Comparison between endoscopic and surgical resection of mucosal esophageal adenocarcinoma in Barrett’s esophagus at two high-volume centers. Ann Surg. 2011;254:67-72. [PMID: 21532466 DOI: 10.1097/sla.0b013e31821d4bf6]

Outcomes in the management of esophageal cancer

Esophageal cancer rates have continued to rise in the Western World. Esophageal cancer will be responsible for an estimated 15,450 deaths in the United States in 2014 alone. Esophageal resection with or without preoperative therapy remains the mainstay of treatment. Advances in surgical technique and perioperative care have improved short-term outcomes considerably by decreasing operative mortality. Despite these advances though, esophagectomy remains a procedure associated with considerable morbidity from a wide range of complications. Prompt recognition and treatment of complications can lower overall morbidity and mortality. Unfortunately, long-term outcomes remain poor as the vast majority of patients present with loco-regionally advanced or metastatic disease. Surgery by itself provides poor loco-regional control and fails to address micrometastatic disease. Neoadjuvant chemotherapy or chemoradiation provides a modest survival advantage compared to surgical resection alone. Future gains in understanding the molecular biology of esophageal cancer will hopefully lead to improved therapeutics and resultant outcomes.

Treatment trends, risk of lymph node metastasis, and outcomes for localized esophageal cancer

BACKGROUND

Endoscopic resection is increasingly used to treat localized, early-stage esophageal cancer. We sought to assess its adoption, characterize the risks of nodal metastases, and define differences in procedural mortality and 5-year survival between endoscopic and surgical resection in the United States.

METHODS

From the National Cancer Data Base, patients with T1a and T1b lesions were identified. Treatment patterns were characterized, and hierarchical regression methods were used to define predictors and evaluate outcomes. All statistical tests were two-sided.

RESULTS

Five thousand three hundred ninety patients were identified and underwent endoscopic (26.5%) or surgical resection (73.5%). Endoscopic resection increased from 19.0% to 53.0% for T1a lesions (P < .001) and from 6.6% to 20.9% for T1b cancers (P < .001). The strongest predictors of endoscopic resection were depth of invasion (T1a vs T1b: odds ratio [OR] = 4.45; 95% confidence interval [CI] = 3.76 to 5.27) and patient age of 75 years or older (vs age less than 55 years: OR = 4.86; 95% CI = 3.60 to 6.57). Among patients undergoing surgery, lymph node metastasis was 5.0% for T1a and 16.6% for T1b lesions. Predictors of nodal metastases included tumor size greater than 2 cm (vs. <2 cm) and intermediate-/high-grade lesions (vs low grade). For example, 0.5% of patients with low-grade T1a lesions less than 2 cm had lymph node involvement. The risk of 30-day mortality was less after endoscopic resection (hazard ratio [HR] = 0.33; 95% CI = 0.19 to 0.58) but greater for conditional 5-year survival (HR = 1.63; 95% CI = 1.07 to 2.47).

CONCLUSIONS

Endoscopic resection has become the most common treatment of T1a esophageal cancer and has increased for T1b cancers. It remains important to balance the risk of nodal metastases and procedural risk when counseling patients regarding their treatment options.

Endoscopic therapies for Barrett's neoplasia

The standard of care for treatment of Barrett's esophagus (BE) with early esophageal neoplasia, including high-grade dysplasia (HGD) and intramucosal adenocarcinoma (IMC), has undergone a revolution over the past several years. With the introduction and popularization of endoscopic ablative technologies, along with the refinement of endoscopic mucosal resection (EMR) techniques, the majority of cases of early neoplasia in the setting of BE now are managed by endoscopic approaches. As a result, many patients who previously would have been referred for esophagectomy now may be spared from this major surgical procedure with its inherent morbidity, potential for mortality, and negative impact on long-term gastrointestinal function. The esophageal surgeon must be knowledgeable about the indications for such endoscopic therapies, as well as their limitations and potential pitfalls, so as to apply them in the appropriate clinical scenarios.

Sentinel lymph node biopsy in esophageal cancer: an essential step towards individualized care

Lymph node status is the most important prognostic factor in esophageal cancer. Through improved detection of lymph node metastases, using the sentinel lymph node concept, accurate staging and more tailored therapy may be achieved. This review article outlines two principle ways in which the sentinel lymph node concept could dramatically influence current standard of care for patients with esophageal cancer. We discuss three limitations to universal acceptance of the technique, and propose next steps for increasing enthusiasm amongst physicians and surgeons including the development of a universal tracer, and improved contrast agents with novel dual-modality 'visibility'.

Prognostic risk factors of early esophageal adenocarcinomas

OBJECTIVE

To define prognostic risk factors in patients with early adenocarcinomas of the esophagus (eACEs) who were treated by esophagectomy.

BACKGROUND

Although endoscopic resection (ER) is more accepted for eACEs limited to the mucosa, the reported prevalence of lymph node metastases once the tumor infiltrates the submucosa seems to necessitate surgery in these cases.

METHODS

We analyzed the results of 168 patients who had an esophageal resection because of an eACE. On the basis of specimen histologies and clinical follow-up (median, 64 months), we investigated the influence of lymph node metastases (N+), tumor infiltration depth, tumor differentiation (G1-3), and lymphatic or venous infiltration (L+ or V+) on overall and tumor-specific survival and recurrence rates.

RESULTS

The 5-year survival rate was 79%. Lymph node infiltration was the only prognostic factor for the overall survival [hazard ratio (HR), 2.856; 1.314-6.207; P = 0.008], tumor-specific survival (HR, 8.336; 2.734-25.418; P < 0.001), and tumor recurrence (HR, 8.031; 3.041-21.206; P < 0.001) that was consistently present in all multivariate hazard Cox regression analyses. A total of 47% of the patients who had an N+ status developed tumor recurrences compared with 5.2% of those who had no lymph node involvement (P = <0.001). We found a significant correlation between N+ status and increasing depth of tumor infiltration (P = 0.004), lymphatic vessel infiltration (P = 0.002), tumor differentiation (G1 + G2 vs G3; P = 0.014) and vascular infiltration (P = 0.01).

CONCLUSIONS

Lymph node status is the only independent risk factor for survival and recurrence rates. Tumor infiltration depth correlates with the rate of the lymph node metastases, but a clear watershed between deep mucosal and submucosal infiltration does not exist. As a consequence, careful staging procedures, including diagnostic ER, are mandatory to determine which patients can be treated by ER and which require an esophagectomy.

Prevalence and topography of lymph node metastases in early esophageal and gastric cancer

OBJECTIVE

To determine the prevalence and localization of lymph node metastases in patients with pT1 carcinoma of the esophagus, esophagogastric junction, and stomach.

BACKGROUND

Retrospective analysis and topographic description.

METHODS

We included 793 consecutive patients with pT1 carcinomas who underwent primary surgery for squamous cell carcinoma (SCC) of the esophagus, adenocarcinomas of the esophagogastric junction (AEG), or gastric cancer (GC). Clinical records and pathology reports were reviewed, and the prevalence and topography of lymph node metastases were identified.

RESULTS

The prevalence of lymph node metastases in SCC, AEG, and GC was 7%, 0%, and 5% for pT1a tumors and 24%, 18%, and 14% for pT1b tumors, respectively. Positive lymph node status was associated with worse overall survival (P<0.001). Not only infiltration of the submucosa (P=0.002) but also lymphatic vessel invasion (P<0.001), multifocal tumor growth (P=0.001), lower patient age (P=0.001), and poor tumor differentiation (P=0.05) were associated with nodal disease. These 5 parameters allowed the compilation of a nomogram to estimate the individual risk of lymph node metastases. In SCC, lymph node metastases were found from the neck to the celiac axis. In AEG, nodal disease was limited to the lower mediastinum and the D1 compartment. In GC, lymphatic spread exceeded the D1 compartment in 7% of node positive patients.

CONCLUSIONS

Risk estimation for lymph node metastases should not be based on depth of tumor infiltration alone but additional clinicopathological parameters should also be considered. The extent of lymphadenectomy in surgical procedures should respect the presented topography of lymph node metastases.

Long-term efficacy and safety of endoscopic resection for patients with mucosal adenocarcinoma of the esophagus

BACKGROUND & AIMS

Barrett's esophagus-associated high-grade dysplasia is commonly treated by endoscopy. However, most guidelines offer no recommendations for endoscopic treatment of mucosal adenocarcinoma of the esophagus (mAC). We investigated the efficacy and safety of endoscopic resection in a large series of patients with mAC.

METHODS

We collected data from 1000 consecutive patients (mean age, 69.1 ± 10.7 years; 861 men) with mAC (481 with short-segment and 519 with long-segment Barrett's esophagus) who presented at a tertiary care center from October 1996 to September 2010. Patients with low-grade and high-grade dysplasia and submucosal or more advanced cancer were excluded. All patients underwent endoscopic resection of mACs. Patients found to have submucosal cancer at their first endoscopy examination were excluded from the analysis.

RESULTS

After a mean follow-up period of 56.6 ± 33.4 months, 963 patients (96.3%) had achieved a complete response; surgery was necessary in 12 patients (3.7%) after endoscopic therapy failed. Metachronous lesions or recurrence of cancer developed during the follow-up period in 140 patients (14.5%) but endoscopic re-treatment was successful in 115, resulting in a long-term complete remission rate of 93.8%; 111 died of concomitant disease and 2 of Barrett's esophagus-associated cancer. The calculated 10-year survival rate of patients who underwent endoscopic resection of mACs was 75%. Major complications developed in 15 patients (1.5%) but could be managed conservatively.

CONCLUSIONS

Endoscopic therapy is highly effective and safe for patients with mAC, with excellent long-term results. In an almost 5-year follow-up of 1000 patients treated with endoscopic resection, there was no mortality and less than 2% had major complications. Endoscopic therapy should become the standard of care for patients with mAC.

Comparison of endoscopic therapies and surgical resection in patients with early esophageal cancer: a population-based study

BACKGROUND

Outcome data comparing endoscopic eradication therapy (EET) and esophagectomy are limited in patients with early esophageal cancer (EC).

OBJECTIVE

To compare overall survival and EC-related mortality in patients with early EC treated with EET and esophagectomy.

DESIGN AND SETTING

Population-based study.

PATIENTS

Patients with early EC (stages T0 and T1) were identified from the Surveillance, Epidemiology, and End Results database (1998-2009). Demographics, tumor specific data, and survival were compared. Cox proportional hazards regression models were used to evaluate the association between treatment and EC-specific mortality.

INTERVENTION

EET and esophagectomy.

MAIN OUTCOME MEASUREMENTS

Mid- (2 years) and long- (5 years) term overall survival and EC-specific mortality, outcomes based on histology and stage, treatment patterns, and predictors of cancer-specific mortality.

RESULTS

A total of 430 (21%) and 1586 (79%) patients underwent EET and esophagectomy, respectively. There was no difference in the 2-year (EET: 10.5% vs esophagectomy: 12.7%, P = .27).and 5-year (EET: 36.7% vs esophagectomy: 42.8%, P = .16) EC-related mortality rates between the 2 groups. EET patients had higher mortality rates attributed to non-EC causes (5 years: 46.6% vs 20.6%, P < .001). Similar results were noted when comparisons were limited to patients with stage T0 and T1a disease and esophageal adenocarcinoma. There was no difference in EC-specific mortality in the EET compared with the surgery group (hazard ratio 1.4; 95% confidence interval, 0.9-2.03). Variables associated with mortality were older age, year of diagnosis, radiation therapy, higher stage, and esophageal squamous cell carcinoma.

LIMITATIONS

Comorbidities and recurrence rates were not available.

CONCLUSIONS

This population-based study demonstrates comparable mid- and long-term EC-related mortality in patients with early EC undergoing EET and surgical resection.

Endotherapy versus surgery for early neoplasia in Barrett's esophagus: a meta-analysis

BACKGROUND

Esophagectomy is the conventional treatment for Barrett's esophagus with high-grade dysplasia and intramucosal cancer. Endotherapy is an alternative treatment.

OBJECTIVE

To compare the efficacy and safety of these 2 treatments.

DESIGN

PubMed, Web of Science, EMBASE, Cochrane Library and momentous meeting abstracts were searched. Studies comparing endotherapy with esophagectomy were included in the meta-analysis. Pooling was conducted in a random-effects model.

SETTING

Tertiary-care facility.

PATIENTS

Seven studies involving 870 patients were included.

INTERVENTION

Endotherapy and esophagectomy.

MAIN OUTCOME MEASUREMENTS

Neoplasia remission rate, neoplasia recurrence rate, overall survival rate, neoplasia-related death, and major adverse events.

RESULTS

Meta-analysis showed that there was no significant difference between endotherapy and esophagectomy in the neoplasia remission rate (relative risk [RR] 0.96; 95% CI, 0.91-1.01); overall survival rate at 1 year (RR 0.99; 95% CI, 0.94-1.03), 3 years (RR 1.03; 95% CI, 0.96-1.10), and 5 years (RR 1.00; 95% CI, 0.93-1.06); and neoplasia-related mortality (risk difference [RD] 0; 95% CI, -0.02 to 0.01). Endotherapy was associated with a higher neoplasia recurrence rate (RR 9.50; 95% CI, 3.26-27.75) and fewer major adverse events (RR 0.38; 95% CI, 0.20-0.73).

LIMITATIONS

Relatively small number of retrospective studies available, different types of endoscopic treatments were used.

CONCLUSION

Endotherapy and esophagectomy show similar efficacy except in the neoplasia recurrence rate, which is higher after endotherapy. Prospective, randomized, controlled trials are needed to confirm these results.

The degree of segmental aneuploidy measured by total copy number abnormalities predicts survival and recurrence in superficial gastroesophageal adenocarcinoma

BACKGROUND

Prognostic biomarkers are needed for superficial gastroesophageal adenocarcinoma (EAC) to predict clinical outcomes and select therapy. Although recurrent mutations have been characterized in EAC, little is known about their clinical and prognostic significance. Aneuploidy is predictive of clinical outcome in many malignancies but has not been evaluated in superficial EAC.

METHODS

We quantified copy number changes in 41 superficial EAC using Affymetrix SNP 6.0 arrays. We identified recurrent chromosomal gains and losses and calculated the total copy number abnormality (CNA) count for each tumor as a measure of aneuploidy. We correlated CNA count with overall survival and time to first recurrence in univariate and multivariate analyses.

RESULTS

Recurrent segmental gains and losses involved multiple genes, including: HER2, EGFR, MET, CDK6, KRAS (recurrent gains); and FHIT, WWOX, CDKN2A/B, SMAD4, RUNX1 (recurrent losses). There was a 40-fold variation in CNA count across all cases. Tumors with the lowest and highest quartile CNA count had significantly better overall survival (p = 0.032) and time to first recurrence (p = 0.010) compared to those with intermediate CNA counts. These associations persisted when controlling for other prognostic variables.

SIGNIFICANCE

SNP arrays facilitate the assessment of recurrent chromosomal gain and loss and allow high resolution, quantitative assessment of segmental aneuploidy (total CNA count). The non-monotonic association of segmental aneuploidy with survival has been described in other tumors. The degree of aneuploidy is a promising prognostic biomarker in a potentially curable form of EAC.

British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus

These guidelines provide a practical and evidence-based resource for the management of patients with Barrett's oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was followed to provide a methodological strategy for the guideline development. A systematic review of the literature was performed for English language articles published up until December 2012 in order to address controversial issues in Barrett's oesophagus including definition, screening and diagnosis, surveillance, pathological grading for dysplasia, management of dysplasia, and early cancer including training requirements. The rigour and quality of the studies was evaluated using the SIGN checklist system. Recommendations on each topic were scored by each author using a five-tier system (A+, strong agreement, to D+, strongly disagree). Statements that failed to reach substantial agreement among authors, defined as >80% agreement (A or A+), were revisited and modified until substantial agreement (>80%) was reached. In formulating these guidelines, we took into consideration benefits and risks for the population and national health system, as well as patient perspectives. For the first time, we have suggested stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria. In order to improve communication between clinicians, we recommend the use of minimum datasets for reporting endoscopic and pathological findings. We advocate endoscopic therapy for high-grade dysplasia and early cancer, which should be performed in high-volume centres. We hope that these guidelines will standardise and improve management for patients with Barrett's oesophagus and related neoplasia.

Endoscopic management of Barrett's esophagus with high-grade dysplasia and early-stage esophageal adenocarcinoma

Several endoscopic procedures have been recently developed for the treatment of Barrett's esophagus and early esophageal cancer, including endoscopic resection, radiofrequency ablation, and cryoablation. This review article discusses ideal candidates for endoscopic therapies, current treatment modalities, clinical and safety outcomes, and specific management recommendations.

Endoscopic ultrasound is inadequate to determine which T1/T2 esophageal tumors are candidates for endoluminal therapies

OBJECTIVES

Esophageal endoscopic ultrasound is now regarded as essential in the staging of esophageal carcinoma. There is an increasing trend toward endoluminal therapies (ie, endoscopic mucosal resection and radiofrequency ablation) for pre-cancer or early-stage cancers because of concerns of high morbidity associated with esophagectomy. This study reviews our institutional experience with preoperative endoscopic ultrasound staging of early esophageal cancers in patients who underwent an esophagectomy to evaluate the accuracy of staging by endoscopic ultrasound and how this affects treatment recommendations.

METHODS

A prospective esophagectomy database of all patients undergoing an esophagectomy for esophageal cancer at a single high-volume institution was retrospectively reviewed for patients with early-stage esophageal cancer. This study analyzed patients with clinical Tis to T1 disease, as predicted by preoperative endoscopic ultrasound, and correlated this with the pathologic stages after esophagectomy. The surgical outcomes were evaluated to assess the safety of esophagectomy as a treatment modality.

RESULTS

From 2005 to 2011, 107 patients (93 male, 14 female) with a mean age of 66 years (range, 39-91 years) were staged by preoperative endoscopic ultrasound to have esophageal high-grade dysplasia, carcinoma in situ, or T1 cancer and underwent an esophagectomy. Tumor depth was correctly staged by endoscopic ultrasound in only 39% (23/59) of pT1a tumors (invading into the lamina propria or muscularis mucosa) and 51% (18/35) of pT1b tumors (submucosal). Of the endoscopic ultrasound-staged cT1a-lpN0 lesions, there were positive lymph nodes in 15% of pathologic specimens (2/13). Patients with pT1a-mm lesions had a 9% rate of pathologic lymph node involvement (1/11), and those with pT1b tumors had a 17% rate of lymph node spread (6/35). Esophagectomy was performed in all 107 patients with a 30-day mortality rate of less than 1% (1/107).

CONCLUSIONS

The sensitivity and specificity of endoscopic ultrasound for determining true pathologic staging are poor for early-stage esophageal cancers. Lesions thought to be cT1a-lpN0 by endoscopic ultrasound have at least pN1 disease in 15% of cases. Endoluminal therapy of these lesions based on endoscopic ultrasound undertreats a significant number of patients. Esophagectomy is still the standard therapy for early-stage esophageal cancers in the majority of patients.

Survival in esophageal high-grade dysplasia/adenocarcinoma post endoscopic resection

BACKGROUND

Endoscopic resection followed by ablative therapy is frequently used to treat esophageal high-grade dysplasia or early esophageal adenocarcinoma.

AIMS

To study outcomes in patients with high-grade dysplasia compared to those with esophageal adenocarcinoma after endoscopic resection.

METHODS

Retrospective, observational, descriptive, single-centre study from a prospective database. We extracted data from 116 endoscopic resections. Survival was plotted using Kaplan-Meier curves multivariable Cox-proportional hazard assess for possible predictors of survival post-endoscopic resection was performed.

RESULTS

116 patients (64 esophageal adenocarcinoma, 52 high-grade dysplasia) underwent endoscopic resection from May 2003 to June 2010. Mean age was 71 ± 11 years for high-grade dysplasia and 72 ± 10 years for esophageal adenocarcinoma. Median follow-up was 17 months. Eighty-five patients had negative margins on endoscopic resection. Five-year survivals for high-grade dysplasia and esophageal adenocarcinoma were 86% (range 68-100%) and 78% (59-96%), respectively. Survival was not significantly different between groups (p=0.20). Overall mortality rate was 10.6% (9/85). At multivariable Cox regression increased Barrett's oesophagus length was associated with worse survival (HR 1.18 [1.06-1.33], p=0.0039). Survival was not affected by the pathology before resection: HR 2.4 [95%CI, 0.70-8.4], p=0.16.

CONCLUSIONS

Survival in patients with high-grade dysplasia of the oesophagus is similar to those with esophageal adenocarcinoma. Longer Barrett's oesophagus segments are associated with decreased survival.

Survival of patients with superficial esophageal adenocarcinoma after endoscopic treatment vs surgery

BACKGROUND & AIMS

Endoscopic therapy can improve long-term outcomes of patients with superficial esophageal adenocarcinoma (EAC), producing fewer complications than esophagectomy. However, there have been few population-based studies to compare long-term outcomes of patients who received these treatments. We used a large national cancer database to evaluate the outcomes of patients with superficial EAC who underwent endoscopic therapy or surgery.

METHODS

We used the Surveillance Epidemiology and End Results database to identify 1618 patients with Tis or T1 N0M0 EAC from 1998-2009. Patients were grouped on the basis of whether they received endoscopic therapy (n = 306) or surgery (n = 1312). Multivariate logistic regression was performed to identify factors associated with endoscopic therapy. We collected survival data through the end of 2009; overall survival and esophageal cancer-specific survival were compared after controlling for relevant covariates.

RESULTS

The use of endoscopic therapy increased progressively from 3% in 1998 to 29% in 2009. Factors associated with use of endoscopic therapy included age older than 65 years, diagnosis in 2006-2009 vs 1998-2001, and the absence of submucosal invasion. Overall survival after 5 years was higher in the surgery group than in the endoscopic therapy group (70% vs 58%, respectively). After adjusting for patient and tumor factors, patients treated by endoscopy had similar overall survival times (hazard ratio, 1.21; 95% confidence interval, 0.92-1.58) and esophageal cancer-specific survival times (hazard ratio, 0.74; 95% confidence interval, 0.49-1.11).

CONCLUSION

In a population-based analysis, the use of endoscopic therapy for superficial EAC tended to increase from 1998-2009. Long-term survival of patients with EAC did not appear to differ between those who received endoscopic therapy and those treated with surgery.

Research advances in esophageal diseases: bench to bedside

Over the last year, significant steps have been made toward understanding the pathogenesis of esophageal diseases and translating this knowledge to clinical practice. Gastroesophageal reflux disease (GERD) is the most common outpatient diagnosis in gastroenterology and has a high prevalence in the general population. As many as 40% of patients with GERD have incomplete response to medical therapy, and the pathophysiological mechanisms underlying lack of response are now better understood. Novel medical and minimally invasive interventions are available to optimize management of GERD. Esophageal cancer, regardless of the histological subtype, has among the worst survival statistics among all malignancies. Taking advantage of technological advances in genome sequencing, the mutational spectra in esophageal cancer are now emerging, offering novel avenues for targeted therapies. Early diagnosis is another strand for improving survival. While genome-wide association studies are providing insights into genetic susceptibility, novel approaches to early detection of cancer are being devised through the use of biomarkers applied to esophageal samples and as part of imaging technologies. Dysmotility and eosinophilic esophagitis are the differential diagnoses in patients with dysphagia. New pathophysiological classifications have improved the management of motility disorders. Meanwhile, exciting progress has been made in the endoscopic management of these conditions. Eosinophilic esophagitis is still a relatively new entity, and the pathogenesis remains poorly understood. However, it is now clear that an allergic reaction to food plays an important role, and dietary interventions as well as biologic agents to block the inflammatory cascade are novel, promising fields of clinical research.

Perioperative outcomes of laparoscopic transhiatal esophagectomy with antegrade esophageal inversion for high-grade dysplasia and invasive esophageal cancer

BACKGROUND

We examined the safety and effectiveness of antegrade laparoscopic inversion esophagectomy (LIE) for patients with multifocal high-grade dysplasia and distal esophageal cancer.

METHODS

We reviewed our experience with antegrade LIE, using an institutional research board-approved prospective database.

RESULTS

Thirty-six patients with an average age of 64 years underwent LIE. Indications included multifocal high-grade dysplasia (n = 4), adenocarcinoma (n = 30), and squamous cell carcinoma (n = 2); 11 patients had undergone neoadjuvant chemoradiation. LIE was completed successfully in 34 (94%) patients, whereas 2 required a conversion to open transhiatal esophagectomy. LIE required 221 minutes to perform, with a median blood loss of 100 mL. R0 resection was achieved in 97% of cases with a median lymph node harvest 15. Median hospital stay was 8 days, and 61% of patients were discharged to their home. Postoperative complications included anastomotic leak (n = 11) and stricture (n = 18), atrial arrhythmia (n = 5), pneumonia (n = 4), and tracheoesophageal fistula (n = 2). Operative outcomes after neoadjuvant therapy did not differ from those for primary operative resection.

CONCLUSION

Antegrade LIE is a safe treatment approach for patients with high-grade dysplasia and distal esophageal cancer. Complete resection with an adequate lymph node harvest can be achieved consistently for primary operative resection or after neoadjuvant chemoradiation.

Safety of endoscopic mucosal resection for Barrett's esophagus

OBJECTIVES

Endoscopic mucosal resection (EMR) is an established technique for the management of Barrett's esophagus (BE). Although EMR is generally perceived to be a relatively safe procedure, the published data regarding EMR-related complications are variable and the expertise of those performing EMR is often not disclosed. Our aim was to determine the complication rates in a large cohort of patients who underwent EMR at a specialized BE unit.

METHODS

A prospectively maintained database was reviewed for patients with BE who underwent EMR from January 1995 to August 2008. EMR was performed in patients with neoplastic appearing lesions. Bleeding, stricture, and perforation related to EMR were reviewed as the main outcome measurements.

RESULTS

In all, 681 patients (83% male; mean age 70 years old) underwent a total of 1,388 endoscopic procedures and 2,513 EMRs. Median length of BE was 3.0 cm (interquartile range (IQR) 1-7). A single experienced endoscopist performed 99% of the EMR procedures. EMR was performed using commercially available EMR kits in 95% (77% cap-snare and 18% band-snare) and a variceal band ligation device in 5% of cases. No EMR-related perforations occurred during the study period. The rate of post-EMR bleeding was 1.2% (8 patients). Seven patients were successfully treated endoscopically and one needed surgery. The rate for symptomatic strictures after EMR was 1.0% (7 cases), and all of the cases did not involve intervening ablation therapies. All strictures were successfully treated with endoscopic dilation.

CONCLUSIONS

This is the largest series reported to date on EMR in BE. In this large retrospective study, EMR for BE was associated with a low rate of complications for selected patients when performed by experienced hands.

Randomized study of two endo-knives for endoscopic submucosal dissection of esophageal cancer

OBJECTIVES

Settings for endoscopic submucosal dissection (ESD) of esophageal cancer have not been standardized, and no studies have directly compared ESD devices in humans.

METHODS

We conducted a randomized study to compare the performances of two different endo-knives, the Flush knife and Mucosectom, for esophageal ESD in 48 lesions. All procedures were initiated by two endoscopists, who were assisted by senior endoscopists with verbal advice. In the Flush-knife group, mucosal incision with a 2-mm Flush knife was followed by submucosal dissection using a 1-mm Flush knife. In the Mucosectom group, mucosal incision with a 2-mm Flush knife was followed by submucosal dissection with a Mucosectom. The primary outcome variable was the procedure time required for submucosal dissection. The secondary outcome variables were total procedure time, self-completion rates, and adverse events.

RESULTS

Total procedure time in the Mucosectom group was significantly shorter than in the Flush-knife group (57±21 vs. 83±27 min, respectively; P<0.001). The submucosal-dissection time in the Mucosectom group was significantly shorter than in the Flush-knife group (40±18 vs. 61±23 min, respectively; P<0.001). The self-completion rate in the Mucosectom group was slightly higher than in the Flush-knife group, but the difference was not significant (91.7% vs. 75%, respectively; P=0.25). One perforation and one postoperative bleeding occurred in the Flush-knife group, both of which were treated successfully by endoscopic treatment.

CONCLUSIONS

The Mucosectom reduced the procedure and submucosal-dissection times of esophageal ESD, without increasing adverse events.

T1 esophageal cancer, request an endoscopic mucosal resection (EMR) for in-depth review

Endoscopic management of superficial esophageal adenocarcinoma has gained wider acceptance with the growing literature on its efficacy. Patient selection is critical in deciding who should be a candidate for surgery or endoscopy in the management of T1 esophageal cancer. This article discusses the key role EMR plays in the diagnostic evaluation.

Recent developments in esophageal adenocarcinoma

Answer questions and earn CME/CNE Esophageal adenocarcinoma (EAC) is characterized by 6 striking features: increasing incidence, male predominance, lack of preventive measures, opportunities for early detection, demanding surgical therapy and care, and poor prognosis. Reasons for its rapidly increasing incidence include the rising prevalence of gastroesophageal reflux and obesity, combined with the decreasing prevalence of Helicobacter pylori infection. The strong male predominance remains unexplained, but hormonal influence might play an important role. Future prevention might include the treatment of reflux or obesity or chemoprevention with nonsteroidal antiinflammatory drugs or statins, but no evidence-based preventive measures are currently available. Likely future developments include endoscopic screening of better defined high-risk groups for EAC. Individuals with Barrett esophagus might benefit from surveillance, at least those with dysplasia, but screening and surveillance strategies need careful evaluation to be feasible and cost-effective. The surgery for EAC is more extensive than virtually any other standard procedure, and postoperative survival, health-related quality of life, and nutrition need to be improved (eg, by improved treatment, better decision-making, and more individually tailored follow-up). Promising clinical developments include increased survival after preoperative chemoradiotherapy, the potentially reduced impact on health-related quality of life after minimally invasive surgery, and the new endoscopic therapies for dysplastic Barrett esophagus or early EAC. The overall survival rates are improving slightly, but poor prognosis remains a challenge.

Esophagectomy for failed endoscopic therapy in patients with high-grade dysplasia or intramucosal carcinoma

Endoscopic therapy (ablation +/- endoscopic resection) for high-grade dysplasia and/or intramucosal carcinoma (IMC) of the esophagus has demonstrated promising results. However, there is a concern that a curable, local disease may progress to systemic disease with repeated endotherapy. We performed a retrospective review of patients who underwent esophagectomy after endotherapy at three tertiary care esophageal centers from 2006 to 2012. Our objective was to document the clinical and pathologic outcomes of patients who undergo esophagectomy after failed endotherapy. Fifteen patients underwent esophagectomy after a mean of 13 months and 4.1 sessions of endotherapy for progression of disease (53%), failure to clear disease (33%), or recurrence (13%). Initially, all had Barrett's, 73% had ≥3-cm segments, 93% had a nodule or ulcer, and 91% had multifocal disease upon presentation. High-grade dysplasia was present at index endoscopy in 80% and IMC in 33%, and some patients had both. Final pathology at esophagectomy was T0 (13%), T1a (60%), T1b (20%), and T2 (7%). Positive lymph nodes were found in 20%: one patient was T2N1 and two were T1bN1. Patients with T1b, T2, or N1 disease had more IMC on index endoscopy (75% vs. 18%) and more endotherapy sessions (median 6.5 vs. 3). There have been no recurrences a mean of 20 months after esophagectomy. Clinical outcomes were comparable to other series, but submucosal invasion (27%) and node-positive disease (20%) were encountered in some patients who initially presented with a locally curable disease and eventually required esophagectomy after failed endotherapy. An initial pathology of IMC or failure to clear disease after three treatments should raise concern for loco-regional progression and prompt earlier consideration of esophagectomy.

Nonneoplastic and neoplastic Barrett's esophagus: the European perspective

The cancer risk of nondysplastic Barrett's esophagus is very low (0.33-0.5 per year). Therefore, any endoscopic ablation technique is an overtreatment. Patients with low-grade intraepithelial neoplasia confirmed by a specialized GI pathologist seem to have a significant risk for developing high-grade intraepithelial neoplasia (HGIN) or cancer. Therefore, endoscopic treatment in this case seems to be justified. However, up to now there has been no prospective study supporting this. In recent years, endoscopic treatment of HGIN and mucosal Barrett's cancer has become a widely accepted treatment approach and even the therapy of choice in many countries. Endoscopic resection (ER) is the best validated treatment method in patients with HGIN and mucosal Barrett's cancer, and is widely used all over the world. In contrast to ablative treatment methods like argon plasma coagulation and radiofrequency ablation, ER allows histological assessment of the resected specimen in order to assess the depth of infiltration of the tumor. However, ER of the neoplastic lesions should always be followed by ablation of the nondysplastic remaining Barrett's esophagus in order to reduce the risk of recurrence or metachronous neoplasia. The long-time complete remission rate with this two-step strategy is ≥95%. A matter of continuing debate is whether patients with Barrett's cancer infiltrating the upper third of the mucosal layer (pT1sm1) can be treated by ER. Data from our and other centers indicate that a subgroup of patients with pT1sm1 adenocarcinomas without the presence of risk factors (poor differentiation grade, lymph or blood vessel infiltration, size >20 mm, ulcerated lesion) have a very low risk for lymph node metastasis (<2%) and endoscopic therapy can be an alternative to radical surgery.

Endotherapy for superficial adenocarcinoma of the esophagus: an American experience

BACKGROUND

EMR and ablation are increasingly being used alone or in combination for treatment of Barrett's neoplasia. Given a very low rate of lymph node metastasis, endotherapy has become an accepted treatment option for T1a esophageal adenocarcinoma (EAC) with low-risk features.

OBJECTIVE

To report our experience of endoscopic management of T1a EAC in a large, tertiary-care center.

DESIGN

Retrospective review.

SETTING

Tertiary-care referral center.

PATIENTS

Patients treated endoscopically for low-risk T1a EAC at our center.

INTERVENTION

EMR and endoscopic ablation.

MAIN OUTCOME MEASUREMENTS

Death related to esophageal cancer, remission of adenocarcinoma, dysplasia, and intestinal metaplasia.

RESULTS

A total of 54 patients underwent endotherapy for low-risk T1a EAC from 2006 to 2012. Mean (± SD) follow-up was 23 (± 16) months, mean (± SD) size of resected adenocarcinoma was 7.1 (± 4.3) mm, and mean (± SD) Barrett's esophagus length was 4.5 (± 3.9) cm. Band-assisted, cap-assisted, and lift and cut EMR were performed in 85%, 11%, and 4% of patients, respectively; 81% underwent additional ablative therapy (radiofrequency ablation 95%, cryotherapy 9%, photodynamic therapy 2%). Complete remission from cancer was achieved in 96%, complete remission from dysplasia in 87%, and complete remission from intestinal metaplasia in 59%. The overall survival was 89%; there were no deaths related to esophageal cancer.

LIMITATIONS

Retrospective study.

CONCLUSION

Endotherapy for T1a EAC was safe and effective in our American cohort. Endotherapy should be considered primary therapy for appropriate patients with low-risk lesions. Complete Barrett's esophagus eradication after EMR is important to reduce the development of metachronous lesions.

Barrett's esophagus in 2012: updates in pathogenesis, treatment, and surveillance

Barrett's esophagus (BE) is the only established precursor lesion in the development of esophageal adenocarcinoma (EAC) and it increases the risk of cancer by 11-fold. It is regarded as a complication of gastroesophageal reflux disease. There is an ever-increasing body of knowledge on the pathogenesis, diagnosis, treatment, and surveillance of BE and its associated dysplasia. In this review, we summarize the latest advances in BE research and clinical practice in the past 2 years. It is critical to understand the molecular underpinnings of this disorder to comprehend the clinical outcomes of the disease. For clinical gastroenterologists, there is also continuous growth of endoscopic approaches which is daunting, and further improvements in the detection and treatment of BE and early EAC are anticipated. In the future, we may see the increased role of biomarkers, both molecular and imaging, in both diagnostic and therapeutic strategies for BE.

Outcomes in patients who have failed endoscopic therapy for dysplastic Barrett's metaplasia or early esophageal cancer

BACKGROUND

Endoscopic therapy (ablation ± mucosal resection) for esophageal high-grade dysplasia (HGD) or intramucosal carcinoma has demonstrated promising results. Little is known about patients who have persistent or progressive disease despite endotherapy. We compared patients who had successful eradication of their disease with those in whom endotherapy failed to try to identify factors predictive of failure and outcomes after salvage therapy.

METHODS

We performed a single-institution retrospective review of patients treated with endotherapy from 2007 to 2012.

RESULTS

Thirty-eight patients underwent endotherapy: 28 had successful eradication of their disease and endotherapy failed in 10 patients. Patients in whom endotherapy failed were more likely to have high-grade dysplasia (HGD) on initial endoscopy, nodules or ulcers, multifocal dysplasia, and persistent nondysplastic Barrett's metaplasia. Patients in whom endotherapy failed also underwent significantly more endotherapy sessions. Seven patients had persistent dysplasia or progression to cancer, and 3 patients had complete eradication of HGD but presented with intramucosal carcinoma an average of 15 months after eradication. The 10 patients in whom endotherapy failed underwent salvage therapy with esophagectomy (7 patients), definitive chemoradiotherapy (1 patient), and endotherapy (2 patients). Patients treated with esophagectomy were disease free at a mean of 25 months postoperatively.

CONCLUSIONS

HGD on initial endoscopy, multifocal dysplasia, mucosal abnormalities, and failure to eradicate nondysplastic Barrett's metaplasia were associated with failure of endotherapy. Patients with these characteristics should be considered at higher risk for treatment failure, and earlier consideration should be given to esophagectomy if there is persistent, progressive, or recurrent neoplasia. Clinical outcomes are good, even after salvage therapy. Continued endoscopic surveillance is mandatory after successful endotherapy because of the risk of recurrent disease.

Oesophageal cancer--an overview

Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.

Esophageal squamous cell carcinoma arising after endoscopic ablation therapy of Barrett's esophagus with high-grade dysplasia. Report of a case

Patients with Barrett's esophagus are at risk for dysplasia and esophageal adenocarcinoma. Although surgery was the mainstay treatment for Barrett's dysplasia and cancer, patients with high-grade dysplasia and early cancers now have several nonsurgical treatment options. Most of the endoscopic therapies are relatively safe but do carry a risk for complications. Treatment failure with progression of the disease is the most severe complication, especially among patients with low surgical risk. Cryoablation has been used with promising results in both high-grade dysplasia and early esophageal cancer. A patient with a well-documented history of Barrett's esophagus with high-grade dysplasia that underwent multiple sessions of photodynamic therapy and salvage cryoablation for residual high-grade dysplasia was presented. The patient was diagnosed with squamous cell carcinoma of the distal esophagus approximately 1 year after cryoablation. This is the first complete report of squamous cell carcinoma occurring after endoscopic ablation for Barrett's neoplasia. Careful follow up is necessary in any endoscopic ablation program due to the risk of recurrent neoplasia.

A novel esophageal-preserving approach to treat high-grade dysplasia and superficial adenocarcinoma in the presence of chronic gastroesophageal reflux disease

BACKGROUND

The optimal treatment strategy of esophageal high-grade dysplasia (HGD) and superficial adenocarcinoma remains controversial.

METHODS

Here, we describe endoscopic, circumferential mucosal-submucosal en-bloc resection of the entire abnormal esophageal epithelium with extracellular matrix (ECM) placement to regenerate neoepithelium and minimize stricture. That procedure was then followed by a laparoscopic fundoplication as a novel esophageal-preserving approach to treat HGD and superficial adenocarcinoma in the face of chronic gastroesophageal reflux disease (GERD).

CONCLUSIONS

This approach could be an ideal option as an alternative to esophagectomy in selected patients.

[Modern diagnostics and stage-oriented surgery: therapy of adenocarcinoma of the esophagogastric junction]

The basis for decision-making about an individualized surgical treatment of adenocarcinoma of the esophagogastric junction is tumor staging and exact evaluation of the topography of the tumor in the small junctional area. The diagnostics mainly comprise endoscopy, biopsy, endosonography, computed tomography and partially diagnostic laparoscopy. This results in a clinical TNM staging and an evaluation according to the AEG classification from oral to aboral in type I (esophagus), type II (cardia) and type III (subcardia). Endoscopic resection is only appropriate for the infrequent mucosal carcinomas whereas the majority of the junctional carcinomas are treated by surgical resection. This is combined with neoadjuvant treatment in case of T3 or resectable T4 carcinomas. A type I carcinoma is removed by radical transthoracic en bloc esophagectomy with high intrathoracic esophagogastrostomy after gastric pull-up. In case of type II or III carcinomas, a transhiatal extended gastrectomy including distal esophageal resection is performed with reconstruction by Roux en Y esophagojejunostomy in the lower mediastinum. However, some advanced type II carcinomas which cannot be resected R0 at the esophagus need esophagectomy and gastric pull-up. This surgical strategy is justified by the topography of the lesion and the corresponding lymphatic drainage. Very rare indications are seen for a limited resection with interposition of small bowel in some mucosal carcinomas or total esophagogastrectomy with colon interposition in very advanced tumors. The neoadjuvant treatment comprises especially chemoradiation for type I and chemotherapy for type II and III carcinomas and leads to a significant survival benefit compared to surgery alone.

Photodynamic Therapy for Barrett's Esophagus and Esophageal Carcinoma

This paper reviews the use of photodynamic therapy (PDT) in patients with Barrett's esophagus and esophageal carcinoma. We describe the history of PDT, mechanics, photosensitizers for PDT in patients with esophageal disease. Finally, we discuss its utility and limitations in this setting.

Advances in endoluminal therapy for esophageal cancer

Advances in endoscopic therapy have resulted in dramatic changes in the way early esophageal cancer is managed as well as in the palliation of dysphagia related to advanced esophageal cancer. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are effective therapies for accurate histopathologic staging and provide a potential for complete cure. Mucosal ablative techniques (radiofrequency ablation and cryotherapy) are effective adjuncts to EMR and ESD and reduce the occurrence of synchronous and metachronous lesions within the Barrett esophagus. The successes of these techniques have made endoscopic therapy the primary means of management of early esophageal cancer.

Endoscopic therapy of Barrett esophagus

Barrett esophagus (BE) is a well-established premalignant condition for esophageal adenocarcinoma (EAC), a lethal cancer with a dismal survival rate. The current guidelines recommend surveillance of patients with BE to detect dysplasia or early cancer before the development of invasive EAC. Recently, endoscopic eradication therapies have been shown to be safe and effective in the treatment of BE-related high-grade dysplasia and early EAC. This article reviews the various treatment options for BE and discusses the current evidence and gaps in knowledge in the understanding of treatment of this condition. In addition, recommendations are provided in context to the recently published guidelines by the American Gastroenterological Association.

Radiotherapy as a component of multidisciplinary treatment for esophageal cancer: Recent research progress

Surgery is the standard therapy for early esophageal cancer; however, the optimal therapeutic modality for patients with advanced disease remains unclear. In this article, we collect clinical data on multidisciplinary treatment for esophageal cancer in recent years and discuss the role of neoadjuvant therapy, the value of postoperative radiotherapy, the clinical effects of radiotherapy versus surgery, new radiotherapy techniques, and targeted therapy in patients with advanced esophageal cancer.

Management of stage 1 esophageal cancer

Barrett esophagus surveillance programs and more liberal use of upper endoscopy are leading to the identification of more patients with high-grade dysplasia or early stage esophageal adenocarcinoma. These patients have several options for therapy, including endoscopic mucosal resection, vagal-sparing esophagectomy, and a combination of endoscopic resection and ablation. Factors that should be considered include the length of the Barrett segment, the presence of a nodule or ulcer within the Barrett segment, and the age and overall physical condition of the patient. Of particular importance will be the incidence of recurrent Barrett esophagus or cancer in the long-term in patients that were initially successfully treated endoscopically.

Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus

BACKGROUND

Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy).

OBJECTIVES

We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)).

SEARCH METHODS

We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012.

SELECTION CRITERIA

Types of studies: RCTs comparing endotherapies with surgery in the treatment of or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately.

TYPES OF PARTICIPANTS

patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus.Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent.

DATA COLLECTION AND ANALYSIS

Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9.

MAIN RESULTS

We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies.

AUTHORS' CONCLUSIONS

This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.

Intramucosal esophageal adenocarcinoma: primum non nocere

OBJECTIVES

Intramucosal esophageal cancer treatment is evolving. Less-invasive therapies have emerged, necessitating review of safety, effectiveness, and determinants of long-term outcome after esophagectomy to clarify the role of this traditional, maximally invasive, and potentially harmful therapy.

METHODS

From January 1983 to January 2011, 164 patients underwent esophagectomy alone for intramucosal adenocarcinoma. Cancers were subdivided by depth of invasion: lamina propria 50 (30%) and muscularis mucosa 114 (70%; inner 42 [26%], middle 16 [10%], and outer 56 [34%]). We assessed complications and esophagectomy-related mortality (safety) and cancer recurrence (effectiveness), and identified determinants of long-term outcomes.

RESULTS

Barrett esophagus (P = .005), larger cancers (P < .001), worse histologic grade (P < .001), lymphovascular invasion (P < .001), and overstaging (P = .02) were associated with deeper cancers. One patient had regional lymph node metastases (0.6%). Seventy-five patients (46%) had complications. Seven of 9 deaths within 6 months were esophagectomy related, 6 from respiratory failure. Seven patients had recurrence, all within 4 years. Five-, 10-, and 15-year survivals were 82%, 69%, and 60%, respectively, which were similar to those of a matched general population. Determinants of late mortality were older age (P = .004), poorer lung function (P < .0001), longer cancer (P = .04), postoperative pneumonia (P = .06), cancer recurrence (P < .0001), and second cancers (P < .0001).

CONCLUSIONS

Survival after esophagectomy for intramucosal adenocarcinoma is excellent, determined more by patient than cancer characteristics. Patient selection and respiratory function are crucial to minimize harm. Considering the outcome of emerging therapies, esophagectomy should be reserved for patients with a long intramucosal adenocarcinoma or those in whom endoscopic therapies fail or are inappropriate.

Multimodal treatment of esophageal cancer

BACKGROUND

The treatment of localized esophageal cancer has been debated controversially over the past decades. Neoadjuvant treatment was used empirically, but evidence was limited due to the lack of high-quality confirmatory studies. Meanwhile, data have become much clearer due to recently published well-conducted randomized controlled trials and meta-analyses.

METHODS

Neoadjuvant and perioperative platinum fluoropyrimidine-based combination chemotherapy has now an established role in the treatment of stage II and stage III esophageal adenocarcinoma and cancer of the esophago-gastric junction. Neoadjuvant chemoradiation is now the standard of care for treating stage II and stage III esophageal squamous cell cancer and can also be considered for treating esophageal adenocarcinoma.

RESULTS

Patients with esophageal squamous cell cancer treated with definitive chemoradiation achieve comparable long-term survival compared with surgery. Short-term mortality is less with chemoradiation alone, but local tumor control is significantly better with surgery.

CONCLUSION

This expert review article outlines current data and literature and delineates recommendable treatment guidelines for localized esophageal cancer.