Esophagectomy versus endoscopic resection for T1b esophageal adenocarcinoma: Depth matters!

Abstract

We read with great interest the article by Otaki and Ma,1Otaki F. Ma G.K. Outcomes of patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study.Gastrointest Endosc. 2020; 92: 31-39Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar which retrospectively compared the outcomes of surgical resection (SR) versus endoscopic resection (ER) in 141 patients with T1b esophageal adenocarcinoma (EAC).1Otaki F. Ma G.K. Outcomes of patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study.Gastrointest Endosc. 2020; 92: 31-39Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar The authors report a significantly higher overall survival in the SR group. Besides older age and comorbidities, a positive deep margin was an independent predictor of survival. There is little disagreement that ER alone is insufficient for medically fit patients with deep submucosal invasion (T1bSM2-3), lymphovascular invasion, or poor differentiation.2Ajani J.A. D'Amico T.A. Esophageal and esophagogastric junction cancers version 1.2015.J Natl Compr Canc Netw. 2015; 13: 194-227Crossref PubMed Scopus (283) Google Scholar,3Evans J.A. Early D.S. The role of endoscopy in the assessment and treatment of esophageal cancer.Gastrointest Endosc. 2013; 77: 328-344Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar An area of controversy not specifically addressed in the current study is whether ER or SR is the most appropriate therapy for well-differentiated T1b EAC with only superficial submucosal invasion (T1bSM1). Indeed, the National Comprehensive Cancer Network lists both SR and ER as acceptable options for T1bSM1 EAC. We developed a 30-item web-based survey and distributed it to a random sample of gastroenterologists in the United States who were members of the American Society for Gastrointestinal Endoscopy. Of the 113 respondents, 39% worked at an academic medical center (AMC), and 63% performed endoscopic mucosal resection (EMR). Endoscopists were divided as to the optimal treatment for well-differentiated T1bSM1 EAC: 54% recommended SR, whereas 42% preferred ER; 18% and 8% also suggested chemoradiation and ablation, respectively. Interestingly, on logistic regression, the only predictors of SR for T1bSM1 were practicing at an AMC and being aware of published guidelines for esophageal cancer. Concerns about medicolegal risk, acceptance of ER by cancer subspecialists, and inadequate reimbursement were not associated with recommending SR. We commend the authors for collaborating across multiple institutions to gather data over 15 years on ER for T1b EAC. The challenge lies in identifying enough T1bSM1 EACs to perform meaningful comparisons. Notwithstanding, we postulate that in this subgroup, a randomized trial may find that ER reduces morbidity without increasing mortality. All authors disclosed no financial relationships. Outcomes of patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort studyGastrointestinal EndoscopyVol. 92Issue 1PreviewThe treatment of submucosal (T1b) esophageal adenocarcinoma (EAC) remains in evolution, with some evidence supporting endoscopic management of low-risk lesions. Using a multicenter cohort, we evaluated outcomes of patients with T1b EAC and predictors of survival. Full-Text PDF