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Management of superficial esophageal cancer

Authors
Cameron D Wright, MD
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Section Editor
Kenneth K Tanabe, MD
Deputy Editor
Diane MF Savarese, MD

INTRODUCTION

The epidemiology of esophageal cancer has evolved over the last two decades. Although the most marked change is a reversal in the ratio of squamous cell cancers to adenocarcinomas [1], there has also been a shift in stage distribution. The incidence of superficial esophageal cancer (invading no deeper than the submucosa) is increasing, particularly in Asian countries where screening for upper digestive tract cancers is common [2-4]. A similar trend has been seen in the United States and attributed, at least in part, to routine endoscopic surveillance for malignancy and high-grade dysplasia (HGD) in patients with Barrett's esophagus, a complication of longstanding gastroesophageal reflux disease [5-7]. (See "Barrett's esophagus: Pathogenesis and malignant transformation" and "Barrett's esophagus: Surveillance and management" and "Epidemiology, pathobiology, and clinical manifestations of esophageal cancer".)

For many years, the standard treatment for both HGD and superficial esophageal cancer has been esophagectomy [2,8-12]. High cure rates were achieved but at the cost of treatment-related morbidity and mortality. Endoscopic approaches to definitive therapy (eg, endoscopic resection [ER], photodynamic therapy [PDT], laser therapy, and argon plasma coagulation [APC]) have increasingly been used in this country following encouraging early reports from Japan and Europe. However, these techniques are only appropriate for patients who have a very low risk of lymph node metastases or who are poor candidates for esophageal surgery.

This topic review will focus on treatment strategies for superficial esophageal cancer. The epidemiology, clinical presentation, diagnosis, and staging of esophageal cancer; surgical techniques for esophagectomy; and combined modality approaches for the treatment of muscle-invasive disease are discussed in detail elsewhere. (See "Epidemiology, pathobiology, and clinical manifestations of esophageal cancer" and "Diagnosis and staging of esophageal cancer" and "Endoscopic ultrasound in esophageal carcinoma" and "Surgical management of resectable esophageal and esophagogastric junction cancers" and "Radiation therapy, chemoradiotherapy, neoadjuvant approaches, and postoperative adjuvant therapy for localized cancers of the esophagus".)

INITIAL ASSESSMENT

A critical component of choosing the appropriate management strategy for a superficial esophageal cancer is an accurate assessment of disease extent. Submucosal involvement is the most important prognostic determinant for early esophageal cancers because the presence of lymphatic vessels within the submucosa facilitates dissemination of cancer cells. Thus an accurate assessment of tumor extent, often with the utilization of high frequency endoscopic ultrasound, is needed to direct therapy.

Pathologic subclassification and the risk of nodal metastases — Early esophageal cancers are those that are classified as Tis (high-grade dysplasia, which includes all noninvasive neoplastic epithelial that was formerly called carcinoma in situ) or T1 tumors, which are split into T1a and T1b subcategories depending on the depth of invasion (table 1) [13]. The risk of nodal metastases is higher for T1b than for T1a tumors (16.6 versus 5 percent in one series of 3963 patients derived from the National Cancer Data Base (NCDB) who were treated surgically for localized esophageal cancer [14]).

                  

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Literature review current through: Nov 2016. | This topic last updated: Mon Mar 07 00:00:00 GMT+00:00 2016.
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References
Top
  1. Devesa SS, Blot WJ, Fraumeni JF Jr. Changing patterns in the incidence of esophageal and gastric carcinoma in the United States. Cancer 1998; 83:2049.
  2. Wang GQ, Jiao GG, Chang FB, et al. Long-term results of operation for 420 patients with early squamous cell esophageal carcinoma discovered by screening. Ann Thorac Surg 2004; 77:1740.
  3. Kanamoto A, Yamaguchi H, Nakanishi Y, et al. Clinicopathological study of multiple superficial oesophageal carcinoma. Br J Surg 2000; 87:1712.
  4. Tachibana M, Hirahara N, Kinugasa S, Yoshimura H. Clinicopathologic features of superficial esophageal cancer: results of consecutive 100 patients. Ann Surg Oncol 2008; 15:104.
  5. Eloubeidi MA, Mason AC, Desmond RA, El-Serag HB. Temporal trends (1973-1997) in survival of patients with esophageal adenocarcinoma in the United States: a glimmer of hope? Am J Gastroenterol 2003; 98:1627.
  6. Younes M, Henson DE, Ertan A, Miller CC. Incidence and survival trends of esophageal carcinoma in the United States: racial and gender differences by histological type. Scand J Gastroenterol 2002; 37:1359.
  7. Brown LM, Devesa SS. Epidemiologic trends in esophageal and gastric cancer in the United States. Surg Oncol Clin N Am 2002; 11:235.
  8. Endo M, Yoshino K, Kawano T, et al. Clinicopathologic analysis of lymph node metastasis in surgically resected superficial cancer of the thoracic esophagus. Dis Esophagus 2000; 13:125.
  9. Fujita H, Sueyoshi S, Yamana H, et al. Optimum treatment strategy for superficial esophageal cancer: endoscopic mucosal resection versus radical esophagectomy. World J Surg 2001; 25:424.
  10. Liu L, Hofstetter WL, Rashid A, et al. Significance of the depth of tumor invasion and lymph node metastasis in superficially invasive (T1) esophageal adenocarcinoma. Am J Surg Pathol 2005; 29:1079.
  11. Westerterp M, Koppert LB, Buskens CJ, et al. Outcome of surgical treatment for early adenocarcinoma of the esophagus or gastro-esophageal junction. Virchows Arch 2005; 446:497.
  12. Rice TW, Blackstone EH, Goldblum JR, et al. Superficial adenocarcinoma of the esophagus. J Thorac Cardiovasc Surg 2001; 122:1077.
  13. American Joint Committee on Cancer Staging Manual, 7th, Edge SB, Byrd DR, Compton CC, et al (Eds), Springer, New York 2010. p.103.
  14. Merkow RP, Bilimoria KY, Keswani RN, et al. Treatment trends, risk of lymph node metastasis, and outcomes for localized esophageal cancer. J Natl Cancer Inst 2014; 106.
  15. Barbour AP, Jones M, Brown I, et al. Risk stratification for early esophageal adenocarcinoma: analysis of lymphatic spread and prognostic factors. Ann Surg Oncol 2010; 17:2494.
  16. Shimada H, Nabeya Y, Matsubara H, et al. Prediction of lymph node status in patients with superficial esophageal carcinoma: analysis of 160 surgically resected cancers. Am J Surg 2006; 191:250.
  17. Araki K, Ohno S, Egashira A, et al. Pathologic features of superficial esophageal squamous cell carcinoma with lymph node and distal metastasis. Cancer 2002; 94:570.
  18. Ancona E, Rampado S, Cassaro M, et al. Prediction of lymph node status in superficial esophageal carcinoma. Ann Surg Oncol 2008; 15:3278.
  19. Sepesi B, Watson TJ, Zhou D, et al. Are endoscopic therapies appropriate for superficial submucosal esophageal adenocarcinoma? An analysis of esophagectomy specimens. J Am Coll Surg 2010; 210:418.
  20. Hölscher AH, Bollschweiler E, Schröder W, et al. Prognostic impact of upper, middle, and lower third mucosal or submucosal infiltration in early esophageal cancer. Ann Surg 2011; 254:802.
  21. Yamashina T, Ishihara R, Nagai K, et al. Long-term outcome and metastatic risk after endoscopic resection of superficial esophageal squamous cell carcinoma. Am J Gastroenterol 2013; 108:544.
  22. Yanai H, Harada T, Okamoto T, et al. Prognostic value and interobserver agreement of endoscopic ultrasonography for superficial squamous cell carcinoma of the esophagus: a prospective study. Int J Gastrointest Cancer 2003; 34:1.
  23. Eguchi T, Nakanishi Y, Shimoda T, et al. Histopathological criteria for additional treatment after endoscopic mucosal resection for esophageal cancer: analysis of 464 surgically resected cases. Mod Pathol 2006; 19:475.
  24. Shimizu Y, Tsukagoshi H, Fujita M, et al. Long-term outcome after endoscopic mucosal resection in patients with esophageal squamous cell carcinoma invading the muscularis mucosae or deeper. Gastrointest Endosc 2002; 56:387.
  25. Ishihara R, Tanaka H, Iishi H, et al. Long-term outcome of esophageal mucosal squamous cell carcinoma without lymphovascular involvement after endoscopic resection. Cancer 2008; 112:2166.
  26. Akutsu Y, Uesato M, Shuto K, et al. The overall prevalence of metastasis in T1 esophageal squamous cell carcinoma: a retrospective analysis of 295 patients. Ann Surg 2013; 257:1032.
  27. Manner H, Pech O, Heldmann Y, et al. Efficacy, safety, and long-term results of endoscopic treatment for early stage adenocarcinoma of the esophagus with low-risk sm1 invasion. Clin Gastroenterol Hepatol 2013; 11:630.
  28. Nagawa H, Kaizaki S, Seto Y, et al. The relationship of macroscopic shape of superficial esophageal carcinoma to depth of invasion and regional lymph node metastasis. Cancer 1995; 75:1061.
  29. Cen P, Hofstetter WL, Correa AM, et al. Lymphovascular invasion as a tool to further subclassify T1b esophageal adenocarcinoma. Cancer 2008; 112:1020.
  30. Badreddine RJ, Prasad GA, Lewis JT, et al. Depth of submucosal invasion does not predict lymph node metastasis and survival of patients with esophageal carcinoma. Clin Gastroenterol Hepatol 2010; 8:248.
  31. Young PE, Gentry AB, Acosta RD, et al. Endoscopic ultrasound does not accurately stage early adenocarcinoma or high-grade dysplasia of the esophagus. Clin Gastroenterol Hepatol 2010; 8:1037.
  32. Thosani N, Singh H, Kapadia A, et al. Diagnostic accuracy of EUS in differentiating mucosal versus submucosal invasion of superficial esophageal cancers: a systematic review and meta-analysis. Gastrointest Endosc 2012; 75:242.
  33. Pouw RE, Heldoorn N, Alvarez Herrero L, et al. Do we still need EUS in the workup of patients with early esophageal neoplasia? A retrospective analysis of 131 cases. Gastrointest Endosc 2011; 73:662.
  34. Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003; 349:2117.
  35. Dimick JB, Wainess RM, Upchurch GR Jr, et al. National trends in outcomes for esophageal resection. Ann Thorac Surg 2005; 79:212.
  36. Patti MG, Corvera CU, Glasgow RE, Way LW. A hospital's annual rate of esophagectomy influences the operative mortality rate. J Gastrointest Surg 1998; 2:186.
  37. Metzger R, Bollschweiler E, Vallböhmer D, et al. High volume centers for esophagectomy: what is the number needed to achieve low postoperative mortality? Dis Esophagus 2004; 17:310.
  38. van Lanschot JJ, Hulscher JB, Buskens CJ, et al. Hospital volume and hospital mortality for esophagectomy. Cancer 2001; 91:1574.
  39. Kuo EY, Chang Y, Wright CD. Impact of hospital volume on clinical and economic outcomes for esophagectomy. Ann Thorac Surg 2001; 72:1118.
  40. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998; 280:1747.
  41. Gordon TA, Bowman HM, Bass EB, et al. Complex gastrointestinal surgery: impact of provider experience on clinical and economic outcomes. J Am Coll Surg 1999; 189:46.
  42. Gillison EW, Powell J, McConkey CC, Spychal RT. Surgical workload and outcome after resection for carcinoma of the oesophagus and cardia. Br J Surg 2002; 89:344.
  43. Zaninotto G, Parenti AR, Ruol A, et al. Oesophageal resection for high-grade dysplasia in Barrett's oesophagus. Br J Surg 2000; 87:1102.
  44. Ferguson MK, Naunheim KS. Resection for Barrett's mucosa with high-grade dysplasia: implications for prophylactic photodynamic therapy. J Thorac Cardiovasc Surg 1997; 114:824.
  45. Edwards MJ, Gable DR, Lentsch AB, Richardson JD. The rationale for esophagectomy as the optimal therapy for Barrett's esophagus with high-grade dysplasia. Ann Surg 1996; 223:585.
  46. Heitmiller RF, Redmond M, Hamilton SR. Barrett's esophagus with high-grade dysplasia. An indication for prophylactic esophagectomy. Ann Surg 1996; 224:66.
  47. Altorki NK, Lee PC, Liss Y, et al. Multifocal neoplasia and nodal metastases in T1 esophageal carcinoma: implications for endoscopic treatment. Ann Surg 2008; 247:434.
  48. Pennathur A, Farkas A, Krasinskas AM, et al. Esophagectomy for T1 esophageal cancer: outcomes in 100 patients and implications for endoscopic therapy. Ann Thorac Surg 2009; 87:1048.
  49. Tanaka T, Matono S, Nagano T, et al. Esophagectomy with extended lymphadenectomy for submucosal esophageal cancer: long-term outcomes and prognostic factors. Ann Surg Oncol 2012; 19:750.
  50. Tanaka T, Matono S, Mori N, et al. T1 squamous cell carcinoma of the esophagus: long-term outcomes and prognostic factors after esophagectomy. Ann Surg Oncol 2014; 21:932.
  51. Reed MF, Tolis G Jr, Edil BH, et al. Surgical treatment of esophageal high-grade dysplasia. Ann Thorac Surg 2005; 79:1110.
  52. Headrick JR, Nichols FC 3rd, Miller DL, et al. High-grade esophageal dysplasia: long-term survival and quality of life after esophagectomy. Ann Thorac Surg 2002; 73:1697.
  53. Rice TW, Falk GW, Achkar E, Petras RE. Surgical management of high-grade dysplasia in Barrett's esophagus. Am J Gastroenterol 1993; 88:1832.
  54. Korst RJ, Altorki NK. High grade dysplasia: surveillance, mucosal ablation, or resection? World J Surg 2003; 27:1030.
  55. Pera M, Trastek VF, Carpenter HA, et al. Barrett's esophagus with high-grade dysplasia: an indication for esophagectomy? Ann Thorac Surg 1992; 54:199.
  56. Moraca RJ, Low DE. Outcomes and health-related quality of life after esophagectomy for high-grade dysplasia and intramucosal cancer. Arch Surg 2006; 141:545.
  57. Viklund P, Wengström Y, Rouvelas I, et al. Quality of life and persisting symptoms after oesophageal cancer surgery. Eur J Cancer 2006; 42:1407.
  58. Reynolds JV, McLaughlin R, Moore J, et al. Prospective evaluation of quality of life in patients with localized oesophageal cancer treated by multimodality therapy or surgery alone. Br J Surg 2006; 93:1084.
  59. Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg 2012; 256:95.
  60. Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet 2012; 379:1887.
  61. Gemmill EH, McCulloch P. Systematic review of minimally invasive resection for gastro-oesophageal cancer. Br J Surg 2007; 94:1461.
  62. Stein HJ, Feith M, Mueller J, et al. Limited resection for early adenocarcinoma in Barrett's esophagus. Ann Surg 2000; 232:733.
  63. Altorjay A, Kiss J, Paál B, et al. The place of gastro-jejuno-duodenal interposition following limited esophageal resection. Eur J Cardiothorac Surg 2005; 28:296.
  64. Stein HJ, Hutter J, Feith M, von Rahden BH. Limited surgical resection and jejunal interposition for early adenocarcinoma of the distal esophagus. Semin Thorac Cardiovasc Surg 2007; 19:72.
  65. Bergman JJ. Endoscopic resection for treatment of mucosal Barrett's cancer: time to swing the pendulum. Gastrointest Endosc 2007; 65:11.
  66. DeMeester SR. EMR for intramucosal adenocarcinoma of the esophagus: does one size fit all? Gastrointest Endosc 2007; 65:14.
  67. Pech O, Behrens A, May A, et al. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus. Gut 2008; 57:1200.
  68. Sun F, Yuan P, Chen T, Hu J. Efficacy and complication of endoscopic submucosal dissection for superficial esophageal carcinoma: a systematic review and meta-analysis. J Cardiothorac Surg 2014; 9:78.
  69. Yamada M, Oda I, Nonaka S, et al. Long-term outcome of endoscopic resection of superficial adenocarcinoma of the esophagogastric junction. Endoscopy 2013; 45:992.
  70. Nakagawa K, Koike T, Iijima K, et al. Comparison of the long-term outcomes of endoscopic resection for superficial squamous cell carcinoma and adenocarcinoma of the esophagus in Japan. Am J Gastroenterol 2014; 109:348.
  71. Pech O, Bollschweiler E, Manner H, et al. Comparison between endoscopic and surgical resection of mucosal esophageal adenocarcinoma in Barrett's esophagus at two high-volume centers. Ann Surg 2011; 254:67.
  72. Prasad GA, Wu TT, Wigle DA, et al. Endoscopic and surgical treatment of mucosal (T1a) esophageal adenocarcinoma in Barrett's esophagus. Gastroenterology 2009; 137:815.
  73. Das A, Singh V, Fleischer DE, Sharma VK. A comparison of endoscopic treatment and surgery in early esophageal cancer: an analysis of surveillance epidemiology and end results data. Am J Gastroenterol 2008; 103:1340.
  74. Peters FP, Kara MA, Rosmolen WD, et al. Stepwise radical endoscopic resection is effective for complete removal of Barrett's esophagus with early neoplasia: a prospective study. Am J Gastroenterol 2006; 101:1449.
  75. Peters FP, Kara MA, Rosmolen WD, et al. Endoscopic treatment of high-grade dysplasia and early stage cancer in Barrett's esophagus. Gastrointest Endosc 2005; 61:506.
  76. Pacifico RJ, Wang KK, Wongkeesong LM, et al. Combined endoscopic mucosal resection and photodynamic therapy versus esophagectomy for management of early adenocarcinoma in Barrett's esophagus. Clin Gastroenterol Hepatol 2003; 1:252.
  77. Buttar NS, Wang KK, Lutzke LS, et al. Combined endoscopic mucosal resection and photodynamic therapy for esophageal neoplasia within Barrett's esophagus. Gastrointest Endosc 2001; 54:682.
  78. Sharma VK, Wang KK, Overholt BF, et al. Balloon-based, circumferential, endoscopic radiofrequency ablation of Barrett's esophagus: 1-year follow-up of 100 patients. Gastrointest Endosc 2007; 65:185.
  79. Bergman JJ. Radiofrequency energy ablation of Barrett's esophagus: the best is yet to come! Gastrointest Endosc 2007; 65:200.
  80. Nemoto K, Yamada S, Nishio M, et al. Results of radiation therapy for superficial esophageal cancer using the standard radiotherapy method recommended by the Japanese Society of Therapeutic Radiology and Oncology (JASTRO) Study Group. Anticancer Res 2006; 26:1507.
  81. Maingon P, d'Hombres A, Truc G, et al. High dose rate brachytherapy for superficial cancer of the esophagus. Int J Radiat Oncol Biol Phys 2000; 46:71.
  82. Okawa T, Tanaka M, Kita-Okawa M, et al. Superficial esophageal cancer: multicenter analysis of results of definitive radiation therapy in Japan. Radiology 1995; 196:271.
  83. Ishikawa H, Nonaka T, Sakurai H, et al. Usefulness of intraluminal brachytherapy combined with external beam radiation therapy for submucosal esophageal cancer: long-term follow-up results. Int J Radiat Oncol Biol Phys 2010; 76:452.
  84. Pasquier D, Mirabel X, Adenis A, et al. External beam radiation therapy followed by high-dose-rate brachytherapy for inoperable superficial esophageal carcinoma. Int J Radiat Oncol Biol Phys 2006; 65:1456.
  85. Sasaki T, Nakamura K, Shioyama Y, et al. Treatment outcomes of radiotherapy for patients with stage I esophageal cancer: a single institute experience. Am J Clin Oncol 2007; 30:514.
  86. Motoori M, Yano M, Ishihara R, et al. Comparison between radical esophagectomy and definitive chemoradiotherapy in patients with clinical T1bN0M0 esophageal cancer. Ann Surg Oncol 2012; 19:2135.
  87. Kodaira T, Fuwa N, Tachibana H, et al. Retrospective analysis of definitive radiotherapy for patients with superficial esophageal carcinoma: Consideration of the optimal treatment method with a focus on late morbidity. Radiother Oncol 2010; 95:234.