Significance of the Depth of Tumor Invasion and Lymph Node Metastasis in Superficially Invasive (T1) Esophageal Adenocarcinoma

Optimal endoluminal treatment of Barrett's esophagus: integrating novel strategies into clinical practice

Endoluminal therapy has become the first-choice treatment over the last 5 years for early Barrett's neoplasia limited to the mucosa. Long-term follow-up data on endoscopic resection have demonstrated the oncological safety of endoscopic resection in comparison to surgery. However, there is a high rate of recurrent disease, which can be avoided using additional ablation of the remaining Barrett. Radiofrequency ablation was recently introduced as an efficacious means to ablate Barrett's epithelium with a better safety profile than older ablation techniques. Recent studies show that endoscopic resection can be safely combined with radiofrequency ablation for treating dysplastic Barrett's after removal of visible lesions. This constitutes a completely new treatment paradigm that will be integrated in routine clinical practice in the forthcoming years.

Endoscopic resection for Barrett's high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit

OBJECTIVES

Patients with Barrett's high-grade dysplasia (HGD) or early esophageal adenocarcinoma (EAC) that is shown on biopsy alone continue to undergo esophagectomy without more definitive histological staging. Endoscopic resection (ER) may provide more accurate histological grading and local tumor (T) staging, definitive therapy, and complete Barrett's excision (CBE); however, long-term outcome data are limited. Our objective was to demonstrate the effect on histological grade or local T stage, efficacy, safety and long-term outcome of ER for Barrett's HGD/EAC and of CBE in suitable patients.

METHODS

This prospective study at two Australian academic hospitals involved 75 consecutive patients over 7 years undergoing ER for biopsy-proven HGD or EAC, using multiband mucosectomy or cap technique. In addition, CBE by 2-3-stage radical mucosectomy was attempted for all Barrett's segments<or=3 cm in length in patients aged<75 years with minimal comorbidities.

RESULTS

Biopsy histology showed HGD in 89% of patients and EAC in 11%. However, ER histology resulted in altered grading or staging in 48% of patients (down 28%, up 20%), with HGD in 53%, low-grade dysplasia (LGD) in 19%, mucosal adenocarcinoma in 13%, submucosal adenocarcinoma in 9%, and no dysplasia in 4% of patients. The CBE success rate was 94%. Complications were one aspiration (hospitalization with full recovery) and six strictures successfully dilated endoscopically. During the mean follow-up of 31 months (range 3-89), there was no recurrence at ER sites, 11% developed metachronous lesions and five patients underwent esophagectomy for ER-demonstrated submucosal invasion. Esophagectomy specimens were T0N0M0 in three and T1N0M0 in two patients. There were no deaths due to adenocarcinoma.

CONCLUSIONS

ER alters histological grade or local T stage in 48% of patients and dramatically reduces esophagectomy rates by providing safe and effective therapy. ER has a high success rate (94%) for CBE in short segment Barrett's esophagus.

New Endoscopic Techniques: Challenges and Opportunities for Surgical Pathologists

In recent years, significant clinical and technological advances have been made in endoscopic methods for diagnosis and treatment of early gastrointestinal neoplasms. However, essential information related to these novel techniques and their implications for practicing surgical pathologists have largely been missing in the general pathology literature. This article provides a general introduction to these novel therapeutic and diagnostic methods, and discusses their indications, contraindications, and potential limitations. The article aims to enable surgical pathologists to interact more efficiently with basic scientists and clinical colleagues to help implement and improve the existing clinical methods and to advance the new technologies.

Early Barrett's carcinoma: the depth of infiltration of the tumour correlates with the degree of differentiation, the incidence of lymphatic vessel and venous invasion

The incidence of regional lymph node metastasis in early Barrett's carcinoma is determined by the depth of infiltration of the tumour. The present study investigated the possible relationship between the depth of infiltration of the tumour, its degree of differentiation and the incidence of lymphatic vessel and venous invasion in early Barrett's carcinoma. To this end, a total of 805 endoscopically resected specimens obtained from 472 patients with early Barrett's carcinomas were analysed. The results of this analysis revealed that increasing depth of tumour infiltration is associated with an increase in the incidence of poorly differentiated carcinomas--from 0.8% for lesions limited to the mucosa (m1) to 41.4% when the depth of infiltration extended to the lower third of the submucosa (sm3). A similar correlation was also found for the incidence of lymphatic vessel invasion (m1, 0.6%; sm3, 44.8%) and for venous invasion (m1, 0%; sm3, 13.8%). All of these observations proved to be statistically highly significant (p < 0.001). In conclusion, the results show that the degree of differentiation, as well as the incidence of lymphatic vessel and venous invasion, correlates with the depth of infiltration of the early carcinoma in Barrett's oesophagus.

Risk stratification for early esophageal adenocarcinoma: analysis of lymphatic spread and prognostic factors

BACKGROUND

Knowledge of factors related to outcome is vital for the selection of therapeutic alternatives for patients with early (T1) esophageal adenocarcinoma. This study was undertaken to determine predictors of lymphatic spread and prognostic factors for T1 esophageal adenocarcinoma following esophagectomy.

MATERIALS AND METHODS

A prospectively maintained database identified 85 patients with T1 esophageal adenocarcinoma who underwent esophagectomy without neoadjuvant therapy. Depth of tumor invasion (T stage) was subdivided into mucosal (T1a) or submucosal invasion (T1b). Median follow-up was 59 months.

RESULTS

Thoracoscopically assisted 3-phase esophagectomy was performed in 73 of 85 patients (86%). Lymph node metastases (N stage) were identified in 9 of 85 patients (11%). Depth of tumor invasion (T stage), lymphovascular invasion (LVI), and poor differentiation were associated with N stage. The patients could be stratified into 4 risk groups for lymph node metastases: group I--T1a (0 of 35 patients [0%] with positive nodes); group II--T1b, well/moderate differentiation and no LVI (1 of 28 patients [4%] with positive nodes); group III--T1b, poor differentiation and no LVI (2 of 9 patients [22%] with positive nodes); and group IV--T1b any grade with LVI (6 of 13 patients [46%] with positive nodes). Survival analyses found T stage, N stage, LVI, and poor differentiation to be significant prognostic factors.

CONCLUSIONS

Risk stratification is possible for patents with T1 esophageal adenocarcinoma. Local resection techniques without lymphadenectomy may be alternatives for T1a tumors. Esophagectomy should remain the standard of care for patients with T1b tumors and those with LVI or poor differentiation considered for neoadjuvant therapy.

Evaluation and treatment of superficial esophageal cancer

INTRODUCTION

Adenocarcinoma of the esophagus is the fastest increasing cancer in the USA, and an increasing number of patients are identified with early-stage disease. The evaluation and treatment of these superficial cancers differs from local and regionally advanced lesions.

METHODS

This paper is a review of the current methods to diagnose, stage, and treat superficial esophageal adenocarcinoma.

RESULTS

Intramucosal adenocarcinoma can be effectively treated with endoscopic resection techniques and with less morbid surgical options including a vagal-sparing esophagectomy. However, submucosal lesions are associated with a significant risk for lymph node metastases and are best treated with esophagectomy and lymphadenectomy.

DISCUSSION

There has been a major shift in the treatment for Barrett's high-grade dysplasia and superficial esophageal adenocarcinoma in the past 10 years. New therapies minimize the morbidity and mortality of traditional forms of esophagectomy and in some cases allow esophageal preservation. Individualization of therapy will allow maximization of successful outcome and quality of life with minimization of complications and recurrence of Barrett's or cancer.

Superficial esophageal squamous cell carcinoma with bulky gastric hiatus lymph node metastasis: a case report

In patients with superficial esophageal cancer, especially in those with tumor invasion above the muscularis mucosae, lymph node metastasis is very rare. We report a case of superficial esophageal cancer who presented with lymph node metastasis. In another hospital a 49-year-old man was found to have a bulky tumor adjacent to the cardiac area of the stomach and a total gastrectomy was carried out. Postoperatively, the tumor was identified as a lymph node containing metastatic squamous cell carcinoma. The main lesion could not be identified on fluorodeoxyglucose positron emission tomography. On esophagogastric endoscopy, using the iodine spray technique, we found an unstained lesion about 32 cm from the incisor teeth. The tumor was removed using endoscopic mucosal resection. The entire resected specimen was examined histopathologically; the depth of the tumor was above the muscularis mucosae. Thirty-four months after endoscopic mucosal resection, there is no sign of tumor recurrence or metastasis.

Changes in screening, prognosis and therapy for esophageal adenocarcinoma in Barrett's esophagus

PURPOSE OF REVIEW

Significant changes in concepts of managing Barrett's esophagus have led to change in the recommendations concerning screening, surveillance, biomarkers, and therapies in this condition over the past several years. We summarize the important changes in this regard.

RECENT FINDINGS

Narrow band imaging and esophageal capsule endoscopy are alternative methods to screen for Barrett's esophagus. Narrow band imaging provides clear visualization of the mucosal pit patterns and vascular patterns, which improve the diagnostic value for specialized intestinal mataplasia. Esophageal capsule endoscopy is a new potential tool that allows a direct noninvasive visualization of esophagus. Research efforts are currently directed towards risk stratification of patients and biomarkers have been developed to predict development of esophageal adenocarcinoma. Recent studies have reported that frequent loss of heterozygosity (LOH) as well as allelic imbalances in chromosomes in esophageal adenocarcinoma. Fluorescent in-situ hybridization technique, which uses fluorescently labeled DNA probes to detect chromosomal alterations in cells, obtained from cytology specimens has been developed. It showed more sensitive and specific for abnormalities than PCR based techniques. Currently, many studies support the concept of endoscopic elimination of dysplastic lesions in the esophagus by a mucosal ablation therapy. Photodynamic therapy and radiofrequency ablation are recently developed, emerging techniques.

SUMMARY

Recent advances in screening; prognostication and therapy for esophageal adenocarcinoma in Barrett's esophagus have brought a significant new insight in clinical practices and will eventually ensure better patients outcomes.

[Surgical treatment for early Barrett cancer]

Adenocarcinomas in Barrett's oesophagus are more commonly diagnosed at an early stage due to effective surveillance programmes. Subtotal oesophagectomy with extended lymphadenectomy is considered the best curative treatment for patients with early adenocarcinoma of the oesophagus. However, such treatment carries substantial morbidity and compromises quality of life. Limited resection, minimal invasive surgical procedures or endoscopic mucosal ablation have been proposed as less invasive alternatives. A comparison of treatment associated morbidity, recurrence rate, long-term survival and functional outcome suggests that none of these alternative methods can be universally recommended. An individualized strategy should be employed based on staging (tumour penetration into the mucosa/submucosa, presence of lymph node metastasis), multicentricity, length of the underlying Barrett mucosa and risk factors of the patient. Surgical resection (radical or limited) remains the treatment of choice for tumours invading the submucosa, or multicentric and recurrent tumours after endoscopic mucosectomy.

Impact of tumor length on long-term survival of pT1 esophageal adenocarcinoma

INTRODUCTION

The impact of esophageal tumor length on pT1 esophageal adenocarcinoma has not been well evaluated.

METHODS

Case histories of all patients (n = 133) undergoing esophageal resection from 1979 to 2007 with pT1 adenocarcinoma of the esophagus were reviewed. Univariate and multivariate analyses of esophageal tumor length and other standard prognostic factors were performed.

RESULTS

Patients with early-stage pT1 esophageal adenocarcinoma with tumors less than 3 cm demonstrate decreased long-term survival (3 years: >3 cm = 46% vs 93%; P < .001) and higher risk of lymph node involvement (lymph node positive: >3 cm = 47% vs 10%; P < .001). Multivariable analysis shows that esophageal tumor length (>3 cm) is an independent risk factor for survival in patients with pT1 early-stage esophageal cancer (hazard ratio: 4.8, 95% confidence intervals: 1.4-16.5; P < .001) even when controlled for submucosal involvement, lymph node involvement, and lymphatic/vascular invasion status. In combination with submucosal involvement, esophageal tumor length (>3 cm) identifies a high-risk population of pT1 esophageal adenocarcinoma (3 years: group 1 [0 risk factors] = 100%, group 2 [1 risk factor] = 87%, and group 3 [2 risk factors] = 33%; P < .001).

CONCLUSIONS

This study demonstrates that esophageal tumor length (>3 cm) is a risk factor for long-term survival and lymph node involvement in early-stage pT1 esophageal adenocarcinoma. Esophageal tumor length (>3 cm) in combination with submucosal involvement may help to identify a high-risk group of patients with pT1 esophageal adenocarcinoma.

Novel endoscopic therapeutic modalities for superficial neoplasms arising in Barrett's esophagus: a primer for surgical pathologists

This review introduces some of the novel endoscopic modalities used for the treatment of superficial neoplasms arising in the setting of Barrett's esophagus, namely endoscopic mucosal resection and photodynamic therapy. We describe the appropriate technical details for pathologists to know to effectively communicate with the gastroenterologists as well as the pitfalls in the evaluation of endoscopic mucosal resection specimens and post photodynamic therapy follow-up biopsies.

Esophagectomy for T1 esophageal cancer: outcomes in 100 patients and implications for endoscopic therapy

OBJECTIVES

Esophagectomy is the standard treatment for T1 esophageal cancer (EC). Interest in endoscopic therapies, particularly for T1 EC, is increasing. We evaluated the long-term outcomes after esophagectomy and examined the pathologic features of T1 cancer to determine the suitability for potential endoscopic therapy.

METHODS

We reviewed the outcomes of esophagectomy in 100 consecutive patients with T1 EC. The primary end points studied were overall survival (OS) and disease-free survival (DFS). In addition to detailed pathology review, we evaluated prognostic variables associated with survival.

RESULTS

Esophagectomy was performed in 100 patients (79 men, 21 women; median age, 68 years) for T1 EC, comprising adenocarcinoma, 91; squamous, 9; intramucosal (T1a), 29; and submucosal (T1b), 71. The 30-day mortality was 0%. Resection margins were microscopically negative in 99 patients (99%). N1 disease was present in 21 (T1a, 2 of 29 [7%]; T1b, 19 of 71 [27%]), associated high-grade dysplasia in 64 (64%), and angiolymphatic invasion in 19 (19%). At a median follow-up of 66 months, estimated 5-year OS was 62% and 3-year DFS was 80% for all patients (including N1). Nodal status and tumor size were significantly associated with OS and DFS, respectively.

CONCLUSIONS

Esophagectomy can be performed safely in patients with T1 EC with good long-term results. Many patients with T1 EC have several risk factors that may preclude adequate treatment with endoscopic therapy. Further prospective studies are required to evaluate endoscopic therapies. Esophagectomy should continue to remain the standard treatment in patients with T1 EC.

New treatments, new challenges: pathology's perspective on esophageal carcinoma

While frank esophageal carcinoma rarely presents a diagnostic challenge, early lesions are often tricky to assess. This difficulty stems in part from drawbacks in the classification systems designed to stratify early lesions as a guide for deciding treatment. These systems are complex and wrought with specific pathologic challenges brought on by new treatment modalities. Such interventions as endoscopic mucosal resection, photodynamic therapy, and chemotherapy/radiation combinations present the pathologist with new histologic challenges that have a direct impact on patient care. In this article, we discuss staging issues pertinent to early cancers, histologic sequelae of various treatments, and how these factors affect the pathologist's role in evaluating esophageal carcinoma.

Role of endoscopic ultrasound in superficial esophageal cancer

The recent increase in the incidence of superficial esophageal cancer and promising developments in potentially curative endoscopic therapies have placed endoscopic ultrasound in a central position with regard to decision making. This is a review of the literature to determine the role of endoscopic ultrasound and high frequency probe ultrasonography in the assessment of superficial esophageal carcinomas.

Vascular and lymphatic properties of the superficial and deep lamina propria in Barrett esophagus

A well-known type of mesenchymal/epithelial interaction occurs in Barrett esophagus (BE) characterized by the formation of a new, superficially located, muscularis mucosae (MM), which results in the division of the lamina propria (LP) into a superficial and deep compartment. The vascular and lymphatic properties of these 2 regions of LP are unknown. The risk of metastases of carcinomas that infiltrate these 2 anatomic areas also remains unclear. The aim of this study was to evaluate the density of blood vessels and lymphatic spaces within the superficial and deep LP and submucosa in patients with BE, and to compare the results to normal squamous-lined esophagus. Thirty esophago-gastrectomy specimens were stained immunohistochemically with CD31 (stains blood vessel and lymphatic endothelium) and D2-40 (stains lymphatic endothelium only). The density of CD31+ blood and lymphatic vessels (per 20 x field) in BE (superficial LP=37 and deep LP=38) was significantly lower compared with the LP of squamous-lined esophagus (68; P<0.001). However, the total number of blood and lymphatic vessels in the superficial and deep LP in BE was statistically similar to the LP of squamous-lined esophagus. The density of CD31+ blood and lymphatic vessels (per 20x field) in the submucosa of BE (21) was not significantly different from the submucosa of squamous-lined esophagus (23; P>0.05). We conclude that in BE, the "native" LP in squamous-lined esophagus is separated into 2 LP compartments (superficial and deep) by the formation of a new MM. These findings suggest that carcinomas that invade through the superficial MM into the deep LP should be considered "intramucosal" rather than "submucosal." Further outcome studies are needed to evaluate the risk of vascular/lymphatic metastasis in BE patients with different levels of LP invasion.

Prediction of lymph node status in superficial esophageal carcinoma

BACKGROUND

Esophageal carcinoma is among the cancers with the worst prognosis. Real chances for cure depend on both early recognition and early treatment. The ability to predict lymph node involvement allows early curative treatment with less invasive approaches.

AIMS

To determine clinicohistopathological criteria correlated with lymph node involvement in patients with early esophageal cancer (T1) and to identify the best candidate patients for local endoscopic or less invasive surgical treatments.

METHODS

A total of 98 patients with pT1 esophageal cancer [67 with squamous cell carcinomas (SCC) and 31 with adenocarcinomas (ADK)] underwent Ivor-Lewis or McKeown esophagectomy in the period between 1980 and 2006 at our institution. Based on the depth of invasion, lesions were classified as m1, m2, or m3 if mucosal, and sm1, sm2, or sm3 if submucosal.

RESULTS

The rates of lymph node metastasis were 0% for the 27 mucosal carcinomas (T1m) and 28% for the 71 submucosal (T1sm) carcinomas (P < 0.001). Sm1 carcinomas were associated with a lower rate of lymph-node metastasis (8.3% versus 49 % sm2/3, P = 0.003). As for histotype, the rates of lymph node metastasis for sm1 were 0% for ADK and 12.5% for SCC; for sm2/3 there were no significant differences. On multivariate analysis, depth of infiltration, lymphocytic infiltrate, angiolymphatic and neural invasion were significantly associated with lymph node involvement. Neural invasion was the single parameter with the greatest accuracy (82%); depth of infiltration and angiolymphatic invasion had 75% accuracy. Altogether these three parameters had an accuracy of 97%. Five-year survival rate was 56.7% overall: 77.7% for T1m and 53.3% for T1sm (P = 0.048).

CONCLUSIONS

The most important factors for predicting lymph node metastasis in early esophageal cancer are depth of tumor infiltration, angiolymphatic invasion, neural invasion and grade of lymphocytic infiltration. The best candidates for endoscopic therapy are tumors with high-grade lymphocytic infiltration, no angiolymphatic or neural invasion, mucosal infiltration or sm1 (only for ADK), and tumor <1 cm in size. For sm SCC and sm2/3 ADK the treatment of choice remains esophagectomy with standard lymphadenectomy.

Muscularis mucosae duplication and the musculo-fibrous anomaly in endoscopic mucosal resections for barrett esophagus: implications for staging of adenocarcinoma

Endoscopic mucosal resection (EMR) is increasingly used for management of Barrett esophagus (BE)-related neoplasia. Duplication of the muscularis mucosae (MM) has been described in BE esophagectomy specimens, where it can pose difficulties with accurate staging of carcinoma. The frequency, morphologic characteristics, and effect of MM duplication in adenocarcinoma staging in EMRs have not yet been evaluated. We studied 122 EMR specimens from 100 patients from 1999 to 2006. The following histologic features were scored: depth of EMR, presence of MM duplication and its extent, prolapse changes (extension of smooth muscle into lamina propria), gland entrapment, and diagnosis (original and study/final). Carcinomas reaching the level of submucosa were classified as invasive adenocarcinoma (INV); those confined to lamina propria or MM were classified as intramucosal adenocarcinoma (IMAC). Of 122 EMRs, 11 (9%) reached mucosa only, 109 (89%) extended to submucosa, and 2 (2%) extended into muscularis propria. MM duplication was present in 67% (75 of 111 specimens that reached at least submucosa). Prolapse changes were noted in 65 (54%) cases and gland entrapment in 67 (56%). Final pathologic diagnoses were 9 (7%) no specialized Barrett mucosa, 4 (3%) BE without dysplasia, 13 (11%) low-grade dysplasia, 51 (42%) high-grade dysplasia, 33 (27%) IMAC, and 12 (10%) INV. EMRs without BE were less likely to show MM duplication (P = 0.01) and there was a trend toward less frequent prolapse change (P = 0.08) and less gland entrapment (P = 0.08) as compared with EMRs with BE. However, there were no significant differences with respect to MM duplication, prolapse change, or gland entrapment between BE with or without dysplasia, IMAC, or INV. Among 33 cases of IMAC, tumor invaded lamina propria in 10 (30%), inner or single MM in 14 (42%), space between duplicated MM in 5 (15%), and outer MM layer in 4(12%). Lymphatic invasion was seen in 2 (10%) cases in which tumor reached the space between MM layers. Overstaging of carcinomas occurred in the original reports in 8 (7%) cases due to misinterpretation of the muscular anatomy, including one case in which the deep MM was interpreted as muscularis propria. These results show that MM duplication is commonly seen in EMR specimens. It is closely associated with the presence of BE but is not affected by neoplastic progression in the Barrett epithelium. Pathologists need to be aware of this distinctive anatomy of BE for accurate staging of adenocarcinomas, particularly to avoid mistaking a thickened outer MM as muscularis propria. Level of IMAC may be a critical feature because of potential access to lymphatic spaces between duplicated MM layers, and we therefore recommend including an explicit statement about the depth of adenocarcinoma invasion rather than using only broad terms such as IMAC or INV in the diagnostic report.

Lymphovascular invasion as a tool to further subclassify T1b esophageal adenocarcinoma

BACKGROUND

Lymphovascular invasion (LVI) and/or lymph node metastases (LNM) adversely influence the overall survival (OS) of patients with T1 esophageal adenocarcinoma. Although endoscopic therapy may be adequate for patients with T1a cancer, patients with T1b cancer require esophagectomy/lymphadenectomy. The authors hypothesized that LVI status would subclassify T1b cancers and facilitate new therapeutic strategies.

METHODS

Ninety-nine consecutive patients with T1 adenocarcinoma were analyzed after they underwent esophagectomy/lymphadenectomy. LNM was assessed in all patients, and LVI was assessed in 89 patients. OS was correlated with pathologic cancer stage in association with LVI and LNM.

RESULTS

The 5-year OS rate for patients with T1a tumors (88%) was superior to that for patients with T1b tumors (62%; P = .001). The 5-year OS rate for patients who had cancers without LVI (85%) was superior to the rate for patients who had cancers with LVI (36%; P = .0001). It is noteworthy that, for cancers without LVI, the 5-year OS rate for patients with T1b tumors (77%) was similar to the rate for patients with T1a tumors (90%; P = .08), but it was superior to the rate for patients with T1b tumors that had LVI (27%; P = .006). The presence of LVI and/or LNM resulted in worse 5-year OS (< or =37%) compared with the lack of LVI and/or LNM (88%; P < .001). The rate of LNM for patients who had T1b tumors without LVI still was 19%, and the relapse rate was 16%.

CONCLUSIONS

The current results demonstrated that LVI distinguishes the biologic behavior of early esophageal cancer, and patients who have T1b cancer without LVI have a clinical biology similar to that of patients with T1a cancer. If LNM before surgery can be diagnosed with high sensitivity by better endoscopic techniques and/or molecular biomarkers, then a new therapeutic paradigm for T1b cancers could emerge. Further research is needed on patients with T1b esophageal adenocarcinoma.

Value of endoscopic ultrasound staging in conjunction with the evaluation of lymphovascular invasion in identifying low-risk esophageal carcinoma

BACKGROUND

With increasing emphasis on endoscopic therapy (ET) for T1 esophageal carcinoma, the identification of low-risk patients is critical. It was hypothesized that endoscopic ultrasonography (EUS) in concert with detailed histopathologic evaluation would identify low-risk cancers for an appropriate but organ-preserving strategy.

METHODS

All patients who had pretreatment EUS and underwent esophagectomy as primary therapy for esophageal cancer between 1999 and 2006 were analyzed retrospectively. The accuracy of EUS in predicting the correct pathologic stage was assessed along with a histopathologic reevaluation including lymphovascular invasion (LVI). Pathologic stage and various features were incorporated into a multivariate logistic regression model.

RESULTS

A total of consecutive 87 esophageal cancer patients (81 with adenocarcinoma) were evaluable for this analysis. EUS correctly diagnosed 59 T1 cancers and 20 T2-4 cancers but understaged cancers in 2 patients and overstaged cancers in 6 patients. EUS correctly identified 8 patients with lymph node metastases but not 13 other patients. The accuracy, sensitivity, and specificity of EUS for T1 cancers were 91%, 91%, and 91%, respectively; for T1a (intramucosal) cancers, the accuracy, sensitivity, and specificity were: 82%, 67%, and 93%, respectively, and for lymph node involvement these same values were 81%, 38%, and 94%, respectively. LVI was found to be an independent predictor of lymph node metastases on the multivariate analysis (P = .02).

CONCLUSIONS

Data from the current study demonstrate that EUS has excellent accuracy, sensitivity, and specificity (91% each) for identifying T1 esophageal cancers and LVI is an independent predictor of lymph node metastases. A strategy for preservation of the esophagus may be possible in patients who have EUS-designated T1 cancer without LVI after successful ET.

Duplication of the muscularis mucosae in Barrett esophagus: an underrecognized feature and its implication for staging of adenocarcinoma

Depth of invasion is one of the most important prognostic indicators in esophageal adenocarcinoma. Unlike other regions of the gastrointestinal tract, the esophagus in Barrett metaplasia frequently develops duplication of the muscularis mucosae (MM), but this feature is underrecognized, and its effect on appropriate staging of superficially invasive adenocarcinoma is unclear. We first randomly selected 50 esophageal resections for high-grade dysplasia or T1 adenocarcinoma in Barrett esophagus (BE) to evaluate the sensitivity and specificity of MM duplication for BE and its histologic characteristics, including percentage of the Barrett segment involved by MM duplication, origin of the duplicated muscle layer, and appearance of the tissue between duplicated MM. Twenty esophageal resections for squamous cell carcinoma served as controls. Next, to study the clinical significance of MM duplication, we evaluated 30 resections for BE that had superficial adenocarcinoma confined to regions of duplicated MM. Each case was classified as: depth of invasion (inner MM, space between duplicated MM, or outer MM), angiolymphatic invasion, and rate of lymph node metastasis. We observed MM duplication in 46 of 50 (92%) BE resections, involving 5% to >90% of the Barrett segment, in contrast to none in 20 (0%) resected squamous cell carcinoma, P<0.0001. In 5 (10%) cases, the MM was focally triplicated. The outer MM was continuous with the single MM beneath squamous epithelium, suggesting that outer MM represents the "original" muscle layer. The space between duplicated MM predominantly consisted of loose fibrovascular tissue similar to submucosa; in 15 (30%) cases, there were also areas of fibrosis or thin muscle strands joining the 2 MM layers. Of 30 adenocarcinomas invading duplicated MM, 10 (33%) invaded only inner MM, 12 (40%) invaded the space between MM, and 8 (27%) invaded the outer MM. Angiolymphatic invasion was present in 5 (17%) cases, and nodal metastases in 3 (10%, 1 case each of invasion into inner MM, between MM, and outer MM). These data show that MM duplication is a characteristic finding in BE, but it can pose difficulty in proper staging of superficial adenocarcinomas. The 17% rate of angiolymphatic invasion and 10% rate of lymph node metastases in our patients with invasion into duplicated MM suggest that these tumors can behave aggressively despite their technically intramucosal location.

"Seedling" mesenchymal tumors (gastrointestinal stromal tumors and leiomyomas) are common incidental tumors of the esophagogastric junction

Gastrointestinal stromal tumors (GISTs) are the most common nonepithelial neoplasm of the gastrointestinal tract and show a predilection for the stomach. Most are detected because of symptoms, but some are incidental findings at autopsy or surgery for other reasons. Incidental GISTs tend to be smaller at diagnosis, but even small (<1 cm) GISTs have been shown to harbor activating KIT mutations at rates similar to advanced GISTs. However, the prevalence and characteristics of small GISTs in surgical resections of the esophagogastric junction (EGJ) remains unclear. We studied 150 esophagogastric resections for esophageal or EGJ carcinomas (100 with preoperative chemoradiation and 50 untreated cases) that had been extensively embedded for histologic examination (mean 30 sections/case). Number, size, morphology, and location of all GISTs and leiomyomas were recorded. All potential GISTs were evaluated with CD117 and CD34 immunohistochemistry, and a subset (35) leiomyomas with smooth muscle actin, desmin, and CD117. We found 18 incidental GISTs in 15 of 150 (10%) patients; 3 patients harbored 2 separate lesions. Prevalence of GIST was identical in treated (10 of 100) and untreated (5 of 50) cases. All (100%) showed positivity for both CD117 and CD34 and all were of spindle cell morphology. Lesions ranged from 0.2 to 3.0 mm in size (mean 1.3 mm). Eight (44%) were based in the outer muscularis propria, 7 (39%) in inner muscularis, and 3 (17%) between the muscle layers. The lesions tended to cluster near the EGJ, with 8 (44%) on the gastric side, 9 (50%) on the esophageal side, and 1 (6%) undetermined owing to overlying ulceration. Leiomyomas were even more common than GIST, occurring in 47% of patients (44% of treated and 52% of untreated, P=0.39), with a mean of 3 leiomyomas per patient (range 1 to 13) and mean size of 1.7 mm (range 0.2 to 12 mm). Unlike colorectal leiomyomas, most (91%) EGJ leiomyomas were located in the inner muscularis propria and only rarely (1%) in muscularis mucosa. These results suggest that GIST and leiomyoma are common incidental "seedling" lesions of the EGJ, found in 10% and 47% of patients undergoing surgery for esophageal carcinoma. The common occurrence of microscopic GISTs compared with the rarity of clinically manifest and malignant esophagogastric GISTs suggests that additional genetic or epigenetic alterations must happen for neoplastic progression.

Endoscopic cap resection for treatment of early Barrett's neoplasia is safe: a prospective analysis of acute and early complications in 216 procedures

This study aimed to prospectively evaluate the safety of endoscopic resection for early neoplasia in Barrett's esophagus (BE) using the endoscopic cap resection (ER cap) technique. All resections performed between September 2000 and March 2006 with the ER-cap technique in patients with BE were included. Complications were classified 'acute' (during the procedure) or 'early' (< 48 h after the procedure). A total of 216 ER-cap procedures were performed in 121 patients, of which 145 were performed with a standard hard cap and 71 with a large flexible cap. Specimens removed with the standard cap had a mean diameter of 20 mm (SD 5.0) versus 23 mm (SD 5.8) for the large cap (P < 0.001). Acute complications occurred in 51 procedures (24%), 49 bleedings and two perforations. All bleedings were effectively treated with hemostatic techniques and classified as mild complications. No patient experienced a drop in hemoglobin levels or required blood transfusions or repeat interventions. The two perforations were classified as severe complications and treated conservatively. Three (1%) early complications, all bleedings, occurred and were effectively treated with endoscopic hemostatic techniques and classified as moderately severe complications. In manova the indication for the resection (high-grade intraepithelial neoplasia or early cancer versus low-grade intraepithelial neoplasia or no dysplasia) was found to be significantly associated with an increased risk of acute bleeding. Endoscopic cap resection in BE is safe. Most complications become apparent immediately during the procedure and can be managed endoscopically. Bleeding after the endoscopic resection procedure and severe acute complications (i.e., perforations) are rare (2%).

Significance of neoplastic involvement of margins obtained by endoscopic mucosal resection in Barrett's esophagus

OBJECTIVES

Although EMR has been used for elimination of neoplasia in BE, the significance of positive carcinoma margins and depth of invasion on endoscopic resection pathology has not been assessed using a valid standard. The aim of this study was to assess the accuracy of tumor staging by EMR using esophagectomy as the standard.

METHODS

Medical records of patients, who underwent endoscopic resection for esophageal carcinoma or high-grade dysplasia in BE followed by esophagectomy, were reviewed. Data were abstracted from a prospectively maintained EMR database. Endosonography and endoscopic resection were performed by a single experienced endoscopist. Two experienced GI pathologists interpreted all histological results. Standard statistical tests were used to compare continuous and categorical variables.

RESULTS

Twenty-five patients were included in the study. Three patients had mucosal carcinoma and 16 had submucosal carcinoma following endoscopic resection. Surgical pathology staging was consistent with preoperative EMR staging in all patients. No patient with negative mucosal resection margins had residual tumor at the resection site at esophagectomy. In patients with submucosal carcinoma, 8 had residual carcinoma at the EMR site at surgery and 5 patients had metastatic lymphadenopathy.

CONCLUSIONS

Tumor staging using EMR pathology is accurate when compared with surgical pathology following esophagectomy. Negative margins on EMR pathology correlate with absence of residual disease at the EMR site at esophagectomy. Submucosal carcinoma on EMR specimens was associated with a high prevalence of residual disease at surgery (50%) and metastatic lymphadenopathy (31%).

EMR for Barrett's esophagus-related superficial neoplasms offers better diagnostic reproducibility than mucosal biopsy

BACKGROUND

EMR of Barrett's esophagus (BE)-related superficial neoplasms represents an efficacious staging modality. It also allows for better pathologic grading compared with mucosal biopsy specimens. However, the interobserver variation in the interpretation of EMR specimens has not been tested.

OBJECTIVE

To evaluate consistency in the diagnosis of BE-related neoplasia on EMR specimens.

DESIGN

Nine pathologists reviewed 25 esophageal EMR specimens and corresponding biopsy specimens independently. Each pathologist classified the cases as either non-neoplastic BE, low-grade dysplasia, high-grade dysplasia, intramucosal adenocarcinoma, or invasive adenocarcinoma. Interobserver concordance for both specimens from EMRs and biopsies was measured by intraclass correlation and Kendall's coefficient of concordance. The proportion of agreement was also calculated for each specimen and compared for EMR and biopsy by using the Wilcoxon signed rank test.

SETTING

Teaching hospitals.

PATIENTS

Twenty-five patients who underwent EMR for BE-related neoplasia.

RESULTS

The intraclass correlation and the Kendall's coefficient for the 25 biopsy specimens was 0.938 (95% CI 0.880-0.965) and 0.677, respectively; for the 25 EMRs, these were significantly improved, at 0.977 (95% CI 0.957-0.987) and 0.831, respectively. In addition, the proportion of agreement for EMR specimens was significantly better compared with biopsy specimens (P = .015).

CONCLUSIONS

Interobserver agreement of BE-related neoplasia on EMR specimens is significantly higher compared with biopsy specimens. The results may relate to the larger tissue sampling compared with biopsy specimens and the ability to evaluate mucosal landmarks, such as double muscularis mucosae. Thus, we suggest that EMRs, in addition to being a staging and therapeutic procedure, improve diagnostic consistency.

Are squamous and adenocarcinomas of the esophagus the same disease?

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

Pathological analysis of clinical target volume margin for radiotherapy in patients with esophageal and gastroesophageal junction carcinoma

PURPOSE

To clarify the radiotherapy clinical target volume (CTV) margin needed for esophageal squamous-cell carcinoma (SCC) and gastroesophageal junction (GEJ) adenocarcinoma.

METHODS AND MATERIALS

Surgical specimens of esophageal SCC (n = 34) and GEJ adenocarcinoma (n = 32) were prospectively collected and analyzed for microscopic spread along the esophagus and GEJ both proximally and distally from gross tumor and for lymph node (LN) metastasis.

RESULTS

For SCC, the mean microscopic spread beyond the gross tumor was 10.5 +/- 13.5 mm proximally (<30 mm in 32 of 34 cases) and 10.6 +/- 8.1 mm distally (<30 mm in 33 of 34 cases). For GEJ adenocarcinoma, the spread was 10.3 +/- 7.2 mm proximally (<30 mm in 29 of 29 cases) and 18.3 +/- 16.3 mm distally (<30 mm in 27 of 32 cases). The extent of microscopic spread of cancer was significantly associated with pathologic T stage (p = 0.012). LN metastases were observed in 12 (35%) of 34 patients with middle and lower esophageal SCC and 15 (47%) of 32 patients with GEJ adenocarcinoma.

CONCLUSIONS

The extent of microscopic spread within esophagus (recommended CTV margin) was <30 mm in about 94% of cases of esophageal cancer, except for distal microscopic spread in GEJ adenocarcinoma, in which 50 mm was needed to cover about 94% of cases.

Clinical biology and surgical therapy of intramucosal adenocarcinoma of the esophagus

BACKGROUND

Mucosal ablation and endoscopic mucosal resection have been proposed as alternatives to surgical resection as therapy for intramucosal adenocarcinoma (IMC) of the esophagus. Acceptance of these alternative therapies requires an understanding of the clinical biology of IMC and the results of surgical resection modified for treatment of early disease.

STUDY DESIGN

Retrospective review of 78 patients (65 men, 13 women; median age 66 years) with IMC who were treated with progressively less-extensive surgical resections (ie, en bloc, transhiatal, and vagal-sparing esophagectomy) from 1987 to 2005.

RESULTS

The tumor was located in a visible segment of Barrett's esophagus in 65 (83%) and in cardia intestinal metaplasia in 13 (17%). A visible lesion was present in 53 (68%) and in all but 4 the lesion was cancer. In those patients with visible Barrett's, the tumor was within 3 cm of the gastroesophageal junction in 66% and within 1 cm in 37%. Esophagectomy was en bloc in 23, transhiatal in 31, vagal-sparing in 20, and transthoracic in 4. Operative mortality was 2.6%. Vagal-sparing esophagectomy had less morbidity, a shorter hospital stay, and no mortality. Of the patients who had en bloc resection, a median of 41 nodes were removed. One patient had one lymph node metastasis on hematoxylin and eosin staining and two others, normal on hematoxylin and eosin staining, had micrometastases on immunohistochemistry. Actuarial survival at 5 years was 88% and was similar for all types of resections. Two patients died from systemic metastases and seven from noncancer causes.

CONCLUSIONS

IMC occurred in cardia intestinal metaplasia and in Barrett's esophagus. Two-thirds of patients with IMC had a visible lesion. Most tumors occurred near the gastroesophageal junction. Node metastases were uncommon, questioning the need for lymphadenectomy. A vagal-sparing technique had less morbidity than other forms of resection and no mortality. Survival after all types of resection was similar. Outcomes of endoscopic techniques should be compared with this benchmark.

New insights in the lymphatic spread of oesophageal cancer and its implications for the extent of surgical resection

In this review new insights in the dissemination pattern of oesophageal tumours and the implications for the (extent of) surgical and endoscopic resection are discussed. Moreover, the sentinel node concept in oesophageal cancer is reconsidered. Three-years survival after a limited resection for cervical-upper thoracic oesophageal cancer was 14-20% after an extended resection. No patients with distant metastases were alive after five years. Therefore, curative surgery for cervical-upper oesophageal cancer with extended lymph node dissection is probably only indicated in patients without distant lymph nodes metastases. Involved coeliac nodes can be found in tumours of the whole oesophagus. Adenocarcinomas of the gastrooesophageal junction do metastasize predominantly to the paracardial and lesser curvature regions. No significant difference was found in a randomized trial comparing two-field transthoracic resection with limited transhiatal resection for adenocarcinoma of the gastrooesophageal junction.(6) Subgroup analysis for patients with a distal oesophageal adenocarcinoma revealed a 17% survival benefit after transthoracic resection. In several Japanese studies a better five-year survival is claimed after a three-field lymph node dissection than after a conventional two-field lymphadenectomy. In a randomized study, however, no statistically significant difference was found in the short- and long-term survival nor in the recurrence rate. If an early lesion is limited to the mucosa, endoscopic mucosal resection (EMR) could be considered because of the low chance of lymph node metastases. However, the technique of EMR has not yet been optimized resulting in high numbers of local cancer recurrences and a high need for endoscopic re-resections. Only few studies investigated whether the sentinel node concept is applicable to the oesophagus or gastric cardia. In one study in patients with oesophageal or cardia cancer, the accuracy was 96% and only two false negative sentinel nodes were identified. The sentinel node concept in oesophageal cancers might change future operative strategies.