J Gastrointest Surg DOI 10.1007/s11605-016-3210-3
2016 SSAT PLENARY PRESENTATION
Esophagectomy Following Endoscopic Resection of Submucosal Esophageal Cancer: a Highly Curative Procedure Even with Nodal Metastases Daniela Molena 1 & Francisco Schlottmann 1 & Joshua A. Boys 2 & Shanda H. Blackmon 3 & Karen J. Dickinson 3 & Christy M. Dunst 4 & Wayne L. Hofstetter 5 & Michal J. Lada 6 & Brian E. Louie 7 & Benedetto Mungo 8 & Thomas J. Watson 6 & Steven R. DeMeester 2
Received: 24 May 2016 / Accepted: 10 July 2016 # 2016 The Society for Surgery of the Alimentary Tract
Abstract Background Despite the increased risk for nodal disease, definitive endoscopic resection is being increasingly offered for lesions invasive into the submucosa based on the success with intramucosal tumors. The aim of this study was to evaluate survival after esophagectomy alone for confirmed submucosal tumors after endoscopic resection. Methods Patients from seven centers in the USA who underwent esophagectomy for submucosal tumors removed with endoscopic resection were analyzed. Nodal involvement was correlated with recurrence and survival. Results We identified 23 patients with submucosal esophageal adenocarcinoma. Esophagectomy was performed at a median of 2 months (Interquartile range 1–3) after the endoscopic resection. There was no postoperative mortality. Positive nodal disease was seen in 26 % of patients on final pathology. At a median of 37 months (Interquartile range 25–55), 91 % of patients were alive and free of disease. The disease-specific 5-year survival was 88 %. Disease-specific 5-year survival was 67 % in patients with positive nodal metastases and 100 % in those without (p = 0.159). Conclusions Esophagectomy is curative in the majority of patients with submucosal tumors even in the presence of nodal metastases. These data serve as a benchmark for comparison when considering extending the indications for therapeutic endoscopic resection for submucosal tumors in the future. Keywords Esophageal cancer . T1b adenocarcinoma . Esophagectomy . Endoscopic therapy * Daniela Molena
[email protected]
Introduction 1
Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
2
Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
3
Department of Surgery, Mayo Clinic, Rochester, MN, USA
4
Department of Surgery, The Oregon Clinic, Portland, OR, USA
5
Department of Surgery, MD Anderson, Houston, TX, USA
6
Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
7
Department of Surgery, Swedish Cancer Institute, Seattle, WA, USA
8
Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
The recent development of advanced endoscopic techniques has pushed the limits of previously accepted therapy for esophageal cancer. Esophagectomy has traditionally been considered the mainstay of treatment for high-grade dysplasia and esophageal cancer. Currently, esophageal organ preservation is the preferred approach for most patients with highgrade dysplasia and increasingly, it is also favored for earlystage tumors because of its low morbidity and excellent success rates in several large series [1–5]. The major limitation of endoscopic therapy is its inability to address potentially involved lymph nodes. Since patients with high-grade dysplasia or intramucosal adenocarcinoma rarely have lymph node metastases, endotherapy is preferred for these lesions in many
J Gastrointest Surg
centers. However, esophagectomy remains the recommended treatment for patients with submucosal tumor given the 15–30 % risk for nodal disease [6–8]. Recently, factors associated with an increased risk for node metastases in superficial esophageal adenocarcinoma have been identified [9, 10]. Some centers have selected patients with “low-risk” submucosal lesions for endotherapy in hopes of avoiding major esophageal resection with its high complication rates and life-changing functional outcomes. However, missed nodal disease could have fatal consequences for these patients. There is little information in the literature about survival after esophagectomy for submucosal tumors that are amenable to endoscopic resection. The aim of this multicenter study was to evaluate survival after esophagectomy alone for tumors pathologically confirmed to be T1b by endoscopic mucosal resection.
Material and Methods All patients who underwent endoscopic resection (ER) followed by esophagectomy for T1b tumors were collected from the following seven institutions: John Hopkins University, University of Southern California, Mayo Clinic Rochester, Oregon Clinic, MD Anderson Cancer Center, University of Rochester Medical Center, and the Swedish Cancer Institute. As previously reported,[9] tumor depth of invasion from the de-identified ER slides was simultaneously but independently determined by three blinded experienced GI pathologists on a multiheaded microscope. T1b was defined as invasive carcinoma involving the submucosa but not the muscularis propria in the ER specimen. Maximal depth of invasion below the deepest fibers of the muscularis mucosae, tumor grade, and presence of LVI were assessed in all cases. All the ER specimens with deep margin invasion, tangential cut, or poorly processed were excluded from this study. Patients with intramucosal carcinoma were excluded as well. Surgical strategy was dependent on tumor location and surgeon’s preference and included open or minimally invasive Ivor-Lewis, transhiatal, three-hole esophagectomy, and total gastrectomy. Lymph node metastases were defined as pathologic lymph node involvement on the final esophagectomy specimen. Pathological features presented in the ER slides were previously identified to gauge the risk of nodal involvement in T1b tumors.[9] Disease-specific survival was evaluated in the entire population and compared between patients with and without nodal involvement. Statistical analysis was performed with the Statistical Package for Social Sciences (version 22, SPSS Inc., Chicago, IL, USA). Survival curves were developed using the Kaplan-Meier method and differences in long-term survivals were compared using the log- rank test. P values
