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Chan MW, Nieuwenhuis EA, Meijer SL, Jansen M, Vieth M, van Berge Henegouwen MI, Pouw RE. Reassessment reveals underestimation of infiltration depth in surgical resection specimens with lymph-node positive T1b esophageal adenocarcinoma. Endosc Int Open 2025; 13:a25097208. [PMID: 40007654 PMCID: PMC11855241 DOI: 10.1055/a-2509-7208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Accepted: 12/16/2024] [Indexed: 02/27/2025] Open
Abstract
Background and study aims Endoscopic resection (ER) has proven effective and safe for T1 esophageal adenocarcinoma (EAC). However, uncertainty remains concerning risk-benefit return of esophagectomy for submucosal lesions (T1b). Surgical series in past decades have reported significant risk of lymph node metastasis (LNM) in T1b EAC, but these rates may be overestimated due to limitations in histological assessment of surgical specimens. We aimed to test this hypothesis by reassessing histological risk features in surgical specimens from T1b EAC cases with documented LNM. Patients and methods A retrospective cross-sectional study (1994-2005) was conducted. Patients who underwent direct esophagectomy without prior neoadjuvant therapy for suspected T1b EAC with LNM were included. Additional tissue sections were prepared from archival tumor blocks. A consensus diagnosis on tumor depth, differentiation grade, and lymphovascular invasion (LVI) was established by a panel of experienced pathologists. Results Specific depth of submucosal invasion (sm1 to sm3) was not specified in 10 of 11 archival case sign-out reports. LVI status was not reported in seven of 11 cases. Following reassessment, one patient was found to have deep tumor invasion into the muscularis propria (T2). The remaining 10 of 11 patients exhibited deep submucosal invasion (sm2-3), with five showing one or more additional risk features (poor differentiation and/or LVI). Conclusions Our findings highlight the potential for underestimating tumor depth of invasion and other high-risk features in surgical specimens. Despite the limited cohort size, our study confirmed a consistent high-risk histological profile across all cases. Caution is warranted when extrapolating LNM risk data from historic heterogeneous cross-sectional surgical cohorts to the modern ER era.
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Affiliation(s)
- Man Wai Chan
- Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Locatie VUmc, Amsterdam, Netherlands
| | - Esther A. Nieuwenhuis
- Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Locatie VUmc, Amsterdam, Netherlands
| | - Sybren L Meijer
- Pathology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Marnix Jansen
- Pathology, University College London Hospitals NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
- University College London Cancer Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Michael Vieth
- Histopathology, Klinikum Bayreuth GmbH, Bayreuth, Germany
| | | | - R. E. Pouw
- Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Locatie VUmc, Amsterdam, Netherlands
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2
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Leclercq P, Bisschops R, Bergman JJGHM, Pouw RE. Management of high risk T1 esophageal adenocarcinoma following endoscopic resection. Best Pract Res Clin Gastroenterol 2024; 68:101882. [PMID: 38522880 DOI: 10.1016/j.bpg.2024.101882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/17/2024] [Indexed: 03/26/2024]
Abstract
High-risk T1 esophageal adenocarcinoma (HR-T1 EAC) is defined as T1 cancer, with one or more of the following histological criteria: submucosal invasion, poorly or undifferentiated cancer, and/or presence of lympho-vascular invasion. Esophagectomy has long been the only available treatment for these HR-T1 EACs and was considered necessary because of a presumed high risk of lymph node metastases up to 46%. However, endoscopic submucosal disscection have made it possible to radically remove HR-T1 EAC, irrespective of size, while leaving the esophageal anatomy intact. Parallel to this development, new publications demonstrated that the risk of lymph node metastases for HR-T1 EAC may be even <24%. Therefore, indications for endoscopic treatment of HR-T1 EAC are being reconsidered and current research aims at finding the optimal management strategy for this indication, where watchful waiting may proof to be an acceptable strategy in selected patients. In this review, we will discuss the latest developments in this field.
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Affiliation(s)
- Philippe Leclercq
- Departement of Gastroenterology, Universitair Ziekenhuis Leuven, 49 Herestraat, 3000, LEUVEN, Belgium.
| | - Raf Bisschops
- Departement of Gastroenterology, Universitair Ziekenhuis Leuven, 49 Herestraat, 3000, LEUVEN, Belgium.
| | - Jacques J G H M Bergman
- Dept. of Gastroenterology and Hepatology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, 1081, HV, Netherlands.
| | - Roos E Pouw
- Dept. of Gastroenterology and Hepatology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, 1081, HV, Netherlands.
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3
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Ye H, Chen P, Wang YF, Cai XJ. Endoscopic Versus Surgical Therapy for Early Esophagogastric Junction Adenocarcinoma Based on Lymph Node Metastasis Risk: A Population-Based Analysis. Front Oncol 2021; 11:716470. [PMID: 34976786 PMCID: PMC8718685 DOI: 10.3389/fonc.2021.716470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background In this study, we aimed to compare the prognosis and lymph node metastasis (LNM) risk in patients with early-stage esophagogastric junction (EGJ) adenocarcinoma after endoscopic treatment (ET) or radical surgery. Methods We collected data from eligible patients based on the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2016. Logistic regression analysis was used to determine independent predictors of LNM (examination of at least 16 lymph nodes). Cox regression analysis and propensity score-matched (PSM) analysis were subsequently utilized to compare the overall survival (OS) and cancer-specific survival (CSS) of patients treated with ET or radical surgery. Results In total, 3708 patients were identified. Among them, 856 patients had greater than or equal to 16 examined lymph nodes (LNs) (LNE≥16). The LNM rates were 18.8% in all patients 8.3% in T1a patients and 24.6% in T1b patients. Independent predictors of LNM were submucosal invasion, tumor size ≥3cm and decreasing differentiation (P<0.05). The LNM rate decreased to approximately 5.3% in T1b tumors with well differentiation and tumor size <3cm. However, the LNM incidence increased to 17.9% or 33.3% in T1a tumors with poor differentiation or with both tumor size≥3cm and poor differentiation. Cox regression analysis demonstrated CSS was not significantly different in early-stage EGJ adenocarcinoma patients undergoing ET and those treated with radical surgery (HR= 1.004, P=0.974), which were robustly validated after PSM analysis. Moreover, subgroup analysis stratified by T1a and T1b showed similar results. Conclusions The findings of this study indicated ET as an alternative to radical surgery in early EGJ adenocarcinoma.
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Affiliation(s)
- Hua Ye
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Gastrointestinal and Hernia Ward, HwaMei Hospital, University Of Chinese Academy Of Sciences, Ningbo, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, China
| | - Ping Chen
- Department of Gastrointestinal and Hernia Ward, HwaMei Hospital, University Of Chinese Academy Of Sciences, Ningbo, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, China
| | - Yi-Fan Wang
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiu-Jun Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Xiu-Jun Cai,
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4
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Benech N, O'Brien JM, Barret M, Jacques J, Rahmi G, Perrod G, Hervieu V, Jaouen A, Charissoux A, Guillaud O, Legros R, Walter T, Saurin JC, Rivory J, Prat F, Lépilliez V, Ponchon T, Pioche M. Endoscopic resection of Barrett's adenocarcinoma: Intramucosal and low-risk tumours are not associated with lymph node metastases. United European Gastroenterol J 2021; 9:362-369. [PMID: 32903167 PMCID: PMC8259244 DOI: 10.1177/2050640620958903] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Superficial oesophageal adenocarcinoma can be resected endoscopically, but data to define a curative endoscopic resection are scarce. Objective Our study aimed to assess the risk of lymph node metastasis depending on the depth of invasion and histological features of oesophageal adenocarcinoma. Methods We retrospectively included all patients undergoing an endoscopic resection for T1 oesophageal adenocarcinoma among seven expert centres in France in 2004–2016. Mural invasion was defined as either intramucosal or submucosal tumours; the latter were further divided into superficial submucosal (<1000 mm) and deep submucosal (>1000 mm). Absence or presence of lymphovascular invasion and/or poorly differentiated cancer (G3) defined a low‐risk or a high‐risk tumour, respectively. For submucosal tumours, invasion depth and histological features were systematically confirmed after a second dedicated histological assessment (new 2‐mm thick slices) performed by a second pathologist. Occurrence of lymph node metastasis was recorded during the follow‐up from histological or PET CT reports when an invasive procedure was not possible. Results In total, 188 superficial oesophageal adenocarcinomas were included with a median follow‐up of 34 months. No lymph node metastases occurred for intramucosal oesophageal adenocarcinomas (n = 135) even with high‐risk histological features. Among submucosal oesophageal adenocarcinomas, only tumours with lymphovascular invasion or poorly differentiated cancer or with a depth of invasion >1000 μm developed lymph node metastasis tumours (n = 10/53%; 18.9%; hazard ratio 12.04). No metastatic evolution occurred under a 1000‐mm threshold for all low‐risk tumours (0/25), nor under 1200 mm (0/1) and three over this threshold (3/13%, 23.1%). Conclusion Intramucosal and low‐risk tumours with shallow submucosal invasion up to 1200 mm were not associated with lymph node metastasis during follow‐up. In case of high‐risk features and/or deep submucosal invasion, endoscopic resections are not sufficient to eliminate the risk of lymph node metastasis, and surgical oesophagectomy should be carried out. These results must be confirmed by larger prospective series.
Superficial oesophageal adenocarcinoma (OAC) can be resected endoscopically. Data to define a curative endoscopic resection with a low lymph node metastasis (LNM) risk are scarce especially for tumours invading the submucosa. Curative endoscopic resections have been reported in selected OAC invading the first 500 mm of the submucosa, but surgical series showed an LNM risk ranging from 0% to 50%, making endoscopic resection a questionable curative treatment. High‐risk histological features were not associated with LNM in intramucosal tumours. LNM occurred only for tumours invading the submucosa with a depth ≥1200 mm or with high‐risk histological features regardless of the depth of invasion. Endoscopic resection may be a valid and curative therapeutic option for all intramucosal tumours and for submucosal oesophageal adenocarcinoma with an invasion depth ≤1000 mm and low‐risk histological features.
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Affiliation(s)
- Nicolas Benech
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France
| | - Jean Marc O'Brien
- Université Claude Bernard Lyon 1, Lyon, France.,Service d'Hépato-Gastroentérologie, Hôpital de La Croix-Rousse, Hospices civils de Lyon, Lyon, France
| | | | - Jéremie Jacques
- Service d'Hepato-Gastroenterologie, Dupuytren University Hospital, Limoges, France
| | - Gabriel Rahmi
- Service d'Hepato-Gastroenterologie, Hôpital Europeen Georges Pompidou, Paris, France
| | - Guillaume Perrod
- Service d'Hepato-Gastroenterologie, Hôpital Europeen Georges Pompidou, Paris, France
| | - Valérie Hervieu
- Service d'Anatomo-Pathologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Alexandre Jaouen
- Service d'Anatomo-Pathologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Aurélie Charissoux
- Service d'Anatomo-Pathologie, Dupuytren University Hospital, Limoges, France
| | - Olivier Guillaud
- Service d'Hepato-Gastroenterologie, Clinique de la Sauvegarde, Lyon, France
| | - Romain Legros
- Service d'Hepato-Gastroenterologie, Dupuytren University Hospital, Limoges, France
| | - Thomas Walter
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Jean-Christophe Saurin
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Jérôme Rivory
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France
| | - Fréderic Prat
- Service d'Hepato-Gastroentérologie, Hôpital Cochin, Paris, France
| | - Vincent Lépilliez
- Service d'Hepato-Gastroentérologie, Mermoz Private Hospital, Lyon, France
| | - Thierry Ponchon
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,INSERM U1032, Lab Tau, Lyon, France
| | - Mathieu Pioche
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,INSERM U1032, Lab Tau, Lyon, France
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Eichelmann AK, Nikitina M, Bahde R, Mardin WA, Slepecka P, Kebschull L, Senninger N, Pascher A, Palmes D. Merendino Resection vs. Transhiatal Gastric Conduit After Resection of the Cardia and the Gastroesophageal Junction. Am Surg 2021; 88:194-200. [PMID: 33502212 DOI: 10.1177/0003134820983185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reconstruction after combined cardia resection and removal of the gastroesophageal junction can be carried out by the Merendino procedure or via a gastric conduit. This study compares postoperative complications and quality of life for both approaches. METHODS All patients who underwent Merendino or gastric conduit reconstruction from 2011-2017 were included. Both groups were investigated regarding postoperative length of stay, complications, and gastrointestinal quality of life. RESULTS 45 patients were identified, of which, 39 remained for analysis: 22 patients in the Merendino group and 17 patients in the gastric conduit group. The median age of patients in the gastric conduit group (71 (53-92) years) was significantly higher than in the Merendino group (58 (19-75) years), P = .0002. Hospital stay was significantly longer in the gastric conduit group (35.9 (11-82) days vs. 18.2 (7-43) days, P = .0299) and incidence of anastomotic leakage was higher (24% vs. 9%, P = .0171). General incidence of complications (Clavien-Dindo) did not vary (P = .1694). However, grade 5 complications only occurred in the Merendino group (n = 1). Evaluation of long-term outcome and quality of life showed dysphagia to only have occurred in the Merendino group (n = 3, 14%). DISCUSSION Both approaches have advantages and disadvantages: The Merendino procedure showed reduced incidence of anastomotic leakage and shorter hospital stay but was associated with a higher in-hospital mortality rate. Discrepancies in subgroup populations as well as small patient numbers limit the interpretation of the findings. This study does however provide a first comparison of these surgical approaches and may serve as a basis for further investigation.
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Affiliation(s)
| | - Milana Nikitina
- Department of General, Visceral and Transplant Surgery, University of Muenster, Germany
| | - Ralf Bahde
- Department of General, Visceral and Transplant Surgery, University of Muenster, Germany
| | - Wolf A Mardin
- Department of Medical Controlling, University Hospital of Muenster, Germany
| | - Patrycja Slepecka
- Department of General, Visceral and Transplant Surgery, University of Muenster, Germany
| | - Linus Kebschull
- Department of General, Visceral and Transplant Surgery, University of Muenster, Germany
| | - Norbert Senninger
- Department of General, Visceral and Transplant Surgery, University of Muenster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University of Muenster, Germany
| | - Daniel Palmes
- Department of General, Visceral and Transplant Surgery, University of Muenster, Germany
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Li Y, Du L, Wang Y, Gu Y, Zhen X, Hu X, Sun X, Dong H. Modeling the Cost-effectiveness of Esophageal Cancer Screening in China. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:33. [PMID: 32944005 PMCID: PMC7488134 DOI: 10.1186/s12962-020-00230-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/02/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND This study aimed to examine the cost-effectiveness of one-time standard endoscopic screening with Lugol's iodine staining for esophageal cancer (EC) in China. METHODS A Markov decision analysis model with eleven states was built. Individuals aged 40 to 69 years were classified into six age groups in five-year intervals. Three different strategies were adopted for each cohort: (1) no screening; (2) one-time endoscopic screening with Lugol's iodine staining with an annual follow-up for low-grade intraepithelial neoplasia (LGIN); and (3) one-time endoscopic screening with Lugol's iodine staining without follow-up. Quality-adjusted life-years (QALYs) indicated the effectiveness of the model. The incremental cost-effectiveness ratio (ICER) was used as the evaluation indicator. Sensitivity analysis was performed to assess the robustness of the model. RESULTS One-time screening with follow-up was the undominated strategy for individuals aged 40-44 and 45-49 years, which saved USD 10,942.57 and USD 6611.73 per QALY gained compared to nonscreening strategy. For those aged 50-69 years, the nonscreening scenarios were undominated. One-time screening without follow-up was the extended dominated strategy. Compared to screening strategies without follow-up, all the screening strategies with follow-up were more cost-effective, with the ICER increasing from 299.57 USD/QALY for individuals aged 40-44 years to 1617.72 USD/QALY for individuals aged 65-69 years. Probabilistic sensitivity analysis (PSA) supported the results of the base case analysis. CONCLUSIONS One-time EC screening with follow-up targeting individuals aged 40-49 years was the most cost-effective strategy.
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Affiliation(s)
- Yuanyuan Li
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Rd., 310058 Hangzhou, Zhejiang China
| | - Lingbin Du
- Department of Cancer Prevention, Institute of Cancer Research and Basic Medical Science of Chinese Academy of Sciences, Cancer Hospital of University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, 38 Banshan Guangqiao Rd., 310022 Hangzhou, Zhejiang China
| | - Youqing Wang
- Department of Cancer Prevention, Institute of Cancer Research and Basic Medical Science of Chinese Academy of Sciences, Cancer Hospital of University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, 38 Banshan Guangqiao Rd., 310022 Hangzhou, Zhejiang China
| | - Yuxuan Gu
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Rd., 310058 Hangzhou, Zhejiang China
| | - Xuemei Zhen
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Rd., 310058 Hangzhou, Zhejiang China
| | - Xiaoqian Hu
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Rd., 310058 Hangzhou, Zhejiang China
| | - Xueshan Sun
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Rd., 310058 Hangzhou, Zhejiang China
| | - Hengjin Dong
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Rd., 310058 Hangzhou, Zhejiang China
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7
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Zhu M, Cao B, Li X, Li P, Wen Z, Ji J, Min L, Zhang S. Risk factors and a predictive nomogram for lymph node metastasis of superficial esophagogastric junction cancer. J Gastroenterol Hepatol 2020; 35:1524-1531. [PMID: 32023349 DOI: 10.1111/jgh.15004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/03/2020] [Accepted: 01/31/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIM No predictive model for lymph node metastasis (LNM) of superficial esophagogastric junction (EGJ) cancer exists. This study aimed to evaluate incidence, identify risk factors, and develop a predictive nomogram for LNM in patients with superficial EGJ cancers. METHODS Data were extracted from the Surveillance, Epidemiology, and End Results database for model development and internal validation. Another data set was obtained from two hospitals for external validation. A nomogram was developed based on independent risk factors that resulted from a multivariate logistic regression analysis. Internal and external validations were performed to assess the performance of nomogram model by receiver operating characteristic and calibration plot. RESULTS Prevalence of LNM was 11.41% for intramucosal cancer and increased to 26.50% for submucosal cancer. On the multivariate analysis, large tumor size (odds ratio [OR] = 1.42; P < 0.001), moderately and poorly/un-differentiated pathological type (OR = 5.62 and 7.67; P = 0.024 and 0.008, respectively), and submucosal invasion (OR = 2.73; P = 0.004) were independent risk factors of LNM. The nomogram incorporating these three predictors demonstrated good discrimination (area under the estimated receiver operating characteristic curve [AUC]: 0.74; 95% confidence interval [95%CI]: 0.68, 0.80) and calibration (mean absolute error was 0.012). Moreover, the discrimination in the internal and external validation sets was good (AUC: 0.73 [95%CI: 0.66, 0.81] and 0.74 [95%CI: 0.60, 0.89], respectively). Nomogram provided better clinical usefulness as assessed by a decision curve analysis. CONCLUSIONS Prevalence of LNM in superficial EGJ cancer was high. The first risk-predictive nomogram model for LNM of superficial EGJ cancer may help clinicians to decide optimal treatment option preoperatively.
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Affiliation(s)
- Min Zhu
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Beijing, China
| | - Bin Cao
- Department of Endocrinology, Beijing Key Laboratory of Diabetes Research and Care, Center for Endocrine Metabolism and Immune Diseases, Lu He Hospital, Capital Medical University, Beijing, China
| | - Xiao Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Beijing, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Beijing, China
| | - Zixian Wen
- Department of Gastrointestinal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing, China
| | - Jiafu Ji
- Department of Gastrointestinal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing, China
| | - Li Min
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Beijing, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Beijing, China
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8
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Results of the different surgical options for the treatment of cancer of the esophagogastric junction: Review of the evidence. Cir Esp 2019; 97:445-450. [PMID: 31027834 DOI: 10.1016/j.ciresp.2019.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/09/2019] [Indexed: 11/21/2022]
Abstract
There is significant controversy in the management of cardiac cancer. It seems unanimous that Siewert type I tumors be operated on as cancer of the esophagus and Siewert type III as gastric cancer. However, for "true" cancer of the gastric cardia or Siewert II, the authors do not agree. There is the obvious need for free proximal and distal margins, as well as correct lymphadenectomy. For some, esophagectomy is necessary to perform correct radical oncological surgery, but other authors defend that an abdominal approach is sufficient to perform total gastrectomy and distal esophagectomy. Recent and older papers published do not clarify this issue, and their results are contradictory. Chemotherapy prior to surgery can reduce the size of the tumor and the presence of lymphadenopathies.
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9
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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]
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10
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Analatos A, Lindblad M, Rouvelas I, Elbe P, Lundell L, Nilsson M, Tsekrekos A, Tsai JA. Evaluation of resection of the gastroesophageal junction and jejunal interposition (Merendino procedure) as a rescue procedure in patients with a failed redo antireflux procedure. A single-center experience. BMC Surg 2018; 18:70. [PMID: 30165834 PMCID: PMC6117955 DOI: 10.1186/s12893-018-0401-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 08/22/2018] [Indexed: 01/02/2023] Open
Abstract
Background Primary antireflux surgery has high success rates but 5 to 20% of patients undergoing antireflux operations can experience recurrent reflux and dysphagia, requiring reoperation. Different surgical approaches after failed fundoplication have been described in the literature. The aim of this study was to evaluate resection of the gastroesophageal junction with jejunal interposition (Merendino procedure) as a rescue procedure after failed fundoplication. Methods All patients who underwent a Merendino procedure at the Karolinska University Hospital between 2004 and 2012 after a failed antireflux fundoplication were identified. Data regarding previous surgical history, preoperative workup, postoperative complications, subsequent investigations and re-interventions were collected retrospectively. The follow-up also included questionnaires regarding quality of life, gastrointestinal function and the dumping syndrome. Results Twelve patients had a Merendino reconstruction. Ten patients had undergone at least two previous fundoplications, of which one patient had four such procedures. The main indication for surgery was epigastric and radiating back pain, with or without dysphagia. Postoperative complications occurred in 8/12 patients (67%). During a median follow-up of 35 months (range 20–61), four (25%) patients had an additional redo procedure with conversion to a Roux-en-Y esophagojejunostomy within 12 months, mainly due to obstructive symptoms that could not be managed conservatively or with endoscopic techniques. Questionnaires scores were generally poor in all dimensions. Conclusions In our experience, the Merendino procedure seems to be an unsuitable surgical option for patients who require an alternative surgical reconstruction due to a failed fundoplication. However, the small number of patients included in this study as well as the small number of participants who completed the postoperative workout limits this study.
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Affiliation(s)
- Apostolos Analatos
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden. .,Department of Surgery, Nyköping Hospital, Nyköping, Sweden. .,Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.
| | - Mats Lindblad
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
| | - Ioannis Rouvelas
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
| | - Peter Elbe
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
| | - Lars Lundell
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
| | - Magnus Nilsson
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
| | - Andrianos Tsekrekos
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
| | - Jon A Tsai
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
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11
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Current challenges in gastric cancer surgery: European perspective. Surg Oncol 2018; 27:650-656. [PMID: 30449488 DOI: 10.1016/j.suronc.2018.08.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 07/22/2018] [Accepted: 08/16/2018] [Indexed: 02/06/2023]
Abstract
Gastric cancer (GC) remains one of the most common causes of cancer death worldwide with expected 5-year survival rates around 25% in Western countries. In order to improve treatment strategy, a most effective staging process should be completed. A novel TNM staging for GC has been proposed recently, along with a separate staging system for GC patients who underwent preoperative therapy (ypStage). Availability of high-quality imaging and access to diagnostic laparoscopy with lavage cytology should be applied while planning the multimodal therapy. In the European setting, GC treatment is based on a combination of surgery and perioperative chemotherapy. However, in selected groups of patients with high risk of locoregional recurrence, adjuvant chemoradiotherapy should be considered. New epidemiological trends of GC in the Western countries include an upward shift in the location of the primary tumour and a relative increase of advanced and diffuse type tumours. These trends dictate modification of surgical techniques towards a more individualized GC treatment approach.
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12
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Mönig S, Chevallay M, Niclauss N, Zilli T, Fang W, Bansal A, Hoeppner J. Early esophageal cancer: the significance of surgery, endoscopy, and chemoradiation. Ann N Y Acad Sci 2018; 1434:115-123. [PMID: 30138532 DOI: 10.1111/nyas.13955] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 07/18/2018] [Accepted: 07/26/2018] [Indexed: 12/22/2022]
Abstract
Early carcinomas of the esophagus are histologically classified as adenocarcinoma or squamous cell carcinoma and microscopically subdivided into mucosal and submucosal carcinomas depending on infiltration depth. The prevalence of lymph node metastasis in mucosal carcinoma remains low. However, lymph node metastases arise frequently from tumors with submucosal infiltration, with increasing prevalence in the deeper submucosal sublayers. According to current German guidelines, endoscopic resection is the recommended treatment in mucosal adenocarcinoma without histologic risk factors (lymphatic invasion 1, vascular invasion 1, >grade 2, R1-margin). In superficial submucosal infiltration without histologic risk factors, endoscopic resection can be considered. In squamous cell carcinoma, endoscopic resection is indicated up to middle layer mucosal carcinoma. Beyond these criteria, surgical resection should be considered. The gold standard is a subtotal transthoracic esophagectomy with two-field lymphadenectomy. Total esophagectomy is performed in cervical esophageal carcinoma and transhiatal extended gastrectomy in carcinoma of the cardia. Minimally invasive procedures show good oncologic results and reduce the morbidity of radical esophagectomy. Reduced morbidity might be an argument for surgical resection in borderline cases between endoscopic and surgical resection. In early squamous cell cancer, the combination of endoscopic resection and adjuvant chemoradiotherapy is a therapeutic option with promising results.
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Affiliation(s)
- Stefan Mönig
- Visceral Surgery Department, Geneva University Hospital, Geneva, Switzerland
| | - Mickael Chevallay
- Visceral Surgery Department, Geneva University Hospital, Geneva, Switzerland
| | - Nadja Niclauss
- Visceral Surgery Department, Geneva University Hospital, Geneva, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.,Faculty of Medicine, Geneva University, Geneva, Switzerland
| | - Wentao Fang
- Department of Thoracic Surgery, Shanghai Chest Hospital Clinical Center for Esophageal Diseases, Shanghai Jiaotong University, Shanghai, China
| | - Ajay Bansal
- Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas.,Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Jens Hoeppner
- Department of General and Visceral Surgery, Faculty of Medicine, University of Freiburg Medical Center, Freiburg, Germany
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13
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Bourke MJ, Neuhaus H, Bergman JJ. Endoscopic Submucosal Dissection: Indications and Application in Western Endoscopy Practice. Gastroenterology 2018; 154:1887-1900.e5. [PMID: 29486200 DOI: 10.1053/j.gastro.2018.01.068] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/11/2022]
Abstract
Endoscopic submucosal dissection was developed in Japan, early in this century, to provide a minimally invasive yet curative treatment for the large numbers of patients with early gastric cancer identified by the national screening program. Previously, the majority of these patients were treated surgically at substantial cost and with significant risk of short- and long-term morbidity. En-bloc excision of these early cancers, most with a limited risk of nodal metastasis, allowed complete staging of the tumor, stratification of the subsequent therapeutic approach, and potential cure. This transformative innovation changed the nature of endoscopic treatment for superficial mucosal neoplasia and, ultimately, for the first time allowed endoscopists to assert that the early cancer had been definitively cured. Subsequently, Western endoscopists have increasingly embraced the therapeutic possibilities offered by endoscopic submucosal dissection, but with some justifiable scientific caution. Here we provide an evidence-based critical appraisal of the role of endoscopic submucosal dissection in advanced endoscopic tissue resection.
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Affiliation(s)
- Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.
| | - Horst Neuhaus
- Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Jacques J Bergman
- Academic Medical Centre, Department of Gastroenterology and Hepatology, Amsterdam, Netherlands
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14
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Niclauss N, Chevallay M, Frossard JL, Mönig SP. [Surgical strategy for early stage carcinoma of the esophagus]. Chirurg 2018; 89:339-346. [PMID: 29392342 DOI: 10.1007/s00104-018-0589-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Early stage carcinomas of the esophagus are histologically differentiated into adenocarcinomas and squamous cell carcinomas and subdivided into mucosal (m1-3) and submucosal (sm1-3) carcinomas depending on the infiltration depth. While the prevalence of lymph node metastases in mucosal carcinomas is very low, the probability of lymph node metastases increases from submucosal infiltration with increasing depth. According to the current German S3 guidelines endoscopic resection is the recommended treatment strategy for mucosal adenocarcinoma without histological risk factors (lymphatic invasion [L1], venous invasion [V1], poorly differentiated [>G2], microscopic residual disease [R1] at the deep resection margin). For superficial submucosal infiltration (sm1) without histological risk factors endoscopic resection can also be carried out, whereby in this case the guidelines make a stronger recommendation for esophagectomy. For squamous cell carcinoma endoscopic resection is indicated for an infiltration depth up to middle layer mucosal carcinoma (m2) without histological risk factors. Outside of these criteria an esophageal resection should always be carried out. The surgical gold standard is a subtotal abdominothoracic esophagectomy with two-field lymphadenectomy. Alternative procedures are total esophagectomy in proximal esophageal carcinoma and transhiatal extended gastrectomy for carcinoma of the cardia. Limited proximal or distal esophageal resections can be performed in proximal or distal mucosal carcinoma without the possibility of endoscopic resection; however, partial resections are not superior in terms of functional results and are not oncologically equivalent due to limited lymphadenectomy. Minimally invasive procedures show good oncological results and reduce the morbidity of radical esophagectomy. Reduced morbidity might be an argument for surgical resection in borderline cases between endoscopic and surgical resection.
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Affiliation(s)
- N Niclauss
- Service de chirurgie viscérale, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, 1205, Genf, Schweiz
| | - M Chevallay
- Service de chirurgie viscérale, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, 1205, Genf, Schweiz
| | - J L Frossard
- Service de gastroentérologie et hépatologie, Hôpitaux Universitaires de Genève, Genf, Schweiz
| | - S P Mönig
- Service de chirurgie viscérale, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, 1205, Genf, Schweiz.
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15
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Haist T, Knabe M, May A, Lorenz D. [Endoscopic and surgical treatment of early gastric and esophageal carcinoma]. Chirurg 2017; 88:997-1004. [PMID: 29110039 DOI: 10.1007/s00104-017-0543-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The treatment of early gastric (EGC) and esophageal carcinomas (EEC) is an interdisciplinary challenge. The risk of lymph node metastasis (LNM) is the crucial point in choosing the correct treatment option. OBJECTIVE This article gives an overview of the current treatment options and provides help in choosing the correct therapy. METHOD Current concepts and therapy algorithms are presented on the basis of a literature review and data from our own center. RESULTS Endoscopic submucosal dissection (ESD) is recommended for mucosal gastric cancer with good or moderate differentiation (G1,2) without macroscopic ulceration, in elevated type lesions smaller than 2 cm in size or depressed lesions smaller than 1 cm in size. In additional chromoendoscopy should be carried out. The extent of surgical resection is defined by the location of the tumor. A safety margin of at least 3 cm should be applied in distal gastric resections whereas the first line goal in gastrectomy is to achieve an R0 resection. In cN0 tumors a D1 lymphadenectomy (LA) seems to be sufficient. Minimally invasive techniques currently show promising results especially for a subtotal resection. The treatment strategy in EEC differs depending on the tumor entity. Mucosal squamous cell carcinoma with high risk factors (L1,V1) and all cN0 submucosal tumors without the detection of LNM should be referred to primary surgical resection. Early stage cN+ squamous cell carcinomas should be preoperatively treated with chemoradiotherapy. Adenocarcinoma with infiltration of the deeper submucosa (sm2,3) and high-risk sm1 tumors require surgical treatment. The standard operating procedure for EEC is an Ivor Lewis esophagectomy with 2‑field LA preferably performed as a hybrid or by a completely minimally invasive procedure. The procedure of choice in endoscopic resection of EEC is resection with the suck and cut technique.
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Affiliation(s)
- T Haist
- Abteilung Allgemein- und Viszeralchirurgie, Sana Klinikum Offenbach, Starkenburgring 66, 63069, Offenbach, Deutschland
| | - M Knabe
- Medizinische Klinik II/IV, Sana Klinikum Offenbach, Offenbach, Deutschland
| | - A May
- Medizinische Klinik II/IV, Sana Klinikum Offenbach, Offenbach, Deutschland
| | - D Lorenz
- Abteilung Allgemein- und Viszeralchirurgie, Sana Klinikum Offenbach, Starkenburgring 66, 63069, Offenbach, Deutschland.
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16
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Abstract
Endoscopic therapies have become the standard of care for most cases of Barrett's esophagus with high-grade dysplasia or intramucosal adenocarcinoma. Despite a rapid and dramatic evolution in treatment paradigms, esophagectomy continues to occupy a place in the therapeutic armamentarium for superficial esophageal neoplasia. The managing physician must remain cognizant of the limitations of endoscopic approaches and consider surgical resection when they are exceeded. Esophagectomy, performed at experienced centers for appropriately selected patients with early-stage disease can be undertaken with the expectation of cure as well as low mortality, acceptable morbidity, and good long-term quality of life.
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Affiliation(s)
- Thomas J Watson
- Division of Thoracic and Esophageal Surgery, Department of Surgery, MedStar Washington, Georgetown University School of Medicine, 3800 Reservoir Road Northwest, 4PHC, Washington, DC 20007, USA.
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17
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Lymph Node Retrieval is Inferior in the Modified Merendino Resection for Early Barrett’s Carcinoma: A Matched-Pair Comparison with Ivor Lewis Resection. World J Surg 2017; 41:2583-2590. [PMID: 28550435 DOI: 10.1007/s00268-017-4061-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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18
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Manner H, Wetzka J, May A, Pauthner M, Pech O, Fisseler-Eckhoff A, Stolte M, Vieth M, Lorenz D, Ell C. Early-stage adenocarcinoma of the esophagus with mid to deep submucosal invasion (pT1b sm2-3): the frequency of lymph-node metastasis depends on macroscopic and histological risk patterns. Dis Esophagus 2017; 30:1-11. [PMID: 26952572 DOI: 10.1111/dote.12462] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The rate of lymph-node (LN) metastasis in early adenocarcinoma (EAC) of the esophagus with mid to deep submucosal invasion (pT1b sm2/3) has not yet been precisely defined. The aim of the this study was to evaluate the rate of LN metastasis in pT1b sm2/3 EAC depending on macroscopic and histological risk patterns to find out whether there may also be options for endoscopic therapy as in cancers limited to the mucosa and the upper third of the submucosa. A total of 1.718 pt with suspicion of EAC were referred for endoscopic treatment (ET) to the Dept. of Internal Medicine II at HSK Wiesbaden 1996-2010. In 230/1.718 pt, the suspicion (endoscopic ultrasound, EUS) or definitive diagnosis of pT1b EAC (ER/surgery) was made. Of these, 38 pt had sm2 lesions, and 69 sm3. Rate of LN metastasis was analyzed depending on risk patterns: histologically low-risk (hisLR): G1-2, L0, V0; histologically high-risk (hisHR): ≥1 criterion not fulfilled; macroscopically low-risk (macLR): gross tumor type I-II, tumor size ≤2 cm; macroscopically high-risk (macHR): ≥1 criterion not fulfilled; combined low-risk (combLR): hisLR+macLR; combined high-risk (combHR): at least 1 risk factor. LN rate was only evaluated in pt who had proven maximum invasion depth of sm2/sm3, and who in case of ET had a follow-up (FU) by EUS of at least 24 months. 23/38 pt with pT1b sm2 lesions and 39/69 pt with sm3 lesions fulfilled our inclusion criteria. In the pT1b sm2 group, rate of LN metastasis in the hisLR, hisHR, combLR, and combHR groups were 8.3% (1/12), 36.3% (4/11), 0% (0/5), and 27.8% (5/18). In the pT1b sm3 group, rate of LN metastasis in the hisLR, hisHR, combLR and combHR groups were 28.6% (2/7), 37.5% (12/32), 25% (1/4), and 37.1% (13/35). 30-day mortality of surgery was 1.7% (1/58 pt). In EAC with pT1b sm2/3 invasion, the frequency of LN metastasis depends on macroscopic and histological risk patterns. Surgery remains the standard treatment, because the rate of LN metastasis appears to be higher than the mortality risk of surgery. Whether a highly selected group of pT1b sm2 patients with a favourable risk pattern may be candidates for endoscopic therapy cannot be decided until the results of larger case volumes are available.
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Affiliation(s)
- H Manner
- Department of Internal Medicine II, HSK Hospital, Teaching Hospital of the University Medicine of Mainz, Wiesbaden, Germany
| | - J Wetzka
- Department of Internal Medicine II/IV, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
| | - A May
- Department of Internal Medicine II/IV, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
| | - M Pauthner
- Department of General and Visceral Surgery, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
| | - O Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | | | - M Stolte
- Institute of Pathology, Kulmbach Hospital, Germany
| | - M Vieth
- Institute of Pathology, Bayreuth Hospital, Germany
| | - D Lorenz
- Department of General and Visceral Surgery, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
| | - C Ell
- Department of Internal Medicine II/IV, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
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19
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18FDG-PET-CT improves specificity of preoperative lymph-node staging in patients with intestinal but not diffuse-type esophagogastric adenocarcinoma. Eur J Surg Oncol 2017; 43:196-202. [DOI: 10.1016/j.ejso.2016.08.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 08/12/2016] [Indexed: 01/01/2023] Open
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20
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Zhou Y, Du J, Li H, Luo J, Chen L, Wang W. Clinicopathologic analysis of lymph node status in superficial esophageal squamous carcinoma. World J Surg Oncol 2016; 14:259. [PMID: 27729036 PMCID: PMC5059900 DOI: 10.1186/s12957-016-1016-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 10/04/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Endoscopic approaches are gradually considered as a reliable treatment of intramucosal esophageal squamous carcinoma. However, endoscopic resection (ER) is limited by the potential lymph node metastasis (LNM) at various depths of mucosal and submucosal invasion. METHODS We conducted a retrospective review of 498 patients with pT1 superficial esophageal squamous carcinoma (SESC) who underwent surgical resection from January 2008 to August 2015. Pathological characteristics of tumors including location, size, appearance, differentiation, invasion depth, and nodal status were reviewed, and risk factors were analyzed. RESULTS LNM was found in 0.0, 2.7, 6.3, 18.2, 15.9, and 34.3 % of the m1, m2, m3, sm1, sm2, and sm3 lesions, respectively. Univariate logistic regression identified the presence of the tumor size > 2 cm (p < 0.05), the presence of the poor tumor differentiation (p < 0.05), and the depth of tumor invasion (p < 0.05) and angiolymphatic invasion (p < 0.05) to be the important risk factors associated with the prevalence of tumor-positive lymph nodes. These findings were confirmed in multivariate logistic regression as independent predictors for LNM. CONCLUSIONS ER is considered as a reliable treatment of m1 to m2 lesions. Radical surgical resection (SR) is the standard and irreplaceable therapy of sm1 to sm3 lesions. Patients with m3 lesions should undergo ER as the initial procedure for diagnosis. And this treatment is supported only by a successful description of the tumor's characteristics, including (1) only muscularis mucosa invasion and without invasion of the resection margins and (2) without any risk predictors for LNM. Otherwise, SR is recommended.
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Affiliation(s)
- Yue Zhou
- Department of Cardiothoracic Surgery, First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029 China
| | - Junjie Du
- Department of Cardiothoracic Surgery, First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029 China
| | - Hai Li
- Department of Pathology, First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029 China
| | - Jinhua Luo
- Department of Cardiothoracic Surgery, First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029 China
| | - Liang Chen
- Department of Cardiothoracic Surgery, First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029 China
| | - Wei Wang
- Department of Cardiothoracic Surgery, First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029 China
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21
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Noordman BJ, Wijnhoven BPL, van Lanschot JJB. Optimal surgical approach for esophageal cancer in the era of minimally invasive esophagectomy and neoadjuvant therapy. Dis Esophagus 2016; 29:773-779. [PMID: 26382935 DOI: 10.1111/dote.12407] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The optimal surgical technique for the potentially curative treatment of patients with esophageal cancer is still under debate. The transhiatal esophagectomy (THE) with limited lymphadenectomy mainly focuses on a decrease of postoperative morbidity and mortality by preventing a formal thoracotomy. The transthoracic esophagectomy (TTE) with extended two-field lymphadenectomy attempts to improve the radicality of the resection and thus to increase locoregional tumor control, but is associated with increased postoperative morbidity. The recent introduction of different minimally invasive techniques probably decreases postoperative morbidity following TTE, with reduction of especially pulmonary complications, but high-quality evidence is still limited. It is widely agreed that extended lymphadenectomy as performed during TTE provides the benefit of more accurate staging, but its effect on improvement of survival is still debated. The literature on this topic is contradictory and the choice of surgical approach is primarily driven by personal opinions and institutional preferences. Moreover, the available evidence is mainly based on patients who underwent surgery alone without neoadjuvant therapy. Results of recent studies suggest that neoadjuvant chemoradiotherapy abolishes any possibly positive effect of extended lymphadenectomy as performed during TTE on survival, but this effect should be confirmed in future research. This review gives an overview and reflects the authors' personal view on the role of TTE and THE in the treatment of potentially curative treatment of patients with locally advanced esophageal cancer in the era of minimally invasive esophagectomy and neoadjuvant treatment and outlines future research perspectives.
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Affiliation(s)
- B J Noordman
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J J B van Lanschot
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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22
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Kauppila JH, Lagergren J. The surgical management of esophago-gastric junctional cancer. Surg Oncol 2016; 25:394-400. [PMID: 27916171 DOI: 10.1016/j.suronc.2016.09.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/04/2016] [Accepted: 09/13/2016] [Indexed: 12/14/2022]
Abstract
The best available surgical strategy in the treatment of resectable esophago-gastric junctional (EGJ) cancer is a controversial topic. In this review we evaluate the current literature and scientific evidence examining the surgical treatment of locally advanced EGJ cancer by comparing esophagectomy with gastrectomy, transhiatal with transthoracic esophagectomy, minimally invasive with open esophagectomy, and less extensive with more extensive lymphadenectomy. We also assess endoscopic procedures increasingly used for early EGJ cancer. The current evidence does not favor any of the techniques over the others in terms of oncological outcomes. Health-related quality of life may be better following gastrectomy compared to esophagectomy. Minimally invasive procedures might be less prone to surgical complications. Endoscopic techniques are safe and effective alternatives for early-stage EGJ cancer in the short term, but surgical treatment is the mainstay in fit patients due to the risk of lymph node metastasis. Any benefit of lymphadenectomy extending beyond local or regional nodes is uncertain. This review demonstrates the great need for well-designed clinical studies to improve the knowledge in how to optimize and standardize the surgical treatment of EGJ cancer.
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Affiliation(s)
- Joonas H Kauppila
- Department of Surgery and Medical Research Center Oulu, University of Oulu, P.O. Box 5000, 90014 Oulu, Finland; Oulu University Hospital, P.O. Box 21, 90029 Oulu, Finland; Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden.
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden; Division of Cancer Studies, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, England, UK
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23
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Schölvinck D, Künzli H, Meijer S, Seldenrijk K, van Berge Henegouwen M, Bergman J, Weusten B. Management of patients with T1b esophageal adenocarcinoma: a retrospective cohort study on patient management and risk of metastatic disease. Surg Endosc 2016; 30:4102-13. [PMID: 27357927 DOI: 10.1007/s00464-016-5071-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/21/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Esophagectomy for submucosal (T1b) esophageal adenocarcinoma (EAC) is performed in order to optimize patient outcomes given the risk of concurrent lymph node metastases (LNM). However, not seldom, comorbidity precludes these patients from surgery. Therefore, the aim of our study was to assess the course of follow-up after treatment in submucosal EAC patients undergoing surgery versus conservative therapy and to evaluate the incidence of metastatic disease. METHODS Between 2001 and 2012, all patients undergoing diagnostic endoscopic resection for EAC in two centers were reviewed. Only patients with histopathologically proven submucosal tumor invasion were included. Submucosal EACs were divided into tumors that were removed radically (R0) and irradically (R1). Subsequently, in the R0 group, EACs were classified as either low risk (LR; submucosal invasion <500 nm, G1-G2, no LVI) or high risk (HR; deep submucosal invasion >500 nm, G3-G4 and/or LVI). Metastatic disease was defined as LNM in surgical resection specimen and/or evidence of malignant disease during follow-up (FU). RESULTS Sixty-nine patients with a submucosal EAC were included [23 R1-resections and 46 R0-resection (14 R0-LR and 32 R0-HR)]. Twenty-six patients underwent surgical treatment (1 R0-LR, 12 R0-HR and 13 R1). None of the 14 R0-LR patients developed metastatic disease after a median FU of 60 months. In the R0-HR group and R1 group, metastatic disease was diagnosed in 16 and 30 % of patients, respectively. Surgical patients tended to have a better overall survival than non-surgical patients (p = 0.09). Tumor-related deaths, however, were 12 % in both groups. CONCLUSIONS In LR submucosal EAC, the risk of metastatic disease appears to be very low. In deep submucosal EAC (either R0- or R1-resection), the rate of metastatic disease is lower than reported in earlier surgical series. Given the reasonable disease-free survival and high background mortality, conservative management of these patients seems to be a valid alternative for surgery in selected cases.
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Affiliation(s)
- Dirk Schölvinck
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Hannah Künzli
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Sybren Meijer
- Department of Pathology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Kees Seldenrijk
- Department of Pathology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands
| | | | - Jacques Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Bas Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands. .,Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Gertler R, Richter J, Stecher L, Nitsche U, Feith M. What to do after R1-resection of adenocarcinomas of the esophagogastric junction? J Surg Oncol 2016; 114:428-33. [PMID: 27333949 DOI: 10.1002/jso.24329] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/31/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES The management of R1-resected adenocarcinoma of the esophagogastric junction (AEG) is unclear. We aimed to identify risk factors and prevalence of R1 resections, their recurrence and prognosis, and efficacy of postoperative therapy. METHODS A single center cohort of 766 consecutive patients undergoing curative intent resection for AEG was analyzed retrospectively. RESULTS R1-resection rate was 13%. Poorer tumor differentiation, higher T-, N-, and UICC/AJCC-stages were associated with R1-resections. Compared to R0-resected patients, R1-resected patients had a higher incidence of tumor recurrence (77% vs. 32%; P < 0.001) and worse overall survival (5-year overall survival 43% vs. 10%; P < 0.001). The pattern of recurrence did not differ between R0- and R1-resections with distant metastases in 90% and 87% of patients with tumor recurrence. We found a trend towards better overall survival for R1-resected patients receiving postoperative therapy compared to R1-resected patients without postoperative therapy (median 17.4 vs. 14.6 months, P = 0.056). CONCLUSIONS The association of R1-resections with poor tumor characteristics allows for identification of patients at risk for R1-resection. As in R0-resections, tumor recurrence in R1-resections is mainly systemic, not local. The potential benefit of additive local postoperative therapies in R1-resected patients must be balanced against overall prognosis and therapy-specific morbidity and mortality. J. Surg. Oncol. 2016;114:428-433. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ralf Gertler
- Chirurgische Klinik und Poliklinik, Technische Universität München, Munich, Germany
| | - Julia Richter
- Chirurgische Klinik und Poliklinik, Technische Universität München, Munich, Germany
| | - Lynne Stecher
- Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Ulrich Nitsche
- Chirurgische Klinik und Poliklinik, Technische Universität München, Munich, Germany
| | - Marcus Feith
- Chirurgische Klinik und Poliklinik, Technische Universität München, Munich, Germany
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Gamboa AM, Kim S, Force SD, Staley CA, Woods KE, Kooby DA, Maithel SK, Luke JA, Shaffer KM, Dacha S, Saba NF, Keilin SA, Cai Q, El-Rayes BF, Chen Z, Willingham FF. Treatment allocation in patients with early-stage esophageal adenocarcinoma: Prevalence and predictors of lymph node involvement. Cancer 2016; 122:2150-7. [PMID: 27142247 DOI: 10.1002/cncr.30040] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/15/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND In considering treatment allocation for patients with early esophageal adenocarcinoma, the incidence of lymph node metastasis is a critical determinant; however, this has not been well defined or stratified by the relevant clinical predictors of lymph node spread. METHODS Data from the Surveillance, Epidemiology, and End Results database of the National Cancer Institute were abstracted from 2004 to 2010 for patients with early-stage esophageal adenocarcinoma. The incidence of lymph node involvement for patients with Tis, T1a, and T1b tumors was examined and was stratified by predictors of spread. RESULTS A total of 13,996 patients with esophageal adenocarcinoma were evaluated. Excluding those with advanced, metastatic, and/or invasive (T2-T4) disease, 715 patients with Tis, T1a, and T1b tumors were included. On multivariate analysis, tumor grade (odds ratio [OR], 2.76; 95% confidence interval [95% CI], 1.58-4.82 [P<.001]), T classification (OR, 0.47; 95% CI, 0.24-0.91 [P =.025]), and tumor size (OR, 2.68; 95% CI, 1.48-4.85 [P = .001]) were found to be independently associated with lymph node metastases. There was no lymph node spread noted with Tis tumors. For patients with low-grade (well or moderately differentiated) tumors measuring <2 cm in size, the risk of lymph node metastasis was 1.7% for T1a (P<.001) and 8.6% for T1b (P = .001) tumors. CONCLUSIONS For patients with low-grade Tis or T1 tumors measuring ≤2 cm in size, the incidence of lymph node metastasis appears to be comparable to the mortality rate associated with esophagectomy. For highly selected patients with early esophageal adenocarcinomas, the results of the current study support the recommendation that local endoscopic resection can be considered as an alternative to surgical management when followed by rigorous endoscopic and radiographic surveillance. Cancer 2016;122:2150-7. © 2016 American Cancer Society.
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Affiliation(s)
- Anthony M Gamboa
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sungjin Kim
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Seth D Force
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kevin E Woods
- Interventional Endoscopy, Gastroenterology and Nutrition, Cancer Treatment Centers of America, Newnan, Georgia
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jennifer A Luke
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Katherine M Shaffer
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sunil Dacha
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nabil F Saba
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Steven A Keilin
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Qiang Cai
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bassel F El-Rayes
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Zhengjia Chen
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Pauthner M, Haist T, Mann M, Lorenz D. Surgical Therapy of Early Carcinoma of the Esophagus. VISZERALMEDIZIN 2015; 31:326-30. [PMID: 26989387 PMCID: PMC4789960 DOI: 10.1159/000441049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background The modern therapy of early esophageal carcinomas (pT1) requires an excellent cooperation between experienced gastroenterologists, pathologists, and esophageal surgeons. While endoscopic resection (ER) is accepted as the standard curative treatment for mucosal esophageal carcinomas, submucosal tumors are regarded as a strict indication for surgery. There is an ongoing discussion about the operative approach and the extent of lymph node dissection in these cases. Methods A literature review was performed to evaluate the operative treatment of early esophageal cancer. In view of oncological risk factors, treatment strategies, and operative procedures, current studies are summarized and compared to the results of our own center. Results and Conclusion In early esophageal cancer, lymph node involvement is the only independent risk factor for survival and recurrence rates. There is evidence that infiltrated lymph nodes (N+) are significantly correlated with tumor infiltration depth, lymphovascular (L1) and microvascular invasion (V1), and poor tumor differentiation (G3). Several studies suggest that early squamous cell carcinomas (eSCCs) and early adenocarcinomas (eACs) have a different tumor biology and therefore need a different treatment strategy. While eSCCs in stage m1 and m2 can be cured by ER, tumors infiltrating the submucosal layer (sm1-3) show a high rate of lymph node metastasis (LNM); thus, surgical resection (SR) is clearly indicated. In tumors with invasion into the deep mucosa (m3) the risk of LNM is up to 11%; however, reliable data are rare and the type of therapy should be discussed with the patients individually. In eACs, ER is the standard curative treatment for all mucosal tumors (m1-m4) and sm1 tumors with low-risk constellation (G1, L0, VO, R0). All high-risk sm1 tumors and those with deeper submucosal infiltration (sm2, sm3) show a high rate of LNM and require SR. The standard operative procedure for early esophageal carcinomas is an Ivor-Lewis esophagectomy with radical, at least two-field lymphadenectomy.
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Affiliation(s)
- Michael Pauthner
- Department of General and Visceral Surgery, Sana Klinikum Offenbach GmbH, Teaching Hospital of the University Medicine of Frankfurt am Main, Offenbach, Germany
| | - Thomas Haist
- Department of General and Visceral Surgery, Sana Klinikum Offenbach GmbH, Teaching Hospital of the University Medicine of Frankfurt am Main, Offenbach, Germany
| | - Markus Mann
- Department of General and Visceral Surgery, Sana Klinikum Offenbach GmbH, Teaching Hospital of the University Medicine of Frankfurt am Main, Offenbach, Germany
| | - Dietmar Lorenz
- Department of General and Visceral Surgery, Sana Klinikum Offenbach GmbH, Teaching Hospital of the University Medicine of Frankfurt am Main, Offenbach, Germany
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Dubecz A, Kern M, Solymosi N, Schweigert M, Stein HJ. Predictors of Lymph Node Metastasis in Surgically Resected T1 Esophageal Cancer. Ann Thorac Surg 2015; 99:1879-85; discussion 1886. [PMID: 25929888 DOI: 10.1016/j.athoracsur.2015.02.112] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/21/2015] [Accepted: 02/06/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The application of endoscopic therapies for early cancers of the esophagus is limited by the possible presence of regional lymph node metastases. Our objective was to determine the prevalence and predictors of lymph node metastases in patients with pT1 carcinoma of the esophagus and the gastric cardia. METHODS The National Cancer Institute's Surveillance Epidemiology and End Results Database (2004 to 2010) was used to identify all patients with pT1 carcinomas who underwent primary surgical resection for squamous cell carcinoma (SCC) or adenocarcinoma (EAC) of the esophagus and of the esophagogastric junction (AEG). Prevalence of lymph node metastases was assessed, and survival in all types of cancer was calculated. Multivariate logistic regression was used to identify factors predicting positive lymph node status. RESULTS There were 1,225 patients (84% male), with a mean age of 64 ± 10 years, and 90% were white. Intramucosal disease was present in 44% of patients, and submucosal invasion (T1b) was present in 692 (56%). Prevalence of lymph node metastases in EAC, SCC, and AEG was 6.4%, 6.9%, and 9.5% for pT1a tumors and 19.6%, 20%, and 22.9% for pT1b tumors, respectively. In patients with more than 23 lymph nodes removed during resection, prevalence of lymph node metastases in EAC, SCC, and AEG was 8.1%, 25%, and 7.4% for pT1a tumors and 27.8%, 33.3%, and 22% for pT1b tumors, respectively. Positive lymph node status was associated with worse overall 5-year survival in EAC (N0 vs N+: 78% vs 52%) and AEG (N0 vs N+: 83% vs 44%) but did not have a significant effect on the long-term survival of patients with SCC. Infiltration of the submucosa, tumor size exceeding 10 mm, and poor tumor differentiation were independently associated with the risk of nodal disease. Prevalence of lymph node metastasis negative for these three risk factors was only 4.8%. CONCLUSIONS Prevalence of lymph node metastasis in early esophageal cancer is high in patients with T1 cancer. Inadequate lymphadenectomy underestimates lymph node status. Endoscopic treatment can be considered only in a select group of patients with early esophageal cancer.
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Affiliation(s)
- Attila Dubecz
- Department of Surgery, Private Medical University Nürnberg, Nuremberg, Germany.
| | - Marcus Kern
- Department of Surgery, Private Medical University Nürnberg, Nuremberg, Germany
| | - Norbert Solymosi
- Faculty of Veterinary Science, Szent István University Budapest, Hungary
| | - Michael Schweigert
- Department of Thoracic Surgery, Klinikum Dresden-Friedrichstadt, Dresden, Germany
| | - Hubert J Stein
- Department of Surgery, Private Medical University Nürnberg, Nuremberg, Germany
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Espinel J, Pinedo E, Ojeda V, Rio MGD. Multiband mucosectomy for advanced dysplastic lesions in the upper digestive tract. World J Gastrointest Endosc 2015; 7:370-380. [PMID: 25901216 PMCID: PMC4400626 DOI: 10.4253/wjge.v7.i4.370] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 12/20/2014] [Accepted: 01/19/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic resection (ER) is at present an accepted treatment for superficial gastrointestinal neoplasia. ER provides similar efficacy to surgery; however, it is minimally invasive and less expensive. Endoscopic mucosal resection (EMR) is superior to biopsy for diagnosing advanced dysplasia and can change the diagnostic grade and the management. Several EMR techniques have been described that are alternatively used dependent upon the endoscopist personal experience, the anatomic conditions and the endoscopic appearance of the lesion to be resected. The literature suggests that EMR offers comparable outcomes to surgery for selected indications. EMR techniques using a cap fitted endoscope and EMR using a ligation device [multiband mucosectomy (MBM)] are the most frequently use. MBM technique does not require submucosal injection as with the endoscopic resection-cap technique, multiple resections can be performed with the same snare, pre-looping the endoscopic resection-snare in the ridge of the cap is not necessary, MBM does not require withdrawal of the endoscope between resections and up to six consecutive resections can be performed. This reduces the time and cost required for the procedure, while also reducing patient discomfort. Despite the increasing popularity of MBM, data on the safety and efficacy of this technique in upper gastrointestinal lesions with advanced dysplasia, defined as those lesions that have high-grade dysplasia or early cancer, is limited.
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Zapletal C, Heesen C, Origer J, Pauthner M, Pech O, Ell C, Lorenz D. Quality of life after surgical treatment of early Barrett's cancer: a prospective comparison of the Ivor-Lewis resection versus the modified Merendino resection. World J Surg 2015; 38:1444-52. [PMID: 24378548 DOI: 10.1007/s00268-013-2410-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The Merendino (MER) procedure has been evaluated as an alternative to transthoracic esophageal resection (TER) for early stage Barrett's carcinoma. Apart from reducing morbidity and mortality, improvements concerning postoperative health-related quality of life (HRQL) have been postulated. The aim of our study was to compare HRQL between these procedures. MATERIALS AND METHODS Between July 2000 and July 2007, 117 patients with early Barrett's carcinoma underwent surgery. Patients with tumor recurrence were excluded from the study. HRQL was assessed 1 and 2 years after surgery using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (EORTC-QLQ-C30) and the QLQ-OES18 module. Patients recently diagnosed with early Barrett's carcinoma served as controls. Symptoms that showed a difference of more than ten between the control and the study groups were considered clinically relevant and were tested for significant differences between the study groups using the Mann-Whitney U test (p < 0.05). RESULTS The response rates for the questionnaires ranged between 70 and 93 %. In the MER group, more items reflected a clinical relevant impairment of HRQL than in the TER group. Significant complaints in the MER group included nausea/vomiting, appetite loss, local pain, difficulties with social eating, and choking. Moreover, we found a significant restriction concerning global health and emotional and social functioning in this group 1 year after surgery. 2 years postoperatively, hardly any differences between the operative techniques could be detected. The only symptom in favor of the MER procedure was a better dysphagia score postoperatively. CONCLUSION Our study suggests that MER procedure is not superior to subtotal esophagectomy with regard to HRQL.
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Affiliation(s)
- Ch Zapletal
- Department of Surgery, Dr. Horst-Schmidt-Klinik, Ludwig-Erhard-Str. 100, 65199, Wiesbaden, Germany,
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Manner H, Pech O, Heldmann Y, May A, Pauthner M, Lorenz D, Fisseler-Eckhoff A, Stolte M, Vieth M, Ell C. The frequency of lymph node metastasis in early-stage adenocarcinoma of the esophagus with incipient submucosal invasion (pT1b sm1) depending on histological risk patterns. Surg Endosc 2014; 29:1888-96. [PMID: 25294553 DOI: 10.1007/s00464-014-3881-3] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 08/27/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND A prerequisite for endoscopic treatment (ET) of not only mucosal, but also submucosal early adenocarcinoma of the esophagus (EAC) would be a rate of lymph node (LN) metastasis below the mortality rate of esophagectomy (2-5%). The aim of the present study was to evaluate the rate of LN metastasis in patients with pT1b sm1 EAC. METHODS 1996-2010, 1,718 patients with suspicion of EAC were referred to the Department of Internal Medicine II at HSK Wiesbaden. In 123/1718 patients, the suspicion (endoscopic ultrasound, EUS) or definitive diagnosis of sm1 EAC (ER/surgery) was made. Rate of LN metastasis was analyzed separately for low-risk (LR; G1-2, L0, V0) and high-risk lesions (HR; G3, L1, V1; ≥ 1 risk factor). LN metastasis was only evaluated in patients who had a proven maximum invasion depth of sm1 (ER and/or surgery), and who in case of ET had a follow-up (FU) by EUS of at least 24 months. RESULTS Of the 72/123 patients included into the study, 49 patients had LR (68%) and 23 HR lesions (32%). In endoscopically treated LR patients (37/49), mean EUS-FU was 60 ± 30 mo (range 25-146); in HR patients undergoing ET (6/23), it was 63 ± 17 mo (46-86; p = 0.4). Mean number of resected LN was 27 ± 16 (12-62) in operated LR patients and 27 ± 10 (12-47) in HR-patients. The rate of LN metastasis was 2% in the LR (1 patient) and 9% in the HR group (2 patients; p = 0.24). Mortality of esophagectomy was 3%. CONCLUSIONS The rate of LN metastasis in pT1b sm1 early adenocarcinoma with histological LR pattern was lower than the mortality rate of esophagectomy. ER may therefore be used alternatively to surgery in this group of patients.
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Affiliation(s)
- Hendrik Manner
- Department of Internal Medicine II, HSK Hospital, Teaching Hospital of the University Medicine of Mainz, Klinik Innere Medizin II, HSK Wiesbaden, Ludwig-Erhard-Strasse 100, 65199, Wiesbaden, Germany,
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Ronellenfitsch U, Najmeh S, Andalib A, Perera RM, Rousseau MC, Mulder DS, Ferri LE. Functional outcomes and quality of life after proximal gastrectomy with esophagogastrostomy using a narrow gastric conduit. Ann Surg Oncol 2014; 22:772-9. [PMID: 25212836 DOI: 10.1245/s10434-014-4078-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The best surgical approach for tumors of the proximal stomach remains controversial. For proximal gastrectomy (PG), the evidence regarding quality of life (QoL) and functional outcomes is controversial. Moreover, there are limited data from non-Asian settings. METHODS All patients who underwent PG from September 2005 to July 2013 were identified from an institutional database. Demographic, perioperative and pathologic characteristics were retrieved. Symptom scores (0 = best/4 = worst) for reflux symptoms, dysphagia and validated QoL metrics (FACT scale, where a higher score is better) were assessed during early and late follow-up. Eligible patients for analysis were those with no evidence of recurrence. RESULTS Of 465 upper gastrointestinal cancer resections, 50 were PG for adenocarcinoma (42; 84%), neuroendocrine carcinoma (5; 10%) or other pathologies (3; 6%). R0 resection was achieved in 44 (89.8%) of 49 patients with malignant tumors. Median lymph node collection was 32 (range 7-57). QoL scores did not differ from preoperative to early follow-up but increased compared to both at late follow-up [preoperative, 125 (interquartile range 105-140); early follow-up, 122.5 (97-142); late follow-up, 147 (132-159); p < 0.05]. At early and late follow-up, 9 (21.4%) of 42 and 10 (33.3%) of 30 patients reported reflux symptoms, but most were mild. Endoscopic signs of esophagitis were found in 7 (29%) of 24 patients, but only two of these reported reflux symptoms. Conversely only three of eight patients with reflux symptoms had esophagitis on endoscopy. CONCLUSIONS Global QoL is not reduced early after PG, and increases compared to baseline at late follow-up. Although reflux symptoms are reported by a quarter of patients, most are mild, and there is little correlation with esophagitis. PG should remain a viable option in the management of proximal gastric tumors.
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Affiliation(s)
- Ulrich Ronellenfitsch
- Department of Surgery, Medical Faculty Mannheim of the University of Heidelberg, University Medical Centre Mannheim, Mannheim, Germany
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Ang TL, Seewald S. Endoluminal resection and tissue acquisition. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2014; 12:140-153. [PMID: 24609890 DOI: 10.1007/s11938-014-0010-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Endoscopic resection as curative treatment is feasible and indicated for gastrointestinal adenomas and early cancer limited to the mucosal layer and submucosal layers, where the risk for nodal and distant metastases is minimal. The initial technique of endoscopic resection, endoscopic mucosal resection, was limited by the inability to have en bloc resections for lesions larger than 2 cm. This meant that proper assessment of resection margins and depths was not possible in these cases, with the risk of incomplete resection and remnant lesions. In the last decade, the technique of endoscopic submucosal dissection was introduced, and this has allowed en bloc resection of superficial cancers of the esophagus, stomach, and colon. Cumulative data have shown high en bloc resection rates and excellent short-term and long-term outcomes when treatment inclusion criteria are adhered to. Endoscopic resection techniques were recently applied in the context of submucosal lesions. In the case of lesions located in the muscularis mucosa and submucosal layers, the gastrointestinal wall is not breached during endoscopic resection. However, in the case of submucosal lesion located in the muscularis propria layer, endoscopic mucosal resection or endoscopic submucosal dissection would result in perforation which may not be easily closed endoscopically. The technique of endoscopic submucosal tunneling was introduced in the context of peroral endoscopic myotomy for the treatment of achalasia. The principle was extended to the resection of tumors arising from the muscularis propria layer, with promising results.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Simei, Singapore, 529889,
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Abstract
OBJECTIVE To define prognostic risk factors in patients with early adenocarcinomas of the esophagus (eACEs) who were treated by esophagectomy. BACKGROUND Although endoscopic resection (ER) is more accepted for eACEs limited to the mucosa, the reported prevalence of lymph node metastases once the tumor infiltrates the submucosa seems to necessitate surgery in these cases. METHODS We analyzed the results of 168 patients who had an esophageal resection because of an eACE. On the basis of specimen histologies and clinical follow-up (median, 64 months), we investigated the influence of lymph node metastases (N+), tumor infiltration depth, tumor differentiation (G1-3), and lymphatic or venous infiltration (L+ or V+) on overall and tumor-specific survival and recurrence rates. RESULTS The 5-year survival rate was 79%. Lymph node infiltration was the only prognostic factor for the overall survival [hazard ratio (HR), 2.856; 1.314-6.207; P = 0.008], tumor-specific survival (HR, 8.336; 2.734-25.418; P < 0.001), and tumor recurrence (HR, 8.031; 3.041-21.206; P < 0.001) that was consistently present in all multivariate hazard Cox regression analyses. A total of 47% of the patients who had an N+ status developed tumor recurrences compared with 5.2% of those who had no lymph node involvement (P = <0.001). We found a significant correlation between N+ status and increasing depth of tumor infiltration (P = 0.004), lymphatic vessel infiltration (P = 0.002), tumor differentiation (G1 + G2 vs G3; P = 0.014) and vascular infiltration (P = 0.01). CONCLUSIONS Lymph node status is the only independent risk factor for survival and recurrence rates. Tumor infiltration depth correlates with the rate of the lymph node metastases, but a clear watershed between deep mucosal and submucosal infiltration does not exist. As a consequence, careful staging procedures, including diagnostic ER, are mandatory to determine which patients can be treated by ER and which require an esophagectomy.
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Hosogi H, Yoshimura F, Yamaura T, Satoh S, Uyama I, Kanaya S. Esophagogastric tube reconstruction with stapled pseudo-fornix in laparoscopic proximal gastrectomy: a novel technique proposed for Siewert type II tumors. Langenbecks Arch Surg 2014; 399:517-523. [PMID: 24424495 DOI: 10.1007/s00423-014-1163-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 01/03/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE The incidence of adenocarcinoma of the esophagogastric junction is increasing, but laparoscopic proximal gastrectomy is not widely accepted due to the absence of a standardized technique of reconstruction. This report describes a novel technique of esophagogastric tube reconstruction in laparoscopic proximal gastrectomy for Siewert type II tumors. METHODS Laparoscopic proximal gastrectomy, sometimes with transhiatal distal esophagectomy, was performed. After a perigastric, suprapancreatic, and lower thoracic paraesophageal lymphadenectomy, a gastric tube of 35-mm width was prepared. An esophagogastric tube anastomosis with pseudo-fornix was made with a no-knife linear stapler to prevent postoperative reflux esophagitis. RESULTS Fifteen patients with Siewert type II tumors underwent this operation. They included six patients with early-stage cancer, six at high risk for transhiatal total gastrectomy due to several comorbidities, and three who needed palliative tumor resection. The mean operation time was 315 min. One postoperative anastomotic leak was treated conservatively, and three anastomotic stenoses were resolved with endoscopic balloon dilatation. Postoperative 1-year follow-up endoscopy revealed four cases of reflux esophagitis that were well controlled by medication. CONCLUSIONS This new technique of reconstruction was feasible. With the advantage of a gastric tube, a tension-free anastomosis was possible even for bulky tumors that needed lower esophagectomy. Although long-term follow-up and a larger number of patients are required to evaluate long-term functional outcomes and oncological adequacy, our procedure has the potential of becoming a treatment of choice for early-stage Siewert type II tumors and/or for some selected high-risk patients who need tumor resection.
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Affiliation(s)
- Hisahiro Hosogi
- Department of Surgery, Osaka Red Cross Hospital, 5-30, Fudegasaki-cho, Tennouji-ku, Osaka, 543-8555, Japan,
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35
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Abstract
OBJECTIVE To determine the prevalence and localization of lymph node metastases in patients with pT1 carcinoma of the esophagus, esophagogastric junction, and stomach. BACKGROUND Retrospective analysis and topographic description. METHODS We included 793 consecutive patients with pT1 carcinomas who underwent primary surgery for squamous cell carcinoma (SCC) of the esophagus, adenocarcinomas of the esophagogastric junction (AEG), or gastric cancer (GC). Clinical records and pathology reports were reviewed, and the prevalence and topography of lymph node metastases were identified. RESULTS The prevalence of lymph node metastases in SCC, AEG, and GC was 7%, 0%, and 5% for pT1a tumors and 24%, 18%, and 14% for pT1b tumors, respectively. Positive lymph node status was associated with worse overall survival (P<0.001). Not only infiltration of the submucosa (P=0.002) but also lymphatic vessel invasion (P<0.001), multifocal tumor growth (P=0.001), lower patient age (P=0.001), and poor tumor differentiation (P=0.05) were associated with nodal disease. These 5 parameters allowed the compilation of a nomogram to estimate the individual risk of lymph node metastases. In SCC, lymph node metastases were found from the neck to the celiac axis. In AEG, nodal disease was limited to the lower mediastinum and the D1 compartment. In GC, lymphatic spread exceeded the D1 compartment in 7% of node positive patients. CONCLUSIONS Risk estimation for lymph node metastases should not be based on depth of tumor infiltration alone but additional clinicopathological parameters should also be considered. The extent of lymphadenectomy in surgical procedures should respect the presented topography of lymph node metastases.
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Karakas E, Oetzmann von Sochaczewski C, Haist T, Pauthner M, Lorenz D. Grenzen der Chirurgie bei Karzinomen des oberen Intestinaltraktes. Chirurg 2014; 85:186-91. [DOI: 10.1007/s00104-013-2598-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Macefield RC, Jacobs M, Korfage IJ, Nicklin J, Whistance RN, Brookes ST, Sprangers MAG, Blazeby JM. Developing core outcomes sets: methods for identifying and including patient-reported outcomes (PROs). Trials 2014; 15:49. [PMID: 24495582 PMCID: PMC3916696 DOI: 10.1186/1745-6215-15-49] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 01/17/2014] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Synthesis of patient-reported outcome (PRO) data is hindered by the range of available PRO measures (PROMs) composed of multiple scales and single items with differing terminology and content. The use of core outcome sets, an agreed minimum set of outcomes to be measured and reported in all trials of a specific condition, may improve this issue but methods to select core PRO domains from the many available PROMs are lacking. This study examines existing PROMs and describes methods to identify health domains to inform the development of a core outcome set, illustrated with an example. METHODS Systematic literature searches identified validated PROMs from studies evaluating radical treatment for oesophageal cancer. PROM scale/single item names were recorded verbatim and the frequency of similar names/scales documented. PROM contents (scale components/single items) were examined for conceptual meaning by an expert clinician and methodologist and categorised into health domains. A patient advocate independently checked this categorisation. RESULTS Searches identified 21 generic and disease-specific PROMs containing 116 scales and 32 single items with 94 different verbatim names. Identical names for scales were repeatedly used (for example, 'physical function' in six different measures) and others were similar (overlapping face validity) although component items were not always comparable. Based on methodological, clinical and patient expertise, 606 individual items were categorised into 32 health domains. CONCLUSION This study outlines a methodology for identifying candidate PRO domains from existing PROMs to inform a core outcome set to use in clinical trials.
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Affiliation(s)
- Rhiannon C Macefield
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Marc Jacobs
- Department of Medical Psychology, Academic Medical Center/University of Amsterdam, Meibergdreef 5, Amsterdam NL 1105 AZ, Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, P.O. Box 2040, Rotterdam NL 3000 CA, Netherlands
| | - Joanna Nicklin
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Level 3, Dolphin House, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK
| | - Robert N Whistance
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Sara T Brookes
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Mirjam AG Sprangers
- Department of Medical Psychology, Academic Medical Center/University of Amsterdam, Meibergdreef 5, Amsterdam NL 1105 AZ, Netherlands
| | - Jane M Blazeby
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Level 3, Dolphin House, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK
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Depth of submucosal tumor infiltration and its relevance in lymphatic metastasis formation for T1b squamous cell and adenocarcinomas of the esophagus. J Gastrointest Surg 2014; 18:242-9; discussion 249. [PMID: 24091912 DOI: 10.1007/s11605-013-2367-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 09/20/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgery for early esophageal carcinoma has been challenged by less invasive endoscopic approaches. Selecting patients in need for surgical intervention according to their risk of lymphatic spread is mandatory. OBJECTIVE The aim of this study was to evaluate risk factors for lymphatic metastasis formation in T1b esophageal carcinomas. METHODS Histopathological specimens following surgical resection for T1b esophageal carcinomas were reevaluated for overall submucosal layer thickness, depth of submucosal tumor infiltration, tumor length as well as lymphatic and vascular infiltration. Depth of tumor infiltration to overall submucosal thickness was divided in thirds (SM1, SM2, and SM3) and factors influencing lymphatic metastasis formation were assessed. RESULTS A total of 67 patients with pT1b tumors were analyzed, including 36 adenocarcinomas (53.7 %) and 31 squamous cell carcinomas (46.3 %). Lymph node involvement was seen in 22.4 % (15/67) patients without significant differences between SM1 3/11 (27.3 %), SM2, 4/18 (22.2 %), and SM3 (8/38) (21.8 %) (p = 0.909) carcinomas. On binomial log-regression models, only lymphangioinvasion and tumor length >2 cm was significantly associated with lymph node involvement. CONCLUSION As depth of submucosal tumor infiltration did not correlate with the formation of lymph node metastases and in regard of the risk of lymphatic spread in these cases, surgical resection is warranted in pT1b carcinomas.
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Wong RF, Bhutani MS. Therapeutic endoscopy and endoscopic ultrasound for gastrointestinal malignancies. Expert Rev Anticancer Ther 2014; 5:705-18. [PMID: 16111470 DOI: 10.1586/14737140.5.4.705] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Gastrointestinal endoscopy and endoscopic ultrasound not only provide strategies to diagnose and stage malignancy, but also to administer palliative and definitive care. Options for anticancer therapy include endoscopic mucosal resection, photodynamic therapy, thermal therapy, self-expanding metal stents and recently, endoscopic ultrasound-guided therapy, such as intratumoral injection. This review summarizes the available endoscopic techniques with a discussion of indications and recent clinical data pertaining to gastrointestinal malignancy. This review will inform the reader of emerging treatment options and stress the importance of incorporating gastroenterologists into the multidisciplinary approach in the management of gastrointestinal cancers.
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Affiliation(s)
- Robert F Wong
- Division of Gastroenterology, Department of Internal Medicine, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, UT 84132, USA.
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Vallböhmer D, Sisic L, Blank S, Kraus S, Stoecklein NH, Knoefel WT, Büchler MW, Ott K. Clinically Staged cT2 Adenocarcinomas of the Gastroesophageal Junction: Accuracy of Staging and Therapeutic Consequences. Oncol Res Treat 2014; 37:97-104. [DOI: 10.1159/000360177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 01/14/2014] [Indexed: 11/19/2022]
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Fitzgerald RC, di Pietro M, Ragunath K, Ang Y, Kang JY, Watson P, Trudgill N, Patel P, Kaye PV, Sanders S, O'Donovan M, Bird-Lieberman E, Bhandari P, Jankowski JA, Attwood S, Parsons SL, Loft D, Lagergren J, Moayyedi P, Lyratzopoulos G, de Caestecker J. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut 2014; 63:7-42. [PMID: 24165758 DOI: 10.1136/gutjnl-2013-305372] [Citation(s) in RCA: 868] [Impact Index Per Article: 78.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
These guidelines provide a practical and evidence-based resource for the management of patients with Barrett's oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was followed to provide a methodological strategy for the guideline development. A systematic review of the literature was performed for English language articles published up until December 2012 in order to address controversial issues in Barrett's oesophagus including definition, screening and diagnosis, surveillance, pathological grading for dysplasia, management of dysplasia, and early cancer including training requirements. The rigour and quality of the studies was evaluated using the SIGN checklist system. Recommendations on each topic were scored by each author using a five-tier system (A+, strong agreement, to D+, strongly disagree). Statements that failed to reach substantial agreement among authors, defined as >80% agreement (A or A+), were revisited and modified until substantial agreement (>80%) was reached. In formulating these guidelines, we took into consideration benefits and risks for the population and national health system, as well as patient perspectives. For the first time, we have suggested stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria. In order to improve communication between clinicians, we recommend the use of minimum datasets for reporting endoscopic and pathological findings. We advocate endoscopic therapy for high-grade dysplasia and early cancer, which should be performed in high-volume centres. We hope that these guidelines will standardise and improve management for patients with Barrett's oesophagus and related neoplasia.
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Bergeron EJ, Lin J, Chang AC, Orringer MB, Reddy RM. Endoscopic ultrasound is inadequate to determine which T1/T2 esophageal tumors are candidates for endoluminal therapies. J Thorac Cardiovasc Surg 2013; 147:765-71: Discussion 771-3. [PMID: 24314788 DOI: 10.1016/j.jtcvs.2013.10.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 10/01/2013] [Accepted: 10/11/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Esophageal endoscopic ultrasound is now regarded as essential in the staging of esophageal carcinoma. There is an increasing trend toward endoluminal therapies (ie, endoscopic mucosal resection and radiofrequency ablation) for pre-cancer or early-stage cancers because of concerns of high morbidity associated with esophagectomy. This study reviews our institutional experience with preoperative endoscopic ultrasound staging of early esophageal cancers in patients who underwent an esophagectomy to evaluate the accuracy of staging by endoscopic ultrasound and how this affects treatment recommendations. METHODS A prospective esophagectomy database of all patients undergoing an esophagectomy for esophageal cancer at a single high-volume institution was retrospectively reviewed for patients with early-stage esophageal cancer. This study analyzed patients with clinical Tis to T1 disease, as predicted by preoperative endoscopic ultrasound, and correlated this with the pathologic stages after esophagectomy. The surgical outcomes were evaluated to assess the safety of esophagectomy as a treatment modality. RESULTS From 2005 to 2011, 107 patients (93 male, 14 female) with a mean age of 66 years (range, 39-91 years) were staged by preoperative endoscopic ultrasound to have esophageal high-grade dysplasia, carcinoma in situ, or T1 cancer and underwent an esophagectomy. Tumor depth was correctly staged by endoscopic ultrasound in only 39% (23/59) of pT1a tumors (invading into the lamina propria or muscularis mucosa) and 51% (18/35) of pT1b tumors (submucosal). Of the endoscopic ultrasound-staged cT1a-lpN0 lesions, there were positive lymph nodes in 15% of pathologic specimens (2/13). Patients with pT1a-mm lesions had a 9% rate of pathologic lymph node involvement (1/11), and those with pT1b tumors had a 17% rate of lymph node spread (6/35). Esophagectomy was performed in all 107 patients with a 30-day mortality rate of less than 1% (1/107). CONCLUSIONS The sensitivity and specificity of endoscopic ultrasound for determining true pathologic staging are poor for early-stage esophageal cancers. Lesions thought to be cT1a-lpN0 by endoscopic ultrasound have at least pN1 disease in 15% of cases. Endoluminal therapy of these lesions based on endoscopic ultrasound undertreats a significant number of patients. Esophagectomy is still the standard therapy for early-stage esophageal cancers in the majority of patients.
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Affiliation(s)
- Edward J Bergeron
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Mich
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Mich
| | - Andrew C Chang
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Mich
| | - Mark B Orringer
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Mich
| | - Rishindra M Reddy
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Mich.
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Pattern of abdominal nodal spread and optimal abdominal lymphadenectomy for advanced Siewert type II adenocarcinoma of the cardia: results of a multicenter study. Gastric Cancer 2013; 16:301-8. [PMID: 22895616 DOI: 10.1007/s10120-012-0183-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 07/15/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND It remains uncertain whether radical lymphadenectomy combined with total gastrectomy actually contributes to long-term survival for Siewert type II adenocarcinoma of the cardia. We identified the pattern of abdominal nodal spread in advanced type II adenocarcinoma and defined the optimal extent of abdominal lymphadenectomy. METHODS Eighty-six patients undergoing R0 total gastrectomy for advanced type II adenocarcinoma were identified from the gastric cancer database of 4,884 patients. Prognostic factors were investigated by multivariate analysis. The therapeutic value of lymph node dissection for each station was estimated by multiplying the incidence of metastasis by the 5-year survival rate of patients with positive nodes in each station. RESULTS The overall 5-year survival rate was 37.1%. Age less than 65 years [hazard ratio, 0.455 (95% confidence interval (CI), 0.261-0.793)] and nodal involvement with pN3 as referent [hazard ratio for pN0, 0.129 (95% CI, 0.048-0.344); for pN1, 0.209 (95% CI, 0.097-0.448); and for pN2, 0.376 (95% CI, 0.189-0.746)] were identified as significant prognosticators for longer survival. Perigastric nodes of the lower half of the stomach in positions 4d-6 were considered not beneficial to dissect, whereas there were substantial therapeutic benefits to dissecting the perigastric nodes of the upper half of the stomach in positions 1-3 and the second-tier nodes in positions 7 and 11. CONCLUSIONS Limited lymphadenectomy attained by proximal gastrectomy might suffice as an alternative to extended lymphadenectomy with total gastrectomy for obtaining potential therapeutic benefit in abdominal lymphadenectomy for advanced Siewert type II adenocarcinoma.
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Werner M, Laßmann S. [Update on Barrett esophagus and Barrett carcinoma]. DER PATHOLOGE 2013; 33 Suppl 2:253-7. [PMID: 23011020 DOI: 10.1007/s00292-012-1662-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The definition of Barrett esophagus is currently under discussion. It is now suggested that a distal esophagus coated with cylinder epithelium with cardia-fundus mucosa should also be classified as Barrett esophagus because the risk of cancer is significantly increased even without histological evidence of intestinal metaplasia with goblet cells. The results of recent epidemiological investigations imply that the cancer risk of cylinder cell metaplasia and low grade intraepithelial neoplasia in Barrett esophagus has previously been overestimated. The histological detection of dysplasia still remains the best biomarker for estimation of the risk of cancer of Barrett esophagus. Exact determination of invasion depth in the mucosa, respective submucosa is now established as prognostic marker for overall survival in Patients with early carcinomas and this classification is useful for therapy decisions (endoscopic versus surgical removal). In advanced Barrett carcinoma following neoadjuvant therapy the lymph node status (ypN) is a better prognostic factor than the ypT category. In metastasized tumors therapies targeting HER2/new, EGFR or c-Met have been investigated explicitly in Barrett carcinoma only in phase I/II studies, whereby the predictive value of appropriate molecular pathology investigations is not yet reliably established.
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Affiliation(s)
- M Werner
- Institut für Pathologie, Universitätsklinikum Freiburg, Breisacher Str. 115a, 79106 Freiburg.
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Manner H, Pech O, Heldmann Y, May A, Pohl J, Behrens A, Gossner L, Stolte M, Vieth M, Ell C. Efficacy, safety, and long-term results of endoscopic treatment for early stage adenocarcinoma of the esophagus with low-risk sm1 invasion. Clin Gastroenterol Hepatol 2013; 11:630-5; quiz e45. [PMID: 23357492 DOI: 10.1016/j.cgh.2012.12.040] [Citation(s) in RCA: 155] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 12/06/2012] [Accepted: 12/21/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Patients with early-stage mucosal (T1a) esophageal adenocarcinoma (EAC) are increasingly treated by endoscopic resection. EACs limited to the upper third of the submucosa (pT1b sm1) could also be treated by endoscopy. We assessed the efficacy, safety, and long-term effects of endoscopic therapy for these patients. METHODS We analyzed data from 66 patients with sm1 low-risk lesions (macroscopically polypoid or flat, with a histologic pattern of sm1 invasion, good-to-moderate differentiation [G1/2], and no invasion into lymph vessels or veins) treated by endoscopic therapy at the HSK Hospital Wiesbaden from 1996 through 2010. The efficacy of endoscopic therapy was assessed on the basis of rates of complete endoluminal remission (CER), metachronous neoplasia, lymph node events, and long-term remission (LTR). Safety was assessed on the basis of rate of complications. RESULTS Remissions were assessed in 61 of the 66 patients; 53 of the 61 achieved CER (87%). Of patients with small focal neoplasias ≤2 cm, 97% achieved CER (for those with tumors ≥2 cm, 77%; P = .026). Metachronous neoplasias were observed in 10 of 53 patients (19%; 9 of the 10 underwent repeat endoscopic resection). One patient developed a lymph node metastasis (1.9%). Fifty-one patients achieved LTR (84%); 90% of those with focal lesions ≤2 cm achieved LTR after a mean follow-up period of 47 ± 29.1 months (range, 8-120 months). No tumor-associated deaths were observed, and the estimated 5-year survival rate was 84%. The rate of major complications from endoscopic resection was 1.5%, and no patients died. CONCLUSIONS Endoscopic therapy appears to be a good alternative to esophagectomy for patients with pT1b sm1 EAC, on the basis of macroscopic and histologic analyses. The risk of developing lymph node metastases after endoscopic resection for sm1 EAC is lower than the risk of surgery.
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Affiliation(s)
- Hendrik Manner
- Department of Internal Medicine II, HSK Hospital (Teaching Hospital of the University Medicine of Mainz), Wiesbaden, Germany.
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Saligram S, Chennat J, Hu H, Davison JM, Fasanella KE, McGrath K. Endotherapy for superficial adenocarcinoma of the esophagus: an American experience. Gastrointest Endosc 2013; 77:872-6. [PMID: 23472998 DOI: 10.1016/j.gie.2013.01.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 01/03/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND EMR and ablation are increasingly being used alone or in combination for treatment of Barrett's neoplasia. Given a very low rate of lymph node metastasis, endotherapy has become an accepted treatment option for T1a esophageal adenocarcinoma (EAC) with low-risk features. OBJECTIVE To report our experience of endoscopic management of T1a EAC in a large, tertiary-care center. DESIGN Retrospective review. SETTING Tertiary-care referral center. PATIENTS Patients treated endoscopically for low-risk T1a EAC at our center. INTERVENTION EMR and endoscopic ablation. MAIN OUTCOME MEASUREMENTS Death related to esophageal cancer, remission of adenocarcinoma, dysplasia, and intestinal metaplasia. RESULTS A total of 54 patients underwent endotherapy for low-risk T1a EAC from 2006 to 2012. Mean (± SD) follow-up was 23 (± 16) months, mean (± SD) size of resected adenocarcinoma was 7.1 (± 4.3) mm, and mean (± SD) Barrett's esophagus length was 4.5 (± 3.9) cm. Band-assisted, cap-assisted, and lift and cut EMR were performed in 85%, 11%, and 4% of patients, respectively; 81% underwent additional ablative therapy (radiofrequency ablation 95%, cryotherapy 9%, photodynamic therapy 2%). Complete remission from cancer was achieved in 96%, complete remission from dysplasia in 87%, and complete remission from intestinal metaplasia in 59%. The overall survival was 89%; there were no deaths related to esophageal cancer. LIMITATIONS Retrospective study. CONCLUSION Endotherapy for T1a EAC was safe and effective in our American cohort. Endotherapy should be considered primary therapy for appropriate patients with low-risk lesions. Complete Barrett's esophagus eradication after EMR is important to reduce the development of metachronous lesions.
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Affiliation(s)
- Shreyas Saligram
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Abstract
Surgical resection remains the mainstay of potentially curative therapy for gastroesophageal junction (GEJ) tumors. However, because of the location of the tumor at the boundary between the esophagus and stomach, GEJ tumors have been a source of controversy in regard to their definition, classification, staging and surgical management. The definition of GEJ tumors was addressed with the development of the three-tiered Siewert's classification scheme. There remain many controversies regarding the appropriate surgical approach and the extent of the lymphadenectomies for these tumors. For locally advanced, resectable GEJ tumors, an aggressive surgical resection should be considered and the approach predicated by tumor location as defined by the Siewert's classification. Limited resections for earlier stage tumors have also been evaluated.
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Affiliation(s)
- Alfredo Amenabar
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
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Abstract
Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.
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50
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Jin XF, Sun QY, Chai TH, Li SH, Guo YL. Clinical value of multiband mucosectomy for the treatment of squamous intraepithelial neoplasia of the esophagus. J Gastroenterol Hepatol 2013; 28:650-5. [PMID: 23301863 DOI: 10.1111/jgh.12111] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2012] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIM To evaluate the clinical value of multiband mucosectomy (MBM) for the treatment of squamous intraepithelial neoplasia of the esophagus. METHODS A total of 51 lesions located at esophagus from 43 patients were treated with MBM, among which 11 were diagnosed as middle-grade intraepithelial neoplasia, 25 as high-grade intraepithelial neoplasia, and 15 as early esophageal cancer pathologically. Primary end-points were the rate of complete endoscopic resection and the mean operation time; the second end-points were the postoperative local recurrence rate and acute plus early complications. The histopathological results were compared between pre-MBM biopsy and MBM specimens. All patients were followed up endoscopically. RESULTS A total of 52 MBM procedures with 180 resections were performed in 43 patients. The complete endoscopic resection was achieved in 92.3% (95% confidence interval [CI] 81.8-96.9%). The sizes of the lesions ranged from 10 × 8 mm to 25 × 23 mm. The mean operation time is 37 ± 5 min. The operative acute bleeding complication was 7.6% (95% CI 3-18.1%); no perforations occurred. Early complications consisted of delayed bleeding (one patient 1.9%; 95% CI 0.3-10.1%) and slight esophageal stenosis (one patient). The histopathological diagnosis of 26 cases (51%) was consistent between biopsy and MBM samples, while 20 lesions exhibited higher grade dysplasia. The local recurrence rate was 6.9% (3/43) at 1 year, 9.3% (4/43) at 2 years, and 9.3% at 2.5 years. No death occurred during follow-up. CONCLUSIONS MBM is a safe and effective technique for the treatment of early esophageal cancer and precancerous lesions.
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Affiliation(s)
- Xi-Feng Jin
- Department of Gastroenterology, Tengzhou Central People's Hospital of Jining Medical College, Shandong province, China
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