Endoscopic and surgical treatment of early gastric and esophageal carcinoma

Abstract

The treatment of early gastric (EGC) and esophageal carcinomas (EEC) is an interdisciplinary challenge. The risk of lymph node metastasis (LNM) is the crucial point in choosing the correct treatment option. This article gives an overview of the current treatment options and provides help in choosing the correct therapy. Current concepts and therapy algorithms are presented on the basis of aliterature review and data from our own center. Endoscopic submucosal dissection (ESD) is recommended for mucosal gastric cancer with good or moderate differentiation (G1,2) without macroscopic ulceration, in elevated type lesions smaller than 2 cm in size or depressed lesions smaller than 1 cm in size. In additional chromoendoscopy should be carried out. The extent of surgical resection is defined by the location of the tumor. Asafety margin of at least 3 cm should be applied in distal gastric resections whereas the first line goal in gastrectomy is to achieve an R0 resection. In cN0 tumors a D1 lymphadenectomy (LA) seems to be sufficient. Minimally invasive techniques currently show promising results especially for a subtotal resection. The treatment strategy in EEC differs depending on the tumor entity. Mucosal squamous cell carcinoma with high risk factors (L1,V1) and all cN0 submucosal tumors without the detection of LNM should be referred to primary surgical resection. Early stage cN+ squamous cell carcinomas should be preoperatively treated with chemoradiotherapy. Adenocarcinoma with infiltration of the deeper submucosa (sm2,3) and high-risk sm1 tumors require surgical treatment. The standard operating procedure for EEC is an Ivor Lewis esophagectomy with 2‑field LA preferably performed as a hybrid or by a completely minimally invasive procedure. The procedure of choice in endoscopic resection of EEC is resection with the suck and cut technique.