Early-stage adenocarcinoma of the esophagus with mid to deep submucosal invasion (pT1b sm2-3): the frequency of lymph-node metastasis depends on macroscopic and histological risk patterns

Abstract

The rate of lymph-node (LN) metastasis in early adenocarcinoma (EAC) of the esophagus with mid to deep submucosal invasion (pT1b sm2/3) has not yet been precisely defined. The aim of the this study was to evaluate the rate of LN metastasis in pT1b sm2/3 EAC depending on macroscopic and histological risk patterns to find out whether there may also be options for endoscopic therapy as in cancers limited to the mucosa and the upper third of the submucosa. A total of 1.718 pt with suspicion of EAC were referred for endoscopic treatment (ET) to the Dept. of Internal Medicine II at HSK Wiesbaden 1996-2010. In 230/1.718 pt, the suspicion (endoscopic ultrasound, EUS) or definitive diagnosis of pT1b EAC (ER/surgery) was made. Of these, 38 pt had sm2 lesions, and 69 sm3. Rate of LN metastasis was analyzed depending on risk patterns: histologically low-risk (hisLR): G1-2, L0, V0; histologically high-risk (hisHR): ≥1 criterion not fulfilled; macroscopically low-risk (macLR): gross tumor type I-II, tumor size ≤2 cm; macroscopically high-risk (macHR): ≥1 criterion not fulfilled; combined low-risk (combLR): hisLR+macLR; combined high-risk (combHR): at least 1 risk factor. LN rate was only evaluated in pt who had proven maximum invasion depth of sm2/sm3, and who in case of ET had a follow-up (FU) by EUS of at least 24 months. 23/38 pt with pT1b sm2 lesions and 39/69 pt with sm3 lesions fulfilled our inclusion criteria. In the pT1b sm2 group, rate of LN metastasis in the hisLR, hisHR, combLR, and combHR groups were 8.3% (1/12), 36.3% (4/11), 0% (0/5), and 27.8% (5/18). In the pT1b sm3 group, rate of LN metastasis in the hisLR, hisHR, combLR and combHR groups were 28.6% (2/7), 37.5% (12/32), 25% (1/4), and 37.1% (13/35). 30-day mortality of surgery was 1.7% (1/58 pt). In EAC with pT1b sm2/3 invasion, the frequency of LN metastasis depends on macroscopic and histological risk patterns. Surgery remains the standard treatment, because the rate of LN metastasis appears to be higher than the mortality risk of surgery. Whether a highly selected group of pT1b sm2 patients with a favourable risk pattern may be candidates for endoscopic therapy cannot be decided until the results of larger case volumes are available.

Endoscopic Treatment of Early Barrett’s Adenocarcinoma and Dysplasia: Focus on Submucosal Cancer

“…This reflects our findings with an overall LNM rate of 8% in T1b cancer with no LNM in LR-T1b and one systemic recurrence after 24 months in a surgically treated HR-T1b patient. Manner et al [12] additionally published data where they went one step further. They investigated a cohort of T1b patients with mid-to deep (sm2-3) submucosal infiltration, subdivided into histological and macroscopic risk groups.…”

A Surgeon’s Role in the Management of Early Esophageal, EGJ and Gastric Lesions

“…Some of these reports will be outlined in this review. Manner et al [3] published a prospective clinical study, in which they analyzed risk factors for LN metastases in patients with T1 sm2 and 3 cancers, treated initially with EMR followed by surgery. The overall rates of LN metastases were 21.7% in T1 sm2 and 35.9% in sm3 lesions.…”

Histopathology of Barrett’s Esophagus and Early-Stage Esophageal Adenocarcinoma: An Updated Review

“…On the contrary, pT1b sm2-3 carcinoma carries a much worse prognosis, with lymph node metastases in 44% and a recurrence-free period only in 57% [35]. For pT1b sm2-3, surgical resection is considered as the treatment of choice [36,37]. From a practical point of view, subdivision of submucosa in endoscopically resection specimen is not always possible due to resection procedure and the sample orientation, thus the absolute invasion depths of 500 µm has been proposed to separate sm1 carcinoma from sm2-3.…”

“…For the low risk SAC, which was defined as the one that invades <500 µm, has no lymphovascular invasion, and is well or moderately differentiated, there's no reported lymph node involvement. The frequency of lymph node metastasis increased to 25% with one risk factor, 33% with two risk factors, and in high risk SAC with all three risk factors, the lymph node involvement was present in 50% of cases [37]. A summary of current studies evaluating the depth of invasion in esophageal SAC is presented in Table 1 [32,[35][36][37][38][39][40][41][42][43][44][45][46][47].…”