Early ca esophagus
- 1. Role of surgery in early esophageal cancer Dr Rajiv Paul DNB trainee Dept of Surgical Oncology RGCI
- 2. Introduction 5th most frequent cancer worldwide and 6th leading cause of mortality. Marked change in ratio of SCC to adenocarcinoma over the last two decades. Increasing incidence of early esophageal cancer particularly in western countries.
- 3. Superficial Esophageal Carcinoma Japanese Esophageal Society Esophagus 2009;6:1-25 T1a + T1b AJCC/TNM 7th Edition Early Esophageal Carcinoma Japanese Esophageal Society Esophagus 2009;6:1-25 T1a AJCC/TNM 7th Edition What is Early Esophageal Cancer?
- 4. Definition and classification Early esophageal cancers are Tis(high grade dysplasia) and T1 lesions. T1a-tumor invades lamina propria and muscularis mucosa T1b-tumor invades submucosa.
- 5. For many years, the standard treatment for both HGD and superficial esophageal cancer has been esophagectomy. High cure rates were achieved but at the cost of treatment- related morbidity and mortality. Endoscopic approaches have been increasingly used after encouraging results in 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.
- 6. Risk factors of LN metastasis
- 7. Subclassification of Depth of Invasion by Superficial Carcinoma of the Esophagus in Surgically Resected Specimens Endoscopic Resection Specimens sm1 carcinoma: invades less than 200 microns into the submucosa Japanese Esophageal Society. Japanese Classification of Esophageal Cancer. !0th Ed. Esophagus 2009;6:1-25
- 9. 4 out of 38 patients (10.3%) with M3 lesions without LY had LNM, whereas five out of 12 patients (41.7%) with M3 lesions and LY had LNM. For M3 tumors without LVI, endoscopic therapy is a reasonable strategy.
- 10. Among 402 patients with superficial squamous cell esophageal cancer, the cumulative five-year metastasis rate (both lymphatic and distant) in patients with M3 cancers was 8.7 percent. Among patients with mucosal cancer (M1, 2, or 3), the five-year rate of metastases with and without lymphovascular invasion was 47 versus 0.7 percent, respectively.
- 11. The rates of LN metastasis and LN recurrence were 16% in sm1, 35% in sm2, and 62% in sm3 cases. The incidence of hematological recurrence was 0% in m1, m2, m3, and sm1 cases; 9% in sm2 cases; and 13% in sm3 cases. The overall risk of metastasis was 9% in m3, 16% in sm1, 38% in sm2, and 64% in sm3 patients. Endoscopic treatments should be avoided in all submucosal tumors.
- 12. Diagnosis and Staging of Early (T1a) and Superficial (T1a+T1b) Esophageal Carcinoma
- 13. Endoscopic Diagnosis of Early Esophageal Carcinoma Fujinon “FICE” Olympus “Tri-Modality”
- 14. Can we predict the risk of lymph node metastasis? 27% 50% 20% 10% 10% Incidence of nodal metastasis Takubo et al. Histopathology 2007;51:733-742
- 15. High Risk Factors for Lymph Node Metastasis Depth of invasion – T1b Morphology – types 0-I and 0-III Lymphatic permeation Poor histological differentiation Tumor size >2cm Infiltrative growth pattern Takubo et al. Histopathology 2007;51:733-742
- 16. Accuracy of EUS staging Endoscopic ultrasound (EUS) is the most accurate noninvasive method to assess depth of invasion. Overall accuracy of EUS for T and N staging is 80 to 90 percent. EUS had a sensitivity and specificity for diagnosing T1a tumors of 85 and 87 percent, respectively. For T1b tumors, the sensitivity and specificity were both 86 percent.
- 17. If the EUS identifies esophageal cancer that invades the muscularis mucosa or if there is evidence of lymph node involvement, then surgical therapy is often recommended. If the EUS identifies only mucosal disease and the patient is potentially eligible for endoscopic treatment, an endoscopic resection is then performed to precisely define the depth of invasion.
- 18. Endoscopic therapy Both therapeutic and staging purpose. The available options are ER and various ablation methods, including RFA, PDT, and cryotherapy. Indicated in limited early stage disease .i.e Tis and T1a, <2cm Well or moderately differentiated scc or adeno Elderely with multiple comorbidities Patient preference
- 19. Emerging Treatment Paradigm EMR of all resectable dysplastic lesions Favourable histology? Multifocality? Ablation of the remaining Barrett‘s - ?RFA Endoscopic Surveillance
- 20. Endoscopic Mucosal Resection as intermediate staging strategy More accurate depth of invasion. The pathology result from the endoscopic resection (particularly the presence or absence of LVI) can be used to guide the final decision as to whether endoscopic therapy alone is sufficient or if surgery should be recommended.
- 21. Endoscopic resection Vs esophagectomy Equivalent long term outcome in HGD and intramucosal carcinoma. Lower morbidity(0% vs 30%). Higher recurrence rate 18% at median follow of 43mth (Mayo clinic). Majority can be managed by repeat endoscopic treatment. Similar long term complete response rate(98% vs 100%) Similar OS and DFS at 5yrs.
- 22. Esophagectomy in early esophageal cancer Rational Occult, synchronous, invasive carcinoma has been detected in a significant proportion of esophagectomy specimens, averaging 37% in multiple surgical series; Invasive cancer may arise within dysplastic BE over the short to medium term.
- 23. The potential advantages of esophagectomy include Precise pathologic staging information, Permanent removal of all Barrett's mucosa at risk Treatment is definitive, without the need for posttreatment surveillance or salvage therapy in the event of a recurrence.
- 24. Indications for Esophagectomy T1b: ≥20% incidence of nodal metastasis Intramucosal M3 tumors with LVI Unfavorable histological characteristics Poor differentiation Lymphovascular invasion Multi-focal cancer Persistent positive margins after endoscopic treatment Long segment lesions not amenable to endoscopic treatment(>2cm) Extensive pTis or nodular pT1a not amenable to ER. Peri-esophageal lymphadenopathy at EUS
- 26. Cure rate
- 27. Quality of life For patients undergoing esophageal resection for early neoplasia, when there is a high chance of cure and a long life expectancy, QOL becomes an important consideration, especially relative to the ability to eat and gastrointestinal side effects.
- 28. Greene CL, DeMeester SR, Worrell SG, et al 40 patients who underwent esophagectomy were assessed at a median follow up of 12 years . The majority (88%) reported no dysphagia; 90% were able to eat 3 meals per day, and 93% were able to finish 50% of a typical meal. Dumping, diarrhea 3 times per day, or regurgitation occurred in 33% of patients. Scores for QOL were at the population mean . Other studies have confirmed that QOL, as a whole, remains normal after esophagectomy.
- 29. Transhiatal vs. Transthoracic? Randomised clinical trial Adenocarcinoma: Siewert types 1 or 2 Final analysis on 205 patients No difference in post-operative mortality 5 year actual survival benefit for transthoracic operation Limited to patients with 1-8 positive nodes Overall survival: 14% benefit Recurrence-free survival: 41% benefit Hulscher et al. N Eng J Med 2002;347:1662-9; Omloo et al. Ann Surg 2007;246:992-1000
- 30. Minimal invasive esophagectomy MIE have been designed in an attempt to reduce morbidity and mortality with equivalent oncologic outcome. It includes Thoracoscopy Laparoscopy Combined thoracoscopic and laparoscopic Robotic These techniques have been applied to all stages of resectable esophageal carcinoma, but most applicable in early esophageal carcinoma.
- 31. Outcomes After Minimally Invasive Esophagectomy Luketich et al
- 32. Outcome of MIE in T1 lesion Luketich et al Majority had T1b lesion(90%). 30 day mortality was 0%. R0 resection was achieved in 99%. 3yr and 5yr OS were 80% and 62%. The authors concluded that MIE remain standard of care of T1 lesions.
- 33. MIE Transhiatal vs. Transthoracic Transhiatal 433 patients Transthoracic 1499 patients Vocal cord palsy 10% 6.4% Leakage 13% 7.6% Respiratory complic. 22% 22% Re-operation 3% 6.8% Mortality 4.6% 2.4% Lymph node count 10 (5-15) 17 (7-62) Decker et al. European Journal of Cardio-Thoracic Surgery. 2009;35:13-21
- 34. Minimally invasive esophagectomy vs open esophagectomy for esophageal cancer: a meta-analysis. 2016 Lu Lv, Weidong Hu, Yanchen Ren, and Xiaoxuan Wei Patients get less respiratory complications (risk ratio =0.74, 95% CI =0.58–0.94, P=0.01) and better overall survival (hazard ratio =0.54, 95% CI =0.42–0.70, P<0.00001) in the MIE group than the OE group. No statistical difference was observed between the two groups in terms of lymph node harvest, R0 resection, and other major complications.
- 35. What is the Aim of Esophagectomy? T1a/Low-risk for lymph node metastasis – to eradicate the primary tumor Conventional laparoscopic transhiatal operation Vagus-preserving esophagectomy Merindino operation T1b/High-risk for lymph node metastasis – to achieve radical lymphadenectomy Trans-thoracic esophagectomy
- 36. Laparoscopic Vagus-Sparing Esophagectomy Less extensive operation Enhanced perfusion of gastric conduit No need for pyloroplasty Dumping & diarrhoea in less than 10% Less weight loss Less infectious complications ? cardioprotective Peyre et al. Ann Surg 2007;246:665-671 DeMeester S. Personal communication, 2010
- 37. Segmental Resection of the Gastroesophageal Junction and Reconstruction with a Pedicled Flap of Jejunum (Merindino Operation) • 94 patients • T1a or T1b adenocarcinoma • Transhiatal (11) vs. Transthoracic (60) vs. Merindino (24) • Similar lymph node retrieval • Merindino operation: – Less complications – No mortality Stein et al. Ann Surg 2000;232:733-742
- 38. Summary • The incidence of early esophageal cancer is increasing globally. • Two major treatment options are esophagectomy and endoscopic resection (ER). • For fit patients with submucosal (T1b) cancer, esophagectomy is recommended over ER. • For M1 , M2 tumors and well-differentiated M3 disease without lymphovascular invasion , ER is a valid alternative if performed at institutions with expertise in this technique. • For fit patients with M3 disease and lymphatic invasion, esophagectomy is recommended. • Patients needing esophagectomy should be referred to a high-volume center for better outcome.
Editor's Notes
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