From the Journals

Endoscopic treatment effective in T1b esophageal cancer



Findings from a systematic review may help guide treatment of patients with T1b esophageal cancer.

The review suggests that endoscopic submucosal dissection and endoscopic mucosal resection are appropriate for T1b esophageal cancers with a low risk of metastasis. The authors identified several factors associated with a higher risk of lymph node metastasis and said patients with these risk factors may benefit from adjuvant chemotherapy and radiation.

Mohamed O. Othman, MD, of Baylor College of Medicine, Houston, and colleagues conducted the review. Their report is in Clinical Gastroenterology and Hepatology.

The authors cited studies suggesting that survival rates are not significantly different among early-stage esophageal cancer patients who undergo esophagectomy and those who receive endoscopic treatment (Am J Gastroenterol. 2008;103:1340-5, Gastric Cancer. 2017;20:84-91).

However, studies have indicated that patients with submucosal invasion and an increased risk of metastasis may fare better when endoscopic treatment is combined with chemoradiation (Clin Transl Gastroenterol. 2017;8:e110, Radiat Oncol. 2015;10:31).

With that in mind, the authors described several factors associated with a higher risk of lymph node metastasis in T1b tumors.

First, the risk of lymph node metastasis is higher in esophageal squamous cell carcinoma (ESCC) than in esophageal adenocarcinoma (EAC). The risk is also higher in patients with deeper submucosal invasion (greater than 200 mcm for ESCC or greater than 500 mcm for EAC).

In fact, research suggested the risk of lymph node metastasis is:

Patients also have a higher risk of lymph node metastasis if they have Paris type 0-I protruded lesions or Paris type 0-III excavated lesions. Research suggested that, in ESCC, these lesions confer the highest risk of deep mucosal invasion — 79% for type 0-I protruded lesions and 84% for type 0-III excavated lesions (Surgery 1998;123:432-9).

An additional factor associated with a higher risk of lymph node metastasis in ESCC is type B microvessels. Researchers found that type B vessels could estimate the depth of invasion with 90.5% accuracy (Esophagus 2017;14:105-112).

Patients with poorly differentiated tumors, tumors larger than 2 cm, or lymphovascular invasion have a higher risk of lymph node metastasis as well.

In a study of 782 patients who underwent esophagectomy, those with poorly differentiated tumors and/or tumors larger than 2 cm had a higher rate of lymph node metastasis (Ann Surg Oncol 2018;25:318-25). And in a study of 90 patients with resected T1 EAC, lymphovascular invasion was significantly associated with tumor recurrence and overall survival (Am J Surg Pathol 2005;29:1079-85).

Research has also suggested that immunohistochemistry markers, such as E-cadherin and cyclin D1, are associated with a higher risk of lymph node metastasis (J Surg Oncol 2002;79:166-73).

“Future research should focus on novel biological and immunohistochemistry markers which can aid in the prediction of tumor behavior and lymph node metastasis status in T1b esophageal cancer,” Dr. Othman and colleagues concluded.

The authors disclosed relationships with Olympus, Boston Scientific, Lumendi, Aries Pharmaceutical, and Fujinon.

SOURCE: Othman MO et al. Clin Gastroenterol Hepatol 2019. doi: 10.1016/j.cgh.2019.05.045.

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