Surgical aspects of the patient with high-grade dysplasia

Management of Clinical T1N0M0 Esophageal Cancer

Background/Aims

Endoscopic resection is a standard treatment for stage T1a esophageal cancer, with esophagectomy or radical radiation therapy (RT) performed for stage T1b lesions. This study aimed to compare treatment outcomes of each modality for clinical stage T1 esophageal cancer.

Methods

In total, 179 patients with clinical T1N0M0-stage esophageal cancer treated from 2006 to 2016 were retrospectively evaluated. Sixty-two patients with clinical T1a-stage cancer underwent endoscopic resection. Among 117 patients with clinical T1b-stage cancer, 82 underwent esophagectomy, and 35 received chemoradiotherapy or RT. We compared overall survival (OS) and recurrence-free survival (RFS) rates for each treatment modality.

Results

The median follow-up time was 32 months (range, 1 to 120 months). The 5-year OS and RFS rates for patients with stage T1a cancer receiving endoscopic resection were 100% and 85%, respectively. For patients with stage T1b, the 5-year OS and RFS rates were 78% and 77%, respectively, for the esophagectomy group; 80% and 44%, respectively, for the RT alone group; and 96% and 80%, respectively, for the chemoradiation group. The esophagectomy group showed significantly higher RFS than the RT alone group (p=0.04). There was no significant difference in RFS between the esophagectomy and chemoradiation groups (p=0.922). Grade 4 or higher treatment-related complications occurred in four patients who underwent esophagectomy.

Conclusions

Endoscopic resection appeared to be an adequate treatment for patients with T1a-stage esophageal cancer. The multidisciplinary approach involving chemoradiation was comparable to esophagectomy in terms of survival outcome without serious complications for T1b-stage esophageal cancer.

The Molecular Biologic Basis of Esophageal and Gastric Cancers

Esophageal cancer and gastric cancer are leading causes of cancer-related mortality worldwide. In this article, the authors discuss the molecular biology of esophageal and gastric cancer with a focus on esophageal adenocarcinoma. They review data from The Cancer Genome Atlas project and advances in the molecular stratification and classification of esophageal carcinoma and gastric cancer. They also summarize advances in microRNA, molecular staging, gene expression profiling, tumor microenvironment, and detection of circulating tumor DNA. Finally, the authors summarize some of the implications of understanding the molecular basis of esophageal cancer and future directions in the management of esophageal cancer.

Detection of Premalignant Gastrointestinal Lesions Using Surface-Enhanced Resonance Raman Scattering-Nanoparticle Endoscopy

Cancers of the gastrointestinal (GI) tract are among the most frequent and most lethal cancers worldwide. An important reason for this high mortality is that early disease is typically asymptomatic, and patients often present with advanced, incurable disease. Even in high-risk patients who routinely undergo endoscopic screening, lesions can be missed due to their small size or subtle appearance. Thus, current imaging approaches lack the sensitivity and specificity to accurately detect incipient GI tract cancers. Here we report our finding that a single dose of a high-sensitivity surface-enhanced resonance Raman scattering nanoparticle (SERRS-NP) enables reliable detection of precancerous GI lesions in animal models that closely mimic disease development in humans. Some of these animal models have not been used previously to evaluate imaging probes for early cancer detection. The studies were performed using a commercial Raman imaging system, a newly developed mouse Raman endoscope, and finally a clinically applicable Raman endoscope for larger animal studies. We show that this SERRS-NP-based approach enables robust detection of small, premalignant lesions in animal models that faithfully recapitulate human esophageal, gastric, and colorectal tumorigenesis. This method holds promise for much earlier detection of GI cancers than currently possible and could lead therefore to marked reduction of morbidity and mortality of these tumor types.

Regenerative Medicine Strategies for Esophageal Repair

Pathologies that involve the structure and/or function of the esophagus can be life-threatening. The esophagus is a complex organ comprising nonredundant tissue that does not have the ability to regenerate. Currently available interventions for esophageal pathology have limited success and are typically associated with significant morbidity. Hence, there is currently an unmet clinical need for effective methods of esophageal repair. The present article presents a review of esophageal disease along with the anatomic and functional consequences of each pathologic process, the shortcomings associated with currently available therapies, and the latest advancements in the field of regenerative medicine with respect to strategies for esophageal repair from benchtop to bedside.

Clinical and psychosocial variables associated with behavioral intentions to undergo surveillance endoscopy

Background

Many patients with Barrett’s esophagus do not adhere to guideline-recommended endoscopic surveillance. Among patient factors related to cancer prevention behaviors, patients’ stated behavioral intention is a strong predictor of behavior performance. Little is known about the patient factors associated with having a strong behavioral intention to pursue surveillance endoscopy. This study explores the association of clinical and psychosocial variables and behavioral intention to pursue surveillance endoscopy among patients with Barrett’s Esophagus and no or low-grade dysplasia.

Methods

Potential subjects were screened using electronic medical records of a regional Veterans Affairs Medical Center and a pathologically confirmed Barrett’s esophagus registry. Eligible participants were recruited by a mailer or phone call and completed a questionnaire to measure six distinct psychosocial factors, their behavioral intention to undergo surveillance endoscopy, and various demographic and clinical variables. Univariate and multivariate linear regression identified the relation of behavioral intention with each of six psychosocial variables.

Results

One-hundred and one subjects consented and returned surveys. The analytical sample for this study consists of the 94% of surveys with complete responses to the behavior intention items. Three of the six psychosocial domains were statistically significant predictors of intention in both univariate and adjusted univariate analysis (salience/coherence β = 0.59, 95% CI = 0.45-0.76, P <0.01; self-efficacy β = 0.30, 95% CI = 0.10-0.51, P <0.01; and social influence β = 0.20, 95% CI = 0.08-0.33, P <0.01). In a multivariate analysis only salience/coherence (β = 0.65, 95% CI = 0.42-0.88, P <0.01) remained statistically significant predictor of intention.

Conclusion

This study established the validity of a scale to measure psychosocial variables associated with behavioral intentions to undergo surveillance endoscopy. Results demonstrate the importance of assessing self-efficacy, social influences, and bottom-line belief in the value of surveillance endoscopy when evaluating a patient’s likelihood of completing surveillance endoscopy.

[Subjective grading of Barrett's neoplasia by pathologists: correlation with objective histomorphometric variables]

Even though pathologists are trained to recognize the same histological features for the diagnosis and grading of different histological images, not all pathologists are influenced to a similar level of intensity by the same morphological characteristics of the tissue when scoring Barrett's dysplasia/neoplasia. The variables which most pathologists have intuitively chosen to use for scoring of the severity of Barrett's changes are mainly those related to the general tissue architecture, such as nuclear crowding, orientation and stratification. Interestingly, nuclear size is not used by most pathologists but nuclear pleomorphism and symmetry does influence a significant number of pathologists. Maybe the most difficult variables for the human eye to recognize are variables of chromatin texture (such as margination or heterogeneity), the predictive importance of which has been demonstrated in a previously published work. Textural variables may therefore remain the subject of a computerized analysis. Nevertheless, the fact that a few pathologists do actually correlate with nuclear texture in scoring, argues in favor of making further attempts to train pathologists to also rely on texture, similar to cytologists, when scoring Barrett's dysplasia.

Oesophageal carcinoma

Oesophageal carcinoma affects more than 450,000 people worldwide and the incidence is rapidly increasing. Squamous-cell carcinoma is the predominant form of oesophageal carcinoma worldwide, but a shift in epidemiology has been seen in Australia, the UK, the USA, and some western European countries (eg, Finland, France, and the Netherlands), where the incidence of adenocarcinoma now exceeds that of squamous-cell types. The overall 5-year survival of patients with oesophageal carcinoma ranges from 15% to 25%. Diagnoses made at earlier stages are associated with better outcomes than those made at later stages. In this Seminar we discuss the epidemiology, pathophysiology, diagnosis and staging, management, prevention, and advances in the treatment of oesophageal carcinoma.

Management strategies of Barrett's esophagus

Barrett's esophagus is a condition resulting from chronic gastro-esophageal reflux disease with a documented risk of esophageal adenocarcinoma. Current strategies for improved survival in patients with Barrett's adenocarcinoma focus on detection of dysplasia. This can be obtained by screening programs in high-risk cohorts of patients and/or endoscopic biopsy surveillance of patients with known Barrett's esophagus (BE). Several therapies have been developed in attempts to reverse BE and reduce cancer risk. Aggressive medical management of acid reflux, lifestyle modifications, antireflux surgery, and endoscopic treatments have been recommended for many patients with BE. Whether these interventions are cost-effective or reduce mortality from esophageal cancer remains controversial. Current treatment requires combinations of endoscopic mucosal resection techniques to eliminate visible lesions followed by ablation of residual metaplastic tissue. Esophagectomy is currently indicated in multifocal high-grade neoplasia or mucosal Barrett's carcinoma which cannot be managed by endoscopic approach.

An analysis of esophagectomy and other techniques in the management of high-grade dysplasia of Barrett's esophagus

Barrett's esophageal (BE) metaplasia is a premalignant condition of the distal esophagus that develops as a consequence of gastroesophageal reflux disease. The progression to carcinogenesis results from progressive dysplastic changes of the metaplastic epithelium through low-grade and then high-grade dysplasia (HGD) to eventually adenocarcinoma of the esophagus. The management of HGD is controversial with proponents for each of the three major management strategies: endoscopic surveillance, endoscopic ablative therapies, and esophagectomy. The aim of the study was to define and discuss the various management strategies of HGD arising from BE metaplasia. There is a paucity of randomized controlled data from which to draw definitive conclusions. All strategies for the management of HGD are reasonable options and are complimentary. BE with HGD is a malignant lesion. A multidisciplinary approach individualizing therapy should be undertaken when possible. Esophageal resection should be reserved for otherwise healthy patients. Endoscopic techniques are viable alternatives to surgery.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Resection for esophageal cancer: strategies for optimal management

There are several controversies in the optimal management of esophageal cancer, including the surgical approach, extent of resection, and the role of multimodality treatment. Optimal surgical treatment strategies include patient selection, accurate staging and risk assessment, selection of an appropriate surgical approach, and the use of multimodality treatment in the management of these patients. In addition, other factors such as hospital and surgeon volume are important in reducing the risks of esophagectomy. In this article we discuss our approach and review the literature on these aspects that have an impact on outcomes after esophagectomy.

Role of photodynamic therapy in unresectable esophageal and lung cancer

The incidence of esophageal cancer has increased dramatically in the Western population in the last two decades. Many of these patients tend to present late in the disease course with symptoms of dysphagia and malnutrition. Thus a majority of patients at presentation may require palliation of their symptoms. Lung cancer is the most common cause of cancer related mortality in the United States. Similar to esophageal cancer, many patients present in advanced stages where surgical resection for cure may not be an option. Endobronchial obstruction from both primary and metastatic neoplasm causes significant morbidity. The modalities, which are currently available for palliation of symptoms include surgery, photodynamic therapy, dilation, external beam radiation, stents, Nd:YAG laser therapy, and brachytherapy. Each of these modalities has their specific advantages and drawbacks. In this article, we discuss the role of photodynamic therapy in the palliation of esophageal and lung cancer.