|
1
|
Peters EJ, Robinson M, Patel N, Kidane B. Esophagectomy Versus Endoscopic Resection with Adjuvant Therapy for T1b/T2 Esophageal Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel) 2025; 17:680. [PMID: 40002274 PMCID: PMC11853579 DOI: 10.3390/cancers17040680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Revised: 02/13/2025] [Accepted: 02/13/2025] [Indexed: 02/27/2025] Open
Abstract
Esophageal cancer is the seventh most common cause of cancer-related death worldwide [...].
Collapse
Affiliation(s)
- Eagan J. Peters
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada;
| | - Madeline Robinson
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9, Canada;
| | - Noopur Patel
- Michigan State University College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48824, USA;
| | - Biniam Kidane
- Section of Thoracic Surgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
- CancerCare Manitoba Research Institute, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
- Department of Physiology & Pathophysiology, University of Manitoba, Winnipeg, MB R3E 0J9, Canada
- Department of Biomedical Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada
| |
Collapse
|
|
2
|
Jin G, Liu K, Guo Z, Dong Z. Precision therapy for cancer prevention by targeting carcinogenesis. Mol Carcinog 2024; 63:2045-2062. [PMID: 39140807 DOI: 10.1002/mc.23798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/11/2024] [Accepted: 07/16/2024] [Indexed: 08/15/2024]
Abstract
Cancer represents a major global public health burden, with new cases estimated to increase from 14 million in 2012 to 24 million by 2035. Primary prevention is an effective strategy to reduce the costs associated with cancer burden. For example, measures to ban tobacco consumption have dramatically decreased lung cancer incidence and vaccination against human papillomavirus can prevent cervical cancer development. Unfortunately, the etiological factors of many cancer types are not completely clear or are difficult to actively control; therefore, the primary prevention of such cancers is not practical. In this review, we update the progress on precision therapy by targeting the whole carcinogenesis process, especially for three high-risk groups: (1) those with chronic inflammation, (2) those with inherited germline mutations, and (3) those with precancerous lesions like polyps, gastritis, actinic keratosis or dysplasia. We believe that attenuating chronic inflammation, treating precancerous lesions, and removing high-risk tissues harboring germline mutations are precision methods for cancer prevention.
Collapse
Affiliation(s)
- Guoguo Jin
- Henan Key Laboratory of Chronic Disease Management, Fuwai Central China Cardiovascular Hospital, Zhengzhou, Henan, China
- China-US (Henan) Hormel Cancer Institute, Zhengzhou, Henan, China
| | - Kangdong Liu
- China-US (Henan) Hormel Cancer Institute, Zhengzhou, Henan, China
- Department of Pathophysiology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| | - Zhiping Guo
- Henan Key Laboratory of Chronic Disease Management, Fuwai Central China Cardiovascular Hospital, Zhengzhou, Henan, China
| | - Zigang Dong
- China-US (Henan) Hormel Cancer Institute, Zhengzhou, Henan, China
- Department of Pathophysiology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| |
Collapse
|
|
3
|
Rubenstein JH, Sawas T, Wani S, Eluri S, Singh S, Chandar AK, Perumpail RB, Inadomi JM, Thrift AP, Piscoya A, Sultan S, Singh S, Katzka D, Davitkov P. AGA Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett's Esophagus and Related Neoplasia. Gastroenterology 2024; 166:1020-1055. [PMID: 38763697 PMCID: PMC11345740 DOI: 10.1053/j.gastro.2024.03.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
BACKGROUND & AIMS Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Endoscopic eradication therapy (EET) can be effective in eradicating BE and related neoplasia and has greater risk of harms and resource use than surveillance endoscopy. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for the use of EET in BE and related neoplasia. METHODS The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients, conducted an evidence review, and used the Evidence-to-Decision Framework to develop recommendations regarding the use of EET in patients with BE under the following scenarios: presence of (1) high-grade dysplasia, (2) low-grade dysplasia, (3) no dysplasia, and (4) choice of stepwise endoscopic mucosal resection (EMR) or focal EMR plus ablation, and (5) endoscopic submucosal dissection vs EMR. Clinical recommendations were based on the balance between desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS The panel agreed on 5 recommendations for the use of EET in BE and related neoplasia. Based on the available evidence, the panel made a strong recommendation in favor of EET in patients with BE high-grade dysplasia and conditional recommendation against EET in BE without dysplasia. The panel made a conditional recommendation in favor of EET in BE low-grade dysplasia; patients with BE low-grade dysplasia who place a higher value on the potential harms and lower value on the benefits (which are uncertain) regarding reduction of esophageal cancer mortality could reasonably select surveillance endoscopy. In patients with visible lesions, a conditional recommendation was made in favor of focal EMR plus ablation over stepwise EMR. In patients with visible neoplastic lesions undergoing resection, the use of either endoscopic mucosal resection or endoscopic submucosal dissection was suggested based on lesion characteristics. CONCLUSIONS This document provides a comprehensive outline of the indications for EET in the management of BE and related neoplasia. Guidance is also provided regarding the considerations surrounding implementation of EET. Providers should engage in shared decision making based on patient preferences. Limitations and gaps in the evidence are highlighted to guide future research opportunities.
Collapse
Affiliation(s)
- Joel H Rubenstein
- Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Cancer Control and Population Sciences Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Tarek Sawas
- Division of Digestive and Liver Disease, University of Texas Southwestern, Dallas, Texas
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Swathi Eluri
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida
| | - Shailendra Singh
- Division of Gastroenterology, West Virginia University, Morgantown, West Virginia; Advanced Center for Endoscopy, West Virginia University Medicine, Morgantown, West Virginia
| | - Apoorva K Chandar
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - John M Inadomi
- Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota; Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - David Katzka
- Division of Gastroenterology and Hepatology, Columbia University, New York, New York
| | - Perica Davitkov
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Division of Gastroenterology, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio
| |
Collapse
|
|
4
|
di Pietro M, Trudgill NJ, Vasileiou M, Longcroft-Wheaton G, Phillips AW, Gossage J, Kaye PV, Foley KG, Crosby T, Nelson S, Griffiths H, Rahman M, Ritchie G, Crisp A, Deed S, Primrose JN. National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma. Gut 2024; 73:897-909. [PMID: 38553042 PMCID: PMC11103346 DOI: 10.1136/gutjnl-2023-331557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/15/2024] [Indexed: 05/12/2024]
Abstract
Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma, a cancer with very poor prognosis. The main risk factors for Barrett's oesophagus are a history of gastro-oesophageal acid reflux symptoms and obesity. Men, smokers and those with a family history are also at increased risk. Progression from Barrett's oesophagus to cancer occurs via an intermediate stage, known as dysplasia. However, dysplasia and early cancer usually develop without any clinical signs, often in individuals whose symptoms are well controlled by acid suppressant medications; therefore, endoscopic surveillance is recommended to allow for early diagnosis and timely clinical intervention. Individuals with Barrett's oesophagus need to be fully informed about the implications of this diagnosis and the benefits and risks of monitoring strategies. Pharmacological treatments are recommended for control of symptoms, but not for chemoprevention. Dysplasia and stage 1 oesophageal adenocarcinoma have excellent prognoses, since they can be cured with endoscopic or surgical therapies. Endoscopic resection is the most accurate staging technique for early Barrett's-related oesophageal adenocarcinoma. Endoscopic ablation is effective and indicated to eradicate Barrett's oesophagus in patients with dysplasia. Future research should focus on improved accuracy for dysplasia detection via new technologies and providing more robust evidence to support pathways for follow-up and treatment.
Collapse
Affiliation(s)
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | | | - Gaius Longcroft-Wheaton
- Department of Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
- Department of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Alexander W Phillips
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - James Gossage
- Department of Gastrointestinal Surgery, St Thomas' Hospital, London, UK
| | - Philip V Kaye
- Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kieran G Foley
- Division of Cancer and Genetics, Cardiff University, Cardiff, Cardiff, UK
| | - Tom Crosby
- Department of Clinical Oncology, Velindre University NHS Trust, Cardiff, UK
| | - Sophie Nelson
- Kenmore Medical Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Muksitur Rahman
- National Institute for Health and Care Excellence, London, UK
| | - Gill Ritchie
- National Institute for Health and Care Excellence, London, UK
| | - Amy Crisp
- National Institute for Health and Care Excellence, London, UK
| | - Stephen Deed
- National Institute for Health and Care Excellence, London, UK
| | - John N Primrose
- Department of Surgery, University of Southampton, Southampton, UK
| |
Collapse
|
|
5
|
Maan ADI, Sharma P, Koch AD. Curative criteria for endoscopic treatment of oesophageal adenocarcinoma. Best Pract Res Clin Gastroenterol 2024; 68:101886. [PMID: 38522884 DOI: 10.1016/j.bpg.2024.101886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/23/2024] [Indexed: 03/26/2024]
Abstract
The incidence of oesophageal adenocarcinoma has been increasing rapidly in the Western world. A well-known risk factor for developing this type of tumour is reflux disease, which can cause metaplasia from the squamous cell mucosa to columnar epithelium (Barrett's Oesophagus) which can progress to dysplasia and eventually adenocarcinoma. With the rise of the incidence of oesophageal adenocarcinoma, research on the best way to manage this disease is of great importance and has changed treatment modalities over the last decades. The gold standard for superficial adenocarcinoma has shifted from surgical to endoscopic management when certain criteria are met. This review will discuss the different curative criteria for endoscopic treatment of oesophageal adenocarcinoma.
Collapse
Affiliation(s)
- Annemijn D I Maan
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas and VA Medical Centre, 4801 E Linwood Blvd, Kansas City, USA.
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| |
Collapse
|
|
6
|
Singh RR, Desai M, Bourke M, Falk G, Konda V, Siddiqui U, Repici A, Hassan C, Sharma P. Real-world evidence of safety and effectiveness of Barrett's endoscopic therapy. Gastrointest Endosc 2023; 98:155-161.e1. [PMID: 36914140 DOI: 10.1016/j.gie.2023.03.009] [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: 10/09/2022] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND AND AIMS Real-world data on the adverse events and the survival benefit of Barrett's endoscopic therapy (BET) are limited. The aim of this study was to examine the safety and effectiveness (survival benefit) of BET in patients with neoplastic Barrett's esophagus (BE). METHODS An electronic health record-based database (TriNetX) was used to select patients with BE with dysplasia and esophageal adenocarcinoma (EAC) from 2016 to 2020. Primary outcome was 3-year mortality among patients with high-grade dysplasia (HGD) or EAC who underwent BET versus 2 comparison cohorts: patients with HGD or EAC who had not undergone BET and patients with GERD but no BE/EAC. Secondary outcome was adverse events (esophageal perforation, upper GI bleeding, chest pain, and esophageal stricture) after BET. To control for confounding variables, 1:1 propensity score matching was performed. RESULTS We identified 27,556 patients with BE and dysplasia, of whom 5295 underwent BET. After propensity score matching, patients with HGD and EAC who underwent BET had significantly lower 3-year mortality (HGD risk ratio [RR], .59; 95% CI, .49-.71; EAC RR, .53; 95% CI, .44-.65) compared with corresponding cohorts who did not undergo BET (P < .001). There was no difference in median 3-year mortality between control subjects (GERD without BE/EAC) compared with patients with HGD (RR, 1.04; 95% CI, .84-1.27) who underwent BET. Finally, there was no difference in median 3-year mortality between patients who underwent BET compared with patients who underwent esophagectomy among both HGD (RR, .67; 95% CI, .39-1.14; P =.14) and EAC (RR, .73; 95% CI, .47-1.13; P = .14). Esophageal stricture was the most common adverse event (6.5%) after BET. CONCLUSIONS Real-world, population-based evidence from this large database shows that endoscopic therapy is safe and effective for patients with BE. Endoscopic therapy is associated with a significantly lower 3-year mortality; however, it leads to esophageal strictures in 6.5% of treated patients.
Collapse
Affiliation(s)
- Ritu R Singh
- Department of Public Health, Johns Hopkins University, Baltimore, Maryland, USA; Division of Medicine, Indiana University School of Medicine, Fort Wayne, Indiana, USA.
| | - Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA; Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Michael Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Gary Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vani Konda
- Baylor Scott & White Center for Esophageal Diseases, Dallas, Texas, USA
| | - Uzma Siddiqui
- Department of Medicine, Section of Gastroenterology, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA
| | - Alessandro Repici
- Humanitas Clinical and Research Center, Endoscopy Unit, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Cesare Hassan
- Humanitas Clinical and Research Center, Endoscopy Unit, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy; Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Prateek Sharma
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA; Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| |
Collapse
|
|
7
|
Hu ZH, Li RX, Wang JT, Wang GJ, Deng XM, Zhu TY, Gao BL, Zhang YF. Thoracolaparoscopic esophagectomy for esophageal cancer with a cervical incision to extract specimen. Asian J Surg 2023; 46:348-353. [PMID: 35525693 DOI: 10.1016/j.asjsur.2022.04.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 10/24/2021] [Accepted: 04/20/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Surgical treatment is the most important and effective therapy for resectable esophageal cancer. Minimally invasive esophagectomy (MIE) can reduce surgical trauma. A neck incision can be performed for extraction of surgical specimen. This study was performed to investigate the safety and feasibility of neck incision to extract surgical specimen in thoracolaparoscopic esophagectomy for esophageal cancer. MATERIALS AND METHODS Thirty-four patients who experienced thoracolaparoscopic esophagectomy for esophageal cancer and a neck incision for extraction of surgical specimen were enrolled. The clinical, surgical and follow-up data were analyzed. RESULTS The procedure was successful in all patients (100%), with a neck incision to extract the surgical specimen. The median surgical time was 309 min, and the median blood loss was 186 ml, with the mean length of hospital stay of 11.5 days. Pulmonary complications occurred in 8 patients (23.5%). Anastomotic leakage occurred in 5 patients (14.7%), with one patient being treated conservatively to recover and four (11.8%) who received interventional drainage. One patient with interventional drainage died of severe infection, resulting in a 30-day surgical mortality of 2.9% (n = 1). Gastrointestinal complications happened in 5 patients (14.7%), including ileus in three patients and anastomotic stenosis in two patients. Follow-up was performed at a median time of 20 months (interquartile range, 14-32 months), with no death during this period. No recurrence was found in the first 12 months after radical resection. CONCLUSION The cervical incision to extract surgical specimen is safe and feasible with improved cosmetic effect in thoracolaparoscopic esophagectomy for esophageal cancer.
Collapse
Affiliation(s)
- Zhi-Hao Hu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Rui-Xin Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Jing-Tao Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Guo-Jun Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
| | - Xiu-Mei Deng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Tian-Yu Zhu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Bu-Lang Gao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Yun-Fei Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| |
Collapse
|
|
8
|
Vantanasiri K, Iyer PG. State-of-the-art management of dysplastic Barrett's esophagus. Gastroenterol Rep (Oxf) 2022; 10:goac068. [PMID: 36381221 PMCID: PMC9651477 DOI: 10.1093/gastro/goac068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 10/19/2022] [Accepted: 10/24/2022] [Indexed: 08/15/2023] Open
Abstract
Endoscopic eradication therapy (EET) has become a standard of care for treatment of dysplastic Barrett's esophagus (BE) and early Barrett's neoplasia. EET mainly consists of removal of any visible lesions via endoscopic resection and eradication of all remaining Barrett's mucosa using endoscopic ablation. Endoscopic mucosal resection and endoscopic submucosal dissection are the two available resection techniques. After complete resection of all visible lesions, it is crucial to perform endoscopic ablation to ensure complete eradication of the remaining Barrett's segment. Endoscopic ablation can be done either with thermal techniques, including radiofrequency ablation and argon plasma coagulation, or cryotherapy techniques. The primary end point of EET is achieving complete remission of intestinal metaplasia (CRIM) to decrease the risk of dysplastic recurrence after successful EET. After CRIM is achieved, a standardized endoscopic surveillance protocol needs to be implemented for early detection of BE recurrence.
Collapse
Affiliation(s)
- Kornpong Vantanasiri
- Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Prasad G Iyer
- Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
|
9
|
Maione F, Chini A, Maione R, Manigrasso M, Marello A, Cassese G, Gennarelli N, Milone M, De Palma GD. Endoscopic Diagnosis and Management of Barrett's Esophagus with Low-Grade Dysplasia. Diagnostics (Basel) 2022; 12:1295. [PMID: 35626450 PMCID: PMC9141542 DOI: 10.3390/diagnostics12051295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 02/05/2023] Open
Abstract
Barrett's Esophagus is a common condition associated with chronic gastroesophageal reflux disease. It is well known that it has an association with a higher incidence of esophageal adenocarcinoma, but this neoplastic transformation is first preceded by the onset of low and high-grade dysplasia. The evaluation of low grade dysplastic esophageal mucosa is still controversial; although endoscopic surveillance is preferred, several minimally invasive endoscopic therapeutic approaches are available. Endoscopic mucosal resection and radiofrequency ablation are the most used endoscopic treatments for the eradication of low-grade dysplasia, respectively, for nodular and flat dysplasia. Novel endoscopic treatments are cryotherapy ablation and argon plasma coagulation, that have good rates of eradication with less complications and post-procedural pain.
Collapse
Affiliation(s)
- Francesco Maione
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Alessia Chini
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Rosa Maione
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Michele Manigrasso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy;
| | - Alessandra Marello
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Gianluca Cassese
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Nicola Gennarelli
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| |
Collapse
|
|
10
|
Lu W, Li P, Wen W, Jian Y. Comparison of Long-Term Survival Between cT1N0 Stage Esophageal Cancer Patients Receiving Endoscopic Dissection and Esophagectomy: A Meta-Analysis. Front Surg 2022; 9:917689. [PMID: 36017523 PMCID: PMC9396621 DOI: 10.3389/fsurg.2022.917689] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/21/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Endoscopic dissection (ED) shows relatively high clinical value in early esophageal cancer (cT1N0) such as lower incidence of postoperative complications and hospitalization costs and enhanced recovery. However, whether ED still has certain advantages over esophagectomy in terms of long-term survival remains unclear. PURPOSE The aim of this meta-analysis was to compare the long-term outcomes of ED and surgery in the treatment of cT1N0 esophageal cancer. METHODS Several electronic databases including the PubMed, EMBASE, Web of Science and Cochrane Library databases were searched up to April 7, 2022 for studies which compared the overall survival (OS) and disease-specific survival (DSS) of cT1N0 esophageal cancer patients receiving the ED or esophagectomy. The hazard ratios (HRs) and 95% confidence intervals (CIs) were combined and all statistical analysis was conducted through STATA 15.0 software. RESULTS A total of 12 studies involving 3,732 patients were enrolled. No significant difference in the OS between ED and surgery groups was observed (HR = 0.78, 95% CI, 0.59-1.04, p = 0.089). However, the DSS of the ED group was significantly longer than that of the surgery group (HR = 0.56, 95% CI, 0.39-0.82, p = 0.003). CONCLUSION In overall, the current evidence manifested that the long-term survival of cT1N0 esophageal cancer patients undergoing ED was not worse than that of patients undergoing esophagectomy. ED may be considered as the primary treatment for cT1N0 esophageal carcinoma patients.
Collapse
Affiliation(s)
| | | | - Wu Wen
- Department of Gastroenterology, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Yi Jian
- Department of Gastroenterology, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| |
Collapse
|
|
11
|
Choi KKH, Sanagapalli S. Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies. World J Gastrointest Oncol 2022; 14:568-586. [PMID: 35321279 PMCID: PMC8919017 DOI: 10.4251/wjgo.v14.i3.568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 11/12/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.
Collapse
Affiliation(s)
- Kevin Kyung Ho Choi
- AW Morrow Gastroenterology Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, NSW, Australia
| | - Santosh Sanagapalli
- Department of Gastroenterology, St Vincent’s Hospital, Darlinghurst 2010, NSW, Australia
| |
Collapse
|
|
12
|
Response to the Comment on "The Prevalence of Lymph Node Metastases in Patients With T1 Esophageal Adenocarcinoma A Retrospective Review of Esophagectomy Specimens". Ann Surg 2021; 274:e106-e107. [PMID: 31188223 DOI: 10.1097/sla.0000000000003373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
|
13
|
Kamboj AK, Katzka DA, Iyer PG. Endoscopic Screening for Barrett's Esophagus and Esophageal Adenocarcinoma: Rationale, Candidates, and Challenges. Gastrointest Endosc Clin N Am 2021; 31:27-41. [PMID: 33213798 PMCID: PMC8127641 DOI: 10.1016/j.giec.2020.08.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), a cancer with increasing incidence and poor survival. Risk of EAC in patients with BE is higher compared with the general population. Endoscopic screening for BE is performed to identify patients earlier in the metaplasia-dysplasia-carcinoma sequence from BE to EAC to enable eradication therapy. BE screening should be considered in individuals with multiple risk factors for BE and EAC. Challenges to BE screening include the absence of a cost-effective, widely applicable minimally invasive screening tool, gastroesophageal reflux disease centric screening recommendations, and limitations of current endoscopic surveillance practice.
Collapse
|
|
14
|
Badgery H, Read M, Winter NN, Taylor ACF, Hii MW. The role of esophagectomy in the management of Barrett's esophagus with high-grade dysplasia. Ann N Y Acad Sci 2020; 1481:72-89. [PMID: 32812261 DOI: 10.1111/nyas.14439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/12/2020] [Accepted: 06/24/2020] [Indexed: 12/19/2022]
Abstract
Barrett's esophagus (BE) with high-grade dysplasia (HGD) has previously been a routine indication for esophagectomy. Recent advances in endoscopic therapy have resulted in a shift away from surgery. Current international guidelines recommend endoscopic therapy for BE with HGD irrespective of recurrence or progression of dysplasia. Current guidelines do not address the ongoing role of esophagectomy as an adjunct in the setting of failed endoscopic therapy. This review examines the role of esophagectomy as an adjunct to endoscopy in the management of patients with BE and HGD, with a specific focus on patients with persistent, progressive, or recurrent disease, disease resistant to endoscopic therapy, in patients with concomitant esophageal pathology, and in those patients in whom lifelong surveillance may not be possible or desired.
Collapse
Affiliation(s)
- Henry Badgery
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Matthew Read
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Nicole N Winter
- Department of Upper Gastrointestinal Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Andrew C F Taylor
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, the University of Melbourne, Melbourne, Victoria, Australia
| | - Michael W Hii
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
|
15
|
Molena D, DeMeester SR. When less is just less: endoscopic therapy for submucosal T1b esophageal cancer. Gastrointest Endosc 2020; 92:40-43. [PMID: 32586565 DOI: 10.1016/j.gie.2020.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 03/05/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Daniela Molena
- Department of Cardiothoracic Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | | |
Collapse
|
|
16
|
Workload, Recurrence, Quality of Life and Long-term Efficacy of Endoscopic Therapy for High-grade Dysplasia and Intramucosal Esophageal Adenocarcinoma. Ann Surg 2020; 271:701-708. [PMID: 30247330 DOI: 10.1097/sla.0000000000003038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To review the workload, type and frequency of recurrence, long-term quality of life (QOL), and late oncologic outcomes with endoscopic therapy. BACKGROUND The short-term oncologic efficacy of endoscopic resection (ER) and ablation for patients with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC) is well-established in the literature. METHODS A retrospective chart review was performed of the initial 40 patients who had endoscopic therapy from 2001 to 2010 at 1 center by 1 physician. RESULTS Initial pathology was HGD in 22 and IMC in 18 patients, but 9 patients (41%) with HGD progressed to invasive cancer during endotherapy. The median follow-up was 82 months. Four patients had an esophagectomy, and in the remaining 36 patients, 70 ERs and 111 ablations were performed. The median number of endoscopic sessions was 4 in patients with short segment compared with 7 in patients with long-segment Barrett's. Complete resolution of intestinal metaplasia (CRIM) was achieved in 30 patients (83%) at a median of 21 months. In 18 patients (60%), CRIM was maintained, whereas 12 patients developed recurrence at a median of 14 months. Additional endotherapy (n = 11) led to CRIM again in 10 patients (83%). There were no cancer deaths when CRIM was achieved. Overall survival with endotherapy was 73% at 5 years and 67% at 10 years. Quality of life (QOL) was below population means in 4 of 8 areas, but alimentary satisfaction was good after endotherapy. CONCLUSIONS Endotherapy is successful in most patients, but multiple sessions are usually required and disease progression can occur. Once CRIM is achieved, recurrence is common and mandates continued endoscopic follow-up. QOL is impaired with endotherapy, but alimentary satisfaction and oncologic outcomes support esophageal preservation with endotherapy for patients with HGD or IMC.
Collapse
|
|
17
|
Bennett C, Green S, DeCaestecker J, Almond M, Barr H, Bhandari P, Ragunath K, Singh R, Jankowski J. Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus. Cochrane Database Syst Rev 2020; 5:CD007334. [PMID: 32442322 PMCID: PMC7390331 DOI: 10.1002/14651858.cd007334.pub5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy). OBJECTIVES We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)). SEARCH METHODS We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012. SELECTION CRITERIA Types of studies: RCTs comparing endotherapies with surgery in the treatment of high-grade dysplasia or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately. TYPES OF PARTICIPANTS patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus. Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent. DATA COLLECTION AND ANALYSIS Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9. MAIN RESULTS We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies. AUTHORS' CONCLUSIONS This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.
Collapse
Affiliation(s)
- Cathy Bennett
- Centre for Innovative Research Across the Life Course (CIRAL), Coventry University, Coventry, UK
| | - Susi Green
- Gastroenterology, Portsmouth Hospitals Trust, Cosham, UK
| | | | - Max Almond
- Department of Oesphogastric Surgery, Gloucestershire Royal Hospital, Gloucester, UK
| | - Hugh Barr
- Surgery, Gloucester Royal Hospital, Gloucester, UK
| | - Pradeep Bhandari
- Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Krish Ragunath
- Wolfson Digestive Diseases Centre, Queens Medical Centre, Nottingham University NHS Trust, Nottingham, UK
| | - Rajvinder Singh
- Gastroenterology, The Lyell McEwin Hospital, Elizabeth Vale, Australia
| | | |
Collapse
|
|
18
|
Raphael KL, Trindade AJ. Management of Barrett’s esophagus with dysplasia refractory to radiofrequency ablation. World J Gastroenterol 2020; 26:2030-2039. [PMID: 32536772 PMCID: PMC7267696 DOI: 10.3748/wjg.v26.i17.2030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/08/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023] Open
Abstract
Radiofrequency ablation (RFA) is very effective for eradication of flat Barrett’s mucosa in dysplastic Barrett’s esophagus after endoscopic resection of raised lesions. However, in a minority of the time, RFA may be ineffective at eradication of the Barrett’s mucosa. Achieving complete eradication of intestinal metaplasia can be challenging in these patients. This review article focuses on the management of patients with dysplastic Barrett’s esophagus refractory to RFA therapy. Management strategies discussed in this review include optimizing the RFA procedure, optimizing acid suppression (with medical, endoscopic, and surgical management), cryotherapy, hybrid argon plasma coagulation, and EndoRotor resection.
Collapse
Affiliation(s)
- Kara L Raphael
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY 11040, United States
| | - Arvind J Trindade
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY 11040, United States
| |
Collapse
|
|
19
|
Franklin J, Jankowski J. Recent advances in understanding and preventing oesophageal cancer. F1000Res 2020; 9. [PMID: 32399195 PMCID: PMC7194479 DOI: 10.12688/f1000research.21971.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 12/24/2022] Open
Abstract
Oesophageal cancer is a common cancer that continues to have a poor survival. This is largely in part due to its late diagnosis and early metastatic spread. Currently, screening is limited to patients with multiple risk factors via a relatively invasive technique. However, there is a large proportion of patients diagnosed with oesophageal cancer who have not been screened. This has warranted the development of new screening techniques that could be implemented more widely and lead to earlier identification and subsequently improvements in survival rates. This article also explores progress in the surveillance of Barrett’s oesophagus, a pre-malignant condition for the development of oesophageal adenocarcinoma. In recent years, advances in early endoscopic intervention have meant that more patients are considered at an earlier stage for potentially curative treatment.
Collapse
Affiliation(s)
- James Franklin
- Gastroenterology and Endoscopy Department, Kings Mill Hospital NHS Foundation Trust, Sutton-in-Ashfield, Nottinghamshire, NG17 4JL, UK
| | - Janusz Jankowski
- Gastroenterology and Endoscopy Department, Kings Mill Hospital NHS Foundation Trust, Sutton-in-Ashfield, Nottinghamshire, NG17 4JL, UK
- University of Liverpool, Liverpool, UK
- University of Roehampton, London, UK
| |
Collapse
|
|
20
|
Fountoulakis A, Souglakos J, Vini L, Douridas GN, Koumarianou A, Kountourakis P, Agalianos C, Alexandrou A, Dervenis C, Gourtsoyianni S, Gouvas N, Kalogeridi MA, Levidou G, Liakakos T, Sgouros J, Sgouros SN, Triantopoulou C, Xynos E. Consensus statement of the Hellenic and Cypriot Oesophageal Cancer Study Group on the diagnosis, staging and management of oesophageal cancer. Updates Surg 2019; 71:599-624. [DOI: 10.1007/s13304-019-00696-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/26/2019] [Indexed: 12/13/2022]
|
|
21
|
Kumble LD, Silver E, Oh A, Abrams JA, Sonett JR, Hur C. Treatment of early stage (T1) esophageal adenocarcinoma: Personalizing the best therapy choice. World J Meta-Anal 2019; 7:406-417. [DOI: 10.13105/wjma.v7.i9.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/03/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
Esophagectomy is considered the primary form of management for esophageal adenocarcinoma (EAC); however, the surgery is associated with high rates of morbidity and mortality. For patients with early-stage EAC, endoscopic resection (ER) presents a potential curative treatment option that is less invasive and carries fewer risks procedure related risks, but it is associated with higher rates of cancer recurrence following the procedure. For some patients, age and comorbidities may prevent them from having esophagectomy as a treatment option, while other patients may be operative candidates but do not wish to undergo esophagectomy for a variety of reasons related to their values and preferences. Furthermore, while anxiety of cancer recurrence following ER may significantly diminish a patient’s quality of life (QOL), so might the morbidity surrounding esophagectomy. In addition to considering health status, patient preferences, and impacts on QOL, physicians and patients must also consider what treatments would be both beneficial and available to the patient, considering esophagectomy methods-minimally invasive vs open-or the use of chemoradiotherapy in addition to ER. Our article reviews and summarizes available treatment options for patients with early EAC and their potential effects on the health and wellbeing of patients based on the current data. We conclude with a request for more research of available options for early EAC patients, the conditions that determine when each option should be employed, and their effects not only on patient health but also QOL.
Collapse
Affiliation(s)
| | - Elisabeth Silver
- General Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Aaron Oh
- General Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Julian A Abrams
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Joshua R Sonett
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Chin Hur
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| |
Collapse
|
|
22
|
Abstract
Traditionally, early esophageal cancer (i.e., cancer limited to the mucosa or superficial submucosa) was managed surgically; the gastroenterologist's role was primarily to diagnose the tumor. Over the last decade, advances in endoscopic imaging, ablation, and resection techniques have resulted in a paradigm shift-diagnosis, staging, treatment, and surveillance are within the endoscopist's domain. Yet, there are few reviews that provide a focused, evidence-based approach to early esophageal cancer, and highlight areas of controversy for practicing gastroenterologists. In this manuscript, we will discuss the following: (1) utility of novel endoscopic technologies to identify high-grade dysplasia and early esophageal cancer, (2) role of endoscopic resection and imaging to stage early esophageal cancer, (3) endoscopic therapies for early esophageal cancer, and (4) indications for surgical and multidisciplinary management.
Collapse
|
|
23
|
Accuracy of Clinical Staging and Outcome With Primary Resection for Local-Regionally Limited Esophageal Adenocarcinoma. Ann Surg 2019; 267:484-488. [PMID: 28151801 DOI: 10.1097/sla.0000000000002139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The aim of this study was to determine the accuracy of clinical staging, to assess survival with surgical resection alone, and to determine factors associated with understaging in patients with esophageal adenocarcinoma thought to have limited local-regional disease. BACKGROUND Primary surgical resection is the preferred treatment in patients with esophageal adenocarcinoma clinically staged to have limited nodal disease. This approach requires reliable clinical staging. METHODS A retrospective chart review was performed of all patients who had primary esophagectomy for clinical stage T1-3 N0-1 adenocarcinoma (seventh edition AJCC) from January 2002 to May 2013. Clinical and pathologic stages were compared and overall survival was analyzed. RESULTS There were 88 patients who met inclusion criteria. Final pathology confirmed appropriate clinical staging (≤T3N1) in 76% of patients (67/88). There were 21 patients who were understaged (>T3N1), and in all cases, understaging was based on the presence of advanced nodal (N2 or N3) disease. Factors independently associated with understaging were the presence of dysphagia, tumor length >3 cm, and poor differentiation. At a median follow-up of 35 months, 63% of all patients (55/88) remain alive. The 5-year survival in correctly staged patients was 67%, compared with 33% for those who were understaged (P < 0.0001). CONCLUSIONS Modern clinical staging will accurately identify the majority of patients with esophageal adenocarcinoma and limited local-regional disease (≤pT3N1). Survival with surgery alone in correctly staged patients was excellent and unlikely to be improved with neoadjuvant therapy. A combination of dysphagia, poor differentiation, and tumor length >3 cm was associated with understaging in 92% of patients. Patients with these factors are likely to have more advanced disease than clinically suspected and may benefit from neoadjuvant therapy before resection.
Collapse
|
|
24
|
Ramay FH, Vareedayah AA, Visrodia K, Iyer PG, Wang KK, Eluri S, Shaheen NJ, Reddy R, Martin LW, Greenwald BD, Edwards MA. What Constitutes Optimal Management of T1N0 Esophageal Adenocarcinoma? Ann Surg Oncol 2019; 26:714-731. [DOI: 10.1245/s10434-018-07118-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Indexed: 12/27/2022]
|
|
25
|
Min YW, Lee H, Song BG, Min BH, Kim HK, Choi YS, Lee JH, Hwang NY, Carriere KC, Rhee PL, Kim JJ, Zo JI, Shim YM. Comparison of endoscopic submucosal dissection and surgery for superficial esophageal squamous cell carcinoma: a propensity score-matched analysis. Gastrointest Endosc 2018; 88:624-633. [PMID: 29750981 DOI: 10.1016/j.gie.2018.04.2360] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) has been widely accepted for treating superficial esophageal squamous cell carcinoma (SESCC). However, long-term outcomes of ESD and esophagectomy for SESCC have not been compared. We compared the clinical outcomes of ESD and esophagectomy in a matched cohort. METHODS Patients who underwent ESD and esophagectomy for SESCC were included. We selected SESCCs without obvious submucosal invasion from the surgical database by reviewing endoscopic images. To minimize the effect of selection bias, propensity score matching was performed. Overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and metachronous RFS were compared between the 2 groups. Adverse event rates were also compared. RESULTS In a matched cohort of 120 pairs, OS, DSS, and RFS were comparable between the 2 groups. The 5-year OS, DSS, and RFS rates were 93.9% versus 91.2%, 100% versus 97.4%, and 92.8% versus 95.3% for the ESD and esophagectomy groups, respectively. The metachronous RFS was worse in the ESD group than in the esophagectomy group (P = .004). The 5-year metachronous RFS rates were 90.3% versus 100% for the ESD and esophagectomy groups, respectively. The esophagectomy group showed a higher overall adverse event rate than the ESD group (55.5% vs 18.5%, P < .0001). In each subgroup of mucosal and submucosal cancer, OS, DSS, and RFS were also comparable between the 2 groups. CONCLUSIONS ESD provides long-term outcomes comparable with esophagectomy in patients with SESCC without endoscopic evidence of obvious submucosal invasion. ESD should be considered as the first-line treatment for these patients.
Collapse
Affiliation(s)
- Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byeong Geun Song
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Na-Young Hwang
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keumhee C Carriere
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae J Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
|
26
|
Singh T, Sanaka MR, Thota PN. Endoscopic therapy for Barrett’s esophagus and early esophageal cancer: Where do we go from here? World J Gastrointest Endosc 2018; 10:165-174. [PMID: 30283599 PMCID: PMC6162248 DOI: 10.4253/wjge.v10.i9.165] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/13/2018] [Accepted: 06/28/2018] [Indexed: 02/06/2023] Open
Abstract
Since Barrett’s esophagus is a precancerous condition, efforts have been made for its eradication by various ablative techniques. Initially, laser ablation was attempted in non-dysplastic Barrett’s esophagus and subsequently, endoscopic ablation using photodynamic therapy was used in Barrett’s patients with high-grade dysplasia who were poor surgical candidates. Since then, various ablative therapies have been developed with radiofrequency ablation having the best quality of evidence. Resection of dysplastic areas only without complete removal of entire Barrett’s segment is associated with high risk of developing metachronous neoplasia. Hence, the current standard of management for Barrett’s esophagus includes endoscopic mucosal resection of visible abnormalities followed by ablation to eradicate remaining Barrett’s epithelium. Although endoscopic therapy cannot address regional lymph node metastases, such nodal involvement is present in only 1% to 2% of patients with intramucosal adenocarcinoma in Barrett esophagus and therefore is useful in intramucosal cancers. Post ablation surveillance is recommended as recurrence of intestinal metaplasia and dysplasia have been reported. This review includes a discussion of the technique, efficacy and complication rate of currently available ablation techniques such as radiofrequency ablation, cryotherapy, argon plasma coagulation and photodynamic therapy as well as endoscopic mucosal resection. A brief discussion of the emerging technique, endoscopic submucosal dissection is also included.
Collapse
Affiliation(s)
- Tavankit Singh
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
| |
Collapse
|
|
27
|
Chilukuri P, Gromski MA, Johnson CS, Ceppa DKP, Kesler KA, Birdas TJ, Rieger KM, Fatima H, Kessler WR, Rex DK, Al-Haddad M, DeWitt JM. Impact of the development of an endoscopic eradication program for Barrett's esophagus with high grade dysplasia or early adenocarcinoma on the frequency of surgery. Endosc Int Open 2018; 6:E1085-E1092. [PMID: 30211296 PMCID: PMC6133650 DOI: 10.1055/a-0640-3030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/12/2018] [Indexed: 11/20/2022] Open
Abstract
Background and aims The impact of the advent of an institutional endoscopic eradication therapy (EET) program on surgical practice for Barrett's esophagus (BE)-associated high grade dysplasia (HGD) or suspected T1a esophageal adenocarcinoma (EAC) is unknown. The aims of this study are to evaluate the different endoscopic modalities used during development of our EET program and factors associated with the use of EET or surgery for these patients after its development. Methods Patients who underwent primary endoscopic or surgical treatment for BE-HGD or early EAC at our hospital between January 1992 and December 2014 were retrospectively identified. They were categorized by their initial modality of treatment during the first year, and the impact over time for choice of therapy was assessed by multivariable logistic regression. Results We identified 386 patients and 80 patients who underwent EET and surgery, respectively. EET included single modality therapy in 254 (66 %) patients and multimodal therapy in 132 (34 %) patients. Multivariable logistic regression showed that, for each subsequent study year, EET was more likely to be performed in patients who were older ( P = 0.0009), with shorter BE lengths ( P < 0.0001), and with a pretreatment diagnosis of HGD ( P = 0.0054) compared to surgical patients. The diagnosis of EAC did not increase the utilization of EET compared to surgery as time progressed ( P = 0.8165). Conclusion The introduction of an EET program at our hospital increased the odds of utilizing EET versus surgery over time for initial treatment of patients who were older, had shorter BE lengths or the diagnosis of BE-HGD, but not in patients with EAC.
Collapse
Affiliation(s)
- Prianka Chilukuri
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark A. Gromski
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Duy Khanh P. Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenneth A. Kesler
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas J. Birdas
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Karen M. Rieger
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hala Fatima
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - William R. Kessler
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Douglas K. Rex
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John M. DeWitt
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA,Corresponding author John M. DeWitt, MD Indiana University School of Medicine550 University BlvdSuite 4100IndianapolisIN 46202-5250USA+1-317-948-8144
| |
Collapse
|
|
28
|
Plum PS, Ulase D, Bollschweiler E, Chon SH, Berlth F, Zander T, Alakus H, Hölscher AH, Bruns CJ, Schallenberg S, Quaas A, Loeser H. Upregulation of insulin-like growth factor II mRNA-binding protein 3 (IMP3) has negative prognostic impact on early invasive (pT1) adenocarcinoma of the esophagus. J Cancer Res Clin Oncol 2018; 144:1731-1739. [PMID: 29974234 DOI: 10.1007/s00432-018-2698-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 06/28/2018] [Indexed: 01/15/2023]
Abstract
PURPOSE Therapeutic decisions in esophageal adenocarcinomas (EAC) restricted to mucosa (pT1a) or submucosa (pT1b) depend mainly on classic histomorphology-based criteria like tumor grading or lymphovascular invasion with limited success. There is a strong need for reliable pre-therapeutical biomarker-based evaluation also applicable on endoscopically obtained biopsies. METHODS Patients who underwent esophagectomy due to EAC in a high volume center between 1999 and 2016 were included. Tissue microarrays (TMA) were retrospectively established from the formalin-fixed and paraffin-embedded material of the resected specimens and immunohistochemically stained using a monoclonal primary antibody specific for IMP3. IMP3 staining intensity was scored manually according to a 3-tier-scoring system (negative, weak and strong). RESULTS 371 EACs were interpretable for analysis. 109 patients (29%) had early invasive (pT1a/pT1b) and 262 patients (71%) locally advanced EAC (> pT2). 259 EACs (70%) revealed positive immunostaining for IMP3 including 167 strongly and 92 weakly positive. Early EAC had significantly lower IMP3 expression compared to advanced tumor stages (p < 0.0001). IMP3 positive pT1 EAC revealed higher levels of lymph node metastases (LNM) (p = 0.0001) and pT1b tumors showed higher rates of IMP3 positivity compared to pT1a (p = 0.007). Subdividing the submucosa in thirds, there was a significant trend for higher IMP3 expression with deeper tumor infiltration from pT1a to pT1b (sm3) (p = 0.0001). There was an association between IMP3 expression and shortened survival in pT1 EAC (p = 0.038). CONCLUSIONS IMP3 expression correlates with depth of tumor infiltration, rate of LNM and is associated with worse outcome. Thus, IMP3 might be useful for therapeutic decisions in early-invasive EAC.
Collapse
Affiliation(s)
- Patrick Sven Plum
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Dita Ulase
- Department of Pathology, Riga Stradins University, Riga, Latvia
| | - Elfriede Bollschweiler
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Felix Berlth
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Thomas Zander
- Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Hakan Alakus
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Arnulf H Hölscher
- Center for Esophageal and Gastric Surgery, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
| | - Christiane J Bruns
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Simon Schallenberg
- Center for Esophageal and Gastric Surgery, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
| | - Alexander Quaas
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| | - Heike Loeser
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| |
Collapse
|
|
29
|
Boisen ML, Sardesai MP, Kolarczyk L, Rao VK, Owsiak CP, Gelzinis TA. The Year in Thoracic Anesthesia: Selected Highlights From 2017. J Cardiothorac Vasc Anesth 2018; 32:1556-1569. [PMID: 29655515 DOI: 10.1053/j.jvca.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Michael L Boisen
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA
| | - Mahesh P Sardesai
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | | | | |
Collapse
|
|
30
|
Barret M, Prat F. Diagnosis and treatment of superficial esophageal cancer. Ann Gastroenterol 2018; 31:256-265. [PMID: 29720850 PMCID: PMC5924847 DOI: 10.20524/aog.2018.0252] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/29/2018] [Indexed: 02/07/2023] Open
Abstract
Endoscopy allows for the screening, early diagnosis, treatment and follow up of superficial esophageal cancer. Endoscopic submucosal dissection has become the gold standard for the resection of superficial squamous cell neoplasia. Combinations of endoscopic mucosal resection and radiofrequency ablation are the mainstay of the management of Barrett’s associated neoplasia. However, protruded, non-lifting or large lesions may be better managed by endoscopic submucosal dissection. Novel ablation tools, such as argon plasma coagulation with submucosal lifting and cryoablation balloons, are being developed for the treatment of residual Barrett’s esophagus, since iatrogenic strictures still hamper the development of extensive circumferential resections in the esophagus. Optimal surveillance modalities after endoscopic resection are still to be determined. The assessment of the risk of lymph-node metastases, as well as of the need for additional treatments based on qualitative and quantitative histological criteria, balanced to the patient’s condition, requires a dedicated multidisciplinary team decision process. The need for trained endoscopists, expert pathologists and surgeons, and specialized multidisciplinary meetings underlines the role of expert centers in the management of superficial esophageal cancer.
Collapse
Affiliation(s)
- Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Paris, France
| | - Frédéric Prat
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Paris, France
| |
Collapse
|
|
31
|
Plum PS, Hölscher AH, Pacheco Godoy K, Schmidt H, Berlth F, Chon SH, Alakus H, Bollschweiler E. Prognosis of patients with superficial T1 esophageal cancer who underwent endoscopic resection before esophagectomy—A propensity score-matched comparison. Surg Endosc 2018. [DOI: 10.1007/s00464-018-6139-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
|
32
|
McLaren PJ, Dolan JP. Surgical Treatment of High-Grade Dysplasia and Early Esophageal Cancer. World J Surg 2018; 41:1712-1718. [PMID: 28258451 DOI: 10.1007/s00268-017-3958-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The treatment of early-stage esophageal cancer and high-grade dysplasia of the esophagus has changed significantly in recent years. Many early tumors that were traditionally treated with esophagectomy can now be resected with endoscopic therapy alone. These new endoscopic modalities can offer similar survival outcomes without the associated morbidity of a major operation. However, a number of these cases may still require surgical intervention as the best treatment option. METHODS The current scientific literature, national and international guidelines were reviewed for recommendations regarding optimal treatment of early esophageal malignancy. RESULTS The primary advantage of surgery over endoscopic treatment lies in the reduced risk of recurrence as well as the ability to assess harvested lymph nodes for regional disease. We recommend that esophageal tumors that have invaded into the submucosa (T1b) or beyond should be treated with an esophagectomy. In addition, dysplastic lesions and cancers that demonstrate poorly differentiated pathology or lymphovascular or perineural invasion should be surgically resected. Finally, large tumors, multifocal lesions, tumors within a long segment of Barrett's esophagus, tumors adjacent to a hiatal hernia, tumors that cannot be resected enbloc with endoscopic techniques should also be treated with an esophagectomy. CONCLUSIONS When performed at high-volume centers in experienced hands, esophagectomy can have consistently good outcomes for high-grade dysplasia and early esophageal cancers, and should be considered as a treatment option.
Collapse
Affiliation(s)
- Patrick J McLaren
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd., Portland, OR, 97239, USA
| | - James P Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd., Portland, OR, 97239, USA.
| |
Collapse
|
|
33
|
Moreno AC, Zhang N, Verma V, Giordano SH, Lin SH. Treatment disparities affect outcomes for patients with stage I esophageal cancer: a national cancer data base analysis. J Gastrointest Oncol 2018; 10:74-84. [PMID: 30788162 DOI: 10.21037/jgo.2018.10.04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background To examine patterns of care and outcomes for patients with stage I esophageal cancer (EC) in the United States. Methods We identified patients in the National Cancer Data Base diagnosed with stage I EC from 2004 to 2012 and grouped them by primary treatment: esophagectomy (Eso), local excision (LE), concurrent chemoradiation (CRT), or observation (Obs). Multinomial logistic regression was used to predict receipt of treatments. Overall survival (OS) was estimated by Kaplan-Meier methods adjusted for inverse probability of treatment weighting (IPTW) and Cox proportional hazard regressions. Results Of 5,480 patients, 2,312 (42%) underwent Eso, 1,250 (23%) LE, 758 (14%) CRT, and 1,160 (21%) Obs. LE use increased over time from 17% to 29% while Obs declined from 26% to 19%. Patients least likely to undergo surgery were older, had greater comorbidity, were uninsured, were treated at non-academic centers, and were Black. The rate of surgery for Black patients was half of that for White patients (33% vs. 67%). Postoperative mortality rates were higher after Eso vs. LE at 30 days (2.9% vs. 0.5%; P<0.001) and at 90 days (5.5% vs. 1.4%, P<0.001). Five-year OS was 59% with Eso, 63% LE, 29% CRT, and 31% Obs (P<0.001). On multivariate analysis, outcomes were best after LE [vs. Eso: hazard ratio (HR) =1.15, 95% CI: 1.01-1.30, P=0.037; CRT: HR =2.41, 95% CI: 2.09-2.78, P<0.001; Obs: HR =3.79, 95% CI: 3.33-4.32, P<0.001). Conclusions Disparities are evident in the care of patients with stage I EC throughout the United States. LE was associated with favorable outcomes compared to Eso, CRT, and Obs.
Collapse
Affiliation(s)
- Amy C Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ning Zhang
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Buffett Cancer Center, Omaha, NE, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
|
34
|
Tsai FC, Ghorbani S, Greenwald BD, Jang S, Dumot JA, McKinley MJ, Shaheen NJ, Habr F, Wolfsen HC, Abrams JA, Lightdale CJ, Nishioka NS, Johnston MH, Zfass A, Coyle WJ. Safety and efficacy of endoscopic spray cryotherapy for esophageal cancer. Dis Esophagus 2017; 30:1-7. [PMID: 28881903 DOI: 10.1093/dote/dox087] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 06/03/2017] [Indexed: 12/11/2022]
Abstract
Although surgery is traditionally the standard of care for esophageal cancer, esophagectomy carries significant morbidity. Alternative endoscopic therapies are needed for patients who are not candidates for conventional treatment. The objective of this study is to assess the safety, efficacy, and tolerability of spray cryotherapy of esophageal adenocarcinoma. This study includes patients with esophageal adenocarcinoma who had failed or were not candidates for conventional therapy enrolled retrospectively and prospectively in an open-label registry and patients in a retrospective cohort from 11 academic and community practices. Endoscopic spray cryotherapy was performed until biopsy proven local tumor eradication or until treatment was halted due to progression of disease, patient withdrawal or comorbidities. Eighty-eight patients with esophageal adenocarcinoma (median age 76, 80.7% male, mean length 5.1 cm) underwent 359 treatments (mean 4.4 per patient). Tumor stages included 39 with T1a, 25 with T1b, 9 with unspecified T1, and 15 with T2. Eighty-six patients completed treatment with complete response of intraluminal disease in 55.8%, including complete response in 76.3% for T1a, 45.8% for T1b, 66.2% for all T1, and 6.7% for T2. Mean follow-up was 18.4 months. There were no deaths or perforations related to spray cryotherapy. Strictures developed in 12 of 88 patients (13.6%) but were present before spray cryotherapy in 3 of 12. This study suggests that endoscopic spray cryotherapy is a safe, well-tolerated, and effective treatment option for early esophageal adenocarcinoma.
Collapse
Affiliation(s)
- F C Tsai
- Scripps Clinic, La Jolla, California
| | | | - B D Greenwald
- University of Maryland School of Medicine and Greenebaum Cancer Center, Baltimore, Maryland
| | - S Jang
- Cleveland Clinic, Cleveland, Ohio
| | | | - M J McKinley
- North Shore LIJ Health System and ProHEALTHcare Associates, Syosset & Lake Success, New York
| | - N J Shaheen
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - F Habr
- Alpert School of Medicine of Brown University, Providence, Rhode Island
| | - H C Wolfsen
- Mayo Clinic Jacksonville, Jacksonville, Florida
| | - J A Abrams
- Columbia University Medical Center, New York, New York
| | - C J Lightdale
- Columbia University Medical Center, New York, New York
| | - N S Nishioka
- Massachusetts General Hospital, Boston, Massachusetts
| | - M H Johnston
- Lancaster Gastroenterology, Inc., Lancaster, Pennsylvania
| | - A Zfass
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - W J Coyle
- Scripps Clinic, La Jolla, California
| |
Collapse
|
|
35
|
Abstract
Endoscopic therapies have become the standard of care for most cases of Barrett's esophagus with high-grade dysplasia or intramucosal adenocarcinoma. Despite a rapid and dramatic evolution in treatment paradigms, esophagectomy continues to occupy a place in the therapeutic armamentarium for superficial esophageal neoplasia. The managing physician must remain cognizant of the limitations of endoscopic approaches and consider surgical resection when they are exceeded. Esophagectomy, performed at experienced centers for appropriately selected patients with early-stage disease can be undertaken with the expectation of cure as well as low mortality, acceptable morbidity, and good long-term quality of life.
Collapse
Affiliation(s)
- Thomas J Watson
- Division of Thoracic and Esophageal Surgery, Department of Surgery, MedStar Washington, Georgetown University School of Medicine, 3800 Reservoir Road Northwest, 4PHC, Washington, DC 20007, USA.
| |
Collapse
|
|
36
|
Endoscopic Eradication Therapy in Barrett's Esophagus. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017; 19:137-142. [PMID: 29269998 DOI: 10.1016/j.tgie.2017.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic eradication therapy (EET), the standard of care for treatment of Barrett's esophagus with dysplasia and early neoplasia, consists of a combination of endoscopic resection and ablative modalities. Resection techniques primarily include endoscopic mucosal resection or endoscopic submucosal dissection. Resection of nodular disease is generally followed by one of multiple ablative therapies among which radiofrequency ablation has the best evidence supporting safety and efficacy. These advanced endoscopic procedures require both experience and expertise in the cognitive and procedural aspects of EET. However, very few formal programs exist that teach endoscopists the necessary skills to perform EET in a safe, standardized, and efficacious manner. Case volume at both the endoscopist and center level has been shown to impact clinical outcomes based on limited data. As a result, some recent guidelines endorse case volume as a measure of competency. Quality indicators, which can be used as benchmarks for training and as part of pay for quality initiatives, have recently been derived for EET. However, quality metrics in EET have not been widely accepted, nor are they broadly used currently. While the efficacy of EET for BE is established, there is a need for application of quality metrics to both assure adequate training in these procedures, as well as to assess treatment outcomes. A standardized EET training curriculum during endoscopic training, with competency assessment of both new clinicians and endoscopists in practice has potential to improve care in EET.
Collapse
|
|
37
|
Dolan JP, McLaren PJ, Diggs BS, Schipper PH, Tieu BH, Sheppard BC, Gilbert EW, Conroy MA, Hunter JG. Evolution in the Treatment of Esophageal Disease at a Single Academic Institution: 2004-2013. J Laparoendosc Adv Surg Tech A 2017; 27:915-923. [PMID: 28486000 DOI: 10.1089/lap.2017.0069] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Management of benign and malignant esophageal disease has changed rapidly over the past decade. The aim of this study was to analyze evolution in surgical management of esophageal disease at a single academic medical center during this period. MATERIALS AND METHODS We reviewed a retrospective cohort of patients who underwent esophagectomy between 2004 and 2013. Patient, institutional, treatment, and outcomes variables were reviewed. RESULTS 317 patients were analyzed. Median age was 63.5 years; 80% were male. Average inhospital mortality rate was 3.8%. Operative indications changed significantly from 2004 to 2013, with more operations performed for invasive malignancy (77% vs. 95%) and fewer for high-grade dysplasia (12% vs. 3%, P = .008). In 2004, Ivor Lewis esophagectomy was the most common surgical technique, but the three-field technique was the operation of choice in 2013. A minimally invasive approach was used in 19% of cases in 2004 and 100% of cases in 2013 (P < .001). Anastomotic leak ranged from 0% to 21% with no significant difference over the study period (P = .18). Median lymph node harvest increased from seven to 18 nodes from 2004 to 2013 (P = .001). Hospital length of stay decreased from 15 to 8 days (P = .001). In 2013, 79% of patients were discharged to home, compared to 73% in 2004 (P = .04). DISCUSSION Over the last decade, our treatment of esophageal disease has evolved from a predominantly open Ivor Lewis to a minimally invasive three-field approach. Operations for malignancy have also increased dramatically. Postoperative complications and mortality were not significantly changed, but were consistently low during the latter years of the study.
Collapse
Affiliation(s)
- James P Dolan
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Patrick J McLaren
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Brian S Diggs
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Paul H Schipper
- 2 Division of Cardiothoracic Surgery, Section of General Thoracic Surgery, Department of Surgery, Oregon Health & Science University , Portland, Oregon
| | - Brandon H Tieu
- 2 Division of Cardiothoracic Surgery, Section of General Thoracic Surgery, Department of Surgery, Oregon Health & Science University , Portland, Oregon
| | - Brett C Sheppard
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Erin W Gilbert
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Molly A Conroy
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - John G Hunter
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| |
Collapse
|
|
38
|
Bustamante FAC, Hourneaux DE Moura EG, Bernardo W, Sallum RAA, Ide E, Baba E. SURGERY VERSUS ENDOSCOPIC THERAPIES FOR EARLY CANCER AND HIGH-GRADE DYSPLASIA IN THE ESOPHAGUS: a systematic review. ARQUIVOS DE GASTROENTEROLOGIA 2017; 53:10-9. [PMID: 27281499 DOI: 10.1590/s0004-28032016000100004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/19/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Esophageal cancer occurs as a local disease in 22% of cases, and a minority of this disease is limited to the mucosa or submucosa (early lesions). Endoscopic mucosal resection, endoscopic submucosal dissection, photodynamic therapy, laser therapy, and argon plasma coagulation have emerged as alternatives to surgical resection for early lesions. OBJECTIVE The aim of this systematic review is to identify studies that statistically compare survival, disease-free survival, morbidity and mortality associated with the procedure, and mortality associated with cancer in the endoscopic versus surgical therapies. DATA SOURCES A systematic review using MEDLINE, COCHRANE, EMBASE, EBSCO, LILACS, Library University of Sao Paulo, BVS, and SCOPE. STUDY SELECTION Randomized controlled trial, controlled clinical trial, clinical trial, and cohort study. CRITERIA - Studies that statistically compare survival, disease-free survival, morbidity and mortality associated with the procedure, and mortality associated with cancer in patients who underwent endoscopic and surgical therapy for early lesions of esophageal cancer. DATA EXTRACTION Independent extraction of the articles by two authors using predefined data fields, including study quality indicators. LIMITATION Only retrosprospective cohort studies comparing the endoscopic and surgical therapies were recovered. RESULTS The survival rates after 3 and 5 years were different and exhibited superiority with the surgical therapies over time. Endoscopy is superior in the control of mortality related to cancer with a high rate of disease recurrence. With regard to the comorbidity and the mortality associated with the procedure, endoscopy is superior. CONCLUSION There is no evidence from clinical trials. In this systematic review, surgical therapies showed superiority for survival, and endoscopic therapies showed superiority in the control of mortality related to cancer with a high rate of disease recurrence; also, for the comorbidity and the mortality associated with the procedure, endoscopy is superior. Prospective, controlled trials with large sample sizes are necessary to confirm the results of the current analysis.
Collapse
Affiliation(s)
- Fabio Alberto Castillo Bustamante
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| | - Eduardo Guimarães Hourneaux DE Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| | - Wanderley Bernardo
- Projeto Diretrizes, Associação Médica Brasileira, São Paulo, SP, Brasil, Associação Médica Brasileira, São Paulo SP , Brasil
| | - Rubens Antonio Aissar Sallum
- Divisão de Cirurgia Esofágica, Departamento de Gastroenterologia, Hospital das Clinicas Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Departamento de Gastroenterologia, Hospital das Clinicas, Universidade de São Paulo, São Paulo SP , Brazil
| | - Edson Ide
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| | - Elisa Baba
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| |
Collapse
|
|
39
|
Lam YH, Bright T, Leong M, Thompson SK, Mayne G, Watson DI. Oesophagectomy is a safe option for early adenocarcinoma arising from Barrett's oesophagus. ANZ J Surg 2016; 86:905-909. [PMID: 25708344 DOI: 10.1111/ans.13023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Over the last decade, there has been a shift towards endoscopic treatment of high-grade dysplasia (HGD) and T1 stage adenocarcinoma arising in Barrett's oesophagus. Although short-term outcomes are promising, longer-term outcomes remain uncertain and the role of these therapies versus surgery is debated, with surgical mortality rates assumed. However, few studies have specifically determined the outcome for oesophagectomy in the subgroup with HGD or T1 adenocarcinoma. To determine this, we evaluated experience with oesophagectomy for HGD and T1 adenocarcinoma in Barrett's oesophagus. METHODS Data were analysed from a prospective audit database for oesophagectomy performed at two public and four associated private hospitals in Adelaide, South Australia. Patients with HGD, T1a and T1b adenocarcinoma who underwent oesophagectomy from 20 February 1998 to 17 February 2012 were identified, and their perioperative, post-operative and survival outcomes were determined. RESULTS From 452 oesophagectomy procedures, 63 (13.9%) individuals who underwent surgery for HGD or T1 adenocarcinoma were identified; HGD - 19 (30.1%), T1a - 18 (28.5 %), T1b - 26 (41.3%). Major complications occurred in eight (12.7%) patients including one (1.6%) death following surgery. Five-year survival for HGD and T1a cancers using Kaplan-Meier analysis was not significantly different from a matched general population without cancer. CONCLUSION Oesophagectomy for HGD and T1 stage adenocarcinoma in Barrett's oesophagus is associated with favourable outcomes. Outcomes following endoscopic treatments should be benchmarked against these outcomes, not those following oesophagectomy for advanced cancer.
Collapse
Affiliation(s)
- Yick Ho Lam
- Department of Surgery, Flinders University, Adelaide, South Australia, Australia.
| | - Tim Bright
- Department of Surgery, Flinders University, Adelaide, South Australia, Australia
| | - Matthew Leong
- Department of Surgery, Flinders University, Adelaide, South Australia, Australia
| | - Sarah K Thompson
- Department of Surgery, University of Adelaide, Adelaide, South Australia, Australia
| | - George Mayne
- Department of Surgery, Flinders University, Adelaide, South Australia, Australia
| | - David I Watson
- Department of Surgery, Flinders University, Adelaide, South Australia, Australia
| |
Collapse
|
|
40
|
McLaren PJ, Dolan JP. Esophagectomy as a Treatment Consideration for Early-Stage Esophageal Cancer and High-Grade Dysplasia. J Laparoendosc Adv Surg Tech A 2016; 26:757-762. [DOI: 10.1089/lap.2016.29010.pjm] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Patrick J. McLaren
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - James P. Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
| |
Collapse
|
|
41
|
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.
Collapse
|
|
42
|
Neoplastic Barrett’s oesophagus and long-term follow-up after endoscopic therapy: complete histological eradication of Barrett associated with high-grade dysplasia significantly decreases neoplasia relapse. Surg Endosc 2016; 30:5410-5418. [DOI: 10.1007/s00464-016-4898-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/26/2016] [Indexed: 01/28/2023]
|
|
43
|
Abstract
Endoscopic resection and ablation have become the preferred therapy for most patients with high-grade dysplasia or superficial esophageal cancer. Endoscopic therapy offers esophageal preservation with similar oncologic outcomes and significantly fewer complications compared with the alternative of esopahgectomy. The goal of endotherapy is eradication of all the premalignant intestinal metaplasia to minimize the risk for metachronous cancer development. Once accomplished, careful follow-up is necessary to address recurrent intestinal metaplasia or dysplasia and prevent long-term failure of an endoscopic approach in these patients.
Collapse
|
|
44
|
Greene CL, Worrell SG, Attwood SE, Chandrasoma P, Chang K, DeMeester TR, Lord RV, Montgomery E, Pech O, Vallone J, Vieth M, Wang KK, DeMeester SR. Emerging Concepts for the Endoscopic Management of Superficial Esophageal Adenocarcinoma. J Gastrointest Surg 2016; 20:851-860. [PMID: 26691147 DOI: 10.1007/s11605-015-3056-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 12/07/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Endoscopic therapy has revolutionized the treatment of Barrett's esophagus with high-grade dysplasia (HGD) or intramucosal adenocarcinoma by allowing preservation of the esophagus in many patients who would previously have had an esophagectomy. This paradigm shift initially occurred at high-volume centers in North America and Europe but now is becoming mainstream therapy. There is a lack of uniform guidelines and algorithms for the management of these patients. Our aim was to review important concepts and pitfalls in the endoscopic management of superficial esophageal adenocarcinoma. METHODS A small group colloquium consisting of gastroenterologists, surgeons, and pathologists reviewed published data and discussed personal and institutional experiences with endotherapy for HGD and superficial esophageal adenocarcinoma. RESULTS The group reviewed data and provided recommendations and management algorithms for seven areas pertaining to endoscopic therapy for Barrett's HGD and superficial adenocarcinoma: (1) patient selection and evaluation; (2) imaging and biopsy techniques; (3) devices; (4) indications for resection versus ablation; (5) ER specimen handling, processing, and pathologic evaluation; (6) patient care and follow-up after endoscopic therapy; and (7) complications of endoscopic therapy and treatment options. CONCLUSIONS Endoscopic therapy is preferred over esophagectomy for most patients with HGD or intramucosal adenocarcinoma, and may be applicable to select patients with submucosal tumors. Clear guidelines and management algorithms will aid physicians and centers embarking on endoscopic therapy and enable a standardized approach to the management of these patients that is applicable internationally.
Collapse
Affiliation(s)
- Christina L Greene
- Department of Surgery, Keck School of Medicine of the University of Southern California, 1510 San Pablo Street, Suite 514, Los Angeles, CA, 90033, USA
| | - Stephanie G Worrell
- Department of Surgery, Keck School of Medicine of the University of Southern California, 1510 San Pablo Street, Suite 514, Los Angeles, CA, 90033, USA
| | - Stephen E Attwood
- Department of Surgery, North Tyneside General Hospital, Durham University, Tyne and Wear, UK
| | - Parakrama Chandrasoma
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Kenneth Chang
- Division of Gastroenterology and Hepatology, University of California, Irvine, Orange, CA, USA
| | - Tom R DeMeester
- Department of Surgery, Keck School of Medicine of the University of Southern California, 1510 San Pablo Street, Suite 514, Los Angeles, CA, 90033, USA
| | - Reginald V Lord
- Department of Surgery, Notre Dame University School of Medicine, Sydney, Sydney, Australia
| | | | - Oliver Pech
- Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Teaching Hospital of the University of Regensburg, Regensburg, Germany
| | - John Vallone
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Michael Vieth
- Institute of Pathology, Klinikum Bayreuth, Preuschwitzerstr, Bayreuth, Germany
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Steven R DeMeester
- Department of Surgery, Keck School of Medicine of the University of Southern California, 1510 San Pablo Street, Suite 514, Los Angeles, CA, 90033, USA.
| |
Collapse
|
|
45
|
Management of Barrett's esophagus: Screening to newer treatments. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2016. [DOI: 10.1016/j.rgmxen.2016.03.002] [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: 11/22/2022] Open
|
|
46
|
Thoguluva Chandrasekar V, Vennalaganti P, Sharma P. Management of Barrett's esophagus: From screening to newer treatments. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2016; 81:91-102. [PMID: 26964773 DOI: 10.1016/j.rgmx.2015.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/15/2015] [Indexed: 02/07/2023]
Abstract
Barrett's esophagus is a premalignant condition of the esophagus in which the squamous epithelium of the lower end of the esophagus is replaced with columnar epithelium. Since the incidence of esophageal adenocarcinoma is on the rise, the major gastroenterology societies have come up with their recommendations for screening and surveillance. Specific factors like obesity, white race, age over 50 years, early age of onset of GERD, smoking and hiatal hernia have been identified as increasing the risk of Barrett's esophagus and adenocarcinoma. The diagnosis requires both endoscopic identification of columnar-lined mucosa and histological confirmation with biopsy. Most medical societies recommend screening people with GERD and other risk factors with endoscopy, but other alternatives employing less invasive methods are currently being studied. Surveillance strategies vary depending on the endoscopic findings and the Seattle biopsy protocol with random 4-quadrant sampling is recommended. Biomarkers have shown promising results, but more studies are needed in the future. White light endoscopy is the standard practice, but other advanced imaging modalities have shown variable results and hence more studies are awaited for further validation. Endoscopic eradication techniques, including both resection and ablation, have shown good but variable results for treating dysplastic lesions confined to the mucosa. Resection procedures to remove visible lesions followed by ablation of the dysplastic mucosa have shown the best results with higher eradication rates and lower recurrence rates. Surgical management is reserved for lesions with sub-mucosal invasion and lymph node spread with increased risk of metastasis.
Collapse
Affiliation(s)
| | - P Vennalaganti
- Department of Gastroenterology, Hepatology and Motility, University of Kansas Medical Center, Kansas city, Missouri, EE. UU
| | - P Sharma
- Department of Gastroenterology, Hepatology and Motility, University of Kansas Medical Center, Kansas city, Missouri, EE. UU..
| |
Collapse
|
|
47
|
Nason KS. Minimal or maximal surgery for esophageal cancer? J Thorac Cardiovasc Surg 2016; 151:633-635. [DOI: 10.1016/j.jtcvs.2015.09.118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 02/07/2023]
|
|
48
|
Boys JA, Worrell SG, Chandrasoma P, Vallone JG, Maru DM, Zhang L, Blackmon SH, Dickinson KJ, Dunst CM, Hofstetter WL, Lada MJ, Louie BE, Molena D, Watson TJ, DeMeester SR. Can the Risk of Lymph Node Metastases Be Gauged in Endoscopically Resected Submucosal Esophageal Adenocarcinomas? A Multi-Center Study. J Gastrointest Surg 2016; 20:6-12; discussion 12. [PMID: 26408330 DOI: 10.1007/s11605-015-2950-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/14/2015] [Indexed: 02/07/2023]
Abstract
Endoscopic resection (ER) allows for local therapy of superficial esophageal cancers. Factors reported to be associated with an increased risk of lymph node metastases in patients with adenocarcinoma are poor differentiation, lymphovascular invasion (LVI), and submucosal invasion >500 μ. The aim of this study was to determine whether depth of invasion and tumor characteristics in an ER specimen can be used to gauge the risk of lymph node metastases in patients with superficial esophageal adenocarcinoma. Patients from seven US centers that had ER of an adenocarcinoma followed by an esophagectomy were identified. The ER pathology slides were rereviewed by three experienced GI pathologists for depth of invasion, presence of LVI, and tumor differentiation. The findings from the ER specimen were correlated with the presence and number of lymph node metastases in the final esophagectomy specimen. There were 19 T1a and 23 T1b tumors. A median of 24 nodes were resected per patient. None of the T1a tumors had involved lymph nodes despite the presence of LVI in 5% and poor differentiation in 21% of patients. In contrast, 26% of T1b tumors had involved nodes. None of the four patients with submucosal invasion ≤500 μ, no LVI, and no poor differentiation had involved nodes. However, with an increasing number of risk factors, the likelihood of involved lymph nodes increased, reaching 50% when all three factors were present. Endoscopic therapy appears appropriate for intramucosal tumors and may be an option for low-risk T1b tumors. Esophagectomy is preferred for patients with submucosal invasion and one or more risk factors.
Collapse
Affiliation(s)
- Joshua A Boys
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | - Stephanie G Worrell
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | - Parakrama Chandrasoma
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John G Vallone
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Dipen M Maru
- Department of Pathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Lizhi Zhang
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Wayne L Hofstetter
- Department of Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Michael J Lada
- Department of Surgery, University of Rochester, New York, NY, USA
| | - Brian E Louie
- Department of Surgery, Swedish Cancer Institute, Seattle, WA, USA
| | - Daniela Molena
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Thomas J Watson
- Department of Surgery, University of Rochester, New York, NY, USA
| | - Steven R DeMeester
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA.
| |
Collapse
|
|
49
|
Worrell SG, Boys JA, Chandrasoma P, Vallone JG, Dunst CM, Johnson CS, Lada MJ, Louie BE, Watson TJ, DeMeester SR. Inter-Observer Variability in the Interpretation of Endoscopic Mucosal Resection Specimens of Esophageal Adenocarcinoma: Interpretation of ER specimens. J Gastrointest Surg 2016; 20:140-4; discussion 144-5. [PMID: 26503261 DOI: 10.1007/s11605-015-3009-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 10/19/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Endoscopic resection (ER) has revolutionized the staging and therapy of superficial esophageal adenocarcinoma. Pathologic evaluation allows an assessment of the risk of lymph node metastases based on tumor characteristics. The aim of this study was to assess the inter-observer variability in pathologic assessment of ER specimens of esophageal adenocarcinoma. METHODS We performed a retrospective study on ER specimens of superficial esophageal adenocarcinoma from four US institutions. Original endoscopic resection slides were re-reviewed by two blinded, experienced (study) gastrointestinal pathologists for the depth of tumor invasion, tumor grade, and the presence of lymphovascular invasion (LVI). Discordance was considered present only when both study pathologists disagreed with the original report. RESULTS There were 25 ER specimens reviewed for this study, and discordance occurred in 12 of the 25 specimens (48%) for the depth of tumor invasion. In most cases (83%), the discordance was related to overstaging a true T1a lesion. We found that only 38% of true T1a lesions were correctly staged for depth of invasion. Less commonly discordance was secondary to understaging a true T1b lesion. There was concordance between the two study pathologists in 22/25 cases (88%) on the depth of invasion. Discordance was present for tumor grade in 8/18 cases (44%) and for LVI in 4/16 cases (25%). Concordance between the study pathologists was 80% for tumor grade and 88% for LVI. CONCLUSIONS There was an alarmingly high rate of discordance (48%) between the study pathologists and the original pathology assessment for the depth of tumor invasion in ER specimens. This was particularly common for lesions called T1b on the original pathology report. Since critical decisions are made regarding esophageal preservation or esophagectomy on the basis of the pathologic interpretations of ER specimens, it behooves surgeons to understand the inter-observer variability. Review of ER specimens by an experienced GI pathologist is recommended to ensure that patients receive the appropriate treatment for superficial esophageal adenocarcinoma.
Collapse
Affiliation(s)
- Stephanie G Worrell
- Surgery, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | - Joshua A Boys
- Surgery, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | | | - John G Vallone
- Pathology, University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | - Steven R DeMeester
- Surgery, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA.
| |
Collapse
|
|
50
|
Ansari MH, Irani S, Edalat H, Amin R, Mohammadi Roushandeh A. Deregulation of miR-93 and miR-143 in human esophageal cancer. Tumour Biol 2015; 37:3097-103. [PMID: 26427659 DOI: 10.1007/s13277-015-3987-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/25/2015] [Indexed: 12/31/2022] Open
Abstract
Esophageal squamous cell carcinoma (ESCC) is the second and third most common malignancy in Iranian males and females, respectively. Treatment of ESCC is largely ineffective due to lack of detection at early stages of the disease. In recent years, miRNA, a small RNA molecule, has drawn much attention to researchers as a potential biomarker for esophageal cancer. miR-93 and miR-143 are two miRNA molecules reported to be frequently deregulated in various cancers, including prostate, stomach, cervix, and etc. The purpose of this study was to investigate the expression levels of these miRNAs and evaluate their diagnostic and therapeutic potential in esophageal squamous cell carcinoma. In this study, total RNA was extracted from 30 tumor tissues and 30 nontumor tissues of esophageal tumor margins, using RNX-plus solution. After validating the quality and quantity of total RNA, cDNAs of interest were synthesized using microRNA-specific cDNA Synthesis Kit. The expression level of miR-93 and miR-143 was evaluated using quantitative real-time PCR with miRNA-specific primers. Finally, the obtained data was analyzed by SPSS ver.20 software and paired t test was performed to observe the significance of difference between groups. The expression level of miR-93 was significantly increased and of miR-143 was significantly decreased in most of the examined tumor tissues, compared to nontumor tissues. Also, our findings did not detect correlation between mir-93 and mir-143 expressions in regard to stage and grade of the samples. These findings suggest that the deregulation of these miRNAs may play an important role in esophageal squamous cell carcinoma. Both miR-93 and miR-143 might be used as potential biomarkers in esophageal squamous cell carcinoma. However, more studies with large population of samples are necessary.
Collapse
Affiliation(s)
- Mohammad Hossein Ansari
- Research Center for Molecular Medicine, Medicine Faculty, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Shiva Irani
- Department of Biology, School of Basic Sciences, Sciences and Research Branch, Islamic Azad University, Tehran, Iran
| | - Houri Edalat
- Research Center for Molecular Medicine, Medicine Faculty, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Ruhul Amin
- Department of Project Program, Institute of Development, Aging and Cancer (IDAC), Tohoku University, Sendai, Japan
| | - Amaneh Mohammadi Roushandeh
- Research Center for Molecular Medicine, Medicine Faculty, Hamadan University of Medical Sciences, Hamadan, Iran. .,Department of Anatomical Sciences, Medicine Faculty, Hamadan University of Medical Sciences, Hamadan, Iran.
| |
Collapse
|