESD for SESCC. A risk assessment is important for surveillance before and after ESD for SESCC. Number of LVLs and tumor edge type are associated with an increased risk of metachronous cancer in SESCC. Patients will benefit from careful endoscopic surveillance when endoscopists pay attention to these tumor characteristics.

Pathologic assessment of endoscopic resection specimens with superficial carcinoma of the esophagus: current practice and practical issues

Endoscopic resection (ER) has become the first-line therapy for early esophageal cancer and offers a treatment alternative to surgery, owing to less morbidity and better quality of life. ER techniques include endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). EMR is faster, simpler, and cheaper than ESD, but limited by its ability to resect lesions larger than 1.5 centimeters. Piecemeal EMR has limitations, including a high local recurrence rate and a suboptimal specimen for an accurate pathologic assessment. ESD, on the other hand, allows en bloc resections with negative (R0) margins, irrespective of lesion size, providing an excellent pathologic specimen, however, is technically challenging with a higher risk of complications. The evaluation of ER specimens in pathology varies slightly from institution to institution. Our review summarizes the current practices and issues in the pathologic assessment of esophageal ER specimens, which highlights the necessity of a systematic approach and standardization of both macroscopic and microscopic evaluation. There is a need for a comprehensive and standardized pathology report that will allow for uniform terminology for endoscopists, surgeons, and pathologists, which, in turn, will result in better treatment guidance.

Esophageal cancer: challenges, concerns, and recommendations for management amidst the COVID-19 pandemic

Since December 2019, the outbreak of coronavirus disease 2019 (COVID-19) has rapidly spread worldwide, raising great concern, particularly in immunosuppressed cancer patients. The pandemic situation remains extremely dynamic, which necessitates proactive management decisions from oncologists and oncologic surgeons in effort to mitigate the risk of both SARS-CoV-2 infection and cancer metastasis. Esophageal cancer, in particular, is one of the deadliest types of malignancy worldwide, reflecting both aggressive biology and a lack of adequate treatment. Several challenges and concerns regarding the management of esophageal cancer have been raised in light of the ongoing viral pandemic. The primary aim of this review is to summarize the salient evidence for recommendations and optimal treatment strategies for patients with esophageal cancer amidst the COVID-19 pandemic.

Pathological assessment of endoscopic resections of the gastrointestinal tract: a comprehensive clinicopathologic review

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.

Tumor SUVs on 18F-FDG PET/CT and Aggressive Pathological Features in Esophageal Squamous Cell Carcinoma

PURPOSE

Considerable discrepancies are observed between clinical staging and pathological staging after surgical resection in patients with esophageal squamous cell carcinoma (ESCC). In this study, we examined the relationships between tumor SUVs on FDG PET/CT and aggressive pathological features in resected ESCC patients.

METHODS

A total of 220 patients with surgically resected clinical stage I-II ESCC without neoadjuvant treatment were retrospectively analyzed. SUVmax of the primary tumor was measured on pretreatment FDG PET/CT. Pathological features included depth of tumor invasion, lymph node metastasis, tumor differentiation, lymphatic vessel tumor embolus, perineural invasion, Ki-67 index, and p53 protein expression. Receiver operating characteristic curve analysis was used to determine an optimal cutoff of SUVmax to predict pathologically advanced disease. Differences in pathological features associated with SUVmax were examined by t test or χ test.

RESULTS

The number of patients upstaged from clinical stage I-II to pathological stage III-IV was 43 (19.5%). Receiver operating characteristic curve analysis showed that the optimal cutoff SUVmax of 4.0 had good performance for predicting locally advanced disease (area under the receiver operating characteristic curve = 0.844, P < 0.001). Higher tumor SUVmax was significantly associated with advanced depth of tumor invasion (deeper than submucosa, P < 0.001), positive lymph node metastasis (P < 0.001), presence of lymphatic vessel tumor embolus (P < 0.001), presence of perineural invasion (P < 0.001), higher Ki-67 index (P = 0.025), and poor tumor differentiation (P = 0.039).

CONCLUSIONS

SUVmax measured on pretreatment FDG PET/CT is significantly associated with aggressive pathological features and may help clinicians identify patients at risk of advanced disease.

Risk of Recurrence and Metastasis for Patients with T1N0M0 Esophageal Carcinoma Who Achieve Completed Resection via Endoscopic Submucosal Resection: Evidence for the Appropriateness of the Watch and Wait Follow-Up Strategy

Purpose

Endoscopic submucosal dissection (ESD) is a widely performed procedure for esophageal carcinoma when the depth of invasion reaches the epithelium and lamina propria. However, ESD for esophageal carcinoma with depth of invasion exceeding the muscularis mucosa is controversial. This study aimed to evaluate the long-term outcomes of ESD for T1N0M0 (tumor invading the mucosa and submucosa [T1], no regional lymph node metastasis [N0], no distant metastasis [M0]) esophageal cancer.

Patients and Methods

Esophageal cancer was evaluated via pathology and computed tomography (CT) in consecutive patients with negative margin and without additional therapy. A total of 84 patients were included. The mean follow-up time was 42 (range, 9-99) months.

Results

No recurrence and metastasis were detected in the M1 and M2 group. The 5-year locoregional recurrence rate and distant metastasis rate were 4.2% and 5.6% for the M3 group and were 0% and 1.4% for the SM group, respectively. The 3- and 5-year overall survival were 94.4% (M1+M2 group, 95.0%; M3 group, 95.0%; SM group, 92.9%) and 80.9% (M1+M2 group, 95.0%; M3 group, 95.0%; SM group, 92.9%). Meanwhile, the 3- and 5-year disease-specific survival rates were 100% (M1+M2 group, 100%; M3 group, 100%; SM group, 100%) and 90.8% (M1+M2 group, 100%; M3 group, 90.0%; SM group, 85.7%). The major complications were postoperative strictures, most of which were grade 1-2. In total, two (4.8%) and one (1.2%) patient developed grade 3 and 5 late esophageal strictures, respectively.

Conclusion

ESD complete resection yields low recurrence and metastasis rates in early esophageal cancer (T1N0M0). Thus, additional treatment is not necessary, and a watch and wait strategy may be reasonable.

The possibility of endoscopic treatment of cN0 submucosal esophageal cancer: results from a surgical cohort

Background

We analyzed the pathological characteristics and recurrence pattern of cN0 submucosal esophageal cancer after esophagectomy and conducted risk stratification to determine the feasibility of performing endoscopic resection for cN0pT1b esophageal squamous cell malignancies.

Methods

We retrospectively enrolled 167 patients who underwent right-sided transthoracic esophagectomy and extended thoracic/abdominal two-field lymphadenectomy. Patients with pathologically confirmed lymph node metastasis or tumor recurrence constituted the high-risk group for endoscopic submucosal resection, and the remainder were defined as low risk. Factors affecting lymphatic metastasis and long-term recurrence were identified by univariate and multivariate analyses.

Results

Postoperative pathology showed that five patients (5/167; 3%) had lymph node metastases. Follow-up ranged from 12–60 months, with a median of 29 months. A total of 17 patients (10.2%) had recurrences during follow-up, including three patients with pathologic nodal metastasis (pN +) found at surgery. Invasion depth, differentiation, and tumor size differed significantly in high-risk patients. Overall 3-year survival rates were 94.2% (low-risk) and 40.9% (high-risk) (p < 0.01). Twenty-one patients with sm1 cancer, high tumor differentiation, and tumor length < 2 cm had no lymph node metastasis or lymphovascular invasion, and none of these patients experienced recurrence.

Conclusions

Endoscopic submucosal resection alone may be feasible for patients with small (≤ 2 cm) clinically N0 submucosal esophageal squamous cell carcinoma with low invasion depth (sm1) and higher differentiation, but prospective studies are required for confirmation. Other patients require surgical resection with extended two-field thoracic/abdominal lymphadenectomy.

Adjuvant therapy for pT1a-m3/pT1b esophageal squamous cell carcinoma after endoscopic resection: Esophagectomy or chemoradiotherapy? A critical review

Endoscopic resection (ER) combined with adjuvant therapy appears to be a new treatment for esophageal squamous cell cancers (ESCC) invading to deep mucosa (pT1a-m3) or submucosa (pT1b). Adjuvant therapy can take the form of esophagectomy or chemoradiotherapy (CRT), but it is unclear which treatment is better. This review is to explore the outcomes of adjuvant therapy between esophagectomy and CRT for the treatment of pT1a-m3/pT1b ESCC after ER. Ten relevant studies with a total of 285 patients were included. The reported 5-year overall survival rates ranged between 90-100 % for ER-esophagectomy and 75-85 % for ER-CRT. ESCC with the invasion of ≥ sm2 combined with lymphovascular involvement was associated with a high-risk of relapse in patients receiving ER-CRT, but not in ER-esophagectomy. In conclusion, patients with a high-risk of relapse should be treated with ER-esophagectomy; ER-CRT may be used as an alternative treatment for patients with a nonhigh risk of relapse.

Current status of esophageal cancer treatment

Esophageal cancer (EC) remains one of the most common and aggressive diseases worldwide. This review discusses some debates in the modern management of the disease. Endoscopic procedures for early cancer (T1a−b) are now embedded in routine care and the challenge will be to more accurately select patients for endoscopic resection with or without adjuvant therapy. Perioperative multimodal therapies are associated with improved survival compared to surgery alone for locally advanced esophageal cancer. However, there is no global consensus on the optimal regimen. Furthermore, histological subtype (adenocarcinomavs. squamous cell cancer) plays a role in the choice for treatment. New studies are underway to resolve some issues. The extent of the lymphadenectomy during esophagectomy remains controversial especially after neoadjuvant chemoradiation. The ideal operation balances between limiting surgical trauma and optimizing survival. Minimally invasive esophagectomy and enhanced recovery pathways are associated with decreased morbidity and faster recovery albeit there is no consensus yet what approach should be used. Finally, immune checkpoint inhibitors present promising preliminary results in the novel treatment of advanced or metastatic EC but their widespread application in clinical practice is still awaited.

Endoscopic management of esophageal cancer

Esophageal cancer (EC) generally consists of squamous cell carcinoma (which arise from squamous epithelium) and adenocarcinoma (which arise from columnar epithelium). Due to the increased recognition of risk factors associated with EC and the development of screening programs, there has been an increase in the diagnosis of early EC. Early EC is amenable to curative therapy by endoscopy, which can be performed by either endoscopic resection or endoscopic ablation. Endoscopic resection consists of either endoscopic mucosal resection (preferred in cases of adenocarcinoma) or endoscopic submucosal dissection (preferred in cases of squamous cell carcinoma). Endoscopic ablation can be performed by either radiofrequency ablation, cryotherapy, argon plasma coagulation or photodynamic therapy, amongst others. Endoscopy can also assist in the management of complications post-esophageal surgery, such as anastomotic leaks and perforations. Finally, there is a growing role for endoscopy to manage end-of-life palliative symptoms, especially dysphagia. The growing use of esophageal stents, debulking therapy and dilation can assist in improving a patient’s quality of life. In this review, we examine the multiple roles of endoscopy in the management of patients with EC.

Endoscopic or Surgical Resection for Gastro-Esophageal Cancer

BACKGROUND

Early gastro-esophageal cancer is staged as m1 to m3 depending on the infiltration of the anatomical layers of the mucosa or, analogously, as sm1 to sm3 depending on the depth of infiltration into the submucosa. The risk of lymph node metastases is low in mucosal carcinoma but increases with the depth of infiltration into the submucosa.

METHODS

This review is based on pertinent publications retrieved by a selective search in MEDLINE, PubMed, the Cochrane Library, and the International Standard Randomised Controlled Trial Number (ISRCTN) registry.

RESULTS

New technologies such as narrow-band imaging have improved the endo- scopic diagnosis and staging of early gastro-esophageal cancer. The development of endoscopic submucosal dissection has led to a higher R0 resection rate, a lower risk of recurrence, and an increase in the number of endoscopic resections that are performed with curative intent. In squamous-cell carcinoma of the esophagus, surgical oncological esophagectomy is indicated if the cancer infiltrates into the third mucosal layer (T1a, m3) or deeper. In esophageal adenocarcinoma, the prevalence of lymph node metastases is low if the cancer is restricted to the mucosa and in- creases only when the submucosa is infiltrated. In the current German S3 guideline, endoscopic resection is recommended for intramucosal adenocarcinoma as long as there are no further histopathological risk factors. Lymph node metastasis in gastric carcinoma begins in the deep mucosal infiltration stage (m3). If certain special con- ditions ("extended criteria") are met, carcinoma expanding into the first submucosal layer (sm1) can be removed endoscopically. All further stages must be treated with total or subtotal gastrectomy with systematic D2 lymphadenectomy.

CONCLUSION

Borderline cases between endoscopic and surgical resection of early carcinoma of the esophagus or stomach must be managed with an interdisciplinary treatment algorithm. If there is a risk of lymph node metastasis, surgical oncological resection is indicated. Such resections of gastroesophageal cancer in the locally advanced stage should always be part of a multimodal treatment approach.

Comparison of the therapeutic effects of endoscopic submucosal dissection and minimally invasive esophagectomy for T1 stage esophageal carcinoma

BACKGROUND

In recent years, diagnosis of early squamous cell carcinoma of the esophagus has been increasingly emphasized. The application of endoscopic submucosal dissection (ESD) has enabled safe resection of esophageal lesions. Minimally invasive esophagectomy (MIE) is also safe and feasible for early stages of the cancer. This study aimed to compare the therapeutic effects of early esophageal carcinoma treatment, and find the best predictive factor for the selection of treatment for T1a patients.

METHODS

We performed a retrospective study of early-stage patients admitted to Tianjin Medical University Cancer Institute and Hospital between January 2015 and December 2018. A total of 128 patients underwent MIE, while 78 patients underwent ESD. The depth of the tumor invasion, lymph node metastasis, and complications were compared between the two groups.

RESULTS

In the ESD group, 76.92% of the patients were stage T1a, while 34.38% in the MIE group were stage T1a. The lymph node metastasis rate was 16.41% in the MIE group (6.98% in T1a stage), which related to tumor differentiation, tumor length (≥37.5 mm), depth of invasion, and angiolymphatic invasion. However, the R0 resection rate was only 73.08% in the ESD group. Comprehensive analysis of all T1 patients in the two groups revealed that the positive margin was related to tumor differentiation, tumor width (≥13.5 mm), and depth of invasion (≥3.25 mm).

CONCLUSION

For early-stage cases, lymph node metastasis and positive margins are risk factors affecting long-term survival. Efficient predictive factors mentioned in our study would provide a proper indication for treatment strategy selection.

Endoscopic Submucosal Dissection for Esophageal Adenocarcinoma: A North American Perspective

BACKGROUND

Data are limited regarding the application of endoscopic submucosal dissection (ESD) in Western countries or for esophageal adenocarcinoma in any part of the world. We sought to review our experience employing ESD in patients with early esophageal cancer at a high volume North American esophageal cancer treatment center.

METHODS

A prospectively maintained database of all patients with esophageal cancer treated at the McGill University Health Center was used to identify ESDs performed for adenocarcinoma between 2012 and 2016. Patient demographics, pre-resection tumor characteristics, endoscopic resection technical variables, pathologic results, and short- and long-term outcomes were recorded.

RESULTS

Of 650 patients in the database, 26 underwent 27 procedures. The majority (67%) had pre-treatment EUS. There were no post-ESD bleeding events requiring re-intervention. Perforation occurred in 2/27 (7%), one of which required operative repair. Complete RO resection was achieved in 18/27(67%). Salvage laparoscopic esophagectomy was performed in six patients. At a median follow-up of 18.5 (7-35) months, cancer recurrence occurred in only one patient who subsequently underwent successful repeat ESD.

CONCLUSIONS

Although technically challenging, ESD represents a safe and effective treatment of early esophageal adenocarcinoma and has the potential to become a more important tool in management of these early lesions in Western countries.

Durability of radiofrequency ablation for treatment of esophageal squamous cell neoplasia: 5-year follow-up of a treated cohort in China

BACKGROUND AND AIMS

Radiofrequency ablation (RFA) is an accepted treatment for flat Barrett's neoplasia. Less is known about RFA for esophageal squamous cell neoplasia (ESCN). Our group has reported several prospective studies of RFA for ESCN in China with promising results through 12 months of follow-up. In this cohort study we aimed to evaluate longer term outcomes after RFA for ESCN.

METHODS

Patients with flat unstained lesions (USLs) on Lugol's endoscopy containing moderate-/high-grade intraepithelial neoplasia (MGIN/HGIN) or mucosal cancer were treated with RFA every 3 months until complete remission (CR; no MGIN or a worse histologic grade). Patients with CR at 12 months (CR12) were included for follow-up and underwent annual Lugol's endoscopy with biopsy sampling and re-RFA for flat USLs. The clinical course of patients with persistent ESCN at 12 months (treatment failures) is also reported.

RESULTS

Among the 78 patients in CR12, 67 (86%) had sustained CR during a median of 48 months (interquartile range, 48-48) of follow-up and 5 endoscopies (interquartile range, 4-6). Recurrence occurred in 7 of 78 patients (9%; MGIN, n = 6; HGIN, n = 1); all lesions were managed with RFA. Four other patients (5%) had progression (to HGIN, n = 1; submucosal esophageal squamous cell carcinoma, n = 3). During follow-up protocol violations occurred in 46 of 78 patients (59%). Of the 12 treatment failures, progression occurred in 6. Overall, 2 patients developed subepithelial disease that was not visible after Lugol's endoscopy. Based on post-hoc analysis, the pink-color sign at baseline (a pink color change after Lugol's endoscopy) significantly predicted failure after RFA.

CONCLUSIONS

RFA is relatively easy to apply and can efficiently treat large areas with ESCN. Despite protocol violations that may have interfered with the efficacy of RFA in 59% of patients, most patients with CR12 had sustained CR during follow-up. However, some patients progressed to advanced disease and 2 developed subepithelial disease, not visible after Lugol's endoscopy. Based on currently available data, we advise the restriction of the use of RFA for flat MGIN and HGIN without the pink-color sign on Lugol's chromoendoscopy. (Clinical trial registration number: NCT02047305.).

T1N0 oesophageal cancer: patterns of care and outcomes over 25 years

OBJECTIVES

Historically, surgical resection has been the mainstay of treatment for T1N0 oesophageal cancer (OC). More recently, oesophageal sparing endoscopic techniques have shown value for local control in a large institutional series. However, the effect of their utilization upon survival rates in large population series is largely unknown.

METHODS

The surveillance, epidemiology, and end results (SEER) database was queried for T1N0M0-OC patients (1988-2013). Patients with multiple treatment types were excluded. Time periods were divided by 5-year increments. Overall survival and cancer-specific survival (CSS) were compared in the group as a whole and in propensity-matched subgroups. Independent predictors of cancer-specific mortality were studied by the Cox proportional hazard models.

RESULTS

We identified 5497 patients with cT1N0M0 OC. Treatment modalities used were changed significantly over time. The ratio of oesophagectomy when compared with local therapy decreased from 15:1 in 1998-92 to 1.4:1 in 2008-13. The proportion of patients treated with radiation slightly increased (35% vs 41%) between 1988-92 and 2008-13. In the propensity-matched groups, 5-year CSS was similar in patients treated with oesophagectomy and local therapy (81% vs 89%; P = 0.257) (n = 216 in each group), whereas oesophagectomy had superior 5-year CSS compared with radiation alone (73% vs 38%; P < 0.001) (n = 497 in each group). In multivariable analysis, significant predictors of cancer-specific mortality included age [hazard ratio (HR) 1.022], tumour size (HR 1.005), radiation therapy (HR 3.67), tumour Grade III/IV (HR 1.25) and early time period of diagnosis (HR 1.75).

CONCLUSIONS

Oesophageal sparing endoscopic techniques have been increasingly utilized in the treatment of cT1N0-OC but without compromising CSS. Local therapy, either endoscopic techniques or surgery, remains superior to radiation therapy.