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Kumarasinghe MP, Bourke MJ, Brown I, Draganov PV, McLeod D, Streutker C, Raftopoulos S, Ushiku T, Lauwers GY. Pathological assessment of endoscopic resections of the gastrointestinal tract: a comprehensive clinicopathologic review. Mod Pathol 2020; 33:986-1006. [PMID: 31907377 DOI: 10.1038/s41379-019-0443-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/27/2019] [Accepted: 12/10/2019] [Indexed: 12/13/2022]
Abstract
Endoscopic resection (ER) allows optimal staging with potential cure of early-stage luminal malignancies while maintaining organ preservation. ER and surgery are non-competing but complementary therapeutic options. In addition, histological examination of ER specimens can either confirm or refine the pre-procedure diagnosis. ER is used for the treatment of Barrett's related early carcinomas and dysplasias, early-esophageal squamous cell carcinomas and dysplasias, early gastric carcinomas and dysplasia, as well as low-risk submucosal invasive carcinomas (LR-SMIC) and, large laterally spreading adenomas of the colon. For invasive lesions, histological risk factors predict risk of lymph node metastasis and residual disease at the ER site. Important pathological risk factors predictive of lymph node metastasis are depth of tumor invasion, poor differentiation, and lymphovascular invasion. Complete resection with negative margins is critical to avoid local recurrences. For non-invasive lesions, complete resection is curative. Therefore, a systematic approach for handling and assessing ER specimens is recommended to evaluate all above key prognostic features appropriately. Correct handling starts with pinning the specimen before fixation, meticulous macroscopic assessment with orientation of appropriate margins, systematic sectioning, and microscopic assessment of the entire specimen. Microscopic examination should be thorough for accurate assessment of all pathological risk factors and margin assessment. Site-specific issues such as duplication of muscularis mucosa of the esophagus, challenges of assessing ampullectomy specimens and site-specific differences of staging of early carcinomas throughout the gastrointestinal tract (GI) tract should be given special consideration. Finally, a standard, comprehensive pathology report that allows optimal staging with potential cure of early-stage malignancies or better stratification and guidance for additional treatment should be provided.
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Affiliation(s)
- M Priyanthi Kumarasinghe
- Department of Anatomical Pathology, PathWest, QE II Medical Centre and School of Pathology and Laboratory Medicine, University of Western Australia, Hospital Avenue, Nedlands Perth, WA, 6009, Australia.
| | - Michael J Bourke
- Department of Medicine, University of Sydney, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Ian Brown
- Envoi Pathology,Unit 5, 38 Bishop Street, Kelvin Grove, QLD, 4059, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia
| | - Peter V Draganov
- Department of Medicine, University of Florida, 1329 SW 16th Street, Room # 5251, Gainesville, FL, 32608, USA
| | | | - Catherine Streutker
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Director of Pathology, St Michael's Hospital, Toronto, ON, M5B 1W9, Canada
| | - Spiro Raftopoulos
- Sir Charles Gairdner Hospital, QE II Medical Centre, Hospital Avenue, Nedlands Perth, WA, 6009, Australia
| | - Tetsuo Ushiku
- Department of Pathology, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Gregory Y Lauwers
- H. Lee Moffitt Cancer Center & Research Institute and Departments of Pathology & Cell Biology and Oncologic Sciences, University of South Florida, Tampa, FL, USA
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Subramanian CR, Triadafilopoulos G. Endoscopic treatments for dysplastic Barrett's esophagus: resection, ablation, what else? World J Surg 2015; 39:597-605. [PMID: 24841804 DOI: 10.1007/s00268-014-2636-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic eradication therapy for dysplastic Barrett's esophagus (BE) comprises resection and mucosal ablation techniques. Over the years, these techniques have been tried with success, not only for dysplastic Barrett's epithelium but also for non-dysplastic Barrett's epithelium and early adenocarcinoma. Endoscopic resection is usually carried out for visible lesions, either as endoscopic mucosal resection (EMR), which is practiced widely in Western countries, or as endoscopic submucosal dissection, which is more popular in Japan and throughout Asia. Among ablative techniques are photodynamic therapy, cryotherapy, and radiofrequency ablation (RFA). METHODS We reviewed the published evidence pertaining to endoscopic treatments of dysplastic BE, with emphasis on the various resection and ablative techniques, their safety, efficacy, durability of effect, and tolerability. RESULTS Both resection and ablation procedures performed endoscopically have been proved effective, and safe for treating dysplastic BE and early adenocarcinoma. Among the ablative techniques, RFA has shown to be more effective and safe, and is preferred for most cases. CONCLUSIONS Endoscopic therapies have revolutionized the treatment of BE and have minimized the need for surgical intervention in many patients. Concomitant treatment of acid reflux with proton pump inhibitors and continuous surveillance are essential. Combination techniques such as EMR followed by RFA may be also considered in some cases.
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Qumseya B, Panossian AM, Rizk C, Cangemi D, Wolfsen C, Raimondo M, Woodward T, Wallace MB, Wolfsen H. Predictors of esophageal stricture formation post endoscopic mucosal resection. Clin Endosc 2014; 47:155-61. [PMID: 24765598 PMCID: PMC3994258 DOI: 10.5946/ce.2014.47.2.155] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/06/2013] [Accepted: 07/06/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Stricture formation is a common complication after endoscopic mucosal resection. Predictors of stricture formation have not been well studied. METHODS We conducted a retrospective, observational, descriptive study by using a prospective endoscopic mucosal resection database in a tertiary referral center. For each patient, we extracted the age, sex, lesion size, use of ablative therapy, and detection of esophageal strictures. The primary outcome was the presence of esophageal stricture at follow-up. Multivariate logistic regression was used to analyze the association between the primary outcome and predictors. RESULTS Of 136 patients, 27% (n=37) had esophageal strictures. Thirty-two percent (n=44) needed endoscopic dilation to relieve dysphagia (median, 2; range, 1 to 8). Multivariate logistic regression analysis showed that the size of the lesion excised is associated with increased odds of having a stricture (odds ratio, 1.6; 95% confidence interval, 1.1 to 2.3; p=0.01), when controlling for age, sex, and ablative modalities. Similarly, the number of lesions removed in the index procedure was associated with increased odds of developing a stricture (odds ratio, 2.3; 95% confidence interval, 1.3 to 4.2; p=0.007). CONCLUSIONS Stricture formation after esophageal endoscopic mucosal resection is common. Risk factors for stricture formation include large mucosal resections and the resection of multiple lesions on the initial procedure.
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Affiliation(s)
- Bashar Qumseya
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Abraham M Panossian
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA. ; Mercy Gilbert Medical Center, Chandler, AZ, USA
| | - Cynthia Rizk
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA. ; Department of Family Medicine, The Pennsylvania State University Medical Center, Hershey, PA, USA
| | - David Cangemi
- Community Internal Medicine at Mayo Clinic, Jacksonville, FL, USA
| | - Christianne Wolfsen
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Massimo Raimondo
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Timothy Woodward
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Herbert Wolfsen
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
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Kim HG. When is pre-emptive treatment necessary after endoscopic mucosal resection of early esophageal neoplasm? Clin Endosc 2014; 47:124-6. [PMID: 24765592 PMCID: PMC3994252 DOI: 10.5946/ce.2014.47.2.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 02/12/2014] [Indexed: 11/14/2022] Open
Affiliation(s)
- Hyung Gil Kim
- Division of Gastroenterology, Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
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Aranda-Hernandez J, Cirocco M, Marcon N. Treatment of dysplasia in barrett esophagus. Clin Endosc 2014; 47:55-64. [PMID: 24570884 PMCID: PMC3928493 DOI: 10.5946/ce.2014.47.1.55] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 12/27/2013] [Accepted: 12/28/2013] [Indexed: 12/20/2022] Open
Abstract
Barrett esophagus is recognized as a risk factor for the development of dysplasia and adenocarcinoma of the esophagus. Cancer is usually diagnosed at an advanced stage with a 5-year survival rate of 15%. Most of these patients present de novo and are not part of a surveillance program. Endoscopic screening with improvement in recognition of early lesions may change this pattern. In the past, patients diagnosed with dysplasia and mucosal cancer were best managed by esophagectomy. Endoscopic techniques such as endoscopic mucosal resection and radiofrequency ablation have resulted in high curative rates and a shift away from esophagectomy. This pathway is supported by the literature review of esophagectomies performed for mucosal disease, as well as pathologists' interpretation of endoscopic mucosal specimens, which document the low risk of lymph node metastasis. The role of endoscopic therapy for superficial submucosal disease continues to be a challenge.
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Affiliation(s)
- Javier Aranda-Hernandez
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Maria Cirocco
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Norman Marcon
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, ON, Canada
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Abstract
PURPOSE OF REVIEW Endoscopic eradication therapy is frequently used to treat dysplasia and early cancers in Barrett's esophagus. This review addresses some of the recent developments in the field of endoscopic eradication therapy for Barrett's esophagus. RECENT FINDINGS Data on the effectiveness of Barrett's esophagus ablation programs have been published recently, with excellent results for dysplasia eradication. Studies describing long-term results have shed light on the durability of endoscopic ablation, with recurrence of Barrett's esophagus and neoplasia seen in some cases, particularly at the gastroesophageal junction. Risk factors for failed ablation include longer Barrett's esophagus segments and persistent gastroesophageal reflux. New developments include studies combining radiofrequency ablation (RFA) and endoscopic mucosal resection into a single endoscopic session, endoscopic submucosal dissection for Barrett's esophagus neoplasia, and a simplified RFA algorithm. New data on the cost-effectiveness of RFA have also been published, suggesting that RFA is cost-effective for both high-grade and low-grade dysplasia, but not for nondysplastic Barrett's esophagus. A systematic review has shown that lymph node metastases are rare (∼2%) with intramucosal adenocarcinoma, supporting the use of endoscopic eradication for that lesion. SUMMARY Research and clinical experience with the endoscopic therapies for Barrett's esophagus continue to grow. Proper patient selection and technique are critical for ensuring a good outcome. Endoscopic surveillance after any of the ablative therapies still appears to be necessary.
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Qumseya BJ, David W, Wolfsen HC. Photodynamic Therapy for Barrett's Esophagus and Esophageal Carcinoma. Clin Endosc 2013; 46:30-7. [PMID: 23423151 PMCID: PMC3572348 DOI: 10.5946/ce.2013.46.1.30] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 01/14/2013] [Accepted: 01/14/2013] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Bashar J Qumseya
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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