Article

Clinical biology and surgical therapy of intramucosal adenocarcinoma of the esophagus

Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.
Journal of the American College of Surgeons (Impact Factor: 4.45). 09/2006; 203(2):152-61. DOI: 10.1016/j.jamcollsurg.2006.05.006
Source: PubMed

ABSTRACT Mucosal ablation and endoscopic mucosal resection have been proposed as alternatives to surgical resection as therapy for intramucosal adenocarcinoma (IMC) of the esophagus. Acceptance of these alternative therapies requires an understanding of the clinical biology of IMC and the results of surgical resection modified for treatment of early disease.
Retrospective review of 78 patients (65 men, 13 women; median age 66 years) with IMC who were treated with progressively less-extensive surgical resections (ie, en bloc, transhiatal, and vagal-sparing esophagectomy) from 1987 to 2005.
The tumor was located in a visible segment of Barrett's esophagus in 65 (83%) and in cardia intestinal metaplasia in 13 (17%). A visible lesion was present in 53 (68%) and in all but 4 the lesion was cancer. In those patients with visible Barrett's, the tumor was within 3 cm of the gastroesophageal junction in 66% and within 1 cm in 37%. Esophagectomy was en bloc in 23, transhiatal in 31, vagal-sparing in 20, and transthoracic in 4. Operative mortality was 2.6%. Vagal-sparing esophagectomy had less morbidity, a shorter hospital stay, and no mortality. Of the patients who had en bloc resection, a median of 41 nodes were removed. One patient had one lymph node metastasis on hematoxylin and eosin staining and two others, normal on hematoxylin and eosin staining, had micrometastases on immunohistochemistry. Actuarial survival at 5 years was 88% and was similar for all types of resections. Two patients died from systemic metastases and seven from noncancer causes.
IMC occurred in cardia intestinal metaplasia and in Barrett's esophagus. Two-thirds of patients with IMC had a visible lesion. Most tumors occurred near the gastroesophageal junction. Node metastases were uncommon, questioning the need for lymphadenectomy. A vagal-sparing technique had less morbidity than other forms of resection and no mortality. Survival after all types of resection was similar. Outcomes of endoscopic techniques should be compared with this benchmark.

Full-text

Available from: Parakrama T Chandrasoma, Jul 10, 2014
0 Followers
 · 
146 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: Esophagectomy is the conventional treatment for Barrett's esophagus with high-grade dysplasia and intramucosal cancer. Endotherapy is an alternative treatment. To compare the efficacy and safety of these 2 treatments. 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. Tertiary-care facility. Seven studies involving 870 patients were included. Endotherapy and esophagectomy. Neoplasia remission rate, neoplasia recurrence rate, overall survival rate, neoplasia-related death, and major adverse events. 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). Relatively small number of retrospective studies available, different types of endoscopic treatments were used. 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.
    Gastrointestinal endoscopy 09/2013; 79(2). DOI:10.1016/j.gie.2013.08.005 · 4.90 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Surgery for early esophageal carcinoma has been challenged by less invasive endoscopic approaches. Selecting patients in need for surgical intervention according to their risk of lymphatic spread is mandatory. The aim of this study was to evaluate risk factors for lymphatic metastasis formation in T1b esophageal carcinomas. Histopathological specimens following surgical resection for T1b esophageal carcinomas were reevaluated for overall submucosal layer thickness, depth of submucosal tumor infiltration, tumor length as well as lymphatic and vascular infiltration. Depth of tumor infiltration to overall submucosal thickness was divided in thirds (SM1, SM2, and SM3) and factors influencing lymphatic metastasis formation were assessed. A total of 67 patients with pT1b tumors were analyzed, including 36 adenocarcinomas (53.7 %) and 31 squamous cell carcinomas (46.3 %). Lymph node involvement was seen in 22.4 % (15/67) patients without significant differences between SM1 3/11 (27.3 %), SM2, 4/18 (22.2 %), and SM3 (8/38) (21.8 %) (p = 0.909) carcinomas. On binomial log-regression models, only lymphangioinvasion and tumor length >2 cm was significantly associated with lymph node involvement. As depth of submucosal tumor infiltration did not correlate with the formation of lymph node metastases and in regard of the risk of lymphatic spread in these cases, surgical resection is warranted in pT1b carcinomas.
    Journal of Gastrointestinal Surgery 10/2013; DOI:10.1007/s11605-013-2367-2 · 2.39 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: There is good evidence for the safety and efficacy of endoscopic treatment for early neoplasia in Barrett's oesophagus and in oesophageal squamous epithelium within defined margins, and this form of therapy is therefore the treatment of choice. With a low morbidity rate, it offers patients a good quality of life with preservation of the organ. The mortality risk is minimal. The decisive element for success is early diagnosis. Oesophageal resection and radiotherapy/chemotherapy are nowadays reserve procedures in the treatment of early oesophageal carcinoma and should only be used in patients in whom the tumour shows defined histological risk factors or endoscopic therapy has failed. Discussion is currently taking place on whether the criteria used to indicate endoscopic therapy for early Barrett's adenocarcinoma can be expanded to include lesions with superficial submucosal infiltration and no additional histological risk factors.
    Zentralblatt für Chirurgie 02/2014; 139(1):28-31. DOI:10.1055/s-0033-1360280 · 1.19 Impact Factor