Endoscopic Management of Early Esophageal Cancer

Early oesophageal carcinoma with a defect of the oesophageal muscularis propria: a rare case report

We herein report a rare case of early oesophageal cancer combined with an oesophageal muscularis propria defect discovered under endoscopic submucosal dissection. The surgeon did not damage the muscularis propria during endoscopic resection; however, we observed the mediastinal cavity as well as the later occurrence of subcutaneous emphysema. Consequently, the patient was considered to have a muscularis propria defect. This phenomenon has not been reported in the literature to date.

Epidemiology of early esophageal adenocarcinoma

BACKGROUND/AIMS

Endoscopic resection has become the preferred treatment approach for select early esophageal adenocarcinoma (EAC); however, the epidemiology of early stage disease has not been well defined.

METHODS

Surveillance Epidemiology and End Results (SEER) data were analyzed to determine age-adjusted incidence rates among major epithelial carcinomas, including EAC, from 1973 to 2017. The percent change in incidence over time was compared according to tumor subtype. Early T-stage, node-negative EAC without metastasis was examined from 2004 to 2017 when precise T-stage data were available.

RESULTS

The percent change in annual incidence from 1973 to 2017 was 767% for EAC. Joinpoint analysis showed that the average annual percent change in EAC from 1973 to 2017 was 5.11% (95% confidence interval, 4.66%-5.56%). The annual percent change appeared to plateau between 2004 and 2017; however, early EAC decreased from 2010 to 2017, with an annual percent change of -5.78%.

CONCLUSION

There has been a 7-fold increase in the incidence of EAC, which was significantly greater than that of the other major epithelial malignancies examined. More recently, the incidence of early EAC has been decreasing. Approximately one in five patients has node negative, potentially resectable early stage disease.

Short-term clinical outcomes of non-curative endoscopic submucosal dissection for early esophageal adenocarcinoma

OBJECTIVES

Few Western studies highlighted the outcomes of endoscopic submucosal dissection (ESD) for early esophageal adenocarcinoma (EAC). Data regarding the outcomes of noncurative ESDs remains scarce. In this study, we share our experience with ESD for early EAC with a focus on noncurative ESDs.

METHODS

A retrospective single-center analysis of consecutive patients who underwent ESD for early EAC from August 2015 through February 2020. Primary outcomes included the clinical outcomes of noncurative ESDs along with overall en bloc, R0 and curative resection rates. Secondary outcomes included comparing results between T1a and T1b tumors.

RESULTS

Final group included 23 T1a and 17 T1b EAC patients. Patients' median Charlson comorbidity index was five. En bloc resection rate was (97.5%). Compared to the T1b group, the T1a group had a statistically significantly higher R0 (78.3 vs. 41.2%; P = 0.0235), curative (73.9 vs. 11.8%; P = 0.0001) and accumulative endoscopic curative resection rates (82.6 vs. 23.5%; P = 0.0003). A study flowchart is presented in (Fig. 1). Out of the 21 noncurative ESDs, 10 patients (47.6%) underwent R0 esophagectomy, 6 patients (28.6%) are undergoing surveillance endoscopies without additional therapy, 3 patients (14.3%) underwent repeat curative ESD and 1 patient (4.76%) is receiving chemotherapy with surveillance endoscopy. Over median endoscopic follow-up of 22.5 months (IQR, 14.25-30.75), 2 out of 10 patients with noncurative ESDs had recurrent disease.

CONCLUSIONS

ESD achieved a higher curative resection rate in T1a EAC when compared to T1b. Despite a lower curative resection rate in T1b EAC, certain patients might benefit from a conservative multimodal therapy.

Efficacy and safety of endoscopic submucosal dissection versus endoscopic mucosal resection for superficial esophageal carcinoma: a systematic review and meta-analysis

Endoscopic submucosal dissection (ESD) has been developed to overcome the limitations of endoscopic mucosal resection (EMR). Yet, the potential for EMR should not be ignored. This study aimed to compare the efficacy and safety of ESD and EMR in the treatment of superficial esophageal carcinoma (SEC). All relevant articles were retrieved from electronic databases. The primary outcomes included en bloc resection, curative resection, R0 resection, and local recurrence rates. Secondary outcomes included procedure time, rates of perforation, bleeding, and postoperative stricture. Subgroup analyses based on histologic types and lesion sizes were conducted. Twenty-two studies were enrolled. Overall results showed higher en bloc, curative, and R0 resection rate, and lower recurrence rate in ESD compared with EMR. ESD was significantly more time-consuming and induced more perforations than EMR procedure. In subgroup analyses of squamous cell carcinoma (SCC) and Barrett's esophagus (BE)-associated neoplasia and esophageal adenocarcinoma (EAC) subtypes, ESD also excelled in en bloc, curative, R0 resection and local recurrence rates. However, in subgroup analysis stratifying outcomes according to lesion sizes, the superior effect of ESD in en bloc resection, curative resection, and local recurrence rate only manifested when lesion size >20 mm. Overall, ESD seemed to have superior efficacy and similar safety profiles compared to EMR in treating SCC, BE-associated neoplasia and EAC. Nevertheless, the selection of ESD or EMR should take lesion size into consideration. EMR is appropriate when lesion size ≤10 mm, EMR and ESD are both applicable for lesion between 11 and 20 mm, and ESD is preferable for lesions >20 mm. More evidences are needed to confirm the current findings.

Defining low-risk lesions in early-stage esophageal adenocarcinoma

OBJECTIVE

As endoscopic approaches become more widely used to treat early-stage esophageal cancer, reliably identifying patients with less-aggressive tumors is paramount. We sought to identify risk factors for recurrence in patients with completely resected T1 esophageal adenocarcinoma.

METHODS

We retrospectively analyzed a single-institutional database for all patients with completely resected pathologic T1 esophageal adenocarcinoma (1996-2016). Risk factors for recurrence were identified using competing-risk regression methods. Risk stratification was performed on the basis of known preoperative clinicopathologic factors; this model's discriminative power for overall survival was evaluated using a Cox proportional hazards model.

RESULTS

Of 243 patients, 32 experienced recurrence. At a median follow-up among survivors of 4 years (range, 0.05-19 years), the 5-year cumulative incidence of recurrence was 15%, and median time to recurrence was 2 years (range, 0.26-6.13 years). On univariable analysis, submucosal invasion, N1 disease, poor differentiation, tumor length, lymphovascular invasion, and multicentricity were significantly associated with recurrence. On multivariable analysis, N1 disease (hazard ratio, 2.93; 95% confidence interval, 1.17-7.34; P = .022) and tumor length (hazard ratio, 1.44; 95% confidence interval, 1.12-1.86; P = .004) were independently associated with recurrence. Risk stratification showed that patients without lymphovascular invasion and a with median tumor length of 0.8 cm (range, 0.10-1.70 cm) had a <10% risk of recurrence and improved survival.

CONCLUSIONS

Pathologic T1 tumors have a 5-year cumulative incidence of recurrence of 15%. Nodal involvement and tumor length were independent risk factors for recurrence, whereas tumors <2 cm in length without lymphovascular invasion were associated with a low risk of recurrence.

Novel endoscopic treatment strategy for early esophageal cancer in cirrhotic patients with esophageal varices

The safety and efficacy of endoscopic submucosal dissection (ESD) and radiofrequency ablation for early esophageal cancer (EEC) in cirrhotic patients has not been thoroughly investigated to date. The present study aimed to establish a standard treatment strategy for EEC in cirrhotic patients with esophageal varices. Six cirrhotic patients with early flat-type EECs (high-grade intraepithelial neoplasia) on or adjacent to esophageal varices were enrolled. Esophageal varix ligation (EVL) or transjugular intrahepatic portosystemic shunt (TIPS) were used for the initial management of esophageal varices. Follow-up endoscopy was performed two months following the initial procedure. The mean longitudinal length of the lesions was 4.3 cm (range, 2-6 cm). The average procedure time was 72.8 min (range, 34-135 min) and the average longitudinal length of the resected specimens was 45.6 mm (range, 30-90 mm). One case had a tumor-positive lateral margin with lymphovascular infiltration. Both complete and curative resection rates were 80% (4/5 lesions). Large intraoperative bleeding was detected in patients undergoing EVL compared with TIPS prior to the ESD procedure. No severe complications or mortality-associated events, including massive postoperative bleeding, perforation or hepatic failure, were observed. No recurrence and metastasis were observed during the follow-up period. The current study suggested a novel treatment strategy for EECs complicated by esophageal varices in cirrhosis with good treatment results, no neoplastic progression and an acceptable adverse event profile.

Impact of the development of an endoscopic eradication program for Barrett's esophagus with high grade dysplasia or early adenocarcinoma on the frequency of surgery

Background and aims  The impact of the advent of an institutional endoscopic eradication therapy (EET) program on surgical practice for Barrett's esophagus (BE)-associated high grade dysplasia (HGD) or suspected T1a esophageal adenocarcinoma (EAC) is unknown. The aims of this study are to evaluate the different endoscopic modalities used during development of our EET program and factors associated with the use of EET or surgery for these patients after its development. Methods  Patients who underwent primary endoscopic or surgical treatment for BE-HGD or early EAC at our hospital between January 1992 and December 2014 were retrospectively identified. They were categorized by their initial modality of treatment during the first year, and the impact over time for choice of therapy was assessed by multivariable logistic regression. Results  We identified 386 patients and 80 patients who underwent EET and surgery, respectively. EET included single modality therapy in 254 (66 %) patients and multimodal therapy in 132 (34 %) patients. Multivariable logistic regression showed that, for each subsequent study year, EET was more likely to be performed in patients who were older ( P  = 0.0009), with shorter BE lengths ( P  < 0.0001), and with a pretreatment diagnosis of HGD ( P  = 0.0054) compared to surgical patients. The diagnosis of EAC did not increase the utilization of EET compared to surgery as time progressed ( P  = 0.8165). Conclusion  The introduction of an EET program at our hospital increased the odds of utilizing EET versus surgery over time for initial treatment of patients who were older, had shorter BE lengths or the diagnosis of BE-HGD, but not in patients with EAC.

Survival Implications of Increased Utilization of Local Excision for cT1N0 Esophageal Cancer

OBJECTIVE

We hypothesized that patients with cT1N0 esophageal cancer undergoing local excision would have lower survival compared with esophagectomy due to potential discordant staging.

BACKGROUND

Local excision has become an attractive alternative for management of early esophageal cancer, avoiding the morbidity of esophagectomy. It is uncertain if occult nodal metastasis impacts survival.

METHODS

An observational study was conducted using the National Cancer Database (1998-2012) for patients with clinical T1N0 esophageal cancer who underwent local excision (n = 1625) or esophagectomy (n = 3255).

RESULTS

The proportion of patients undergoing local excision increased from 12% in 1998 to 50% in 2012 (P < 0.001). After esophagectomy, 61% of cT1N0 cancers had concordant clinical and pathological staging, with 5.2% having positive nodal disease; 37% were staged concordant after local excision, with excess missing data (60%). Ninety-day mortality was 7.4% after esophagectomy compared with 2.8% after local excision (P < 0.001). While no significant difference was seen in unadjusted survival, adjusted Cox regression analysis indicated worse survival after esophagectomy compared with local excision for all cases [hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.27-1.95] and for patients with concordant staging (HR 1.68, 95% CI 1.23-2.28).

CONCLUSIONS

Local excision for cT1N0 esophageal cancer has increased over time. Contrary to our hypothesis, despite incomplete nodal staging, patients undergoing local excision have favorable survival, particularly in the adenocarcinoma subgroup. This may reflect early differences in mortality due to differences in procedure-related complications and/or selection bias. As this study has limited power to compare outcomes between T1a and T1b cancers, further analysis is warranted.

Early esophageal squamous cell carcinoma management through endoscopic submucosal dissection

The incidence of esophageal cancer is steadily increasing worldwide. Outcome is poor, given that the majority of cases are diagnosed at advanced disease stages. However, when detected at early stages, esophageal tumors can be curatively treated through less invasive methods, resulting in a 5-year survival rate above 90%. Therefore, it is essential to identify the high-risk population and recommend those patients undergo screening using high-resolution endoscopy, adding the resources of chromoendoscopy with Lugol's solution (or digital chromoendoscopy) and magnification. Such systematized examination makes it possible to recognize early-stage esophageal neoplasia and propose endoscopic submucosal dissection as treatment. In that procedure, the tumor is resected en bloc, resulting in lower morbidity and mortality, compared with previous standard treatment, including early-stage esophagectomy. The present article is a review of the latest advances in the management of superficial esophageal tumors through endoscopic submucosal dissection.

Introduction: Esophageal Adenocarcinoma: Updates of Current Status

Esophageal and esophagogastric adenocarcinoma is highly prevalent in the Western populations and is a major cause of cancer-related morbidity and mortality worldwide. The incidence of esophageal adenocarcinoma is rapidly rising in the Western populations. The major predisposing diseases and pathogenesis (gastro-esophageal reflux disease, Barrett esophagus, and dysplasia) of the cancer are well known. There is an urgent need for works of the multidisciplinary teams (clinical, pathological, the molecular biology and translational research) for improved outcomes of patients with this cancer.

Endoscopic Resection for Early-Stage Esophageal Cancer, Are We There for Squamous As Well?

Superficial esophageal squamous cell cancer (SESCC) is often managed with esophagectomy with or without chemoradiotherapy. Esophagectomy has a significant complication rate and is not an option for many patients. In the current issue, a retrospective single center study evaluated 66 patients with SESCC. With endoscopic resection followed by adjuvant chemoradiotherapy, the reported 1-, 3- and 5-year overall survival rates were 98%, 87% and 75% respectively, comparable to survival rates after esophagectomy or definitive chemoradiotherapy. This study suggests a key role for endoscopic management in SESCC, and provides important data on the combination of endoscopic management plus adjuvant chemoradiation.

Endoscopic Management of Early Esophagogastric Cancer

Esophagogastric cancer accounts for the second most common cause of cancer-related mortality worldwide. Significant efforts have been made to detect these malignancies at an earlier stage through the implementation of screening programs in high-risk individuals using advanced diagnostic techniques. Endoscopic management techniques, such as endoscopic mucosal resection and endoscopic submucosal dissection, have consistently demonstrated excellent outcomes in the management of these lesions. These techniques are associated with a lower risk of morbidity and mortality when compared with traditional surgical management.