Clinical Efficacy of Endoscopic Submucosal Dissection for Adenocarcinomas of the Esophagogastric Junction

Abstract

Background and Study Aims There are a few reports about the efficacy of endoscopic submucosal dissection (ESD) for adenocarcinomas of the esophagogastric junction (EGJ). However, there is no detailed analysis that divides EGJ cancers into Barrett’s adenocarcinoma and gastric cardia adenocarcinoma. The aim of this study was to analyze the efficacy of ESD for EGJ cancers, comparing these two adenocarcinomas. Patients and Methods This study included 43 patients who underwent ESD for type II EGJ cancers between 2004 and 2011. Pathological examination of resected specimens confirmed 14 cases of Barrett’s adenocarcinoma and 29 cases of gastric cardia adenocarcinoma. Cutting margins on the oral side were placed 1 cm from the squamocolumnar junction, or 1 cm away from the slight elevation that is an endoscopic sign of subsquamous carcinoma extension. Clinical outcomes, prevalence and length of subsquamous carcinoma extension, and long-term outcomes were compared between these two types of adenocarcinoma. Results No significant differences in clinical outcomes were found between these two types of adenocarcinoma (en bloc, 100 % versus 100 %; complete, 100 % versus 89.7 %; curative, 85.7 % versus 75.9 %). No serious adverse events were encountered. The prevalence of subsquamous carcinoma extension was significantly higher in Barrett’s adenocarcinoma compared with gastric cardia adenocarcinoma. Local and distant recurrence were not observed in any cases with curative resection during the follow-up period (1.6 – 87.6 months). Conclusion ESD for EGJ cancers, including both Barrett’s adenocarcinoma and gastric cardia adenocarcinoma, was efficient and useful. ESD with a 1 cm safety margin may be acceptable for EGJ cancers.

Endoscopic Submucosal Dissection for Adenocarcinomas of the Esophagogastric Junction

“…This classification includes not only adenocarcinoma but also squamous cell carcinoma [9, 13]. On the other hand, Siewert type II tumors, located 1 cm above and 2 cm below the EGJ, are considered true cardiac adenocarcinomas arising from the EGJ epithelium [2, 9, 11, 13]. Barrett’s esophagus is defined as columnar epithelium that is replaced from stratified squamous epithelium of distal esophagus [1, 3, 13].…”

“…Therefore, the following histological criteria are used to diagnose Barrett’s esophagus and Barrett’s adenocarcinoma after endoscopic resection, the presence of esophageal glands, duplication of the muscularis mucosae under the lesions, or a squamous island within the lesions according to the Japanese Classification of Esophageal Cancer (Fig. 1d–f) [7, 9, 11, 13]. Gastric cardiac adenocarcinoma was defined as cancer that did not have these characteristics (Fig.…”

“…Assessing the demarcation line for the presence of an irregular microvascular pattern or irregular microsurface pattern using a systematic, but simple, classification system (the VS classification system) may also be useful for differential diagnosis and for delineating the cancer margin in EGJ adenocarcinoma. Some studies have reported a high complete resection rate in patients without a positively detected cancerous margin using magnifying endoscopy with NBI [7, 8, 10, 11]. …”

“…Optical coherence tomography might be useful even for detecting subsquamous carcinoma extension [19]. Conversely, since most cases of subsquamous carcinoma extension were reported to be less than 1 cm in size, the oral safety margin that is placed 1 cm from the squamocolumnar junction is useful for ESD of EGJ adenocarcinoma resection with the negative oral side horizontal margin including the subsquamous carcinoma extension [11]. …”

“…1a–c) [3, 5, 11]. Although both types exhibit different potentials for lymph-node metastasis, most studies on EGJ adenocarcinoma have conflated the two [10].…”