Commentary: All that glitters isn't gold: Defining low-risk lesions in early-stage esophageal adenocarcinoma

Abstract

Central MessageAmong patients with T1 esophageal adenocarcinoma, those with tumors <2 cm in length without lymphovascular invasion have a low risk of recurrence.See Article page 1272. Among patients with T1 esophageal adenocarcinoma, those with tumors <2 cm in length without lymphovascular invasion have a low risk of recurrence. See Article page 1272. In this issue of the Journal, Shihag and colleagues1Sihag S. Torre S.D.L. Hsu M. Nobel T. Tan K.S. Gerdes H. et al.Defining low-risk lesions in early-stage esophageal adenocarcinoma.J Thorac Cardiovasc Surg. 2021; 162: 1272-1279Abstract Full Text Full Text PDF Scopus (3) Google Scholar identify risk factors for recurrence among patients with completely resected T1 esophageal adenocarcinoma. The main impetus for this analysis is the paradigm shift of treatment for early-stage esophageal adenocarcinoma away from radical esophagectomy and toward organ-sparing techniques, such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). The promise of treating esophageal cancer with endoscopy certainly has the promise of alchemy and has been supported by several retrospective institutional series demonstrating comparable overall survival between EMR and esophagectomy as long as a negative margin is achieved.2Ramay F.H. Vareedayah A.A. Visrodia K. Iyer P.G. Wang K.K. Eluri S. et al.What constitutes optimal management of T1N0 esophageal adenocarcinoma?.Ann Surg Oncol. 2019; 26: 714-731Crossref PubMed Scopus (3) Google Scholar,3Marino K.A. Sullivan J.L. Weksler B. Esophagectomy versus endoscopic resection for patients with early-stage esophageal adenocarcinoma: a national cancer database propensity-matched study.J Thorac Cardiovasc Surg. 2018; 155: 2211-2218Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Unfortunately, as the expression goes, all that glitters is not gold, and we must question whether EMR and ESD is the 24K magic bullet we seek for early-stage esophageal adenocarcinoma. The analysis showed an overall survival of 68.6% at 5 years and a median interval to recurrence of 2.0 years. Most recurrences were distant, with a cumulative incidence of recurrence (CIR) of 11% for distant recurrence but only 4% for locoregional recurrence. In multivariable analysis, only pathologic N1 disease and tumor length were significant risk factors for recurrence. Although useful, this information doesn't allow us to determine which patients may be better suited for endoscopic techniques versus esophagectomy. To that end, the team constructed a final multivariable model using only clinicopathologic variables that may be known preoperatively. In this model, only lymphovascular invasion (LVI) and tumor length were significant. Finally, using this information, they defined a low-risk group and a high-risk group. They found a significantly higher CIR and risk of death in the high-risk group, validating their stratification. The authors conclude that patients without LVI and tumor length <2 cm have the lowest risk of recurrence (<10%) and a 5-year survival of 75%, which may identify them as good candidates for endoscopic resection. In contrast, patients deemed high-risk (LVI or with tumors >3 cm) have a >10% risk of recurrence and may be better treated with esophagectomy. In the end, it appears that the optimal treatment for T1 esophageal adenocarcinoma remains to be determined. Although endoscopic techniques shine and glitter as less morbid yet equally effective treatment options for patients with early-stage esophageal cancer, it may be necessary to parcel these patients based on risk of recurrence to determine who will derive the maximal oncologic benefit. Furthermore, with the rate of distant recurrence double that of locoregional recurrence, it remains to be seen if the decision will remain between two surgical techniques or, as we have witnessed in lung cancer, genetically targeted systemic therapies will evolve into the ultimate 24K magic bullet. Defining low-risk lesions in early-stage esophageal adenocarcinomaThe Journal of Thoracic and Cardiovascular SurgeryVol. 162Issue 4PreviewAs 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. Full-Text PDF