Original article
Alimentary tract
Efficacy, Safety, and Long-term Results of Endoscopic Treatment for Early Stage Adenocarcinoma of the Esophagus With Low-risk sm1 Invasion

https://doi.org/10.1016/j.cgh.2012.12.040Get rights and content

Background & Aims

Patients with early-stage mucosal (T1a) esophageal adenocarcinoma (EAC) are increasingly treated by endoscopic resection. EACs limited to the upper third of the submucosa (pT1b sm1) could also be treated by endoscopy. We assessed the efficacy, safety, and long-term effects of endoscopic therapy for these patients.

Methods

We analyzed data from 66 patients with sm1 low-risk lesions (macroscopically polypoid or flat, with a histologic pattern of sm1 invasion, good-to-moderate differentiation [G1/2], and no invasion into lymph vessels or veins) treated by endoscopic therapy at the HSK Hospital Wiesbaden from 1996 through 2010. The efficacy of endoscopic therapy was assessed on the basis of rates of complete endoluminal remission (CER), metachronous neoplasia, lymph node events, and long-term remission (LTR). Safety was assessed on the basis of rate of complications.

Results

Remissions were assessed in 61 of the 66 patients; 53 of the 61 achieved CER (87%). Of patients with small focal neoplasias ≤2 cm, 97% achieved CER (for those with tumors ≥2 cm, 77%; P = .026). Metachronous neoplasias were observed in 10 of 53 patients (19%; 9 of the 10 underwent repeat endoscopic resection). One patient developed a lymph node metastasis (1.9%). Fifty-one patients achieved LTR (84%); 90% of those with focal lesions ≤2 cm achieved LTR after a mean follow-up period of 47 ± 29.1 months (range, 8–120 months). No tumor-associated deaths were observed, and the estimated 5-year survival rate was 84%. The rate of major complications from endoscopic resection was 1.5%, and no patients died.

Conclusions

Endoscopic therapy appears to be a good alternative to esophagectomy for patients with pT1b sm1 EAC, on the basis of macroscopic and histologic analyses. The risk of developing lymph node metastases after endoscopic resection for sm1 EAC is lower than the risk of surgery.

Section snippets

Patients

From September 1996–December 2010, a total of 1718 patients with suspected EAC were referred to our department. The patients were included in the department's prospective early carcinoma database. In 123 of these patients (104 men, 85%; 19 women, 15%; mean age, 64 ± 10 years), there was a suspected diagnosis (endoscopic ultrasonography [EUS]), or a diagnosis histologically confirmed at ER or from the surgical specimen, of EAC with incipient submucosal invasion (pT1b sm1) (Figure 1). Sixty-six

Complete Endoluminal Remission

The characteristics of the overall group of 66 patients are shown in Table 1. CER was evaluated in 61 of 66 patients included. One patient was still receiving ET at the time of analysis (1.5%). Four patients were lost to FU (6.1%).

Fifty-three of 61 patients (86.9%) achieved CER. A mean of 2.6 ± 2.9 ERs were needed to reach CER (range, 1–4). The mean treatment period was 4.5 ± 5.3 months (1–23 months). CER was not achieved in 8 patients (13.1%; Table 2).

CER was achieved in 97% of patients with

Discussion

During the last decade, ET for mucosal (pT1a) EAC has gained increasing international acceptance1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 as a curative form of treatment, and it was included in national and international guidelines.28, 33, 34

To the present, the gold standard for the treatment of submucosal (pT1b) EAC has been esophageal resection with LN dissection.25, 26, 35 However, surgical series15, 16 were able to show that no LN metastases were found to occur in lesions limited to the upper third

Acknowledgments

This study formed the basis for Yvonne Heldmann's doctoral thesis at the University of Mainz, Germany.

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