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Probst A, Kappler F, Ebigbo A, Albers D, Faiss S, Steinbrück I, Wannhoff A, Allgaier HP, Denzer U, Rempel V, Reinehr R, Dakkak D, Mende M, Pohl J, Schaller T, Märkl B, Muzalyova A, Fleischmann C, Messmann H. Endoscopic submucosal dissection for early esophageal adenocarcinoma: low rates of metastases in mucosal cancers with poor differentiation. Gastrointest Endosc 2024; 100:626-636. [PMID: 38479623 DOI: 10.1016/j.gie.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 08/03/2024]
Abstract
BACKGROUND AND AIMS Endoscopic resection is accepted as standard treatment for intramucosal esophageal adenocarcinoma (EAC) that is well or moderately differentiated. Poor differentiation (PD) is judged as a risk factor for lymph node metastasis (LNM), and surgery is recommended. However, the evidence for this recommendation is weak. The aim of this study was to analyze the clinical course of patients after endoscopic resection of EAC with PD. METHODS Patients undergoing endoscopic submucosal dissection for EAC were included from 16 German centers. Inclusion criteria were PD in the resection specimen, R0 resection, and endoscopic follow-up. Primary outcome was the metastasis rate during follow-up. Analysis was performed retrospectively in a prospectively collected database. RESULTS Twenty-five patients with PD as single risk factor (group A) and 15 patients with PD and additional risk factors (submucosal invasion and/or lymphovascular invasion) (group B) were included. The metastasis rate was was 1 of 25 (4.0%; 95% CI, .4%-17.2%) in group A and 3 of 15 (20.0%; 95% CI, 6.0%-44.4%) in group B, respectively (P = .293). The rate of EAC-associated deaths was 1 of 25 (4%; 95% CI, .4%-17.2%) versus 3 of 15 (20%; 95% CI, 6.0%-44.4%) in group B (P = .293). The overall death rate was 7 of 25 (28.0%; 95% CI, 13.5%-47.3%) versus 3 of 15 (20%; 95% CI, 6.0%-44.4%) (P = .715). Median follow-up was 30 months (interquartile range, 15-53 months). CONCLUSIONS During long-term follow-up, the risk of metastasis is low after endoscopic resection of mucosal EAC with PD as a single risk factor. A conservative approach seems justified in this small patient group. However, the treatment strategy must be determined on an individualized basis until further prospective data are available.
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Affiliation(s)
- Andreas Probst
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany.
| | - Felix Kappler
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Alanna Ebigbo
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - David Albers
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany
| | - Siegbert Faiss
- Department of Gastroenterology, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Ingo Steinbrück
- Department of Gastroenterology, Asklepios Klinik Barmbek, Hamburg, Germany; Department of Medicine and Gastroenterology, Evangelisches Diakoniekrankenhaus Freiburg, Freiburg, Germany
| | - Andreas Wannhoff
- Department of Gastroenterology, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Hans-Peter Allgaier
- Department of Medicine and Gastroenterology, Evangelisches Diakoniekrankenhaus Freiburg, Freiburg, Germany
| | - Ulrike Denzer
- Department of Gastroenterology, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Viktor Rempel
- Department of Gastroenterology, St. Anna Hospital Herne, Herne, Germany
| | - Roland Reinehr
- Department of Medicine and Gastroenterology, Elbe-Elster Klinikum, Herzberg, Germany
| | - Dani Dakkak
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany
| | - Matthias Mende
- Department of Gastroenterology, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Jürgen Pohl
- Department of Gastroenterology, Asklepios Klinik Altona, Hamburg, Germany
| | - Tina Schaller
- Pathology, Medical Faculty Augsburg, University of Augsburg, Augsburg, Germany
| | - Bruno Märkl
- Pathology, Medical Faculty Augsburg, University of Augsburg, Augsburg, Germany
| | - Anna Muzalyova
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Carola Fleischmann
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany; Department of Gastroenterology, Hepatology and Endocrinology, University Hospital, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
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Kamboj AK, Goyal R, Vantanasiri K, Sachdeva K, Passe M, Lansing R, Garg N, Chandi PS, Ramirez FC, Kahn A, Fukami N, Wolfsen HC, Krishna M, Pai RK, Hagen C, Lee HE, Wang KK, Leggett CL, Iyer PG. Clinical Outcomes After Endoscopic Management of Low-Risk and High-Risk T1a Esophageal Adenocarcinoma: A Multicenter Study. Am J Gastroenterol 2024; 119:662-670. [PMID: 37795907 DOI: 10.14309/ajg.0000000000002554] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Endoscopic eradication therapy (EET) is standard of care for T1a esophageal adenocarcinoma (EAC). However, data on outcomes in high-risk T1a EAC are limited. We assessed and compared outcomes after EET of low-risk and high-risk T1a EAC, including intraluminal EAC recurrence, extraesophageal metastases, and overall survival. METHODS Patients who underwent EET for T1a EAC at 3 referral Barrett's esophagus endotherapy units between 1996 and 2022 were included. Patients with submucosal invasion, positive deep margins, or metastases at initial diagnosis were excluded. High-risk T1a EAC was defined as T1a EAC with poor differentiation and/or lymphovascular invasion, with low-risk disease being defined without these features. All pathology was systematically assessed by expert gastrointestinal pathologists. Baseline and follow-up endoscopy and pathology data were abstracted. Time-to-event analyses were performed to compare outcomes between groups. RESULTS One hundred eighty-eight patients with T1a EAC were included (high risk, n = 45; low risk, n = 143) with a median age of 70 years, and 84% were men. Groups were comparable for age, sex, Barrett's esophagus length, lesion size, and EET technique. Rates of delayed extraesophageal metastases (11.1% vs 1.4%) were significantly higher in the high-risk group ( P = 0.02). There was no significant difference in the rates of intraluminal EAC recurrence ( P = 0.79) and overall survival ( P = 0.73) between the 2 groups. DISCUSSION Patients with high-risk T1a EAC undergoing successful EET had a substantially higher rate of extraesophageal metastases compared with those with low-risk T1a EAC on long-term follow-up. These data should be factored into discussions with patients while selecting treatment approaches. Additional prospective data in this area are critical.
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Affiliation(s)
- Amrit K Kamboj
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rohit Goyal
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kornpong Vantanasiri
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Karan Sachdeva
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Melissa Passe
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ramona Lansing
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nikita Garg
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paras S Chandi
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Francisco C Ramirez
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Allon Kahn
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Norio Fukami
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Herbert C Wolfsen
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Murli Krishna
- Department of Pathology, Mayo Clinic, Jacksonville, Florida, USA
| | - Rish K Pai
- Department of Pathology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Catherine Hagen
- Department of Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hee Eun Lee
- Department of Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K Wang
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cadman L Leggett
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Kahn A, Song K, Dhaliwal L, Thanawala S, Hagen CE, Agarwal S, McDonald NM, Gabre JT, Falk GW, Ginsberg GG, Wolfsen HC, Ramirez FC, Leggett CL, Wang KK, Iyer PG. Long-term outcomes following successful endoscopic treatment of T1 esophageal adenocarcinoma: a multicenter cohort study. Gastrointest Endosc 2023; 98:713-721. [PMID: 37356631 DOI: 10.1016/j.gie.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND AND AIMS Endoscopic eradication therapy (EET) is guideline endorsed for management of early-stage (T1) esophageal adenocarcinoma (EAC). Patients with baseline high-grade dysplasia (HGD) and EAC are at highest risk of recurrence after successful EET, but limited data exist on long-term (>5 year) recurrence outcomes. Our aim was to assess the incidence and predictors of long-term recurrence in a multicenter cohort of patients with T1 EAC treated with EET. METHODS Patients with T1 EAC achieving successful endoscopic cancer eradication with a minimum of 5 years' clinical follow-up were included. The primary outcome was neoplastic recurrence, defined as dysplasia or EAC, and it was characterized as early (<2 years), intermediate (2-5 years), or late (>5 years). Predictors of recurrence were assessed by time to event analysis. RESULTS A total of 84 T1 EAC patients (75 T1a, 9 T1b) with a median 9.1 years (range, 5.1-18.3 years) of follow-up were included. The overall incidence of neoplastic recurrence was 2.0 per 100 person-years of follow-up. Seven recurrences (3 dysplasia, 4 EAC) occurred after 5 years of EAC remission. Overall, 88% of recurrences were treated successfully endoscopically. EAC recurrence-related mortality occurred in 3 patients at a median of 5.2 years from EAC remission. Complete eradication of intestinal metaplasia was independently associated with reduced recurrence (hazard ratio, .13). CONCLUSIONS Following successful EET of T1 EAC, neoplastic recurrence occurred after 5 years in 8.3% of cases. Careful long-term surveillance should be continued in this patient population. Complete eradication of intestinal metaplasia should be the therapeutic end point for EET.
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Affiliation(s)
- Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Kevin Song
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Lovekirat Dhaliwal
- Department of Internal Medicine, Louisiana State University Health, Shreveport, Louisiana, USA
| | - Shivani Thanawala
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catherine E Hagen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Siddharth Agarwal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas M McDonald
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joel T Gabre
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gary W Falk
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory G Ginsberg
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Francisco C Ramirez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.
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Iyer PG, Chak A. Surveillance in Barrett's Esophagus: Challenges, Progress, and Possibilities. Gastroenterology 2023; 164:707-718. [PMID: 36746210 PMCID: PMC10079619 DOI: 10.1053/j.gastro.2023.01.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 02/08/2023]
Abstract
Endoscopic surveillance of Barrett's esophagus, aiming to detect prevalent dysplasia and adenocarcinoma, followed by effective endoscopic treatment, is an integral part of the esophageal adenocarcinoma prevention paradigm. However, several limitations, such as the subtle appearance of dysplasia, sampling error (inherent in current surveillance protocols), and noncompliance with surveillance recommendations, lead to missed dysplasia and neoplasia, reducing the effectiveness of surveillance as currently practiced. Careful endoscopic assessment with high-resolution white-light endoscopy, dye-based or electronic chromoendoscopy, and comprehensive sampling of the BE mucosa, remains the cornerstone of endoscopic surveillance. Emerging innovations in this area span the gamut of more efficient sampling methods, advanced imaging tools, artificial intelligence, and molecular marker-powered approaches as adjuncts, to identify prevalent and predict incident dysplasia or adenocarcinoma. Development and implementation of validated quality indicators will allow additional advancement of this critical field. These approaches will hopefully enable efficient and effective cancer prevention and treatment.
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Affiliation(s)
- Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Amitabh Chak
- Division of Gastroenterology and Hepatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
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Ma W, Nuckles B, Frank K, Young KA, Hoffman RL, Blansfield JA. Clinical T2N0M0 Esophageal Cancer-Is Treatment Pathway Associated With Overall Survival? J Surg Res 2023; 283:205-216. [PMID: 36410237 DOI: 10.1016/j.jss.2022.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/26/2022] [Accepted: 10/15/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Esophageal cancer therapy is commonly multimodal. The CROSS trial demonstrated a survival benefit of neoadjuvant chemoradiation versus surgery alone in T1N1 or T2-3N0-1 patients. Theoretically, chemoradiation should be most beneficial to patients with advanced disease. Treating the intermediary stage, T2N0M0, is challenging as national guidelines offer multiple options. This study aims to compare survival outcomes and associated factors in clinical T2N0M0 esophageal cancer via treatment modality and compare clinical to pathological stage. The authors conclude that neoadjuvant therapy use has increased; however, there is no associated survival benefit, which may be due to over- or under-staging. METHODS A retrospective study was performed using the National Cancer Database (2006-2016). Patients who underwent neoadjuvant chemoradiation followed by surgery (NCRT + ESOPH) were compared to patients who underwent esophagectomy first (ESOPH). Multivariable logistic regression was used to determine factors associated with treatment pathway. Overall survival was compared using Kaplan-Meier estimates and log-rank tests at 1-, 3-, and 5-y post-treatment. Additionally, a multiple logistic regression analysis was conducted to identify factors associated with adjuvant therapy in ESOPH patients. RESULTS There were 1662 patients (NCRT + ESOPH: 904 [54.4%], ESOPH: 758 [45.6%]). There was no difference in 5-y survival between NCRT + ESOPH and ESOPH patients. Despite this, NCRT + ESOPH treatment rates rose from 33% to 74% between 2006 and 2016. Patients who received NCRT + ESOPH were younger and more commonly had no Charlson-Deyo comorbidities. Notably, 41% of patients were over-staged (T1 or lower), and 32.8% were under-staged (N ≥ 1). CONCLUSIONS T2N0M0 remains difficult to characterize, and pathological staging corresponds poorly to clinical staging. Neoadjuvant therapy use has increased; however, the lack of a significant survival benefit to correlate with such may be secondary to over- or under-staging.
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Affiliation(s)
- Wanyan Ma
- Geisinger Department of General Surgery, Danville, Pennsylvania.
| | - Brandon Nuckles
- Geisinger Department of General Surgery, Danville, Pennsylvania
| | - Katie Frank
- Geisinger Department of General Surgery, Danville, Pennsylvania
| | - Katelyn A Young
- Geisinger Department of General Surgery, Danville, Pennsylvania
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Lymphovascular and Perineural Invasion after Neoadjuvant Therapy in Esophageal Squamous Carcinoma. Ann Thorac Surg 2022; 115:1386-1394. [PMID: 36027933 DOI: 10.1016/j.athoracsur.2022.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 06/08/2022] [Accepted: 07/16/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Lymphovascular invasion and perineural invasion are unfavorable prognostic factors in patients with esophageal squamous cell carcinoma. However, the prevalence and prognostic importance of lymphovascular invasion and perineural invasion after neoadjuvant chemoradiotherapy in these patients remains unclear. METHODS We retrospectively reviewed specimens of 321 patients with pathologically diagnosed esophageal squamous cell carcinoma who underwent neoadjuvant chemoradiotherapy in our institution from 2017-2020. Lymphovascular invasion and perineural invasion were assessed by hematoxylin and eosin staining. Survival was analyzed using the log-rank test and multivariable Cox regression analysis. RESULTS Lymphovascular invasion and perineural invasion were present in 12.5% (n=40) and 17.8% (n=57) of resection specimens, respectively. Lymphovascular invasion and perineural invasion were significantly more common in patients with advanced cancer (both p < 0.05). In the univariate analyses, lymphovascular invasion and perineural invasion were associated with shorter overall survival and disease-free survival. Multivariable analysis revealed that lymphovascular invasion after neoadjuvant therapy was an independent adverse prognostic factor for overall survival and disease-free survival. Subgroup analyses showed lymphovascular invasion could identify cases with worse overall survival or disease-free survival among node-negative patients, indicating the role of lymphovascular invasion in the precise staging of pN0 patients. CONCLUSIONS Lymphovascular invasion and perineural invasion were significantly negatively correlated with overall survival and disease-free survival. Lymphovascular invasion was an independent prognostic predictor in esophageal squamous cell carcinoma patients after neoadjuvant chemoradiotherapy. Lymphovascular invasion and perineural invasion should be considered in the histopathology workup for esophageal squamous cell carcinoma patients after neoadjuvant chemoradiotherapy.
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Nieuwenhuis EA, van Munster SN, Meijer SL, Brosens LAA, Jansen M, Weusten BLAM, Alvarez Herrero L, Alkhalaf A, Schenk E, Schoon EJ, Curvers WL, Koch AD, van de Ven SEM, Verheij EPD, Nagengast WB, Westerhof J, Houben MHMG, Tang T, Bergman JJGHM, Pouw RE, Ooms A, Huysentruyt C, ten Kate F, Moll F, Kats-Ugurlu G, van Lijnschoten I, van de Laan J, Offerhaus J, Biermann K, Seldenrijk K, Brosens L, Meijer S, Doukas M. Analysis of metastases rates during follow-up after endoscopic resection of early "high-risk" esophageal adenocarcinoma. Gastrointest Endosc 2022; 96:237-247.e3. [PMID: 35288149 DOI: 10.1016/j.gie.2022.03.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/04/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS After endoscopic resection (ER) of early esophageal adenocarcinoma (EAC), the optimal management of patients with high-risk histologic features for lymph node metastases (ie, submucosal invasion, poor differentiation grade, or lymphovascular invasion) remains unclear. We aimed to evaluate outcomes of endoscopic follow-up after ER for high-risk EAC. METHODS For this retrospective cohort study, data were collected from all Dutch patients managed with endoscopic follow-up (endoscopy, EUS) after ER for high-risk EAC between 2008 and 2019. We distinguished 3 groups: intramucosal cancers with high-risk features, submucosal cancers with low-risk features, and submucosal cancers with high-risk features. The primary outcome was the annual risk for metastases during follow-up, stratified for baseline histology. RESULTS One hundred twenty patients met the selection criteria. Median follow-up was 29 months (interquartile range, 15-48). Metastases were observed in 5 of 25 (annual risk, 6.9%; 95% confidence interval [CI], 3.0-15) high-risk intramucosal cancers, 1 of 55 (annual risk, .7%; 95% CI, 0-4.0) low-risk submucosal cancers, and 3 of 40 (annual risk, 3.0%; 95% CI, 0-7.0) high-risk submucosal cancers. CONCLUSIONS Whereas the annual metastasis rate for high-risk submucosal EAC (3.0%) was somewhat lower than expected in comparison with previous reported percentages, the annual metastasis rate of 6.9% for high-risk intramucosal EAC is new and worrisome. This calls for further prospective studies and suggests that strict follow-up of this small subgroup is warranted until prospective data are available.
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Affiliation(s)
- Esther A Nieuwenhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Sanne N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marnix Jansen
- Department of Pathology, UCL Cancer Institute and University College London Hospital, NHS Trust, London, UK
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Ed Schenk
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Erik J Schoon
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands; Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Eva P D Verheij
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands, (12)Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands, (12)Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands, (12)Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | - Thjon Tang
- Department of Gastroenterology and Hepatology, Ijsselland Hospital, Capelle aan den Ijssel, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
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Kamboj AK, Iyer PG. Pushing the boundaries of endoscopic management of early-stage esophageal adenocarcinoma: Caution is advisable! Gastrointest Endosc 2022; 96:248-249. [PMID: 35715236 DOI: 10.1016/j.gie.2022.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Amrit K Kamboj
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Paiji C, Sedarat A. Endoscopic Management of Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14153583. [PMID: 35892840 PMCID: PMC9329770 DOI: 10.3390/cancers14153583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 02/04/2023] Open
Abstract
Advances in technology and improved understanding of the pathobiology of esophageal cancer have allowed endoscopy to serve a growing role in the management of this disease. Precursor lesions can be detected using enhanced diagnostic modalities and eradicated with ablation therapy. Furthermore, evolution in endoscopic resection has provided larger specimens for improved diagnostic accuracy and offer potential for cure of early esophageal cancer. In patients with advanced esophageal cancer, endoluminal therapy can improve symptom burden and provide therapeutic options for complications such as leaks, perforations, and fistulas. The purpose of this review article is to highlight the role of endoscopy in the diagnosis, treatment, and palliation of esophageal cancer.
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Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. Am J Gastroenterol 2022; 117:559-587. [PMID: 35354777 DOI: 10.14309/ajg.0000000000001680] [Citation(s) in RCA: 229] [Impact Index Per Article: 76.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 02/04/2022] [Indexed: 02/07/2023]
Abstract
Barrett's esophagus (BE) is a common condition associated with chronic gastroesophageal reflux disease. BE is the only known precursor to esophageal adenocarcinoma, a highly lethal cancer with an increasing incidence over the last 5 decades. These revised guidelines implement Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the definition and diagnosis of BE, screening for BE and esophageal adenocarcinoma, surveillance of patients with known BE, and the medical and endoscopic treatment of BE and its associated early neoplasia. Important changes since the previous iteration of this guideline include a broadening of acceptable screening modalities for BE to include nonendoscopic methods, liberalized intervals for surveillance of short-segment BE, and volume criteria for endoscopic therapy centers for BE. We recommend endoscopic eradication therapy for patients with BE and high-grade dysplasia and those with BE and low-grade dysplasia. We propose structured surveillance intervals for patients with dysplastic BE after successful ablation based on the baseline degree of dysplasia. We could not make recommendations regarding chemoprevention or use of biomarkers in routine practice due to insufficient data.
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11
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Dunn JM, Reyhani A, Santaolalla A, Zylstra J, Gimson E, Pennington M, Baker C, Kelly M, Van Hemelrijck M, Lagergren J, Zeki SS, Gossage JA, Davies AR. Transition from esophagectomy to endoscopic therapy for early esophageal cancer. Dis Esophagus 2022; 35:6321381. [PMID: 34260693 DOI: 10.1093/dote/doab047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/24/2021] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Jason M Dunn
- Gastroenterology, Guy's and St.Thomas' Esophago-Gastric Centre, London, UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Arasteh Reyhani
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Aida Santaolalla
- Gastroenterology Unit,Translational Oncology & Urology Research(TOUR). King's College London, London UK
| | - Janine Zylstra
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK
| | - Eliza Gimson
- Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Mark Pennington
- Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Cara Baker
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK
| | - Mark Kelly
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK
| | - Mieke Van Hemelrijck
- Gastroenterology Unit,Translational Oncology & Urology Research(TOUR). King's College London, London UK
| | - Jesper Lagergren
- Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Sebastian S Zeki
- Gastroenterology, Guy's and St.Thomas' Esophago-Gastric Centre, London, UK
| | - James A Gossage
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Andrew R Davies
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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12
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Codipilly DC, Chandar AK, Wang KK, Katzka DA, Goldblum JR, Thota PN, Falk GW, Chak A, Iyer PG. Wide-area transepithelial sampling for dysplasia detection in Barrett's esophagus: a systematic review and meta-analysis. Gastrointest Endosc 2022; 95:51-59.e7. [PMID: 34543648 PMCID: PMC8671247 DOI: 10.1016/j.gie.2021.09.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/04/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Seattle protocol forceps biopsy sampling (FB) is currently recommended for surveillance in Barrett's esophagus (BE) but limited by sampling error and lack of compliance. Wide-area transepithelial sampling with 3-dimensional analysis (WATS3D; CDx Diagnostics, Suffern, NY, USA) is reported to increase BE dysplasia detection. We assessed the incremental yield and clinical significance of WATS3D for dysplasia detection over FB in a systematic review and meta-analysis. METHODS We queried major scientific databases for studies using WATS3D and FB from 2000 to 2020. The primary outcome was the incremental yield of WATS3D-detected dysplasia (defined as a composite of indefinite for dysplasia, low- and high-grade dysplasia [HGD] and esophageal adenocarcinoma [EAC]) over FB. Secondary outcomes were incremental yields of HGD/EAC and rate of reconfirmation of WATS3D dysplasia on subsequent FB. RESULTS Meta-analysis of 7 eligible studies demonstrated that FB diagnosed dysplasia in 15.9% of cases, whereas the incremental yield with WATS3D was 7.2% (95% confidence interval, 3.9%-11.5%; I2= 92.1%). Meta-analysis of 6 studies demonstrated that FB diagnosed HGD/EAC in 2.3% of patients, whereas the incremental yield with WATS3D was 2.1% (95% confidence interval, .4%-5.3%; I2= 92.7%). Notably, WATS3D was negative in 62.5% of cases where FB identified dysplasia. Two studies reported reconfirmation of WATS3D dysplasia with FB histology in only 20 patients. CONCLUSIONS WATS3D increases dysplasia detection; however, the clinical significance of this increased dysplasia detection remains uncertain. Data from endoscopic follow-up to ascertain FB histology in patients with dysplasia based solely on WATS3D are needed to determine the optimal clinical application and significance of WATS3D-only dysplasia.
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Affiliation(s)
- D. Chamil Codipilly
- Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Kenneth K. Wang
- Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - David A. Katzka
- Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John R. Goldblum
- Department of Pathology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Prashanthi N. Thota
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gary W. Falk
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amitabh Chak
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio,Division of Gastroenterology and Liver Diseases, Case Western Reserve University, Cleveland, Ohio
| | - Prasad G. Iyer
- Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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13
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Leggett CL, Katzka DA. As far as the AI can see. Endoscopy 2021; 53:884-885. [PMID: 34438451 DOI: 10.1055/a-1352-4811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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14
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Benech N, O'Brien JM, Barret M, Jacques J, Rahmi G, Perrod G, Hervieu V, Jaouen A, Charissoux A, Guillaud O, Legros R, Walter T, Saurin JC, Rivory J, Prat F, Lépilliez V, Ponchon T, Pioche M. Endoscopic resection of Barrett's adenocarcinoma: Intramucosal and low-risk tumours are not associated with lymph node metastases. United European Gastroenterol J 2021; 9:362-369. [PMID: 32903167 PMCID: PMC8259244 DOI: 10.1177/2050640620958903] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Superficial oesophageal adenocarcinoma can be resected endoscopically, but data to define a curative endoscopic resection are scarce. Objective Our study aimed to assess the risk of lymph node metastasis depending on the depth of invasion and histological features of oesophageal adenocarcinoma. Methods We retrospectively included all patients undergoing an endoscopic resection for T1 oesophageal adenocarcinoma among seven expert centres in France in 2004–2016. Mural invasion was defined as either intramucosal or submucosal tumours; the latter were further divided into superficial submucosal (<1000 mm) and deep submucosal (>1000 mm). Absence or presence of lymphovascular invasion and/or poorly differentiated cancer (G3) defined a low‐risk or a high‐risk tumour, respectively. For submucosal tumours, invasion depth and histological features were systematically confirmed after a second dedicated histological assessment (new 2‐mm thick slices) performed by a second pathologist. Occurrence of lymph node metastasis was recorded during the follow‐up from histological or PET CT reports when an invasive procedure was not possible. Results In total, 188 superficial oesophageal adenocarcinomas were included with a median follow‐up of 34 months. No lymph node metastases occurred for intramucosal oesophageal adenocarcinomas (n = 135) even with high‐risk histological features. Among submucosal oesophageal adenocarcinomas, only tumours with lymphovascular invasion or poorly differentiated cancer or with a depth of invasion >1000 μm developed lymph node metastasis tumours (n = 10/53%; 18.9%; hazard ratio 12.04). No metastatic evolution occurred under a 1000‐mm threshold for all low‐risk tumours (0/25), nor under 1200 mm (0/1) and three over this threshold (3/13%, 23.1%). Conclusion Intramucosal and low‐risk tumours with shallow submucosal invasion up to 1200 mm were not associated with lymph node metastasis during follow‐up. In case of high‐risk features and/or deep submucosal invasion, endoscopic resections are not sufficient to eliminate the risk of lymph node metastasis, and surgical oesophagectomy should be carried out. These results must be confirmed by larger prospective series.
Superficial oesophageal adenocarcinoma (OAC) can be resected endoscopically. Data to define a curative endoscopic resection with a low lymph node metastasis (LNM) risk are scarce especially for tumours invading the submucosa. Curative endoscopic resections have been reported in selected OAC invading the first 500 mm of the submucosa, but surgical series showed an LNM risk ranging from 0% to 50%, making endoscopic resection a questionable curative treatment. High‐risk histological features were not associated with LNM in intramucosal tumours. LNM occurred only for tumours invading the submucosa with a depth ≥1200 mm or with high‐risk histological features regardless of the depth of invasion. Endoscopic resection may be a valid and curative therapeutic option for all intramucosal tumours and for submucosal oesophageal adenocarcinoma with an invasion depth ≤1000 mm and low‐risk histological features.
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Affiliation(s)
- Nicolas Benech
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France
| | - Jean Marc O'Brien
- Université Claude Bernard Lyon 1, Lyon, France.,Service d'Hépato-Gastroentérologie, Hôpital de La Croix-Rousse, Hospices civils de Lyon, Lyon, France
| | | | - Jéremie Jacques
- Service d'Hepato-Gastroenterologie, Dupuytren University Hospital, Limoges, France
| | - Gabriel Rahmi
- Service d'Hepato-Gastroenterologie, Hôpital Europeen Georges Pompidou, Paris, France
| | - Guillaume Perrod
- Service d'Hepato-Gastroenterologie, Hôpital Europeen Georges Pompidou, Paris, France
| | - Valérie Hervieu
- Service d'Anatomo-Pathologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Alexandre Jaouen
- Service d'Anatomo-Pathologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Aurélie Charissoux
- Service d'Anatomo-Pathologie, Dupuytren University Hospital, Limoges, France
| | - Olivier Guillaud
- Service d'Hepato-Gastroenterologie, Clinique de la Sauvegarde, Lyon, France
| | - Romain Legros
- Service d'Hepato-Gastroenterologie, Dupuytren University Hospital, Limoges, France
| | - Thomas Walter
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Jean-Christophe Saurin
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Jérôme Rivory
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France
| | - Fréderic Prat
- Service d'Hepato-Gastroentérologie, Hôpital Cochin, Paris, France
| | - Vincent Lépilliez
- Service d'Hepato-Gastroentérologie, Mermoz Private Hospital, Lyon, France
| | - Thierry Ponchon
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,INSERM U1032, Lab Tau, Lyon, France
| | - Mathieu Pioche
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,INSERM U1032, Lab Tau, Lyon, France
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15
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Accurate Nonendoscopic Detection of Barrett's Esophagus by Methylated DNA Markers: A Multisite Case Control Study. Am J Gastroenterol 2020; 115:1201-1209. [PMID: 32558685 PMCID: PMC7415629 DOI: 10.14309/ajg.0000000000000656] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Nonendoscopic Barrett's esophagus (BE) screening may help improve esophageal adenocarcinoma outcomes. We previously demonstrated promising accuracy of methylated DNA markers (MDMs) for the nonendoscopic diagnosis of BE using samples obtained from a capsule sponge-on-string (SOS) device. We aimed to assess the accuracy of these MDMs in an independent cohort using a commercial grade assay. METHODS BE cases had ≥ 1 cm of circumferential BE with intestinal metaplasia; controls had no endoscopic evidence of BE. The SOS device was withdrawn 8 minutes after swallowing, followed by endoscopy (the criterion standard). Highest performing MDMs from a previous study were blindly assessed on extracted bisulfite-converted DNA by target enrichment long-probe quantitative amplified signal (TELQAS) assays. Optimal MDM combinations were selected and analyzed using random forest modeling with in silico cross-validation. RESULTS Of 295 patients consented, 268 (91%) swallowed the SOS device; 112 cases and 89 controls met the pre-established inclusion criteria. The median BE length was 6 cm (interquartile range 4-9), and 50% had no dysplasia. The cross-validated sensitivity and specificity of a 5 MDM random forest model were 92% (95% confidence interval 85%-96%) and 94% (95% confidence interval 87%-98%), respectively. Model performance was not affected by age, gender, or smoking history but was influenced by the BE segment length. SOS administration was well tolerated (median [interquartile range] tolerability 2 [0, 4] on 10 scale grading), and 95% preferred SOS over endoscopy. DISCUSSION Using a minimally invasive molecular approach, MDMs assayed from SOS samples show promise as a safe and accurate nonendoscopic test for BE prediction.
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16
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Outcomes of patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study. Gastrointest Endosc 2020; 92:31-39.e1. [PMID: 31953189 PMCID: PMC7321863 DOI: 10.1016/j.gie.2020.01.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The treatment of submucosal (T1b) esophageal adenocarcinoma (EAC) remains in evolution, with some evidence supporting endoscopic management of low-risk lesions. Using a multicenter cohort, we evaluated outcomes of patients with T1b EAC and predictors of survival. METHODS Patients diagnosed between 2001 and 2016 with T1b EAC were identified from 3 academic medical centers in the United States. Demographic, clinical, and outcome data were collected. Outcomes studied were overall and cancer-free survival. Cox proportional hazards models were constructed to assess independent predictors of survival. RESULTS One hundred forty-one patients were included, of whom 68 (48%) underwent esophagectomy and 73 (52%) were treated endoscopically. Most patients (85.8%) had high-risk histologic features. Thirty-day operative mortality was 2.9%. Median follow-up in the esophagectomy and endoscopic cohorts was 49.4 and 43.4 months, respectively. Patients treated endoscopically were older with higher comorbidity scores, with 46 (63%) achieving histologic remission. Nineteen patients (26.0%) also received chemoradiation. Five-year overall survival rates in the surgical and endoscopic cohorts were 89% and 59%, respectively, whereas 5-year cancer-free survival rates were 92% and 69%. Presence of high-risk histologic features was associated with reduced overall survival. CONCLUSIONS In this large multicenter study of patients with T1b EAC, esophagectomy was associated with improved overall but not cancer-free survival. High-risk histologic features were associated with poorer survival.
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17
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Yang J, Lu Z, Li L, Li Y, Tan Y, Zhang D, Wang A. Relationship of lymphovascular invasion with lymph node metastasis and prognosis in superficial esophageal carcinoma: systematic review and meta-analysis. BMC Cancer 2020; 20:176. [PMID: 32131772 PMCID: PMC7057611 DOI: 10.1186/s12885-020-6656-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 02/18/2020] [Indexed: 12/19/2022] Open
Abstract
Background The development of tumor cells inside the lymphatics or blood vessels is known as lymphovascular invasion (LVI). The correlation between LVI, lymph node metastasis (LNM), and the diagnosis of superficial esophageal carcinoma (SEC) remains unclear. Methods We searched Embase, PubMed, Web of Science, and Cochrane Library databases for prospective articles to better understand the relationship between LVI, LNM, and SEC diagnosis. Results We included 23 articles containing data for 4749 patients (range: 54–598) in our meta-analysis. The hazard ratio between LVI and overall survival (OS) was 1.85 with 95% confidence interval (CI) (1.10–3.11, P = 0.02). LNM rate was higher in SEC patients with LVI than SEC patients without LVI (univariate: OR = 4.94, 95% CI: 3.74–6.53, P < 0.0001; multivariate: OR = 5.72, 95%CI: 4.38–7.4, P < 0.0001). No obvious publication was found. Conclusions The results indicate that LVI plays a dominant role in the prognosis of LNM in SEC and in the prognostic prediction for SEC.
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Affiliation(s)
- Jinxin Yang
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Zhouyi Lu
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Lintao Li
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Yong Li
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Yulong Tan
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Dekang Zhang
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China.
| | - An Wang
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
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18
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Abstract
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.
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Affiliation(s)
- Tania Triantafyllou
- Department of Surgery, Hippocration General Hospital of Athens, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam 3000, the Netherlands
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19
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Iyer PG. Dysplasia detection in Barrett's esophagus: Is the glass half full or half empty? Gastrointest Endosc 2019; 90:742-744. [PMID: 31635713 DOI: 10.1016/j.gie.2019.06.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 06/27/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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20
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Chhabra P, Bhasin DK. Risk assessment for Barrett's esophagus: so near, yet so far! Gastrointest Endosc 2019; 90:718-720. [PMID: 31635712 DOI: 10.1016/j.gie.2019.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/24/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Puneet Chhabra
- Department of Gastroenterology, Max Superspeciality Hospital, Patparganj, New Delhi
| | - Deepak K Bhasin
- Department of Gastroenterology and Hepatology, Fortis Hospital, Mohali, Punjab, India
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21
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Abstract
Barrett esophagus is a metaplastic change in the lining of the distal esophageal epithelium, characterized by replacement of the normal squamous epithelium by specialized intestinal metaplasia. The presence of Barrett esophagus increases the risk of esophageal adenocarcinoma several-fold. Esophageal adenocarcinoma is a malignancy with rapidly rising incidence and persistently poor outcomes when diagnosed after the onset of symptoms. Risk factors for Barrett esophagus include chronic gastroesophageal reflux, central obesity, white race, male gender, older age, smoking, and a family history of Barrett esophagus or esophageal adenocarcinoma. Screening for Barrett esophagus in those with several risk factors followed by endoscopic surveillance to detect dysplasia or adenocarcinoma is currently recommended by society guidelines. Minimally invasive nonendoscopic tools for the early detection of Barrett esophagus are currently being developed. Multimodality endoscopic therapy-using a combination of endoscopic resection and ablation techniques-for the treatment of dysplasia and early adenocarcinoma is successful in eliminating intestinal metaplasia and preventing progression to adenocarcinoma, with outcomes comparable to those after esophagectomy. Risk stratification of those diagnosed with Barrett esophagus is a challenge at present, with active research focused on identifying clinical and biomarker panels to identify those with low and high risk of progression. This narrative review highlights some of the challenges and recent progress in this field.
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Affiliation(s)
- Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY.
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22
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Kahn A, Kamboj AK, Muppa P, Sawas T, Lutzke LS, Buras MR, Golafshar MA, Katzka DA, Iyer PG, Smyrk TC, Wang KK, Leggett CL. Staging of T1 esophageal adenocarcinoma with volumetric laser endomicroscopy: a feasibility study. Endosc Int Open 2019; 7:E462-E470. [PMID: 30931378 PMCID: PMC6428686 DOI: 10.1055/a-0838-5326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/26/2018] [Indexed: 12/17/2022] Open
Abstract
Background and study aims Precise staging in T1 esophageal adenocarcinoma (EAC) is critical in determining candidacy for curative endoscopic resection. High-frequency endoscopic ultrasound (EUS) has demonstrated suboptimal accuracy in T1 EAC staging due to insufficient spatial resolution. Volumetric laser endomicroscopy (VLE) allows for high-resolution wide-field visualization of the esophageal microstructure. We aimed to investigate the role of VLE in staging T1 EAC. Patients and methods Patients undergoing endoscopic mucosal resection (EMR) were prospectively enrolled and only T1 EAC cases were included. EMR specimens were imaged using second-generation VLE immediately after resection. VLE images were analyzed for signal intensity by depth and signal attenuation (dB/mm) in both cross-sectional and en-face orientation. A decision tree model was constructed to combine measured VLE parameters and delineate diagnostic thresholds. Results Thirty EMR scans were obtained - 15 T1a specimens from 9 patients and 15 T1b specimens from 11 patients. T1b specimen VLE scans exhibited higher signal intensity ( P < 0.0001) and higher signal attenuation compared to T1a specimens ( P = 0.03). A combination of signal attenuation and signal intensity at 150 µm depth yielded optimal diagnostic thresholds and an area under the curve (AUC) of 0.77. VLE signal attenuation was significantly associated with grade of differentiation, irrespective of EAC stage. Conclusions VLE signal intensity and signal attenuation are quantitatively distinct in T1a and T1b EAC and associated with grade of differentiation. This is the first study examining the role of VLE for staging of T1 EAC and demonstrates promising diagnostic performance. With further in vivo validation, VLE may serve a role in staging superficial EAC.
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Affiliation(s)
- Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, United States
| | - Amrit K. Kamboj
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Prasuna Muppa
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States
| | - Tarek Sawas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Lori S. Lutzke
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Matthew R. Buras
- Division of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona, United States
| | - Michael A. Golafshar
- Division of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona, United States
| | - David A. Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Thomas C. Smyrk
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Cadman L. Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States,Corresponding author Cadman L. Leggett, M.D. Division of Gastroenterology and HepatologyMayo Clinic
200 1
st
Street SW, Rochester, MN 55905
+1-480-301-8673
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23
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Harada K, Zhao M, Baba H, Ajani JA. Endoscopic resection for esophageal or gastroesophageal junction adenocarcinoma. DIGESTIVE MEDICINE RESEARCH 2019; 2:7. [PMID: 31179442 PMCID: PMC6553865 DOI: 10.21037/dmr.2019.04.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Kazuto Harada
- Department of Gastrointestinal Medical Oncology at the
University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
- Department of Gastroenterological Surgery, Graduate School
of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto 860-8556, Japan
| | - Meina Zhao
- Department of Gastrointestinal Medical Oncology at the
University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School
of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto 860-8556, Japan
| | - Jaffer A. Ajani
- Department of Gastrointestinal Medical Oncology at the
University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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24
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Wang A, Tan Y, Geng X, Chen X, Wang S. Lymphovascular invasion as a poor prognostic indicator in thoracic esophageal carcinoma: a systematic review and meta-analysis. Dis Esophagus 2019; 32:5085982. [PMID: 30169614 DOI: 10.1093/dote/doy083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The ability to further stratify patients with esophageal carcinoma (EC) in the same stage into high-risk patients by the presence of lymphovascular invasion (LVI) may permit refinement of multi-modality therapy. However, the role of LVI in the prognosis of EC is not definite. A meta-analysis was conducted to investigate the relationship between LVI and EC prognosis. We searched PubMed, Embase, Web of Science, and Cochrane Library databases for studies on the association between LVI and prognosis of EC. Only studies with patient survival data related to LVI were included. The effect size for this analysis was the hazard ratio (HR) with 95% confidence intervals (CI) for overall survival (OS) and recurrence-free survival (RFS). Thirty-five studies with 9876 patients were included according to the defined inclusion and exclusion criteria. LVI was a poor indicator for the OS (HR = 1.64, 95% CI: 1.44-1.87, P < 0.001) and RFS (HR = 1.79, 95% CI: 1.38-2.34, P < 0.001). However, the heterogeneity was medium in OS (I2 = 61.2%, P < 0.001) and extreme in RFS (I2 = 77.5%, P < 0.001). In subgroup analysis, heterogeneity was originated from the staining method and proportion of early disease (stage (I + II)). We concluded that LVI was a poor prognostic indicator in patients with EC, especially in those studies with the IHC staining method and a high proportion of early disease (stage (I + II)).
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Affiliation(s)
- A Wang
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Y Tan
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - X Geng
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - X Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - S Wang
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
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25
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Zeki SS, Bergman JJ, Dunn JM. Endoscopic management of dysplasia and early oesophageal cancer. Best Pract Res Clin Gastroenterol 2018; 36-37:27-36. [PMID: 30551853 DOI: 10.1016/j.bpg.2018.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/19/2018] [Indexed: 01/31/2023]
Abstract
In the past decade there have been technological advances in Endoscopic Eradication Therapy (EET) for the management of patients with oesophageal neoplasia and early cancer. Multiple endoscopic techniques now exist for both squamous and Barrett's oesophagus associated neoplasia or early cancer. A fundamental aspect of endotherapy is removal of the target lesion by endoscopic mucosal resection, or endosopic submucosal dissection. Residual tissue is subsequently ablated to remove the risk of recurrence. The most validated technique for Barrett's oesophagus is radiofrequency ablation, but other techniques such as hybrid-APC and cryotherapy also show good results. This chapter will discuss the evolution of EET, and which patients are most likely to benefit. It will also explore the evidence behind the success of different techniques and provide practical advice on how to carry out the endoscopic techniques with a focus on radiofrequency ablation and endoscopic mucosal resection in particular.
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Affiliation(s)
- S S Zeki
- Dept of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, United Kingdom.
| | - J J Bergman
- Dep. of Gastroenterology, Academic Medical Center, Amsterdam, Netherlands
| | - J M Dunn
- Dept of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, United Kingdom
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26
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Abstract
The exponential rise in incidence of esophageal adenocarcinoma (EAC), paired with persistently poor survival, continues to drive efforts to improve and optimize screening and surveillance practices. While advancements in endoscopic therapy have generated a shift in management and significantly improved the outcomes of patients with early-stage EAC, the majority of prevalent EAC continues to be diagnosed at advanced stages, remaining ineligible for curative therapy. Barrett's esophagus (BE) screening, when applied to high-yield target populations, using minimally or noninvasive accurate tests, followed by endoscopic surveillance to detect prevalent or incident dysplasia/EAC (which can then be treated successfully) is the cornerstone of the current BE management paradigm. While supported by some empiric evidence and attractive, this approach faces a number of challenges, which are also balanced by numerous recent advances in these areas. In this manuscript, we review the rationale, supportive evidence, current challenges, and recent progress in BE screening and surveillance.
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Affiliation(s)
- Fouad Otaki
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, OR, USA
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA.
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27
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Friedland S, Triadafilopoulos G. Can endoscopic resection for Barrett's dysplasia and early cancer be curative? Ann N Y Acad Sci 2018; 1434:54-58. [PMID: 29752721 DOI: 10.1111/nyas.13715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/11/2018] [Accepted: 03/16/2018] [Indexed: 12/23/2022]
Abstract
Effective endoscopic treatments for dysplasia and early (intramucosal) cancer, together with expanded and rigorous screening programs to detect Barrett's esophagus, could help reverse the increase in the incidence of esophageal cancer and reduce esophageal cancer-related mortality. In this review, we discuss the long-term outcomes for mucosal resection for dysplasia and early cancer and compares them to esophagectomy as the standard of care choice. Eendoscopic resection for Barrett's dysplasia and early cancer can be curative but only when the lesion can be classified as: Paris type I (polypoid); Paris IIa (slightly elevated); Paris IIb (flat); Paris IIc (slightly depressed); histological grades G1 and G2; high-grade dysplasia. The size of the lesion is important, since <20 mm diameter lesions can be removed using endoscopic mucosal resection or, if they are larger, by endoscopic submucosal dissection. Proper imaging and lesion characterization followed by endoscopic resection as needed are essential in diagnostic and therapeutic decision making. Mucosal (T1a) Barrett's cancer and low-risk submucosal cancers have a minimal risk for lymph node metastasis and local endoscopic treatment is justified. Long-term outcomes of endoscopic therapy are same as surgery.
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Affiliation(s)
- Shai Friedland
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - George Triadafilopoulos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
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28
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Abstract
Esophageal cancer is a serious malignancy with high mortality. The two common distinctive pathologic subtypes of esophageal cancer are squamous cell carcinoma and adenocarcinoma. These differ with regards to etiology, ethnic distribution, pathogenesis, and location in the esophagus. The precursor lesions are also unique to each subtype. Squamous cell carcinoma is more common in East Asia, is linked to smoking and tobacco use, more commonly involves the middle esophagus, and the precursor lesion is squamous dysplasia. Adenocarcinoma is more common in the United States and certain European countries, associated with obesity and gastroesophageal reflux disease (GERD), more commonly involves the distal esophagus, and the precursor lesion is Barrett's esophagus. Endoscopic surveillance with biopsy evaluation is the standard of care in high-risk groups. Endoscopic ablative therapies for early cancers have lower morbidity than surgery. Despite increased awareness, identification of high-risk groups and endoscopic surveillance, a large proportion of patients present with advanced cancers. Surgery and chemoradiation, either in neo-adjuvant or adjuvant setting, is the usual treatment for patients with advanced but resectable esophageal cancers. The prognosis and further management largely depends upon the pathologic tumor-node-metastasis (TNM) staging provided by the American Joint Committee on Cancer (AJCC) and the International Union against Cancer. Currently, the 7th edition of TNM staging system is being applied for prognostication and this is more focused on pathologic evaluation. Eighth edition of AJCC/UICC TNM staging has been introduced and will be implemented for clinical use in 2018.
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Affiliation(s)
- Shilpa Jain
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Sadhna Dhingra
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, USA
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29
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Esophagectomy Outcomes in the Endoscopic Mucosal Resection Era. Ann Thorac Surg 2017; 103:890-897. [DOI: 10.1016/j.athoracsur.2016.08.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 08/15/2016] [Accepted: 08/17/2016] [Indexed: 02/07/2023]
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30
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DaVee T, Ajani JA, Lee JH. Is endoscopic ultrasound examination necessary in the management of esophageal cancer? World J Gastroenterol 2017; 23:751-762. [PMID: 28223720 PMCID: PMC5296192 DOI: 10.3748/wjg.v23.i5.751] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/23/2016] [Accepted: 12/21/2016] [Indexed: 02/06/2023] Open
Abstract
Despite substantial efforts at early diagnosis, accurate staging and advanced treatments, esophageal cancer (EC) continues to be an ominous disease worldwide. Risk factors for esophageal carcinomas include obesity, gastroesophageal reflux disease, hard-alcohol use and tobacco smoking. Five-year survival rates have improved from 5% to 20% since the 1970s, the result of advances in diagnostic staging and treatment. As the most sensitive test for locoregional staging of EC, endoscopic ultrasound (EUS) influences the development of an optimal oncologic treatment plan for a significant minority of patients with early cancers, which appropriately balances the risks and benefits of surgery, chemotherapy and radiation. EUS is costly, and may not be available at all centers. Thus, the yield of EUS needs to be thoughtfully considered for each patient. Localized intramucosal cancers occasionally require endoscopic resection (ER) for histologic staging or treatment; EUS evaluation may detect suspicious lymph nodes prior to exposing the patient to the risks of ER. Although positron emission tomography (PET) has been increasingly utilized in staging EC, it may be unnecessary for clinical staging of early, localized EC and carries the risk of false-positive metastasis (over staging). In EC patients with evidence of advanced disease, EUS or PET may be used to define the radiotherapy field. Multimodality staging with EUS, cross-sectional imaging and histopathologic analysis of ER, remains the standard-of-care in the evaluation of early esophageal cancers. Herein, published data regarding use of EUS for intramucosal, local, regional and metastatic esophageal cancers are reviewed. An algorithm to illustrate the current use of EUS at The University of Texas MD Anderson Cancer Center is presented.
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31
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Ballard DD, Choksi N, Lin J, Choi EY, Elmunzer BJ, Appelman H, Rex DK, Fatima H, Kessler W, DeWitt JM. Outcomes of submucosal (T1b) esophageal adenocarcinomas removed by endoscopic mucosal resection. World J Gastrointest Endosc 2016; 8:763-769. [PMID: 28042390 PMCID: PMC5159674 DOI: 10.4253/wjge.v8.i20.763] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/23/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To investigate the outcomes and recurrences of pT1b esophageal adenocarcinoma (EAC) following endoscopic mucosal resection (EMR) and associated treatments.
METHODS Patients undergoing EMR with pathologically confirmed T1b EAC at two academic referral centers were retrospectively identified. Patients were divided into 4 groups based on treatment following EMR: Endoscopic therapy alone (group A), endoscopic therapy with either chemotherapy, radiation or both (group B), surgical resection (group C) or no further treatment/lost to follow-up (< 12 mo) (group D). Pathology specimens were reviewed by a central pathologist. Follow-up data was obtained from the academic centers, primary care physicians and/or referring physicians. Univariate analysis was performed to identify factors predicting recurrence of EAC.
RESULTS Fifty-three patients with T1b EAC underwent EMR, of which 32 (60%) had adequate follow-up ≥ 12 mo (median 34 mo, range 12-103). There were 16 patients in group A, 9 in group B, 7 in group C and 21 in group D. Median follow-up in groups A to C was 34 mo (range 12-103). Recurrent EAC developed overall in 9 patients (28%) including 6 (38%) in group A (median: 21 mo, range: 6-73), 1 (11%) in group B (median: 30 mo, range: 30-30) and 2 (29%) in group C (median 21 mo, range: 7-35. Six of 9 recurrences were local; of the 6 recurrences, 5 were treated with endoscopy alone. No predictors of recurrence of EAC were identified.
CONCLUSION Endoscopic therapy of T1b EAC may be a reasonable strategy for a subset of patients including those either refusing or medically unfit for esophagectomy.
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32
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Martinucci I, de Bortoli N, Russo S, Bertani L, Furnari M, Mokrowiecka A, Malecka-Panas E, Savarino V, Savarino E, Marchi S. Barrett’s esophagus in 2016: From pathophysiology to treatment. World J Gastrointest Pharmacol Ther 2016; 7:190-206. [PMID: 27158534 PMCID: PMC4848241 DOI: 10.4292/wjgpt.v7.i2.190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 11/05/2015] [Accepted: 03/18/2016] [Indexed: 02/06/2023] Open
Abstract
Esophageal complications caused by gastroesophageal reflux disease (GERD) include reflux esophagitis and Barrett’s esophagus (BE). BE is a premalignant condition with an increased risk of developing esophageal adenocarcinoma (EAC). The carcinogenic sequence may progress through several steps, from normal esophageal mucosa through BE to EAC. A recent advent of functional esophageal testing (particularly multichannel intraluminal impedance and pH monitoring) has helped to improve our knowledge about GERD pathophysiology, including its complications. Those findings (when properly confirmed) might help to predict BE neoplastic progression. Over the last few decades, the incidence of EAC has continued to rise in Western populations. However, only a minority of BE patients develop EAC, opening the debate regarding the cost-effectiveness of current screening/surveillance strategies. Thus, major efforts in clinical and research practice are focused on new methods for optimal risk assessment that can stratify BE patients at low or high risk of developing EAC, which should improve the cost effectiveness of screening/surveillance programs and consequently significantly affect health-care costs. Furthermore, the area of BE therapeutic management is rapidly evolving. Endoscopic eradication therapies have been shown to be effective, and new therapeutic options for BE and EAC have emerged. The aim of the present review article is to highlight the status of screening/surveillance programs and the current progress of BE therapy. Moreover, we discuss the recent introduction of novel esophageal pathophysiological exams that have improved the knowledge of the mechanisms linking GERD to BE.
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33
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Blevins CH, Iyer PG. Endoscopic therapy for Barrett's oesophagus. Best Pract Res Clin Gastroenterol 2015; 29:167-77. [PMID: 25743464 DOI: 10.1016/j.bpg.2014.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 11/24/2014] [Indexed: 02/06/2023]
Abstract
Barrett's oesophagus (BO) is thought to progress through the development of dysplasia (low grade and high grade) to oesophageal adenocarcinoma, a lethal cancer with poor survival. The overall goal of endoscopic therapy of BO is to eliminate metaplastic and dysplastic epithelium, to prevent and/or reduce the risk of progression to OAC. Endoscopic therapy techniques can be divided into two broad complementary techniques: tissue acquiring (endoscopic mucosal resection and endoscopic submucosal dissection) and ablative. Endoscopic therapy has been established as safe and effective for the subjects with intra-mucosal cancer (IMC), high-grade dysplasia (HGD) and more recently in treating low-grade dysplasia (LGD). Challenges to endoscopic therapy are being recognized, such as incomplete response and recurrence. While eradication of intestinal metaplasia is the immediate goal of endoscopic therapy, surveillance must continue after complete elimination of intestinal metaplasia, to detect and treat recurrences.
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Affiliation(s)
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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