Management Of Early Esophageal Cancer Research Articles

Endoscopic management of early esophageal cancer in patients with concomitant cirrhosis.

Endoscopic management of early esophageal cancer in patients with concomitant cirrhosis.

72218 - Management of early esophageal cancer – a register-based study in Sweden

72218 - Management of early esophageal cancer – a register-based study in Sweden

Endoscopic management of early esophageal cancer: a literature review

Endoscopic management of early esophageal cancer: a literature review

S2294 Endoscopic Management of Esophageal Cancer in a Patient with Decompensated Cirrhosis: The Importance of Multidisciplinary Collaboration and Peri-Procedure Planning in Complex Clinical Scenarios

Introduction: Endoscopic therapy is effective for management of early esophageal cancer (EC), however serious complications such as bleeding and perforation can occur. Patient selection, optimization of co-morbidities and peri-procedure management help mitigate risk and improve patient outcomes. We present a patient with decompensated cirrhosis who required complex peri-procedure planning prior to endoscopic treatment of early EC. Case Description/Methods: A 71-year male with decompensated cirrhosis (portal hypertension, esophageal varices, ascites) and recent DVT on apixaban was found to have a 1cm raised focal lesion at the GEJ; biopsies revealed high-grade dysplasia (HGD). He was referred for endoscopic mucosal resection (EMR). After extensive discussion with hematology, patient was admitted for anticoagulation management with intravenous (IV) heparin. EGD confirmed an 8mm nodule at the GEJ (Figure 1A,B,C). Grade 3 non-bleeding esophageal varices were noted at the GEJ and in the distal esophagus, prohibiting safe EMR. Biopsies again showed HGD. After multidisciplinary tumor board discussion, a transjugular portosystemic shunt (TIPS) was performed to decompress the portal system and reduce bleeding risk from the planned EMR. Doppler ultrasound a few weeks later confirmed patent TIPS. Repeat diagnostic EGD showed decompression of varices. EUS revealed a mucosal lesion with no lymphadenopathy. Biopsy revealed intramucosal adenocarcinoma. Based on this evaluation and after detailed discussion with the patient, EMR was planned with appropriate anticoagulation management. En-bloc multiband mucosectomy was performed (Figure 1D,E). Intraprocedural bleeding was controlled with band ligation and hemostatic spray (Figure 1F). Patient remained inpatient for observation on octreotide and IV pantoprazole drip without further bleeding. Apixaban 2.5mg was resumed on day 3 and he was discharged home on acid suppression. Pathology confirmed well-differentiated adenocarcinoma, pT1a. Tumor board discussion recommended continued endotherapy (cryotherapy) to the residual dysplastic Barrett’s mucosa which he is tolerating well. Discussion: Endoscopic treatment is effective for the management of early EC. However, when complex scenarios present in an elderly frail patient, multidisciplinary collaborative management and stepwise risk-mitigation strategies need to be in place to minimize morbidity and maximize success (Table). Tumor board and shared decision making are key patient centric strategies that reflect best practice.Figure 1.: A: Nodular distal esophageal lesion; B: Lesion in high-definition white light endoscopy (HDWLE); C: Lesion in narrow band imaging (NBI), D: Band placed at the base of the lesion, E: EMR defect, F: Hemostatic spray was used to achieve hemostasis of an area of focal bleeding after EMR. Table 1. - Risk Mitigation Strategies in Complex Endoscopy Practice – Best Practice Principles Pre-procedure consultation (nonemergent diagnostic/elective procedures) Pre-procedure planning (labs, imaging) Optimization of treatment for co-morbidities Anesthesia consultation Detailed high-risk informed consent Shared decision making Multidisciplinary GI tumor board discussion Medical record documentation Guideline-based anti-thrombotic management Appropriate procedure back-up and support (IR, surgery, radiology, critical care)

Survival Implications of Increased Utilization of Local Excision for cT1N0 Esophageal Cancer.

We hypothesized that patients with cT1N0 esophageal cancer undergoing local excision would have lower survival compared with esophagectomy due to potential discordant staging. Local excision has become an attractive alternative for management of early esophageal cancer, avoiding the morbidity of esophagectomy. It is uncertain if occult nodal metastasis impacts survival. An observational study was conducted using the National Cancer Database (1998-2012) for patients with clinical T1N0 esophageal cancer who underwent local excision (n = 1625) or esophagectomy (n = 3255). The proportion of patients undergoing local excision increased from 12% in 1998 to 50% in 2012 (P < 0.001). After esophagectomy, 61% of cT1N0 cancers had concordant clinical and pathological staging, with 5.2% having positive nodal disease; 37% were staged concordant after local excision, with excess missing data (60%). Ninety-day mortality was 7.4% after esophagectomy compared with 2.8% after local excision (P < 0.001). While no significant difference was seen in unadjusted survival, adjusted Cox regression analysis indicated worse survival after esophagectomy compared with local excision for all cases [hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.27-1.95] and for patients with concordant staging (HR 1.68, 95% CI 1.23-2.28). Local excision for cT1N0 esophageal cancer has increased over time. Contrary to our hypothesis, despite incomplete nodal staging, patients undergoing local excision have favorable survival, particularly in the adenocarcinoma subgroup. This may reflect early differences in mortality due to differences in procedure-related complications and/or selection bias. As this study has limited power to compare outcomes between T1a and T1b cancers, further analysis is warranted.

Endoscopic Treatment of Early-Stage Esophageal Cancer.

Esophageal cancer is a leading cause of global cancer-related mortality. Here, we discuss the major endoscopic treatment modalities for management of early esophageal cancer (EEC). Advances in endoscopic imaging and therapy have shifted the paradigm of managing early esophageal cancers. Though esophagectomy remains the preferred management for advanced cancers, guidelines now recommend endoscopic resection followed by ablative therapy for early (Tis and T1a) cancers. Available data suggests endoscopic treatment is comparable to surgery with regard to overall and cancer-specific survival with lower procedural morbidity and mortality. Endoscopic modalities are emerging as frontline treatment options for patients with early esophageal cancers. Accurate clinical staging with assessment of disease extent, tumor grade, and risk of nodal metastases is crucial when determining eligibility for endoscopic management of EEC. High-quality routine surveillance endoscopy is critical in patients who have undergone resection and/or ablation.

Screening and prevention strategies and endoscopic management of early esophageal cancer.

Esophageal cancer is the 8th most common cancer worldwide and the 6th most common cause of cancer-related death. Its two main subtypes, esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC), have varying incidences globally, but recent decades have seen a demonstrated rise of EAC in Western countries whereas ESCC remains highly prevalent in Eastern Africa, Central Asia, and China. Screening interventions have focused on using endoscopy to identify Barrett's esophagus (BE) as a precursor to EAC, and squamous cell dysplasia prior to onset of ESCC. However, additional cost-effective screening interventions that can be applied to larger populations at risk for esophageal cancer are needed. Advances in endoscopic ablative techniques and endoscopic resection via endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have proven to be effective in eradicating dysplasia and early stage cancer. Preventive strategies involving reduction in tobacco and alcohol consumption as well as regular use of proton pump inhibitors and nonsteroidal anti-inflammatory drugs are aimed at reducing the incidence of dysplasia and esophageal cancer, but require further study before being recommended for widespread use.

Endoscopic submucosal dissection and endoscopic mucosal resection for early stage esophageal cancer.

Mortality from esophageal cancer remains high despite advances in medical therapy. Although the incidence of squamous cell carcinoma of the esophagus remains unchanged, the incidence of the esophageal adenocarcinoma has increased over time. Gastroesophageal reflux disease (GERD and obesity are contributing factors to the development of Barrett's esophagus and subsequent development of adenocarcinoma. Early recognition of the disease can lead to resection of esophageal cancer prior to the development of lymphovascular invasion. Various modalities have been implemented to aid identification of precancerous lesions and early esophageal cancer. Chromoendoscopy, narrowband imaging and endoscopic ultrasound examination are typically used for evaluating early esophageal lesions. Recently, confocal laser endomicroscopy (CLE) and volumetric laser scanning were implemented with promising results. Endoscopic management of early esophageal cancer may be done using endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Both techniques allow resection of the mucosa (and possibly a portion of the submucosa) containing the early tumor without interruption of deeper layers. A submucosal injection creating a cushion coupled with snare resection or cap assisted mucosal suction followed by ligation and snare resection are the most common techniques of EMR. EMR can remove lesions less than 2 cm in size en bloc. Larger lesions may require resection in piecemeal fashion. This may limit assessment of the margins of the lesion and orienting the lesion's border. ESD offers en bloc dissection of the lesion regardless of its size. ESD is performed with specialized needle knives, which allow incision followed by careful dissection of the lesion within the submucosal layer. Tumor recurrence after ESD is rare but the technique is labor intensive and has an increased risk of perforation. Esophageal stenosis remains a concern after extensive EMR or ESD. Dilation with balloon or stent placement is usually sufficient to treat post-resection stenosis.

Endoscopic Management of Early Esophageal Cancer.

The absolute incidence of esophageal adenocarcinoma has increased 7-fold over the past 5 decades, and esophageal adenocarcinoma is the most rapidly increasing epithelial malignancy in the United States. The incidence of early esophageal cancer has also increased proportionately. In the past decade, radiofrequency ablation has become the standard first-line therapy for high-grade dysplasia when found in the precursor lesion to esophageal adenocarcinoma, Barrett's esophagus. Success in the endoscopic management of high-grade dysplasia has furthered efforts to treat early esophageal cancers endoscopically. Although surgery remains the mainstay of treatment for more advanced tumors, national guidelines now recommend endoscopic mucosal resection followed by radiofrequency ablation for intramucosal carcinomas and T1a cancers. T1b cancers represent a more challenging group-very good results have been reported in highly selected subsets of patients with T1b tumors; however, many recommendations favor individualization or a surgical approach for this stage. This review examines the current data and recommendations regarding the endoscopic management of early esophageal adenocarcinomas.

Endoscopic mucosal resection for staging and treatment of early esophageal carcinoma: a single institution experience.

Endoscopic mucosal resection (EMR) has emerged for evaluation and treatment of esophageal nodules. We report our initial experience with EMR for T staging and management of early esophageal cancer. We reviewed patients undergoing EMR for esophageal adenocarcinoma between 2008 and 2013. The primary outcome measure was needed for esophagectomy. Secondary outcomes included complete eradication of adenocarcinoma, recurrence or persistence of cancer, nodal status for those undergoing esophagectomy, and complications of endoscopic treatment. During the study period, 24 patients underwent EMR demonstrating carcinoma, and a grossly margin negative endoscopic resection was achieved in all cases. Ten patients (42 %) had evidence of submucosal invasion and were referred for esophagectomy. Patients with margin negative EMR (n = 10, 42 %) or positive radial margins (n = 4, 16 %) underwent endoscopic surveillance and treatment with radiofrequency ablation or repeat EMR as needed. Thirteen patients (93 %) with intramucosal cancer (IMC) have been successfully managed with ongoing endoscopic surveillance and treatment with a median follow-up of 15.5 months. One patient underwent esophagectomy due to recurrent IMC in the setting of long-segment multifocal high-grade dysplasia. There were no esophageal perforations, one patient developed a self-limited gastrointestinal hemorrhage following EMR, and one had an esophageal stricture following endoscopic management. IMC can be successfully managed endoscopically and thus esophagectomy is avoided in a significant proportion of patients. Endoscopic management may be utilized in the setting of complete resection or radial margin involvement without evidence of submucosal invasion. Close endoscopic follow-up is of paramount importance even in those with negative margins, because recurrent disease may occur following EMR in these patients.

Endoscopic approaches for early-stage esophageal cancer: current options.

Early esophageal cancer is confined to the mucosa or submucosa of the esophagus. While most esophageal cancer is detected at an advanced stage (requiring surgical resection, chemotherapy, and radiation), early-stage mucosal lesions may be detected through Barrett's surveillance programs or incidentally on diagnostic upper endoscopies performed for other reasons. These early-stage cancers are often amenable to endoscopic therapies, including mucosal resection, ablation, and cryotherapy. Studies suggest equivalent survival rates and reduced morbidity but higher recurrence rates with endoscopic removal of early-stage cancers compared to surgical resection. There is emerging data regarding the efficacy and long-term outcomes of endoscopic therapy for early esophageal cancer that is promising, and further research is needed to better define the role of endoscopic therapy in the management of early esophageal cancer.

Current Readings: Endoesophageal Management of Early Esophageal Cancer and Dysplastic Barrett Esophagus: A Review of Recent and Influential Studies

DURABILITY OF RADIOFREQUENCY ABLATION IN BARRETT’S ESOPHAGUS WITH DYSPLASIA. Shaheen NJ, Bergein FO, Richard ES, et al. Gastroenterology 141(2):460-469, 2011. After multiple studies revealed that radiofrequency ablation (RFA) of Barrett esophagus (BE) with dysplasia was safe in selected cases, this randomized trial provided evidence that RFA is efficacious and durable in eradicating dysplastic BE. This trial is an extension of a previous study that documented excellent short-term results and sought to examine the long-term rates of pathologic eradication associated with RFA (compared with sham treatment) in patients with dysplastic BE. The extended follow-up is crucial to further validate that RFA can be used successfully to treat dysplastic BE without significant recurrences. In this randomized multisite trial, participants were recruited based on inclusion criteria that included age 18-80, endoscopically evident (nonnodular) BE, and length of BE o8 cm. Patients with esophageal cancer (EC) or poor life expectancy were excluded. Subjects were randomized to RFA or sham treatment at 2:1 ratio and received endoscopy with biopsy and treatment (or sham treatment) at 6 and 12 months (low-grade dysplasia arm), or 3, 6, 9, and 12 months (highgrade dysplasia [HGD] arm). After completion of the 12-month assessment, patients in the sham group were offered crossover to “open-label” RFA therapy. A total of 127 patients met the inclusion criteria and were randomized according to the study protocol (84 RFA, 43 sham). Of them, 117 (78 RFA, 39

A Case Series of Endoscopic Management of Early Esophageal Cancer

Purpose: Esophageal adenocarcinoma (EAC) is typically treated with esophagectomy. There is emerging data that is showing promise of endoscopic therapy in the management of early T1a EAC. We present a series of three patients with T1a EAC that were successfully managed with endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA). The first was a 64-year-old Caucasian male diagnosed with a 2cm EAC at the gastroesophageal junction with no metastatic lesions on positron emission tomography (PET) scan. He successfully underwent EMR followed by 2 sessions of RFA. At the 15 month follow-up esophagogastroduodenoscopy (EGD) all biopsies taken were negative for any malignancy. In the second case, a 74-year-old Caucasian male with T1aN0M0 EAC was successfully treated with 2 sessions of EMR followed by 2 sessions of RFA. At the follow-up EGD 10 months later, the patient was cancer free with no malignancy found on biopsies. In the final case, a 63-year-old Caucasian male with a distal esophageal T1aEAC underwent 2 EMR procedures followed by 2 RFA sessions. The 6 month follow up showed no residual malignancy. Typically EAC is managed with surgical resection, chemotherapy, or combination of the two. Emerging data is showing that successful treatment is comparable between surgical and endoscopic management of early EAC. The clear difference between the two modalities of treatment is significant when comparing mortality and morbidity of each therapy. EMR/RFA is a well tolerated procedure with a strong safety profile. The 2 most common complications associated with the procedure being bleeding and perforation (5%). Surgical management of EAC with esophagectomy is associated with an incidence of death of 1-2% at high-volume centers and as high as 5-10% at lower-volume centers. The morbidity of esophagectomy has been reported between 30-50% while EMR/RFA rarely results in hospitalization. Esophagectomy requires hospitalization and is frequently managed in intensive care units. Typically EMR/RFA requires 2 to 3 procedures at 2 month intervals to achieve a cure of early EAC. Despite the multiple procedures, the quality-adjusted life-years (QALYs) of EMR/RFA were estimated at $8,081 while esophagectomy QALYs were estimated at $39,720. A recent study by Zehetner et al., have shown that endoscopic therapy for early EAC has lower morbidity (0% vs 39%) with the same survival at 3 year follow-up when compared with esophagectomy.

Endoscopic Submucosal Dissection Versus Endoscopic Mucosal Resection in Management of Superficial Squamous Esophageal Neoplasms

Background: The efficacy and risks of endoscopic submucosal dissection (ESD) versus endoscopic mucosal resection (EMR) in management of early esophageal cancer has not been compared previously. This study aims to evaluate the outcomes and morbidities of both techniques in management superficial squamous esophageal neoplasms. Methods: A retrospective analysis of all patients with high-grade intraepithelial neoplasms (high grade dysplasia and noninvasive carcinoma) or intramucosal invasive carcinoma resected endoscopically between 2002 and 2007 was performed. Clinical and pathologic outcomes were compared. ESD was performed with a combination of knifes including the insulated tip (IT) knife, hook knife and triangular tip knife (KD 610L, KD 620LR, KD 640L Olympus Co. Ltd., Tokyo, Japan). Submucosal lifting was accomplished by injection of a novel hyaluronic acid, indigocarmine, epinephrine and normal saline mixture. EMR was performed using the suction cap-assisted method. The lesion was resected with the use of a snare loop. Results: ESD was performed in 18 lesions (15 patients) and cap-EMR in 14 lesions (11 patients). The mean (S.D.) follow-up time was 16.46 (15.55) months. ESD resected a significantly larger specimen (5.42 +/− 4.49 cm2 vs 0.91 +/−0.50 cm2, P = 0.002), and was associated with a higher enbloc resection rate (94.44% vs 71.43%, P = 0.032) when compared to cap-EMR. More patients with lesions extending for more than half the circumference of the esophagus were resected by ESD than by EMR (50% and 0% respectively, P = 0.002). There were no significant differences between ESD and EMR in the rate of lateral margin involvement (30% and 14.29%, P = 0.412) and local recurrence (0% and 11.11%, P = 0.492). More procedure-related morbidities occurred in ESD (n = 4) than EMR (n = 1), but the difference was statistically insignificant (P = 0.355). Perforation occurred in one ESD case and was managed conservatively. Esophageal strictures occurred in three ESD treated patients, and they were successfully managed with serial endoscopic dilations. There was no procedure related mortality in the entire series. Conclusion: ESD of early squamous esophageal neoplasms is feasible. ESD increases the extent of resection and rate of enbloc removal when compared to EMR. However, the procedure is associated with higher risk of morbidities without any increase in mortality. Further studies are required to assess the long-term efficacy of the technique.

Prevention and management of early esophageal cancer

Early esophageal cancer is defined by its limitation to the esophageal mucosa and submucosa. It has become a curable malignant disease, in sharp contrast to the dismal prognosis of esophageal cancer at advanced stages, which still represents the majority of patients. Understanding the risk factors, establishing surveillance programs for patients at risk, and developing preventative interventions such as dietary and lifestyle changes or pharmacologic interventions hold the potential of reducing the incidence of the disease and of shifting the stage distribution toward early cancer. Endoscopic ultrasound examination is pivotal for distinguishing early from advanced stages of the disease because it allows for accurate assessment of tumor infiltration and regional lymph node involvement. The therapeutic mainstay for early esophageal cancer remains surgery. New, less invasive surgical techniques are being tested that are associated with less morbidity and mortality than standard radical esophagectomies. For patients who are not candidates for surgery, definitive chemoradiation is a viable alternative. New endoscopic ablation techniques, such as endoscopic mucosa resection and photodynamic therapy, are potential alternatives to surgery in patients with cancers limited to the mucosa. For patients with adenocarcinoma of the gastroesophageal junction with submucosal involvement, adjuvant chemoradiation should be considered because of its potential to increase survival.