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.

Download full-text


Available from: Parakrama T Chandrasoma, Jul 10, 2014
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Early squamous cell carcinoma and early adenocarcinoma of the esophagus are potentially curable diseases. Limited surgical procedures are carried out as alternatives to either endoscopic mucosectomy or to radical esophagectomy for T1 esophageal cancer. In this stage the only indication for limited surgery with curative intent is in patients who have no evidence of lymph node metastasis as the procedure is not comprising an adequate lymphadenectomy. The depth of tumor infiltration into the mucosal and submucosal layers is correlated with the rate of nodal metastases and therefore with long-term prognosis. The crucial point is to define the right stage of T1 carcinoma for this type of therapy. METHODS: A review of the literature was performed to gather published data concerning the status of limited surgery for 'early' cancer of the esophagus. RESULTS: For mucosal esophageal cancer endoscopic mucosal resection is an alternative treatment option but requires intensive follow-up since the rate of complete resections is lower than in limited and in radical surgical procedures. On the other hand, low postinterventional morbidity and functional integrity of the tubular esophagus support the indication of endoscopic mucosal resection for mucosal cancer. The Merendino procedure may offer another option in the treatment of early esophageal cancer. Major advantages of this operation over endoscopic mucosectomy include the possibility of complete resection of the carcinoma and the entire Barrett segment. The lower postoperative morbidity and mortality compared to radical surgery are in favour of the Merendino resection. Vagal-sparing esophagectomy is another surgical option in esophageal cancer limited to the mucosa. However, both limited procedures are not appropriate in case of lymph node metastases. None of these techniques have been validated in prospective clinical studies. CONCLUSION: Procedures with limited radicality are technically feasible but should strictly be reserved for patients with mucosal cancer. Results of limited surgery should be validated in clinical studies compared to radical esophagectomy comparing functional and prognostic outcome. GRUNDLAGEN: Das Plattenepithelfrühkarzinom und das Adenofrühkarzinom des Ösophagus sind potenziell heilbare Erkrankungen. Limitierte chirurgische Resektionen werden entweder als Alternative zur endoskopischen Mukosektomie oder zur radikalen Ösophagektomie bei T1-Ösophaguskarzinomen ausgeführt. In diesem Stadium besteht die einzige Indikation für limitierte Chirurgie mit kurativer Intention bei Patienten, die keine Hinweise für Lymphknotenmetastasen haben, da diese Maßnahme keine adäquate Lymphadenektomie beinhaltet. Die Tiefe der Tumorinfiltration in der Mukosa und Submukosa korreliert eng mit der Rate von Lymphknotenmetastasen und gleichzeitig mit der Langzeitprognose. Das entscheidende ist das richtige Stadium des T1-Karzinoms für diese Therapie zu definieren. METHODIK: Die publizierten Daten hinsichtlich der limitierten Chirurgie für das Frühkarzinom des Ösophagus wurden ausgewertet und die entsprechenden Resultate zusammengestellt. ERGEBNISSE: Beim Mukosakarzinom des Ösophagus stellt die endoskopische Mukosaresektion eine gute Therapieoption dar. Diese erfordert jedoch eine intensive Nachsorge, da die Rate kompletter Resektionen sehr viel geringer ist als bei limitierter Chirurgie oder radikaler Operation. Andererseits sind die Vorteile der Mukosektomie die geringe Morbidität und die Erhaltung der funktionellen Integrität des tubulären Ösophagus. Die Merendino-Operation stellt eine andere Option in der Behandlung des Ösophagusfrühkarzinoms dar. Besondere Vorteile dieser Operation gegenüber der endoskopischen Mukosektomie umfassen die komplette Resektion des Karzinoms in Verbindung mit dem gesamten Segment des Barrett-Ösophagus. Die geringere postoperative Morbidität und Mortalität im Vergleich zur radikalen Ösophagektomie sind Vorteile des Merendino-Verfahrens. Die Vagus erhaltende Ösophagektomie ist eine andere chirurgische Option beim Mukosakarzinom. Insgesamt sind alle limitierten Verfahren nicht adäquat, wenn Lymphknotenmetastasen vorhanden sind. Keine dieser Techniken ist bisher in prospektiven klinischen Studien validiert worden. SCHLUSSFOLGERUNGEN: Verfahren mit limitierter Radikalität sind machbar; sie sollten jedoch nur bei Patienten mit Mukosakarzinom angewendet werden. Die Ergebnisse der limitierten Chirurgie müssen in klinischen Studien im Vergleich zur radikalen Ösophagektomie validiert werden in Hinsicht auf funktionelle und prognostische Kriterien.
    European Surgery 39(5):273-280. DOI:10.1007/s10353-007-0361-1 · 0.26 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Describes an improvement of ultrasonic environment-sensors for driver assistant systems. Ultrasonic sensors are effective under bad weather conditions where the optical sensors are ineffective. However, they have a fatal weak point that their longitudinal detectable range is very short. Moreover, because the propagation velocity of sound waves is slow, we cannot use a scanning method. Therefore, the authors extended the longitudinal detectable range by increasing the power of emitted sound wave and shortening the sensing time by using multi-receiver method. In order to detect the relative velocity between vehicle and objects, Doppler shift was measured by using FM (frequency modulation) method. Because, this FM method requires complex electric circuits, a DSP was used for simplifying the circuits. Sometimes, walls located at both side of the ultrasonic sensor cause a mis-detection of objects. Thus, a method to avoid this miss-detection is proposed in the paper. Experiments were carried out and useful results were obtained.
    Intelligent Vehicle Symposium, 2002. IEEE; 07/2002
  • [Show abstract] [Hide abstract]
    ABSTRACT: This paper presents a discrete nonlinear control scheme for PWM inverters. Based on the dynamic model of the PWM inverter a control algorithm is deduced by imposing a desired linear dynamics in the output voltage. The proposed scheme has shown its robustness on low voltage distortion, excellent voltage regulation and it is insensitive to load and input voltage variations. A simple and fast digital algorithm, that could be implemented on a low-cost DSP, carries out the discrete control.
    IECON 02 [Industrial Electronics Society, IEEE 2002 28th Annual Conference of the]; 12/2002