101
|
Ge PS, Muthusamy VR. Endoscopic Mucosal Resection for Barrett's Esophagus. J Laparoendosc Adv Surg Tech A 2016; 27:404-411. [PMID: 27901624 DOI: 10.1089/lap.2016.0532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Endoscopic mucosal resection (EMR) is an increasingly popular minimally invasive technique that is used for the management of superficial lesions in the upper and lower gastrointestinal tract. The goal of this article is to describe the indications and technique of EMR, with a focus on the endoscopic management of Barrett's esophagus (BE). The two major EMR techniques-cap EMR and band EMR-will be presented, along with a discussion of their efficacy as well as their integration into the broader treatment paradigm of endoscopic eradication therapy for BE.
Collapse
Affiliation(s)
- Phillip S Ge
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA , Los Angeles, California
| | - V Raman Muthusamy
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA , Los Angeles, California
| |
Collapse
|
102
|
Hölscher AH, Babic B. New approaches in esophageal carcinomas. Innov Surg Sci 2016; 1:87-95. [PMID: 31579724 PMCID: PMC6753992 DOI: 10.1515/iss-2016-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 10/18/2016] [Indexed: 11/15/2022] Open
Abstract
New approaches in the treatment of esophageal cancer comprise endoscopy with refinements of esophagoscopic intraluminal resection by endoscopic submucosal dissection. Radical open surgery is more and more replaced by minimally invasive esophagectomy (MIO), especially in the hybrid technique with laparoscopic gastrolysis and transthoracic esophageal resection and gastric pull-up. Total MIO also in the robotic technique has not yet shown that it produces superior results than the hybrid technique. Fluorescent dye can improve the intraoperative visualization of the vascularization of the gastric conduit. The individualization of neoadjuvant therapy is the magic word in clinical research of multimodal treatment of esophageal cancer. This means response prediction based on molecular markers or clinical response evaluation. The documentation of the diversity of postoperative complications is now standardized by an international consensus. The value of enhanced recovery after surgery is not yet approved compared to conventional management.
Collapse
Affiliation(s)
- Arnulf H. Hölscher
- Center for Esophageal and Gastric Surgery, Agaplesion Markus Krankenhaus, Wilhelm-Epstein-Straße 4, 60431 Frankfurt am Main, Germany
| | - Benjamin Babic
- Center for Esophageal and Gastric Surgery, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| |
Collapse
|
103
|
McLaren PJ, Dolan JP. Esophagectomy as a Treatment Consideration for Early-Stage Esophageal Cancer and High-Grade Dysplasia. J Laparoendosc Adv Surg Tech A 2016; 26:757-762. [DOI: 10.1089/lap.2016.29010.pjm] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Patrick J. McLaren
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - James P. Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
| |
Collapse
|
104
|
Mortality after esophagectomy is heavily impacted by center volume: retrospective analysis of the Nationwide Inpatient Sample. Surg Endosc 2016; 31:2491-2497. [PMID: 27660245 DOI: 10.1007/s00464-016-5251-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 09/13/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The effects of hospital volume on in-hospital mortality after esophageal resection are disputed in the literature. We sought to analyze treatment effects in patient subpopulations that undergo esophagectomy for cancer based on hospital volume. METHODS We performed a retrospective analysis of the Nationwide Inpatient Sample from 1998 to 2011. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using ICD-9 codes. Patients <18 years and those with peritoneal disease were excluded. Multivariate logistic regression analyses were used with mortality as the independent variable to evaluate the effect of low (<6), intermediate (6-19), and high (≥20) hospital volume of esophagectomies. These analyses were repeated in different subsets of patients to determine whether hospital volume affected mortality depending on the subpopulation evaluated. Subgroups were created depending on age, race, gender, operative approach, comorbidities, and tumor pathology. RESULTS A total of 23,751 patients were included. The overall perioperative mortality rate was 7.7 % (low volume: 11.4 %; intermediate volume: 8.39 %, high volume: 4.01 %), and multivariate analysis revealed that high hospital volume had a protective effect (OR 0.54, 95 % CI 0.45-0.65). On subgroup analyses for low- and intermediate-volume hospitals, mortality was uniformly elevated for the subpopulations when comparing to high-volume hospitals (p < 0.05). There was no difference in mortality between low- and medium-volume hospitals and between subgroups. CONCLUSION No lower mortality risk subgroup could be identified in this nationwide collective. This analysis emphasizes that perioperative mortality after esophagectomy for cancer is lower in high-volume hospitals.
Collapse
|
105
|
Lordick F, Mariette C, Haustermans K, Obermannová R, Arnold D. Oesophageal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2016; 27:v50-v57. [PMID: 27664261 DOI: 10.1093/annonc/mdw329] [Citation(s) in RCA: 663] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- F Lordick
- University Cancer Centre Leipzig, University Hospital Leipzig, Leipzig, Germany
| | - C Mariette
- Department of Digestive and Oncological Surgery, University Hospital Claude Huriez, Lille, France
| | - K Haustermans
- Department of Radiation Oncology, Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - R Obermannová
- Clinic of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - D Arnold
- Instituto CUF de Oncologia, Lisbon, Portugal
| | | |
Collapse
|
106
|
Abstract
Esophageal cancer carries a poor prognosis among gastrointestinal malignancies. Although esophageal squamous cell carcinoma predominates worldwide, Western nations have seen a marked rise in the incidence of esophageal adenocarcinoma that parallels the obesity epidemic. Efforts directed toward early detection have been difficult, given that dysplasia and early cancer are generally asymptomatic. However, significant advances have been made in the past 10 to 15 years that allow for endoscopic management and often cure in early stage esophageal malignancy. New diagnostic imaging technologies may provide a means by which cost-effective, early diagnosis of dysplasia allows for definitive therapy and ultimately improves the overall survival among patients.
Collapse
Affiliation(s)
- Benjamin R Alsop
- Department of Gastroenterology and Hepatology, Kansas City VA Medical Center, 4801 Linwood Boulevard, Kansas City, MO 64128, USA; Department of Gastroenterology and Hepatology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 1023, Kansas City, KS 66160, USA.
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, Kansas City VA Medical Center, 4801 Linwood Boulevard, Kansas City, MO 64128, USA; Department of Gastroenterology and Hepatology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 1023, Kansas City, KS 66160, USA
| |
Collapse
|
107
|
Fock KM, Talley N, Goh KL, Sugano K, Katelaris P, Holtmann G, Pandolfino JE, Sharma P, Ang TL, Hongo M, Wu J, Chen M, Choi MG, Law NM, Sheu BS, Zhang J, Ho KY, Sollano J, Rani AA, Kositchaiwat C, Bhatia S. Asia-Pacific consensus on the management of gastro-oesophageal reflux disease: an update focusing on refractory reflux disease and Barrett's oesophagus. Gut 2016; 65:1402-15. [PMID: 27261337 DOI: 10.1136/gutjnl-2016-311715] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/15/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Since the publication of the Asia-Pacific consensus on gastro-oesophageal reflux disease in 2008, there has been further scientific advancement in this field. This updated consensus focuses on proton pump inhibitor-refractory reflux disease and Barrett's oesophagus. METHODS A steering committee identified three areas to address: (1) burden of disease and diagnosis of reflux disease; (2) proton pump inhibitor-refractory reflux disease; (3) Barrett's oesophagus. Three working groups formulated draft statements with supporting evidence. Discussions were done via email before a final face-to-face discussion. We used a Delphi consensus process, with a 70% agreement threshold, using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to categorise the quality of evidence and strength of recommendations. RESULTS A total of 32 statements were proposed and 31 were accepted by consensus. A rise in the prevalence rates of gastro-oesophageal reflux disease in Asia was noted, with the majority being non-erosive reflux disease. Overweight and obesity contributed to the rise. Proton pump inhibitor-refractory reflux disease was recognised to be common. A distinction was made between refractory symptoms and refractory reflux disease, with clarification of the roles of endoscopy and functional testing summarised in two algorithms. The definition of Barrett's oesophagus was revised such that a minimum length of 1 cm was required and the presence of intestinal metaplasia no longer necessary. We recommended the use of standardised endoscopic reporting and advocated endoscopic therapy for confirmed dysplasia and early cancer. CONCLUSIONS These guidelines standardise the management of patients with refractory gastro-oesophageal reflux disease and Barrett's oesophagus in the Asia-Pacific region.
Collapse
Affiliation(s)
- Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Nicholas Talley
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | - Khean Lee Goh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kentaro Sugano
- Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Peter Katelaris
- Gastroenterology Department, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Gerald Holtmann
- Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - John E Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Prateek Sharma
- University of Kansas and VA Medical Center, Kansas City, Kansas, USA
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Michio Hongo
- Department of Comprehensive Medicine, Tohoku University, Sendai, Japan
| | - Justin Wu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, China
| | - Minhu Chen
- Division of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Myung-Gyu Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ngai Moh Law
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Bor-Shyang Sheu
- Department of Internal Medicine, National Cheng Kung University Hospital, Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Jun Zhang
- The Second Affiliated Hospital, Xian Jiaotong University, Xian, China
| | - Khek Yu Ho
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore, Singapore
| | - Jose Sollano
- Department of Medicine, University of Sano Tomas, Manila, Philippines
| | - Abdul Aziz Rani
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Chomsri Kositchaiwat
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Shobna Bhatia
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| |
Collapse
|
108
|
Cummings LC, Kou TD, Schluchter MD, Chak A, Cooper GS. Outcomes after endoscopic versus surgical therapy for early esophageal cancers in an older population. Gastrointest Endosc 2016; 84:232-240.e1. [PMID: 26801375 PMCID: PMC4949078 DOI: 10.1016/j.gie.2016.01.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 01/05/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic treatment of early esophageal cancer provides an alternative to esophagectomy, which older patients may not tolerate. Population-based data regarding short-term outcomes and recurrence after endoscopic treatment for esophageal cancer are limited. We compared short-term outcomes, treated recurrence, and survival after endoscopic versus surgical therapy for early esophageal cancers in an older population. METHODS We conducted a retrospective cohort study identifying patients aged ≥66 years with Tis or T1a tumors without nodal involvement diagnosed from 1994 to 2011 from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. RESULTS Of 2193 patients, 41% (n = 893) underwent esophagectomy, and 12% (n = 255) underwent endoscopic treatment within 6 months of diagnosis. Those treated endoscopically were older and more likely to have a Charlson comorbidity score ≥2. A composite endpoint, hospitalization and/or adverse events at 60 days, was higher in surgical patients than in the endoscopic treatment group (30% vs 12%; P < .001). In a Cox model stratified by histology, adjusting for other factors, endoscopic treatment was associated with improved 2-year survival (hazard ratio 0.51; 95% CI, 0.36-0.73). CONCLUSIONS In this older population, a composite short-term endpoint was worse in the surgical group. Endoscopic treatment was associated with improved survival through 2 years. These results suggest that endoscopic treatment is a reasonable approach for early esophageal cancers in the elderly.
Collapse
Affiliation(s)
- Linda C. Cummings
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
- Case Western Reserve University, Cleveland, Ohio
| | | | | | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
- Case Western Reserve University, Cleveland, Ohio
| | - Gregory S. Cooper
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
- Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
109
|
Künzli HT, van Berge Henegouwen M, Gisbertz S, Seldenrijk C, Kuijpers K, Bergman J, Wiezer M, Weusten B. Thoracolaparoscopic dissection of esophageal lymph nodes without esophagectomy is feasible in human cadavers and safe in a porcine survival study. Dis Esophagus 2016; 29:649-55. [PMID: 26228037 DOI: 10.1111/dote.12395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
High-risk early esophageal adenocarcinoma (i.e. submucosal invasion >500 nm, poor differentiation, and/or presence of lymphovascular invasion) is currently treated with esophagectomy with lymph node (LN) dissection given the high rates of LN metastases. However, esophagectomy is associated with substantial morbidity and mortality. Endoscopic radical resection followed by thoracolaparoscopic LN dissection without concomitant esophagectomy could be an alternative. The study aim was to evaluate the feasibility and safety of thoracolaparoscopic dissection of esophageal LNs in a preclinical setting. (i) In human cadavers, thoracolaparoscopic dissection of LNs involved in drainage of the esophagus was performed. Subsequently, esophagectomy was performed to be able to detect retained LNs. Outcome parameters included the number of dissected LNs, the number of retained LNs in the esophagectomy specimen (ES), and technical success. (ii) In swine, thoracolaparoscopic LN dissection was also performed. After the procedure, the swine survived for 28 days. Thereafter, the swine were sacrificed and esophagectomy was performed. Outcome parameters included the presence of ischemia and/or stenosis in the ES and other complications. (i) In five human cadavers, a median of 26 LNs (interquartile range 22-46) were dissected. In two ES, one retained LN was found: one high paraesophageal, one low paraesophageal. Technical success rate was 100%. (ii) None of the seven porcine ES showed signs of ischemia or stenosis. One swine died because of ventricular fibrillation during surgery; during follow up no complications were observed. Thoracolaparoscopic dissection of LNs involved in the drainage of the esophagus is feasible in human cadavers and swine. The porcine survival study suggests that the esophageal vascularity is not severely compromised by the procedure. As anatomy differs between swine and humans, safety of the procedure will have to be investigated thoroughly before applying this new technique as the treatment of choice.
Collapse
Affiliation(s)
- H T Künzli
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | | | - S Gisbertz
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - C Seldenrijk
- Department of Pathology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - K Kuijpers
- Department of Pathology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - M Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - B Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
110
|
Hui YY, Chen X, Wang BM. Yesterday and today of Barrett's esophagus: Historical evolution and research hotspots. Shijie Huaren Xiaohua Zazhi 2016; 24:3077-3086. [DOI: 10.11569/wcjd.v24.i20.3077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
It has been more than 60 years since the concept of Barrett's esophagus (BE) was put forward, and over these a few decades, we have made great progress in the diagnosis and treatment of BE. BE does not cause clinical symptoms, but it attracts wide attention, because it is an important precursor lesion of esophageal adenocarcinoma. The purpose of this article is to review the process of the recognition of BE and the current research hotspots as well as to discuss the current status of esophageal adenocarcinoma screening in BE patients. We aim to provide clinicians with an overview of the ins and outs of the disease, which will help them improve the diagnosis and treatment of BE in clinical practice and provide patients with beneficial treatment.
Collapse
|
111
|
Ellison HB, Parker DM, Horsley RD, McField D, Friscia ME, Petrick AT. Laparoscopic transhiatal esophagectomy for esophageal adenocarcinoma identified at laparoscopic Roux-en-Y gastric bypass. Int J Surg Case Rep 2016; 25:179-83. [PMID: 27379750 PMCID: PMC4933034 DOI: 10.1016/j.ijscr.2016.05.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/25/2016] [Accepted: 05/29/2016] [Indexed: 11/18/2022] Open
Abstract
Preoperative endoscopy is indicated bariatric patients with history of gastroesophageal reflux. Laparoscopic transhiatal esophagectomy can be safely performed in patient with history of Roux-en-Y gastric bypass. The gastric remnant provides a good conduit for reconstruction following esophagectomy in patients with a previous Roux-en-Y gastric bypass.
Introduction More than one third of Americans are obese. Obesity is a risk factor for gastroesophageal reflux disease (GERD) and esophageal adenocarcinoma (EA). The only durable treatment for morbid obesity and its comorbid conditions is bariatric surgery. There is no consensus among bariatric surgeons, however, regarding the role of preoperative screening upper endoscopy in bariatric surgery. Presentation of case Two cases of incidental EA were identified by completion EGD following laparoscopic Roux-en-Y gastric bypass (LRYGB). EGD was done for anastomotic surveillance and provocative leak testing. Esophageal masses were identified and biopsies demonstrated adenocarcinoma. In both cases a laparoscopic transhiatal esophagectomy (LTHE) was completed using the gastric remnant as conduit; the biliopancreatic limb was divided proximal to the jejunojejunostomy and anastomosed to the proximal roux limb to complete the reconstruction. Discussion Obesity is a risk factor for GERD and EA. The role of EGD prior to bariatric surgery is unclear. Studies have demonstrated routine EGD prior to bariatric surgery may diagnose foregut pathology; however, few of the findings alter the planned treatment. The cost effectiveness of this strategy is questionable. There are reports of EA developing after bariatric surgery; however, we found no previous case reports of EA identified at LRYGB. Conclusion Our institution has opted for selective preoperative endoscopy in patients with preoperative gastrointestinal symptoms. In post gastric bypass patients LTHE can be performed with good results.
Collapse
Affiliation(s)
- Halle B Ellison
- Geisinger Medical Center, Department of General Surgery, 100 North Academy Ave., Danville PA, 17821, United States
| | - David M Parker
- Geisinger Medical Center, Department of General Surgery, 100 North Academy Ave., Danville PA, 17821, United States.
| | - Ryan D Horsley
- Geisinger Medical Center, Department of General Surgery, 100 North Academy Ave., Danville PA, 17821, United States
| | - Daaron McField
- Geisinger Medical Center, Department of General Surgery, 100 North Academy Ave., Danville PA, 17821, United States
| | - Michael E Friscia
- Geisinger Medical Center, Department of Thoracic Surgery, 100 North Academy Ave., Danville PA, 17821, United States
| | - Anthony T Petrick
- Geisinger Medical Center, Department of General Surgery, 100 North Academy Ave., Danville PA, 17821, United States
| |
Collapse
|
112
|
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.
Collapse
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
| |
Collapse
|
113
|
Neoplastic Barrett’s oesophagus and long-term follow-up after endoscopic therapy: complete histological eradication of Barrett associated with high-grade dysplasia significantly decreases neoplasia relapse. Surg Endosc 2016; 30:5410-5418. [DOI: 10.1007/s00464-016-4898-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/26/2016] [Indexed: 01/28/2023]
|
114
|
Abstract
Endoscopic resection and ablation have become the preferred therapy for most patients with high-grade dysplasia or superficial esophageal cancer. Endoscopic therapy offers esophageal preservation with similar oncologic outcomes and significantly fewer complications compared with the alternative of esopahgectomy. The goal of endotherapy is eradication of all the premalignant intestinal metaplasia to minimize the risk for metachronous cancer development. Once accomplished, careful follow-up is necessary to address recurrent intestinal metaplasia or dysplasia and prevent long-term failure of an endoscopic approach in these patients.
Collapse
|
115
|
Fuchs HF, Broderick RC, Harnsberger CR, Divo FA, Coker AM, Jacobsen GR, Sandler BJ, Bouvet M, Horgan S. Intraoperative Endoscopic Botox Injection During Total Esophagectomy Prevents the Need for Pyloromyotomy or Dilatation. J Laparoendosc Adv Surg Tech A 2016; 26:433-8. [PMID: 27043862 DOI: 10.1089/lap.2015.0575] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Esophagectomy may lead to impairment in gastric emptying unless pyloric drainage is performed. Pyloric drainage may be technically challenging during minimally invasive esophagectomy and can add morbidity. We sought to determine the effectiveness of intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-assisted esophagectomy as an alternative to surgical pyloric drainage. MATERIALS AND METHODS We performed a retrospective analysis of patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus or gastroesophageal junction who underwent robotic-assisted transhiatal esophagectomy (RATE) without any surgical pyloric drainage. Patients with and without intraoperative endoscopic injection of 200 units of botulinum toxin in 10 cc of saline (BOTOX group) were compared to those that did not receive any pyloric drainage (noBOTOX group). Main outcome measure was the incidence of postoperative pyloric stenosis; secondary outcomes included operative and oncologic parameters, length of stay (LOS), morbidity, and mortality. RESULTS From November 2006 to August 2014, 41 patients (6 females) with a mean age of 65 years underwent RATE without surgical drainage of the pylorus. There were 14 patients in the BOTOX group and 27 patients in the noBOTOX group. Mean operative time was not different between the comparison groups. There was one conversion to open surgery in the BOTOX group. No pyloric dysfunction occurred in the BOTOX group postoperatively, and eight stenoses in the noBOTOX group (30%) required endoscopic therapy (P < .05). There were no differences in incidence of anastomotic strictures or anastomotic leaks. One patient in group noBOTOX required pyloroplasty 3 months after esophagectomy. There was one death in the noBOTOX group postoperatively (30-day mortality 2.4%). Mean LOS was 9.6 days, and BOTOX patients were discharged earlier (7.4 versus 10.7, P < .05). CONCLUSION Intraoperative endoscopic injection of botulinum toxin into the pylorus during RATE is feasible, safe, and effective and can prevent the need for pyloromyotomy.
Collapse
Affiliation(s)
- Hans F Fuchs
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California.,2 Department of Surgery, University of Cologne , Cologne, Germany
| | - Ryan C Broderick
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California
| | - Cristina R Harnsberger
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California
| | - Francisco Alvarez Divo
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California
| | - Alisa M Coker
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California
| | - Garth R Jacobsen
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California
| | - Bryan J Sandler
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California.,3 VA Healthcare , San Diego, California
| | - Michael Bouvet
- 4 Department of Surgery, University of California , San Diego, California
| | - Santiago Horgan
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California
| |
Collapse
|
116
|
Predictors Of Treatment Failure After Radiofrequency Ablation For Intramucosal Adenocarcinoma in Barrett Esophagus. Am J Surg Pathol 2016; 40:554-62. [DOI: 10.1097/pas.0000000000000566] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
117
|
Mohiuddin K, Dorer R, El Lakis MA, Hahn H, Speicher J, Hubka M, Low DE. Outcomes of Surgical Resection of T1bN0 Esophageal Cancer and Assessment of Endoscopic Mucosal Resection for Identifying Low-Risk Cancers Appropriate for Endoscopic Therapy. Ann Surg Oncol 2016; 23:2673-8. [PMID: 27020584 DOI: 10.1245/s10434-016-5138-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Invasive esophageal cancers have been managed historically with esophagectomy. Low-risk T1b patients are being proposed for nonsurgical management. The purpose of this study was to evaluate the ability of endoscopic mucosal resections (EMR) to identify low-risk T1b patients and to review surgical treatment outcomes for T1b cancer. METHODS All esophageal cancer patients, in an institutional review board-approved prospective database, between 2000 and 2013 with clinical stage (cT1bN0), pathological stage (pT1bN0), and no neoadjuvant therapy were retrospectively reviewed. RESULTS Fifty-one patients, 38 pT1b and 13 cT1b, were assessed. All cT1b had preoperative EMR and five were found to be understaged at esophagectomy. pT1bN0 patients had a mean age of 66 years, mean BMI of 30, and 95 % had adenocarcinoma. Thirty-eight pT1bN0 patients underwent esophagectomy with a median hospital length of stay (LOS) of 9 days. Complications occurred in 14 patients, but 71 % were minor (Accordion score 1-2). In-hospital 30- and 90-day mortality was zero. EMR specimens were re-reviewed to assess low-risk criteria. Degree of differentiation and the presence of lymphovascular invasion could be assessed in all EMR specimens; however, assessment of submucosal invasion limited to the superficial submucosal layer could not be determined in the majority of cases. Kaplan-Meier 5-year overall survival in pT1bN0 patients was 78.7 %. CONCLUSIONS Clinical staging of superficial esophageal cancer can be inaccurate especially in submucosal tumors. EMR should be routinely used for preoperative staging. Healthy patients with clinical tumor stage greater than cT1a should undergo multidisciplinary review and be considered for surgical resection.
Collapse
Affiliation(s)
- Kamran Mohiuddin
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Russell Dorer
- Department of Pathology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Mustapha A El Lakis
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Hejin Hahn
- Department of Pathology, Virginia Mason Medical Center, Seattle, WA, USA
| | - James Speicher
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michal Hubka
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA.
| |
Collapse
|
118
|
Knabe M, May A, Ell C. Endoscopic Therapy of Early Carcinoma of the Oesophagus. VISZERALMEDIZIN 2016; 31:320-5. [PMID: 26989386 PMCID: PMC4789909 DOI: 10.1159/000441075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Oesophageal cancer is a comparatively rare disease in the Western world. Prognosis is highly dependent on the choice of treatment. Early stages can be treated by endoscopic resection, whereas surgery needs to be performed in the case of advanced carcinomas. Technical progress has enabled high-definition endoscopes and technical add-ons which help the endoscopist in finding fine irregularities in the oesophageal mucosa, though interpretation still remains challenging. Methods In this review, we discuss both novel and old diagnostic procedures and their value, as well as the current recommendations for the diagnosis and treatment of early oesophageal carcinomas. The database of PubMed and Medline was searched and analysed to provide all relevant literature for this review. Results and Conclusion Endoscopic resection is the therapy of choice in early oesophageal cancer. In case of adenocarcinoma it is mandatory to perform subsequent ablation of all residual Barrett's mucosa to avoid metachronous lesions.
Collapse
Affiliation(s)
- Mate Knabe
- Department of Medicine II/IV, Sana Klinikum Offenbach, Offenbach, Germany
| | - Andrea May
- Department of Medicine II/IV, Sana Klinikum Offenbach, Offenbach, Germany
| | - Christian Ell
- Department of Medicine II/IV, Sana Klinikum Offenbach, Offenbach, Germany
| |
Collapse
|
119
|
Chadwick G, Riley S, Hardwick RH, Crosby T, Hoare J, Hanna G, Greenaway K, Varagunam M, Cromwell DA, Groene O. Population-based cohort study of the management and survival of patients with early-stage oesophageal adenocarcinoma in England. Br J Surg 2016; 103:544-52. [PMID: 26865114 DOI: 10.1002/bjs.10116] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/12/2015] [Accepted: 12/21/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Until recently, oesophagectomy was the treatment of choice for early oesophageal cancer. Endoscopic treatment has been introduced relatively recently. This observational national database study aimed to describe how endoscopic therapy has been introduced in England and to examine the safety of this approach. METHODS A population-based cohort study was undertaken of patients diagnosed with oesophageal adenocarcinoma between October 2007 and June 2009 using three linked national databases. Patients with early-stage disease (T1 tumours with no evidence of spread) were identified, along with the primary treatment modality where treatment intent was curative. Short-term outcomes after treatment and 5-year survival were evaluated. RESULTS Of 5192 patients diagnosed with oesophageal adenocarcinoma, 306 (5·9 per cent) were considered to have early-stage disease before any treatment, of whom 239 (79·9 per cent of 299 patients with data on treatment intent) were managed with curative intent. Of 175 patients who had an oesophagectomy, 114 (65·1 (95 per cent c.i. 57·6 to 72·7) per cent) survived for 5 years. Among these, 47 (30·3 per cent of 155 patients with tissue results available) had their disease upstaged after pathological staging; this occurred more often in patients who did not have staging endoscopic ultrasonography before surgery. Of 41 patients who had an endoscopic resection, 27 (66 (95 per cent c.i. 49 to 80) per cent) survived for 5 years. Repeat endoscopic therapy was required by 23 (56 per cent) of these 41 patients. CONCLUSION Between 2007 and 2009, oesophagectomy remained the initial treatment of choice (73·2 per cent) among patients with early-stage oesophageal cancer treated with curative intent; one in five patients were managed endoscopically, and this treatment was more common in elderly patients. Although the groups had different patient characteristics, 5-year survival rates were similar.
Collapse
Affiliation(s)
- G Chadwick
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Gastroenterology, St Mary's Hospital, London, UK
| | - S Riley
- Department of Gastroenterology, Northern General Hospital, Sheffield, UK
| | - R H Hardwick
- Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - T Crosby
- Velindre Cancer Centre, Cardiff, UK
| | - J Hoare
- Department of Gastroenterology, St Mary's Hospital, London, UK
| | - G Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
| | - K Greenaway
- Health and Social Care Information Centre, Leeds, UK
| | - M Varagunam
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - D A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - O Groene
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
120
|
Werbrouck E, De Hertogh G, Sagaert X, Coremans G, Willekens H, Demedts I, Bisschops R. Oesophageal biopsies are insufficient to predict final histology after endoscopic resection in early Barrett's neoplasia. United European Gastroenterol J 2016; 4:663-668. [PMID: 27733908 DOI: 10.1177/2050640615626320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 12/13/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Endoscopic resection (ER) with or without ablation is the first choice treatment for early Barrett's neoplasia. Adequate staging is important to assure a good oncological outcome. OBJECTIVE The purpose of this study was to investigate the diagnostic accuracy of pre-operative biopsies in patients who undergo ER for high-grade dysplasia (HGD) or early adenocarcinoma (EAC) in Barrett's oesophagus (BE) and the cardia. METHODS Between November 2005-May 2012, 142 ERs performed in 137 patients were obtained. Worst pre-ER and ER histology were compared. Upgrading/downgrading was defined as any more/less severe histological grading on the ER specimen. RESULTS The accuracy of pre-ER biopsies in predicting final histology was 61%. ER changed the pre-treatment diagnosis in 55 of the 142 procedures (39%) with downgrading in 23 cases (16%) and upgrading from HGD to T1a or T1b in 32 cases (23%). In the majority of upgraded cases, a visible lesion according to the Paris classification could be detected (26/32, 81%). CONCLUSION The diagnostic accuracy of oesophageal biopsies alone in predicting final pathology in Barrett's dysplasia is only 61%. The majority of upgraded lesions are detectable. When ablative therapy is considered in HGD Barrett's dysplasia a meticulous inspection for and removal of all small visible lesions is mandatory.
Collapse
Affiliation(s)
- E Werbrouck
- Department of General Medical Oncology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - G De Hertogh
- Department of Pathology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - X Sagaert
- Department of Pathology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - G Coremans
- Department of Gastroenterology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - H Willekens
- Department of Gastroenterology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - I Demedts
- Department of Gastroenterology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - R Bisschops
- Department of Gastroenterology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
121
|
Early Esophageal Cancer Specific Survival Is Unaffected by Anatomical Location of Tumor: A Population-Based Study. Can J Gastroenterol Hepatol 2016; 2016:6132640. [PMID: 27559535 PMCID: PMC4983357 DOI: 10.1155/2016/6132640] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/15/2016] [Accepted: 06/29/2016] [Indexed: 12/31/2022] Open
Abstract
Background. Approximately one-fifth of all esophageal cancer cases are defined as early esophageal cancer (EEC). Although endoscopic therapy (ET) has been shown to be equally effective as esophagectomy (EST) in patients with EEC, there is little information comparing the survival outcomes of the two therapies based on anatomical location. Methods. A population-based study was conducted and the data was obtained from Surveillance, Epidemiology, and End Results program. Patients with EEC (i.e., stages Tis and T1a) and treated with either ET or EST were analyzed to compare EEC-related survival for three different locations of tumor. Results. The overall EEC-specific 1-year and 5-year mean (±SE) survival rates were 11.66 ± 0.05 and 52.80 ± 0.58 months, respectively. Tumors located in lower third had better 5-year survival compared to those located in middle third (83.50% versus 73.10%, p < 0.01). However, when adjusted for age, race, gender, marital status, grade, stage of tumor, histological type, and treatment modality, there was no significant difference. Conclusion. The EEC-specific 1-year or 5-year adjusted survival did not differ by anatomic location of the tumor. Therefore, ET might serve as a minimally invasive yet effective alternative to EST to treat EEC.
Collapse
|
122
|
Long-term outcomes of a primary complete endoscopic resection strategy for short-segment Barrett's esophagus with high-grade dysplasia and/or early esophageal adenocarcinoma. Gastrointest Endosc 2016; 83:68-77. [PMID: 26096759 DOI: 10.1016/j.gie.2015.04.044] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/26/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Complete endoscopic resection (CER) of Barrett's esophagus (BE) with high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EEA) is a comprehensive and precise staging tool and may produce a sustained treatment response, preventing metachronous disease. There are limited data on long-term clinical outcomes and the sustainability of dysplasia eradication after CER. We aimed to describe long-term outcomes of a primary CER strategy of BE with HGD/EEA. METHODS Patients with biopsy-proven HGD and EEA in short-segment BE (≤ 3 cm in circumferential length and ≤ 5 cm in maximal length) underwent staged CER by multiband mucosectomy or the cap method. The primary endpoint was remission of HGD or EEA (complete resection of HGD/EEA), dysplasia (complete resection of any dysplasia), and complete resection of intestinal metaplasia. RESULTS Of 153 patients (126 HGD, 27 EEA; 83.7% male, median age of 66 years) considered suitable for CER, 138 met all inclusion criteria. CER was technically successful in all patients and was established after a median of 2 sessions. Covert synchronous EEA was found in 1 patient. At a mean follow-up of 40.7 months by intention-to-treat analysis, complete remission of HGD/EEA, dysplasia, and intestinal metaplasia was achieved in 98.5%, 89.1%, and 71.0%, respectively. In 47.1% of patients, CER changed the histological grade compared with pretreatment biopsies (28.1% downstaged and 19.0% upstaged). Esophageal dilation was performed in 36.8% in a mean of 2.5 sessions. At the end of follow-up, 96.4% of patients had no or minimal dysphagia and 90.6% of patients found CER an acceptable treatment. CONCLUSIONS On long-term follow-up, a primary CER strategy was a highly effective, safe, and durable treatment for HGD and EEA. Despite the need for post-CER dilation in one-third of patients, the majority found it an acceptable treatment on long-term follow-up.
Collapse
|
123
|
Boys JA, Worrell SG, Chandrasoma P, Vallone JG, Maru DM, Zhang L, Blackmon SH, Dickinson KJ, Dunst CM, Hofstetter WL, Lada MJ, Louie BE, Molena D, Watson TJ, DeMeester SR. Can the Risk of Lymph Node Metastases Be Gauged in Endoscopically Resected Submucosal Esophageal Adenocarcinomas? A Multi-Center Study. J Gastrointest Surg 2016; 20:6-12; discussion 12. [PMID: 26408330 DOI: 10.1007/s11605-015-2950-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/14/2015] [Indexed: 02/07/2023]
Abstract
Endoscopic resection (ER) allows for local therapy of superficial esophageal cancers. Factors reported to be associated with an increased risk of lymph node metastases in patients with adenocarcinoma are poor differentiation, lymphovascular invasion (LVI), and submucosal invasion >500 μ. The aim of this study was to determine whether depth of invasion and tumor characteristics in an ER specimen can be used to gauge the risk of lymph node metastases in patients with superficial esophageal adenocarcinoma. Patients from seven US centers that had ER of an adenocarcinoma followed by an esophagectomy were identified. The ER pathology slides were rereviewed by three experienced GI pathologists for depth of invasion, presence of LVI, and tumor differentiation. The findings from the ER specimen were correlated with the presence and number of lymph node metastases in the final esophagectomy specimen. There were 19 T1a and 23 T1b tumors. A median of 24 nodes were resected per patient. None of the T1a tumors had involved lymph nodes despite the presence of LVI in 5% and poor differentiation in 21% of patients. In contrast, 26% of T1b tumors had involved nodes. None of the four patients with submucosal invasion ≤500 μ, no LVI, and no poor differentiation had involved nodes. However, with an increasing number of risk factors, the likelihood of involved lymph nodes increased, reaching 50% when all three factors were present. Endoscopic therapy appears appropriate for intramucosal tumors and may be an option for low-risk T1b tumors. Esophagectomy is preferred for patients with submucosal invasion and one or more risk factors.
Collapse
Affiliation(s)
- Joshua A Boys
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | - Stephanie G Worrell
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | - Parakrama Chandrasoma
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John G Vallone
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Dipen M Maru
- Department of Pathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Lizhi Zhang
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Wayne L Hofstetter
- Department of Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Michael J Lada
- Department of Surgery, University of Rochester, New York, NY, USA
| | - Brian E Louie
- Department of Surgery, Swedish Cancer Institute, Seattle, WA, USA
| | - Daniela Molena
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Thomas J Watson
- Department of Surgery, University of Rochester, New York, NY, USA
| | - Steven R DeMeester
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA.
| |
Collapse
|
124
|
ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus. Am J Gastroenterol 2016; 111:30-50; quiz 51. [PMID: 26526079 DOI: 10.1038/ajg.2015.322] [Citation(s) in RCA: 1047] [Impact Index Per Article: 116.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 08/28/2015] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus (BE) is among the most common conditions encountered by the gastroenterologist. In this document, the American College of Gastroenterology updates its guidance for the best practices in caring for these patients. These guidelines continue to endorse screening of high-risk patients for BE; however, routine screening is limited to men with reflux symptoms and multiple other risk factors. Acknowledging recent data on the low risk of malignant progression in patients with nondysplastic BE, endoscopic surveillance intervals are attenuated in this population; patients with nondysplastic BE should undergo endoscopic surveillance no more frequently than every 3-5 years. Neither routine use of biomarker panels nor advanced endoscopic imaging techniques (beyond high-definition endoscopy) is recommended at this time. Endoscopic ablative therapy is recommended for patients with BE and high-grade dysplasia, as well as T1a esophageal adenocarcinoma. Based on recent level 1 evidence, endoscopic ablative therapy is also recommended for patients with BE and low-grade dysplasia, although endoscopic surveillance continues to be an acceptable alternative. Given the relatively common recurrence of BE after ablation, we suggest postablation endoscopic surveillance intervals. Although many of the recommendations provided are based on weak evidence or expert opinion, this document provides a pragmatic framework for the care of the patient with BE.
Collapse
|
125
|
Worrell SG, Boys JA, Chandrasoma P, Vallone JG, Dunst CM, Johnson CS, Lada MJ, Louie BE, Watson TJ, DeMeester SR. Inter-Observer Variability in the Interpretation of Endoscopic Mucosal Resection Specimens of Esophageal Adenocarcinoma: Interpretation of ER specimens. J Gastrointest Surg 2016; 20:140-4; discussion 144-5. [PMID: 26503261 DOI: 10.1007/s11605-015-3009-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 10/19/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Endoscopic resection (ER) has revolutionized the staging and therapy of superficial esophageal adenocarcinoma. Pathologic evaluation allows an assessment of the risk of lymph node metastases based on tumor characteristics. The aim of this study was to assess the inter-observer variability in pathologic assessment of ER specimens of esophageal adenocarcinoma. METHODS We performed a retrospective study on ER specimens of superficial esophageal adenocarcinoma from four US institutions. Original endoscopic resection slides were re-reviewed by two blinded, experienced (study) gastrointestinal pathologists for the depth of tumor invasion, tumor grade, and the presence of lymphovascular invasion (LVI). Discordance was considered present only when both study pathologists disagreed with the original report. RESULTS There were 25 ER specimens reviewed for this study, and discordance occurred in 12 of the 25 specimens (48%) for the depth of tumor invasion. In most cases (83%), the discordance was related to overstaging a true T1a lesion. We found that only 38% of true T1a lesions were correctly staged for depth of invasion. Less commonly discordance was secondary to understaging a true T1b lesion. There was concordance between the two study pathologists in 22/25 cases (88%) on the depth of invasion. Discordance was present for tumor grade in 8/18 cases (44%) and for LVI in 4/16 cases (25%). Concordance between the study pathologists was 80% for tumor grade and 88% for LVI. CONCLUSIONS There was an alarmingly high rate of discordance (48%) between the study pathologists and the original pathology assessment for the depth of tumor invasion in ER specimens. This was particularly common for lesions called T1b on the original pathology report. Since critical decisions are made regarding esophageal preservation or esophagectomy on the basis of the pathologic interpretations of ER specimens, it behooves surgeons to understand the inter-observer variability. Review of ER specimens by an experienced GI pathologist is recommended to ensure that patients receive the appropriate treatment for superficial esophageal adenocarcinoma.
Collapse
Affiliation(s)
- Stephanie G Worrell
- Surgery, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | - Joshua A Boys
- Surgery, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | | | - John G Vallone
- Pathology, University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | - Steven R DeMeester
- Surgery, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA.
| |
Collapse
|
126
|
Kozarek RA. Photodynamic therapy in esophageal cancer. GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.18528/gii1400008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
127
|
Schmidt HM, Mohiuddin K, Bodnar AM, El Lakis M, Kaplan S, Irani S, Gan I, Ross A, Low DE. Multidisciplinary treatment of T1a adenocarcinoma in Barrett's esophagus: contemporary comparison of endoscopic and surgical treatment in physiologically fit patients. Surg Endosc 2015; 30:3391-401. [PMID: 26541725 DOI: 10.1007/s00464-015-4621-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 10/09/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Previous reports comparing endoscopic therapy (ET) and surgical therapy (ST) have predominantly assessed patients with high-grade dysplasia. The study aim was to compare ET to ST in physiologically fit patients with cT1a adenocarcinoma (EAC). METHODS Review of two prospective databases yielded 100 patients presenting with clinical cT1a EAC between 2000 and 2013. Only physiologically fit patients who were candidates for either treatment were analyzed. RESULTS Presenting patient characteristics were similar between ET (n = 36) and ST groups (n = 49). Surgical patients were less likely to be staged with EMR (43 vs 100 %) and were associated with mass lesions >1 cm at EGD (p = 0.01), multifocal EAC (p = 0.03), and positive margins for EAC on EMR (p < 0.05). On multivariate analysis, only multifocal HGD was an independent factor for surgery. Following esophagectomy, R0 resection rates for Barrett's esophagus and cancer were 100 %. Incidence of surgery decreased over the study period from 85 to 25 %. All ET patients had EMR, and 28 patients underwent additional ablative therapies for Barrett's esophagus. Following ET, eradication rates of EAC, dysplasia, and BE were 92, 81, and 53 %, respectively. Morbidity rates were comparable between groups (ST 51 % vs ET 39 %, p = 0.31). In-hospital mortality rate was zero in each group. Recurrence rates in ST and ET group were 2 and 11 % (p = 0.08). In the ET group, two patients with endoluminal cancer recurrence after complete eradication underwent esophagectomy. Age-adjusted overall survival was comparable. CONCLUSION In high-volume esophageal centers, ST and ET provide equally safe and effective treatment for cT1a EAC in medically fit patients. While the results of this study provide a historical perspective and clearly demonstrate an evolution toward ET over time, the appropriate treatment modality is best selected in a multidisciplinary fashion with EMR providing the most accurate staging. In endoscopically treated patients, indefinite endoscopic follow-up required, however, standardized long-term follow-up protocols are needed.
Collapse
Affiliation(s)
- Henner M Schmidt
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Kamran Mohiuddin
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Artur M Bodnar
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Mustapha El Lakis
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Stephen Kaplan
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Shayan Irani
- Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Ian Gan
- Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andrew Ross
- Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Donald E Low
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA.
| |
Collapse
|
128
|
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.
Collapse
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
| |
Collapse
|
129
|
Rubenstein JH, Shaheen NJ. Epidemiology, Diagnosis, and Management of Esophageal Adenocarcinoma. Gastroenterology 2015; 149:302-17.e1. [PMID: 25957861 PMCID: PMC4516638 DOI: 10.1053/j.gastro.2015.04.053] [Citation(s) in RCA: 257] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/27/2015] [Accepted: 04/02/2015] [Indexed: 02/06/2023]
Abstract
Esophageal adenocarcinoma (EAC) is rapidly increasing in incidence in Western cultures. Barrett's esophagus is the presumed precursor lesion for this cancer. Several other risk factors for this cancer have been described, including chronic heartburn, tobacco use, white race, and obesity. Despite these known associations, most patients with EAC present with symptoms of dysphagia from late-stage tumors; only a small number of patients are identified by screening and surveillance programs. Diagnostic analysis of EAC usually commences with upper endoscopy followed by cross-sectional imaging. Endoscopic ultrasonography is useful to assess the local extent of disease as well as the involvement of regional lymph nodes. T1a EAC may be treated endoscopically, and some patients with T1b disease may also benefit from endoscopic therapy. Locally advanced disease is generally managed with esophagectomy, often accompanied by neoadjuvant chemoradiotherapy or chemotherapy. The prognosis is based on tumor stage; patients with T1a tumors have an excellent prognosis, whereas few patients with advanced disease have long-term survival.
Collapse
Affiliation(s)
- Joel H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, Department of Medicine, University of Michigan, Ann Arbor, Michigan.
| | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
130
|
Abstract
The incidence of early esophageal adenocarcinoma has been increasing significantly in recent decades. Prognosis depends greatly on the choice of treatment. Early cancers can be treated by endoscopic resection, whereas advanced carcinomas have to be sent for surgery. Esophageal resection is associated with high perioperative mortality (1-5%) even in specialized centers. Early diagnosis enables curative endoscopic treatment option. Patients with gastrointestinal symptoms and a familial risk for esophageal cancer should undergo upper gastrointestinal endoscopy. High-definition endoscopes have been developed with technical add-on that helps endoscopists to find fine irregularities in the esophageal mucosa, but interpreting the findings remains challenging. In this review we discussed novel and old diagnostic procedures and their values, as well as our own recommendations and those of the authors discussed for the diagnosis and treatment of early Barrett's carcinoma. Endoscopic resection is the therapy of choice in early esophageal adenocarcinoma. It is mandatory to perform a subsequent ablation of all residual Barrett's mucosa to avoid metachronous lesions.
Collapse
Affiliation(s)
- Mate Knabe
- Department for Gastroenterology, Sana Klinikum Offenbach, Offenbach, Germany
| | - Andrea May
- Department for Gastroenterology, Sana Klinikum Offenbach, Offenbach, Germany
| | - Christian Ell
- Department for Gastroenterology, Sana Klinikum Offenbach, Offenbach, Germany
| |
Collapse
|
131
|
Strauss AC, Agoston AT, Dulai PS, Srivastava A, Rothstein RI. Radiofrequency ablation for Barrett's-associated intramucosal carcinoma: a multi-center follow-up study. Surg Endosc 2015; 28:3366-72. [PMID: 24950726 DOI: 10.1007/s00464-014-3629-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Radiofrequency ablation (RFA), with or without endoscopic mucosal resection (EMR), has been validated as a safe, effective and durable treatment option for dysplastic Barrett's esophagus. Its durability in eradicating Barrett's-associated intramucosal carcinoma (IMC), however, is unclear. We set out to assess the long-term safety and efficacy of RFA for IMC. METHODS Retrospective review of two tertiary care facility records for patients undergoing RFA, with or without EMR, for biopsy-proven IMC. Our primary outcome of interest was to quantify the rate of durable complete eradication for intestinal metaplasia and for IMC and associated dysplasia. A multi-variate regression analysis was performed to identify features which correlate with durable eradication of IMC/dysplasia. Our secondary outcome of interest was treatment-related complications. RESULTS 36 patients (26 male; mean age 64 ± 12 years), with a mean Barrett's length of 3.5 ± 2.5 cm, underwent RFA for biopsy-proven IMC. EMR was performed in 31 (86%) prior to or during RFA. Complete eradication of IMC/dysplasia was achieved in 32/36 (89%) and patients required a mean of 1 ± 1 EMR and 2 ± 1 RFA sessions to achieve eradication. During a mean follow-up period of 24 ± 19 months, durable complete eradication of IMC/dysplasia was achieved in 29/36 (81%) patients. On multi-variate regression analysis, undergoing an EMR prior to RFA was associated with an increased likelihood of maintaining durable eradication of IMC/dysplasia (p = 0.03). Treatment-related complications included: bleeding (3%) and stricture formation (19%). CONCLUSION RFA is an effective and durable treatment option for Barrett's-associated IMC. Greater than 80% of patients will achieve and maintain complete eradication of IMC at a mean of 2 years follow-up.
Collapse
Affiliation(s)
- Adam C Strauss
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA,
| | | | | | | | | |
Collapse
|
132
|
Abstract
Barrett's esophagus is the only identifiable premalignant condition for esophageal adenocarcinoma. Endoscopic eradication therapy (EET) has revolutionized the management of Barrett's-related dysplasia and intramucosal cancer. The primary goal of EET is to prevent progression to invasive esophageal adenocarcinoma and ultimately improve survival rates. There are several challenges with EET that can be encountered before, during, or after the procedure that are important to understand to optimize the effectiveness and safety of EET and ultimately improve patient outcomes. This article focuses on the challenges with EET and discusses them under the categories of preprocedural, intraprocedural, and postprocedural challenges.
Collapse
Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Mail Stop F735, 1635 Aurora Court, Room 2.031, Aurora, CO 80045, USA.
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas, 4801 Linwood Boulevard, Kansas City, MO 64128, USA
| |
Collapse
|
133
|
Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection for Endoscopic Therapy of Barrett's Esophagus-related Neoplasia. Gastroenterol Clin North Am 2015; 44:317-35. [PMID: 26021197 DOI: 10.1016/j.gtc.2015.02.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A major paradigm shift has occurred in the management of dysplastic Barrett's esophagus (BE) and early esophageal carcinoma. Endoscopic therapy has now emerged as the standard of care for this disease entity. Endoscopic resection techniques like endoscopic mucosal resection and endoscopic submucosal dissection combined with ablation techniques help achieve long-term curative success comparable with surgical outcomes, in this subgroup of patients. This article is an in-depth review of these endoscopic resection techniques, highlighting their role and value in the overall management of BE-related dysplasia and neoplasia.
Collapse
|
134
|
Abstract
Patients with gastroesophageal reflux disease and Barrett's esophagus can be a management challenge for the treating physician or surgeon. The goals of therapy include relief of reflux symptoms, induction of histologic regression, and prevention of progression of intestinal metaplasia to dysplasia or invasive carcinoma. Antireflux surgery is effective at achieving these end points, although ongoing follow-up and endoscopic surveillance are essential. In cases of dysplasia or early esophageal neoplasia associated with Barrett's esophagus, endoscopic resection and ablation have supplanted esophagectomy as the standard of care in most cases. Esophageal resection continues to have a role, however, in a minority of appropriately selected candidates.
Collapse
Affiliation(s)
- Christian G Peyre
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Avenue, Box Surgery, Rochester, NY 14642, USA
| | - Thomas J Watson
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Avenue, Box Surgery, Rochester, NY 14642, USA.
| |
Collapse
|
135
|
Whiteman DC, Appleyard M, Bahin FF, Bobryshev YV, Bourke MJ, Brown I, Chung A, Clouston A, Dickins E, Emery J, Eslick GD, Gordon LG, Grimpen F, Hebbard G, Holliday L, Hourigan LF, Kendall BJ, Lee EY, Levert-Mignon A, Lord RV, Lord SJ, Maule D, Moss A, Norton I, Olver I, Pavey D, Raftopoulos S, Rajendra S, Schoeman M, Singh R, Sitas F, Smithers BM, Taylor AC, Thomas ML, Thomson I, To H, von Dincklage J, Vuletich C, Watson DI, Yusoff IF. Australian clinical practice guidelines for the diagnosis and management of Barrett's esophagus and early esophageal adenocarcinoma. J Gastroenterol Hepatol 2015; 30:804-820. [PMID: 25612140 DOI: 10.1111/jgh.12913] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2014] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE as most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE. Moreover, there have been recent advances in knowledge and practice about the management of BE and early EAC. To aid clinical decision making in this rapidly moving field, Cancer Council Australia convened an expert working party to identify pertinent clinical questions. The questions covered a wide range of topics including endoscopic and histological definitions of BE and early EAC; prevalence, incidence, natural history, and risk factors for BE; and methods for managing BE and early EAC. The latter considered modification of lifestyle factors; screening and surveillance strategies; and medical, endoscopic, and surgical interventions. To answer each question, the working party systematically reviewed the literature and developed a set of recommendations through consensus. Evidence underpinning each recommendation was rated according to quality and applicability.
Collapse
Affiliation(s)
- David C Whiteman
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
136
|
Pech O. Endoscopic therapy of high-grade dysplasia and intramucosal adenocarcinoma: 2 small steps for the endoscopists but a fine step forward for the patient. Gastrointest Endosc 2015; 81:1167-9. [PMID: 25864893 DOI: 10.1016/j.gie.2015.01.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 01/22/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, Krankenhaus Barmherzige Brüder (St. John of God Hospital), Teaching Hospital of the University of Regensburg, Regensburg, Germany
| |
Collapse
|
137
|
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.
Collapse
|
138
|
Leggett CL, Lewis JT, Wu TT, Schleck CD, Zinsmeister AR, Dunagan KT, Lutzke LS, Wang KK, Iyer PG. Clinical and histologic determinants of mortality for patients with Barrett's esophagus-related T1 esophageal adenocarcinoma. Clin Gastroenterol Hepatol 2015; 13:658-64.e1-3. [PMID: 25151255 PMCID: PMC4336231 DOI: 10.1016/j.cgh.2014.08.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 08/11/2014] [Accepted: 08/11/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Superficial (T1) esophageal adenocarcinoma (EAC) commonly is treated by endoscopic resection, yet little is known about factors that predict outcomes of this approach. We assessed clinical and histologic variables associated with the overall survival times of patients with T1 EAC who received therapy. METHODS In a retrospective analysis, we collected data from patients who underwent endoscopic mucosal resection (EMR) for T1 EAC (194 patients with T1a and 75 patients with T1b) at the Mayo Clinic, from 1995 through 2011. EMR specimens were reviewed systematically for depth of invasion, presence of lymphovascular invasion, grade of differentiation, and status of resection margins. Kaplan-Meier curves and proportional hazards regression models were used in statistical analyses. RESULTS Demographic characteristics were similar between patients with T1a and T1b EAC. Overall survival at 5 years after EMR was 74.4% for patients with T1a (95% confidence interval [CI], 67.6%-81.8%) and 53.2% for patients with T1b EAC (95% CI, 40.3%-70.1%). Of surviving patients with T1a EAC, 94.1% remained free of cancer (95% CI, 89.8%-98.5%), and 94.7% of surviving patients with T1b EAC remained free of cancer (95% CI, 85.2%-100%). A multivariable model associated older age (per 10-year increment), evidence of lymphovascular invasion, and deep margin involvement with reduced overall survival in patients with T1 EAC. CONCLUSIONS Systematic assessment of EMR specimens can help predict mortality and potentially guide treatment options for patients with T1 EAC.
Collapse
Affiliation(s)
- Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Jason T Lewis
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Tsung Teh Wu
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Cathy D Schleck
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Alan R Zinsmeister
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Kelly T Dunagan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Lori S Lutzke
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
139
|
Labenz J, Koop H, Tannapfel A, Kiesslich R, Hölscher AH. The epidemiology, diagnosis, and treatment of Barrett's carcinoma. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:224-33; quiz 234. [PMID: 25869347 DOI: 10.3238/arztebl.2015.0224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 11/25/2014] [Accepted: 11/29/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Roughly 3000 new cases of Barrett's carcinoma arise in Germany each year. In view of recent advances in the epidemiology, diagnosis, and treatment of this disease, an update of the clinical recommendations is in order. METHODS This review is based on selected relevant publications, including current reviews, meta-analyses, and guidelines. RESULTS The risk of progression of Barrett's esophagus to carcinoma lies between 0.10% and 0.15% per year. Risk factors for progression include male sex, age over 50 years, obesity, longstanding and frequent reflux symptoms, smoking, length of the Barrett's esophagus, and intraepithelial neoplasia. Well-differentiated carcinomas that are confined to the esophageal mucosa can be resected endoscopically with a cure rate above 90%. For more advanced, but still locally confined tumors, surgical resection is the treatment of choice. In stages cT3/4, the prognosis can be improved with neo-adjuvant chemo - therapy or combined radiotherapy and chemotherapy. Metastatic Barrett's carcinoma can be treated by endoscopic, chemotherapeutic, radiotherapeutic, and palliative methods. CONCLUSION Early carcinoma can often be cured by endoscopic resection. Locally advanced carcinoma calls for multimodal treatment. Current research focuses on means of preventing the progression of Barrett's esophagus, the scope of applicability of endoscopic techniques, and the optimization of multimodal treatment strategies for advanced disease.
Collapse
Affiliation(s)
- Joachim Labenz
- Department of Internal Medicine and Gastroenterology, Diakonie Klinikum, Jung-Stilling Hospital, Siegen, Department of General Practice, Internal Medicine and Gastroenterology, HELIOS Hospital Berlin-Buch, Institute of Pathology, Ruhr-University Bochum, Dr.-Horst-Schmidt-Kliniken, Wiesbaden, Department of General, Visceral and Cancer Surgery, University of Cologne
| | | | | | | | | |
Collapse
|
140
|
Le Page PA, Velu PP, Penman ID, Couper GW, Paterson-Brown S, Lamb PJ. Surgical and endoscopic management of high grade dysplasia and early oesophageal adenocarcinoma. Surgeon 2015; 14:315-321. [PMID: 25744636 DOI: 10.1016/j.surge.2015.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 11/26/2014] [Accepted: 01/27/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The introduction of endoscopic techniques has led to debate about optimal management of early oesophageal adenocarcinoma. The aim was to evaluate patient selection and outcomes for endoscopic or surgical treatment at a tertiary referral centre. METHODS A prospectively collected database of consecutive patients staged with high-grade dysplasia (HGD) or T1 oesophageal adenocarcinoma treated with curative intent between 2005 and 2013 was undertaken. All patients were discussed at the multidisciplinary team meeting. Surgical treatment was by thoracoscopic assisted or standard/laparoscopic assisted Ivor Lewis oesophagectomy. Endoscopic treatment was a structured programme of endoscopic mucosal resection (EMR) and/or radiofrequency ablation (RFA). Outcomes included treatment variables, recurrence and complications. RESULTS 83 patients treated; 50 with endoscopic therapy (EMR only-4, EMR then RFA-22, RFA only-24) and 38 by surgery (33 straight to surgery and 5 following EMR). Median age (67) and mean follow-up (21 months) were similar. HGD was more common in the endoscopic group (32/50, 64%, vs.3/33, 9%, p = 0.0001). Significant complications were more common following surgery (13/38, 34%, vs. 1/50, 2%, p = 0.0001). There were two in-hospital deaths following oesophagectomy (1 open, 1 thoracoscopic). Endoscopic treatment beyond 12 months for persisting HGD/intramucosal disease was required in 2 patients. Recurrence of HGD/invasive cancer was diagnosed in 2/36 (5.6%, T1a recurrence) of endoscopic and 1/38 (2.6%, T2N0 - subsequent hepatic metastases) surgical patients. CONCLUSION A management algorithm including both endoscopic treatment and oesophagectomy provides optimal outcome for these patients. Due to additional morbidity of surgery, endoscopic treatment is appropriate first-line treatment.
Collapse
Affiliation(s)
- Philip A Le Page
- Department of Oesophago-Gastric Surgery, Royal Infirmary Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK.
| | - Pras P Velu
- Department of Oesophago-Gastric Surgery, Royal Infirmary Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - Ian D Penman
- Department of Gastroenterology, Royal Infirmary Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - Graeme W Couper
- Department of Oesophago-Gastric Surgery, Royal Infirmary Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - Simon Paterson-Brown
- Department of Oesophago-Gastric Surgery, Royal Infirmary Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - Peter J Lamb
- Department of Oesophago-Gastric Surgery, Royal Infirmary Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| |
Collapse
|
141
|
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.
Collapse
Affiliation(s)
- Ch Zapletal
- Department of Surgery, Dr. Horst-Schmidt-Klinik, Ludwig-Erhard-Str. 100, 65199, Wiesbaden, Germany,
| | | | | | | | | | | | | |
Collapse
|
142
|
Chen YF, Zhao Y, Shi RH. Endoscopic submucosal dissection for treatment of early esophageal cancer and precancerous lesions. Shijie Huaren Xiaohua Zazhi 2015; 23:5171. [DOI: 10.11569/wcjd.v23.i32.5171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
143
|
Konda VJA, Gonzalez Haba Ruiz M, Koons A, Hart J, Xiao SY, Siddiqui UD, Ferguson MK, Posner M, Patti MG, Waxman I. Complete endoscopic mucosal resection is effective and durable treatment for Barrett's-associated neoplasia. Clin Gastroenterol Hepatol 2014; 12:2002-10.e1-2. [PMID: 24732285 DOI: 10.1016/j.cgh.2014.04.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 04/08/2014] [Accepted: 04/08/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Barrett's esophagus (BE) with high-grade dysplasia (HGD) or intramucosal carcinoma (IMC) is treated by complete eradication of areas of BE by endoscopic mucosal resection (EMR). By using this approach, histologic analysis also can be performed. We investigated the effectiveness, safety, and durability of this approach, as well as its use in diagnosis after a single referral. METHODS We collected data from 107 patients who were referred to the Center for Endoscopic Research and Therapeutics at the University of Chicago for BE (mean length, 3.6 cm) with suspected HGD or IMC, from August 2003 through December 2012. All patients underwent EMR and were followed up through January 2014 (mean follow-up time, 40.6 mo). The primary outcome was treatment efficacy (complete eradication of BE and associated neoplasia); secondary outcomes included safety, durability, and accuracy of diagnosis. RESULTS BE was eradicated completely by EMR in 80.4% (86 of 107) of patients based on intention-to-treat analysis, and in 98.8% (79 of 80) of patients based on per-protocol analysis. The diagnosis was changed for 25% of patients after EMR, including 4 cases that initially were diagnosed as HGD by biopsy analysis and subsequently were found to have evidence of submucosal invasion when EMR specimens were assessed. Strictures and symptomatic dysphagia developed in 41.1% and 37.3% of patients, respectively, with an average of 2.3 dilations required. Perforations occurred in 2 patients after EMR and in 1 patient after dilation. HGD and IMC recurred in 1 patient each; both were treated successfully with EMR. Based on pathology analysis of the most recently collected specimens, 71.6% of patients (53 of 74) were in complete remission from intestinal metaplasia and 100% were in complete remission from HGD (74 of 74) or cancer (74 of 74). CONCLUSIONS For patients with BE with HGD or neoplasia, complete EMR is an effective and durable treatment and is a relatively safe technique. Specimens collected by EMR also can be analyzed histologically to aid in diagnosis. The common complication of EMR is esophageal stricture, which can be addressed with endoscopic dilation.
Collapse
Affiliation(s)
- Vani J A Konda
- Center for Endoscopic Research and Therapeutics, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Mariano Gonzalez Haba Ruiz
- Center for Endoscopic Research and Therapeutics, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Ann Koons
- Center for Endoscopic Research and Therapeutics, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - John Hart
- Department of Pathology, University of Chicago Medicine, Chicago, Illinois
| | - Shu-Yuan Xiao
- Department of Pathology, University of Chicago Medicine, Chicago, Illinois
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Mark K Ferguson
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Mitchell Posner
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Marco G Patti
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Irving Waxman
- Center for Endoscopic Research and Therapeutics, Department of Medicine, University of Chicago Medicine, Chicago, Illinois.
| |
Collapse
|
144
|
Alzahrani AM, Bazarbashi SN, Rahal MM, Al-Shehri AS, Aljubran AH, Kandil MS, Zekri JE, Al Olayan AA, Alsharm AA, Yamani NM, Alomary IS, Fagih MA. Saudi Oncology Society clinical management guideline series. Esophageal cancer 2014. Saudi Med J 2014; 35:1545-1549. [PMID: 25491227 PMCID: PMC4362166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/13/2014] [Indexed: 02/08/2023] Open
Affiliation(s)
- Ali M Alzahrani
- Oncology Department, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia. E-mail.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
145
|
Bennett M, Mashimo H. Molecular markers and imaging tools to identify malignant potential in Barrett's esophagus. World J Gastrointest Pathophysiol 2014; 5:438-449. [PMID: 25400987 PMCID: PMC4231508 DOI: 10.4291/wjgp.v5.i4.438] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/10/2014] [Accepted: 07/14/2014] [Indexed: 02/06/2023] Open
Abstract
Due to its rapidly rising incidence and high mortality, esophageal adenocarcinoma is a major public health concern, particularly in Western countries. The steps involved in the progression from its predisposing condition, gastroesophageal reflux disease, to its premalignant disorder, Barrett’s esophagus, and to cancer, are incompletely understood. Current screening and surveillance methods are limited by the lack of population-wide utility, incomplete sampling of standard biopsies, and subjectivity of evaluation. Advances in endoscopic ablation have raised the hope of effective therapy for eradication of high-risk Barrett’s lesions, but improvements are needed in determining when to apply this treatment and how to follow patients clinically. Researchers have evaluated numerous potential molecular biomarkers with the goal of detecting dysplasia, with varying degrees of success. The combination of biomarker panels with epidemiologic risk factors to yield clinical risk scoring systems is promising. New approaches to sample tissue may also be combined with these biomarkers for less invasive screening and surveillance. The development of novel endoscopic imaging tools in recent years has the potential to markedly improve detection of small foci of dysplasia in vivo. Current and future efforts will aim to determine the combination of markers and imaging modalities that will most effectively improve the rate of early detection of high-risk lesions in Barrett’s esophagus.
Collapse
|
146
|
Ishihara R, Yamamoto S, Hanaoka N, Takeuchi Y, Higashino K, Uedo N, Iishi H. Endoscopic submucosal dissection for superficial Barrett's esophageal cancer in the Japanese state and perspective. ANNALS OF TRANSLATIONAL MEDICINE 2014; 2:24. [PMID: 25333000 DOI: 10.3978/j.issn.2305-5839.2014.02.03] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 02/13/2014] [Indexed: 01/15/2023]
Abstract
The incidence of Barrett's esophageal cancer is one of the most rapidly increasing among all cancers in the West, and it is also expected to increase in Japan. The optimal treatment for early Barrett's esophageal cancer remains controversial. En bloc esophagectomy with regional lymph node dissection has been considered the standard therapy. Endoscopic therapies are currently being evaluated as alternatives to esophagectomy because they can provide the least postoperative morbidity and the best quality of life. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) allow for removal of visible lesions and histopathologic review of resected tissue, which help in diagnostic staging of the disease. EMR is limited with respect to resection size, and large lesions must be resected in several fragments. Piecemeal resection of lesions is associated with high local recurrence rates, probably because of minor remnants of neoplastic tissue being left in situ. ESD provides larger specimens than does EMR in patients with early Barrett's neoplasia. This in turn allows for more precise histological analysis and higher en bloc and curative resection rates, potentially reducing the incidence of recurrence. Detailed endoscopic examination to determine the invasion depth and spread of Barrett's esophageal cancer is essential before ESD. The initial inspection is usually conducted with white-light imaging followed by narrow-band imaging. The ESD procedure is similar to that for lesions in other parts of the gastrointestinal tract. However, the narrow space of the esophagogastric junction and contraction of the lower esophageal sphincter sometimes disturb the visual field and endoscopic control. Skilled endoscope handling, sometimes including retroflexion, is required during ESD for Barrett's esophageal cancer. Previous reports have shown that ESD achieves en bloc resection in >80% of lesions. Although promising short-term results are reported, a long-term, large-scale study is required for better understanding of ESD for Barrett's esophageal cancer.
Collapse
Affiliation(s)
- Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 3-3 Nakamichi 1-chome, Higashinari-ku, Osaka 537-8511, Japan
| | - Sachiko Yamamoto
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 3-3 Nakamichi 1-chome, Higashinari-ku, Osaka 537-8511, Japan
| | - Noboru Hanaoka
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 3-3 Nakamichi 1-chome, Higashinari-ku, Osaka 537-8511, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 3-3 Nakamichi 1-chome, Higashinari-ku, Osaka 537-8511, Japan
| | - Koji Higashino
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 3-3 Nakamichi 1-chome, Higashinari-ku, Osaka 537-8511, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 3-3 Nakamichi 1-chome, Higashinari-ku, Osaka 537-8511, Japan
| | - Hiroyasu Iishi
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 3-3 Nakamichi 1-chome, Higashinari-ku, Osaka 537-8511, Japan
| |
Collapse
|
147
|
Single center experience of endoscopic submucosal dissection (ESD) in early Barrett's adenocarcinoma. Surg Endosc 2014; 29:1591-7. [PMID: 25294533 DOI: 10.1007/s00464-014-3847-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 08/27/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) or radical surgical resection are the standard treatment options for patients with early Barrett's adenocarcinoma (EBAC). Endoscopic submucosal dissection (ESD) is a new endoscopic technique, which allows--in contrast to EMR--endoscopic en-bloc resection of neoplastic lesions greater than 2 cm with complete histological evaluation of the resected specimen. In contrast to Western countries, Barrett's esophagus is less common in Asia indicating the low volume of published data of ESD in EBAC in Japanese series. Therefore, the aim of the present study is to describe the results of ESD in patients with EBAC performed in a German tertiary referral center. METHODS Between November 2009 and April 2014 ESDs were performed in 22 patients with histologically proven EBAC. Data were given for the en-bloc, the R0, the R0 en-bloc, and the curative resection rate as well as for the complication and the local recurrence rate. RESULTS ESD was technically possible in all of the 22 patients. 20 of the resected EBAC were mucosal carcinomas, whereas in two patients the tumor showed submucosal invasion. The en-bloc, R0, R0 en-bloc, and curative resection rates were 95.5, 81.8, 81.8 %, and 77.3 %, resp. Complication rate was 27.3 % (perforation n = 1, bleeding n = 2, stenosis n = 3). In case of curative tumor resection, only one local tumor recurrence (5.9 %) occurred after a medium follow-up of 1.6 years. CONCLUSIONS Despite the small number of patients and a relatively short follow-up, the present data underline the value of ESD, especially in case of curative resections in the definite and less invasive therapy of EBAC. Attention should be drawn toward subsquamous extension of EBAC requiring a sufficient safety margin as an obligate condition for curative R0 resections. Due to the required learning curve and the management of potential complications, ESD should be restricted to greater endoscopic centers.
Collapse
|
148
|
Anders M, Bähr C, El-Masry MA, Marx AH, Koch M, Seewald S, Schachschal G, Adler A, Soehendra N, Izbicki J, Neuhaus P, Pohl H, Rösch T. Long-term recurrence of neoplasia and Barrett's epithelium after complete endoscopic resection. Gut 2014; 63:1535-43. [PMID: 24389236 DOI: 10.1136/gutjnl-2013-305538] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Current endoscopic therapy for neoplastic Barrett's oesophagus (BO) consists of complete resection/ablation of all Barrett's tissue including neoplastic lesions. Recurrence seems to be frequent after thermal therapy, such as radiofrequency ablation. OBJECTIVE To analyse long-term recurrence of neoplasia and BO after successful widespread endoscopic mucosal resection (EMR). DESIGN In a retrospective analysis, all patients undergoing widespread EMR of neoplastic BO between 2002 and 2007 at two referral centres were followed for at least 3 years after completion of endotherapy. Recurrence was diagnosed if neoplasia and/or BO were detected following previous successful complete removal, defined as at least two negative endoscopies and biopsies. RESULTS Ninety patients undergoing widespread EMR were included (mean age 63 years; 82 male), 58% of whom underwent additional thermal ablation for minor residual disease. Complete eradication of neoplasia and Barrett's tissue was achieved in 90% of patients. On further follow-up (mean 64.8 months), recurrence of neoplastic and non-neoplastic BO was found in 6.2% and 39.5%, respectively. Recurring neoplasia (3 adenocarcinomas, 1 low-grade and 1 high-grade dysplasia) were found after a median of 44 months (range 38-85) and could be retreated endoscopically. In a multivariate analysis, Barrett's length was the only factor significantly associated with recurrence (OR 2.73). CONCLUSIONS Even after seemingly complete endoscopic resection, recurrence of BO is frequent and independent of additional thermal therapy. Due to the possibility of neoplasia recurrence even after long disease-free intervals, follow-up should be extended beyond 5 years.
Collapse
Affiliation(s)
- Mario Anders
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Bähr
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Muhammad Abbas El-Masry
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany Division of Gastroenterology, Department of Internal Medicine, Assiut University, Assiut, Egypt
| | - Andreas H Marx
- Department of Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Koch
- Department of Pathology, Charité University Hospital, Berlin, Germany
| | - Stefan Seewald
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany Gastrozentrum, Hirslanden Clinic, Zürich, Switzerland
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Adler
- Department of Gastroenterology, Charité University Hospital, Berlin, Germany
| | - Nib Soehendra
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob Izbicki
- Department of Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Neuhaus
- Department of Surgery, Charité University Hospital, Berlin, Germany
| | - Heiko Pohl
- VA Medical Center, White River Junction, Vermont, USA
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
149
|
Treatment of High-Grade Dysplasia and Early Stage Esophageal Adenocarcinoma with an Endoscope: The Ultimate in Minimally Invasive, Curative Therapy. CURRENT SURGERY REPORTS 2014. [DOI: 10.1007/s40137-014-0066-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
150
|
Kozarek RA. WITHDRAWN: Photodynamic therapy in esophageal cancer. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|