Approach to early Barrett's cancer

Optimal surgical approach for esophageal cancer in the era of minimally invasive esophagectomy and neoadjuvant therapy

The optimal surgical technique for the potentially curative treatment of patients with esophageal cancer is still under debate. The transhiatal esophagectomy (THE) with limited lymphadenectomy mainly focuses on a decrease of postoperative morbidity and mortality by preventing a formal thoracotomy. The transthoracic esophagectomy (TTE) with extended two-field lymphadenectomy attempts to improve the radicality of the resection and thus to increase locoregional tumor control, but is associated with increased postoperative morbidity. The recent introduction of different minimally invasive techniques probably decreases postoperative morbidity following TTE, with reduction of especially pulmonary complications, but high-quality evidence is still limited. It is widely agreed that extended lymphadenectomy as performed during TTE provides the benefit of more accurate staging, but its effect on improvement of survival is still debated. The literature on this topic is contradictory and the choice of surgical approach is primarily driven by personal opinions and institutional preferences. Moreover, the available evidence is mainly based on patients who underwent surgery alone without neoadjuvant therapy. Results of recent studies suggest that neoadjuvant chemoradiotherapy abolishes any possibly positive effect of extended lymphadenectomy as performed during TTE on survival, but this effect should be confirmed in future research. This review gives an overview and reflects the authors' personal view on the role of TTE and THE in the treatment of potentially curative treatment of patients with locally advanced esophageal cancer in the era of minimally invasive esophagectomy and neoadjuvant treatment and outlines future research perspectives.

Prognostic impact of upper, middle, and lower third mucosal or submucosal infiltration in early esophageal cancer

OBJECTIVE

To identify differences in survival of patients with pT1 esophageal cancer relating to depth of wall infiltration.

BACKGROUND DATA

Histologic analysis of mucosal and submucosal infiltration in thirds has shown an increasing rate of lymph node metastases (LNM) according to the depth of wall infiltration in pT1 esophageal cancer.

METHODS

One hundred seventy-one patients had transthoracic en bloc (n = 161) or transhiatal esophagectomy (n = 10) for pT1 esophageal cancer [121 adenocarcinomas (AC), 50 squamous cell carcinomas (SCC)]. The histologic analysis of the specimen comprised depth of wall penetration of the carcinoma in thirds of pT1a = mucosa (m1, m2, m3) or pT1b = submucosa (sm1, sm2, sm3) and number and infiltration of the resected lymph nodes.

RESULTS

The rate of LNM was 0% for 70 mucosal carcinomas and 34% for 101 submucosal carcinomas (P = 0.001). For sm1, this rate was 13%, for sm2 19% and for sm3 56%. The 5-year survival rate (5Y-SR) was 82% for pN0 and 45% for pN+ patients (P < 0.001). There was no significant prognostic difference between AC and SCC (5Y-SR: 74% vs 71%). The 5Y-SR of the pT1a group was 87% compared with 66% for pT1b (P = 0.046). The 5-year survival rate for sm1 and sm2 were similar; sm1 + sm2 were together significantly better (80%) than sm3 (46%) (P = 0.008). In multivariate analysis, only sm3 was an independent prognostic factor (P = 0.01).

CONCLUSIONS

After esophagectomy, the prognosis of patients with sm1/sm2 infiltration is as good as for patients with mucosal carcinoma. Sm3 infiltration is the worst prognostic factor in pT1 esophageal cancer.

Lymphatic micrometastases in patients with early esophageal adenocarcinoma

BACKGROUND

Both endoscopic and surgical treatments are recommended for m3- or sm1-adenocarcinomas of the esophagus, depending on patients' lymph nodal status. Lymphatic dissemination is related to tumor infiltration depth, but varying incidences have been reported in m3- and sm1-adenocarcinomas. The study aim was to investigate whether the presence of occult tumor cells in lymph nodes could explain this variation.

METHODS

Sixty-three node-negative (N0) patients with early esophageal adenocarcinoma (m2/m3/sm1-tumors) were included. Multilevel-sectioning of lymph nodes was performed; sections were stained by means of immunohistochemistry with cytokeratin marker CAM5.2. Two pathologists searched for micrometastases (0.2-2.0  mm) and isolated tumor cells (ITCs, <0.2  mm).

RESULTS

Positive CAM5.2 staining in lymph nodes was not seen in any of the 18 m2-patients. In 2/25 m3-tumors (8.0%) an ITC was found, but no micrometastases. Tumor cells were identified in 4/20 sm1-tumors (20.0%): three micrometastases and one ITC. Median follow-up was 121 months. Two m3-patients (3.2%) died due to disease recurrence, including one patient in whom an ITC was detected.

CONCLUSIONS

Lymphatic migration of tumor cells was found in node-negative m3- and sm1-adenocarcinomas of the esophagus (8.0% and 20.0%, respectively). However, the clinical relevance of these occult tumor cells should become apparent from large series of endoscopically treated patients.

Surgical management of submucosal esophageal cancer: extended or regional lymphadenectomy?

INTRODUCTION

Radical esophagectomy is considered the standard therapy for tumors that infiltrate the submucosa of the esophagus (T1b), as the prevalence of lymph node metastases has been reported in up to 40% of these patients. It remains unclear whether radical esophagectomy with extended lymphadenectomy is needed or whether a surgical procedure with only regional lymphadenectomy suffices. The aim of this study was to compare outcomes of patients who underwent esophagectomy for T1b cancer through a transthoracic approach with extended lymphadenectomy (TTE) with those of patients in whom transhiatal esophagectomy (THE) was performed with a regional lymph node dissection.

METHODS

Patients who underwent esophagectomy for T1b cancer between 1990 and 2004 and who did not receive (neo)adjuvant therapy were included. Data were collected from prospective databases of 4 centers. In Leuven, Belgium (n = 101), and Los Angeles, CA (n = 31), patients with T1b tumors had been operated on via TTE with extended lymphadenectomy, whereas in Amsterdam (n = 43) and Rotterdam (n = 47), the Netherlands, THE with regional lymphadenectomy had been performed.

RESULTS

The 2 patient groups (TTE, n = 132; THE, n = 90) were comparable with regard to age, body mass index, and ASA classification. Operative time was longer in patients who underwent TTE (390 minutes) versus THE (250 minutes) (P < 0.001). The yield of lymph nodes resected was higher in the TTE group (median: 32) versus THE (median: 10) (P < 0.001). Overall morbidity, in-hospital mortality, and length of hospital stay were comparable between both the groups. In the TTE group, 27.3% of complications were classified as major versus 14.4% in the THE group (P < 0.001); however, the reoperation rate was higher after THE (12.2%) versus TTE (3.8%) (P = 0.01). There was no difference in pathological outcomes (infiltration depth, pN stage, pM stage, positive lymph node ratio) between both groups. Overall, 5-year survival (63.4% TTE vs 69.4% THE; P = 0.55) and disease-free 5-year survival (76.9% TTE vs 78.3% THE; P = 0.65) were comparable between both the groups. In patients with N1 disease, disease-free 5-year survival was 49.8% in the TTE group versus 40.0% in the THE group (P = 0.57).

CONCLUSIONS

In patients with submucosal esophageal cancer (T1b), TTE with extended lymphadenectomy and THE with regional lymphadenectomy had similar short-term outcome and long-term survival. In the selected group of T1bN1 patients, TTE may be the preferred operative technique because of a potential disease-free survival benefit; in patients with T1bN0 disease, THE with en bloc dissection of the esophagus and regional lymph nodes offers an oncologically safe and less invasive treatment.

Initial experience with Barrett's strip endoscopic mucosal excision: a new Barrett's excision device

BACKGROUND

Barrett's mucosa resection techniques are time consuming, often difficult to perform, and used with varying success. This report describes the authors' results with a new device and technique for strip endoscopic mucosal resection (SEMR) using a cold excision blade.

METHODS

A retrospective review of ex vivo and in vivo animal and human esophagi experiments was conducted to develop the essential design characteristics of a transoral strip mucosal excision device. Depth, size, shape, and technique of excision were serially evaluated.

RESULTS

The SEMR device allows precise capsule positioning with satisfactory excision size and depth in ex vivo and in vivo experiments. A total of 10 excisions were performed on five normal ex vivo cadaveric human esophagi. The specimens ranged in size from 3×2.5 to 2.5×2.2 cm. The average specimen thickness was 0.297 mm. For 147 (99.8%) of 150 fields of examination, muscularis mucosa was included. Six additional in vivo experiments demonstrated device safety and feasibility.

CONCLUSION

Satisfactory excision depth was reproducible. Further animal survival experiments and clinical trials will define the role of the SEMR device for patients with Barrett's esophagus.

[Surgical treatment for early Barrett cancer]

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

Treatment options for esophageal cancer

There is considerable controversy over the level of evidence from randomized trials underpinning management decisions for patients presenting with localized cancer of the esophagus and esophago-gastric junction. There is also an optimism that new drugs and new approaches, including response prediction based on sequential (18)FDG-PET scanning following induction chemotherapy, may improve treatments pathways and outcomes. In this review we assess the level of evidence from the major published trials, and discuss new trials and approaches.

Reflux esophagitis, high-grade neoplasia, and early Barrett's carcinoma-what is the place of the Merendino procedure?

INTRODUCTION

Because of the increasing frequency of Barrett's cancer in Western industrialized countries, the management of reflux disease with the potential development of Barrett's esophagus, neoplasia, and early carcinoma is very important. In case of established Barrett's esophagus, the malignant degeneration of the specialized epithelium cannot definitely be prevented by antireflux surgery or continuous medication. Mucosal adenocarcinomas nearly never develop lymph node metastasis and can mostly be treated by endoscopic mucosectomy. The deeper the submucosa is infiltrated, the higher is the rate of lymph node metastasis which is, on the average, 30% for submucosal carcinoma.

CONCLUSIONS

Therefore, radical subtotal esophagectomy is the treatment of choice for submucosal carcinoma, whereas distal esophageal resection with limited lymph node dissection is only indicated in mucosal carcinoma which cannot be completely removed by interventional endoscopy.

Prediction of lymph node status in superficial esophageal carcinoma

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of early esophageal cancer

In early esophageal cancer, squamous cell cancer and early adenocarcinoma must be managed differently because they have different origins, pathogenesis. and clinical characteristics. The current treatment options vary widely, from extended resection with lymphadenectomy to endoscopic mucosectomy or ablation. None of these treatment options can be recommended universally. Instead, an individualized strategy should be based on the depth of tumor infiltration into the mucosa or submucosa, the presence or absence of lymph node metastases, the multicentricity of tumor growth, the length of the segment of intestinal metaplasia, and comorbidities of the patient. Endoscopic mucosectomy may be sufficient in a subset of patients who have m1 or m2 squamous cell carcinoma and in patients who have isolated foci of high-grade intraepithelial neoplasia or mucosal cancer. Surgical resection is the treatment of choice for carcinomas invading the submucosal and multicentric tumors. Limited resection with jejunal interposition provides an effective treatment option for patients who have early esophageal adenocarcinoma. The onset of lymph node involvement is later in patients who have early adenocarcinoma than in patients who have squamous cell cancer, probably because chronic injury and repair mechanisms obliterate the otherwise abundant lymph vessels.

Altered esophageal motility and gastroesophageal barrier in patients with jejunal interposition after distal esophageal resection for early stage adenocarcinoma

INTRODUCTION

Limited resection of the esophagogastric junction has been proven to be safe and oncologically radical in patients with early esophageal cancer. Reconstruction with interposition of isoperistaltic jejunal loop (Merendino procedure) is supposed to prevent gastroesophageal reflux and therefore the recurrence of intestinal metaplasia at the anastomosis. The aim of this study was to assess the frequency of acid and nonacid refluxes after Merendino procedure using multichannel intraluminal impedance-pH (MII-pH) monitoring.

PATIENTS AND METHODS

Between 2002 and 2005, 12 patients with esophageal adenocarcinoma underwent limited resection and jejunal interposition. Ten patients agreed to undergo a Gastrointestinal Symptom Rating Scale assessment, upper gastrointestinal (GI) endoscopy, esophageal manometry, and combined 24-h MII-pH monitoring more than 10 months postoperatively.

RESULTS

Postoperatively, 4 (40%) patients reported belching without heartburn or acid regurgitation, 3 of them having a positive symptom index during 24-h MII-pH monitoring. Upper GI endoscopy revealed no inflammation, metaplasia, or stenosis at the esophagojejunal anastomosis. Esophageal manometry showed ineffective esophageal motility in four of ten patients. Combined 24-h MII-pH monitoring revealed normal distal esophageal acid exposure (% time pH < 4: 0.1% [0-1.5]), normal number of acid reflux episodes (3 [0-11]) but a high number of nonacid reflux episodes (82 [33-184]). Overall, eight patients revealed an abnormal number of nonacid reflux episodes.

CONCLUSION

The limited resection with jejunal interposition for early esophageal cancer is efficient in controlling acid but not nonacid reflux. While the clinical relevance of nonacid reflux in the recurrence of Barrett's esophagus is currently unknown, endoscopic surveillance should be considered in these patients.

Limited surgical resection and jejunal interposition for early adenocarcinoma of the distal esophagus

The need for radical resection and extensive lymphadenectomy for early adenocarcinoma of the distal esophagus has recently been challenged. Limited surgical resection and endoscopic mucosal ablation techniques are increasingly proposed and used as less invasive alternatives. Available data indicate that a limited resection of the distal esophagus and esophagogastric junction with jejunal interposition is associated with less morbidity and mortality, provides similar oncologic results, and offers a better quality of life as compared with radical esophagectomy. In contrast, endoscopic ablation and mucosectomy techniques are still plagued by high tumor recurrence rates, particularly in patients with incomplete removal of the underlying Barrett's mucosa, multicentric tumors, or tumors invading into the submucosa. Attention to technical details of limited resection and jejunal interposition is, however, required to avoid complications, poor functional results, and the need for reintervention.

Adenocarcinoma of the esophago-gastric junction

BACKGROUND

The border between the esophagus and stomach gives rise to many discrepancies in the current literature regarding the etiology, classification and surgical treatment of adenocarcinoma arising at the esophago-gastric junction. We have consequently used the AEG-criteria (adenocarcinoma of the esophago-gastric junction) for classification and have based the selection of the surgical approach on the anatomic topographic subclassification.

METHODS

In the following we report an analysis of a large and homogeneously classified population of 1602 consecutive patients with adenocarcinoma of the esophago-gastric junction, with an emphasis on the surgical approach, the pattern of lymphatic spread, the outcome after surgical treatment and the prognostic factors. Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor subclassifiations.

RESULTS

The study confirms the marked differences in sex distribution, associated specialized intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, lymphatic spread, and stage between the three tumor entities. The degree of resection and lymph node status were the dominating independent prognostic factors by multivariate analysis. The data show no significant differences of long-term survival after abdomino-thoracic esophagectomy and extended total gastrectomy in these patients.

CONCLUSION

The classification of adenocarcinomas of the esophago-gastric junction in three types, AEG type I, type II and type III shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are associated with good long-term prognosis. Better surgical management and standardized procedures will improve the outcome also of patients who need to undergo more radical surgery, i.e. abdomino-thoracic esophagectomy.

Adenocarcinoma of the esophagogastric junction: surgical therapy based on 1602 consecutive resected patients

Because of the borderline location between the esophagus and stomach, many discrepancies exist in the current literature regarding the etiology, classification, and surgical treatment of adenocarcinoma arising at the esophagogastric junction. The classification of adenocarcinomas into three types, AGE type I, type II, and type III, shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are recommended for a good, long-term prognosis. With better surgical management and standardized procedures, even the results in patients with more radical surgical approaches, the abdomino-thoracic esophagectomy improved.

Surgical management of esophagogastric junction tumors

Surgical resection with lymphadenectomy is the mainstay of treatment for all resectable esophagogastric junction tumors, prior to systemic generalization of the disease. This makes accurate pre-treatment staging and classification of the tumors most demanding. A well-established and internationally accepted classification for adenocarcinomas of the esophagogastric junction (AEG) helps to choose the appropriate surgical approach and to make results from different institutions comparable. Distal esophageal adenocarcinomas (AEGI) are distinguished from true cardia carcinomas (AEG II) and subcardiac gastric cancers (AEG III). Substantial advancements in this surgical field during the preceding decades have clearly revealed that individualization of the surgical strategy is the key to successfully approaching these entities. In this review we discuss the surgical management of esophagogastric junction tumors with a tailored surgical strategy.

The histological appearance of oesophageal adenocarcinoma—an analysis based on 215 resection specimens

The current study was performed to determine whether the histopathological appearance of oesophageal adenocarcinoma (AC) differs significantly from that of cardiac or gastric AC. Therefore, HE-stained slides of 215 primarily resected oesophageal AC, 108 cardiac and 184 gastric AC were classified according to a variety of clinico-pathologic parameters. According to Lauren's classification, oesophageal AC (1.4%) less frequently belonged to the diffuse type than cardiac (2.8%) and gastric AC (23.9%; p<0.0001). Tubular and papillary AC, as defined by the WHO classification, were more frequent among oesophageal (94.4%) than among cardiac (87.0%) and gastric AC (59.2%; p<0.0001). Solid carcinomas, according to Carneiro's classification, were less frequent among oesophageal (2.8%) than among cardiac (10.2%) and gastric AC (9.2%; p<0.0001). Oesophageal AC were graded more frequently G1/G2 (53.9%) than cardiac (30.6%) and gastric AC (27.7%; p<0.0001). Among oesophageal AC, Lauren's classification (p=0.0067), Carneiro's classification (p=0.0170), tumour grade (p=0.0005), lymphatic vessel invasion (p<0.0001) but not WHO classification were histological predictors of postoperative survival. In conclusion, oesophageal AC displays the same histological spectrum as cardiac and gastric AC. However, the relative proportion of differentiated, gland-forming carcinomas is significantly more frequent in the oesophagus than in the cardia and in the stomach.

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

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

Surgical strategies for early esophageal adenocarcinoma

The need for extensive surgical resection for early-stage esophageal adenocarcinoma has been challenged by the increasing frequency of early detection in patients with Barrett's esophagus undergoing surveillance endoscopy. Limited endoscopic or surgical procedures are promoted as alternatives to radical esophagectomy and lymphadenectomy in such patients. Currently available data show that limited surgical resection of the distal esophagus with regional lymphadenectomy and interposition of an isoperistaltic jejunal segment is a safe and oncologically adequate procedure in this situation and provides good quality of life. This is in contrast to endoscopic ablation or endoscopic mucosal resection, which are associated with high tumour recurrence rates and persistence of premalignant Barrett esophagus. New technologies for accurate prediction of the presence and pattern of lymphatic spread-e.g. sentinel node techniques and artificial neural networks-may allow a further reduction of the invasiveness of surgical resection without compromising cure rates.

Early esophageal cancer: pattern of lymphatic spread and prognostic factors for long-term survival after surgical resection

OBJECTIVE

The objective of this study was to assess the prevalence and pattern of lymphatic spread in patients with early squamous cell and adenocarcinoma and identify prognostic factors for long-term survival after resection and lymphadenectomy.

SUMMARY BACKGROUND DATA

Limited endoscopic approaches without lymphadenectomy are increasingly applied in patients with early esophageal cancer.

MATERIAL AND METHODS

A total of 290 patients with early esophageal cancer (157 adenocarcinoma, 133 squamous cell cancer) had surgical resection with systematic lymphadenectomy. Specimens were assessed for prevalence and pattern of lymphatic spread. Prognostic factors were determined by multivariate analysis.

RESULTS

None of the 70 patients with adenocarcinoma limited to themucosa had lymphatic spread, as compared with 2 of 26 with mucosal squamous cell cancer. Lymphatic spread was more common in patients with submucosal squamous cell cancer as compared with submucosal adenocarcinoma (36.4% versus 20.7%). Although lymph node metastases were usually limited to locoregional lymph node stations in early adenocarcinoma, distant lymphatic spread was frequent in early squamous cell cancer. On multivariate analysis, only histologic tumor type and the presence of lymph node metastases were independent predictors of long-term survival. Five-year survival rate was 83.4% for early adenocarcinoma versus 62.9% for early squamous cell cancer and 48.2% versus 79.5% for patients with/without lymphatic spread.

DISCUSSION

Prevalence and pattern of lymphatic spread as well as long-term prognosis differ markedly between early esophageal squamous cell and adenocarcinoma. Limited resection techniques and individualized lymphadenectomy strategies appear applicable in patients with early adenocarcinoma.

Early esophageal cancer: pattern of lymphatic spread and prognostic factors for long-term survival after surgical resection

OBJECTIVE

The objective of this study was to assess the prevalence and pattern of lymphatic spread in patients with early squamous cell and adenocarcinoma and identify prognostic factors for long-term survival after resection and lymphadenectomy.

SUMMARY BACKGROUND DATA

Limited endoscopic approaches without lymphadenectomy are increasingly applied in patients with early esophageal cancer.

MATERIAL AND METHODS

A total of 290 patients with early esophageal cancer (157 adenocarcinoma, 133 squamous cell cancer) had surgical resection with systematic lymphadenectomy. Specimens were assessed for prevalence and pattern of lymphatic spread. Prognostic factors were determined by multivariate analysis.

RESULTS

None of the 70 patients with adenocarcinoma limited to themucosa had lymphatic spread, as compared with 2 of 26 with mucosal squamous cell cancer. Lymphatic spread was more common in patients with submucosal squamous cell cancer as compared with submucosal adenocarcinoma (36.4% versus 20.7%). Although lymph node metastases were usually limited to locoregional lymph node stations in early adenocarcinoma, distant lymphatic spread was frequent in early squamous cell cancer. On multivariate analysis, only histologic tumor type and the presence of lymph node metastases were independent predictors of long-term survival. Five-year survival rate was 83.4% for early adenocarcinoma versus 62.9% for early squamous cell cancer and 48.2% versus 79.5% for patients with/without lymphatic spread.

DISCUSSION

Prevalence and pattern of lymphatic spread as well as long-term prognosis differ markedly between early esophageal squamous cell and adenocarcinoma. Limited resection techniques and individualized lymphadenectomy strategies appear applicable in patients with early adenocarcinoma.

Biologic and clinical variations of adenocarcinoma at the esophago-gastric junction: relevance of a topographic-anatomic subclassification

A topographic-anatomic subclassification of adenocarcinomas of the esophago-gastric junction (AEG) in distal esophageal adenocarcinoma (AEG Type I), true carcinoma of the cardia (AEG Type II), and subcardial gastric cancer (AEG Type III) was introduced in 1987 and is now increasingly accepted and used worldwide. Our experience with now more than 1,300 resected AEG tumors indicates that the subtypes differ markedly in terms of surgical epidemiology, histogenesis and histomorphologic tumor characteristics. While underlying specialized intestinal metaplasia can be found in basically all patients with AEG Type I tumors, this is uncommon in Type II tumors and virtually absent in Type III tumors. Stage distribution and overall long-term survival after surgical resection also shows marked differences between the AEG subtypes. Surgical treatment strategies based on tumor type allow a differentiated approach and result in survival rates superior to those reported with other approaches. The subclassification of AEG tumors thus provides a useful tool for the selection of the surgical procedure and allows a better comparison of treatment results.

Prevention and management of early esophageal cancer

Early esophageal cancer is defined by its limitation to the esophageal mucosa and submucosa. It has become a curable malignant disease, in sharp contrast to the dismal prognosis of esophageal cancer at advanced stages, which still represents the majority of patients. Understanding the risk factors, establishing surveillance programs for patients at risk, and developing preventative interventions such as dietary and lifestyle changes or pharmacologic interventions hold the potential of reducing the incidence of the disease and of shifting the stage distribution toward early cancer. Endoscopic ultrasound examination is pivotal for distinguishing early from advanced stages of the disease because it allows for accurate assessment of tumor infiltration and regional lymph node involvement. The therapeutic mainstay for early esophageal cancer remains surgery. New, less invasive surgical techniques are being tested that are associated with less morbidity and mortality than standard radical esophagectomies. For patients who are not candidates for surgery, definitive chemoradiation is a viable alternative. New endoscopic ablation techniques, such as endoscopic mucosa resection and photodynamic therapy, are potential alternatives to surgery in patients with cancers limited to the mucosa. For patients with adenocarcinoma of the gastroesophageal junction with submucosal involvement, adjuvant chemoradiation should be considered because of its potential to increase survival.

Surgery for early stage esophageal adenocarcinoma

Current treatment recommendations for early esophageal adenocarcinoma range from radical esophagectomy with extensive lymphadenectomy, limited surgical resection with/without regional lymphadenectomy to endoscopic mucosectomy or ablation. A comparison of treatment associated morbidity, tumor recurrence rates, and functional outcome suggests that none of these alternatives can be universally recommended. Rather, an individualized strategy should be employed based on depth of tumor penetration into the mucosa/submucosa, presence of lymph node metastases, multicentricity of tumor growth, length of the underlying Barrett mucosa and comorbidity of the affected patient. Endoscopic mucosectomy may suffice for an isolated focus of high-grade neoplasia or mucosal cancer, provided the neoplasia and underlying Barrett mucosa can be removed completely. Surgical resection is the treatment of choice for tumors invading the submucosa, multicentric tumors and recurrence after endoscopic mucosectomy. The extent of surgical resection must be guided by the length of the Barrett mucosa. In most instances a complete tumor resection and removal of the entire Barrett mucosa can be achieved by a limited transabdominal approach, and therefore subtotal esophagectomy may not be necessary. Application of the sentinel node technology may in the future allow to limit systematic lymphadenectomy to the rather small subgroup of patients who in fact have lymph node metastases.

[Sentinel lymph node mapping in gastric and esophageal carcinomas]

During the last 5 years, the concept of sentinel lymph nodes has been investigated in a variety of solid tumors. Despite the multidirectional and complex lymphatic drainage of the stomach, early gastric cancer has been shown to be a suitable model for sentinel lymph node mapping. In contrast, sentinel lymph node mapping of esophageal cancer is compromised by the anatomic location of the esophagus and its lymphatic drainage in the closed space of the mediastinum. The technique and clinical application of sentinel lymph node mapping thus differ between esophageal and gastric cancer. Reliable detection of sentinel lymph nodes in the mediastinum requires radioisotope labelling, while blue dye and radioisotope labelling are both feasible for gastric cancer. In patients with early gastric cancer, laparoscopic resection with sentinel node negative status is already under investigation in clinical trials. In esophageal cancer, sentinel node mapping is still considered an experimental technique. Preliminary data, however, indicate that it may be reliable and feasible in patients with early adenocarcinoma of the distal esophagus.

Improved prognosis of resected esophageal cancer

Because of the perceived high risk of esophagectomy and the assumed poor long-term results, the role of surgical resection as the mainstay of treatment for localized esophageal cancer is currently being challenged. Early tumors are increasingly approached by endoscopic mucosectomy or mucosal ablation techniques, whereas combined radiochemotherapy without surgery has become the treatment of choice for locally advanced tumors at many institutions. Several recent reports and our experience, however, indicate that surgical resection of esophageal cancer has become a safe procedure and long-term survival rates after surgical resection have improved markedly during the past two decades. A number of factors have been associated with the marked reduction in postoperative mortality and improved long-term survival after surgical resection. They include changes in the epidemiology with an increased rate of adenocarcinoma mostly located distally, patient selection for surgery, improvements in surgical technique and perioperative management, and the use of neoadjuvant treatment protocols. The treatment strategy and extent of the surgical procedure can now be tailored based on histologic tumor type, tumor location, tumor stage, and the general condition of the patient. With an individualized approach, surgical resection of esophageal cancer can predictably offer cure. Surgical resection thus remains the major pillar in the successful treatment of esophageal cancer.

Survival after oesophagectomy for cancer of the oesophagus

BACKGROUND

Formerly an inevitably fatal disease, oesophageal cancer today has predictable chances for cure.

METHODS

The recent literature and authors' own experiences in the surgical management of oesophageal cancer was reviewed to identify factors associated with improved survival after oesophagectomy.

RESULTS

Currently reported overall 5-year-survival rates are reaching 40% and more in patients who have had an oesophagectomy performed with curative intention. The reasons for improved survival after surgical resection are multifactorial in nature: decreased postoperative mortality and morbidity (due to improved patient selection, surgical technique and perioperative management), the use of tailored surgical strategies (adopted to the histological tumour type, tumour location, stage of disease and the individual patient's risk profile), and multimodality treatment in patients with locally advanced disease.

CONCLUSION

The prognosis of patients who have had oesophagectomy for oesophageal cancer has markedly improved during the past decades. With improved long-term survival after oesophagectomy, postoperative quality of life gains importance as an additional parameter of outcome after oesophageal cancer surgery.

Sentinel node detection in Barrett's and cardia cancer

Because of surveillance strategies in patients with known Barrett's esophagus, more patients with high-grade dysplasia or early cancer in the distal esophagus and at the esophagogastric junction are identified. The need for and extent of lymphadenectomy in such patients are controversial. The technique of sentinel lymph node dissection (SLND) to diagnose early lymphatic spread is applied increasingly in tumors of the gastrointestinal tract. The poorly defined lymphatic drainage of the esophagogastric junction has so far prevented many investigators from performing SLND in tumors of this anatomic region. We report the first results of SLND in Barrett's and cardia cancer. The preliminary experience indicates that the method is, even in this anatomical area, feasible and yields good results in early tumors. In advanced tumors, the method lacks sensitivity. Mapping should be done with blue dye and a radiocolloid. The concept of sentinel lymph node mapping and detection thus may open the door to individualized therapy for patients with high-grade dysplasia in a Barrett's esophagus or with early Barrett's and cardia cancer.

Cancer of the esophagus and gastric cardia: recent advances

Esophageal cancer and cancer of the gastric cardia, in particular adenocarcinomas, have shown a rapid and largely unexplained increase in incidence in many developed countries around the world. These diseases have a poor prognosis and current therapies have a modest impact on survival. This review presents recent advances in the epidemiology, etiology, diagnosis, staging, prevention and treatment of resectable and advanced disease. Although significant progress has been made in these areas of research and patient management over the past years, prognosis for most patients diagnosed with esophageal cancer or cancer of the gastric cardia remains poor. New diagnostic procedures, improved surgical procedures, combined treatment modalities and new treatment modalities are being evaluated and may be expected to contribute to improved patient outcomes and better palliation of symptoms in the future.