Risk of lymph node metastasis associated with deeper invasion by early adenocarcinoma of the esophagus and cardia: study based on endoscopic resection specimens

Abstract

This study suggests that lymph node metastasis risk for m3 and submucosal AEC may be lower than has been assumed on the basis of surgical series, and that current guidelines are valid regarding suitability of m3 AECs for endoscopic therapy. It may also suggest that selected patients with submucosal cancers are also eligible for endoscopic management. Confirmation of these results is needed in larger series with longer follow-up.

British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus

“…A recent systematic review reported no evidence of nodal metastasis in patients with a final stage of HGD 72. Further stratification of these superficial lesions as in table 8 yields additional prognostic information in that the risk of nodal metastasis correlates with the depth of penetration into the layers,229 234 but not all the studies have confirmed this 230 236…”

“…It is still unclear whether T1sm1 cancer (invading the superficial submucosa within 500 µm) can be confidently treated by ER, and although series from Amsterdam and Wiesbaden suggest this carries a low risk of lymph node metastases,230 234 237 not all the literature supports this 72 236. This debate is further complicated by the technical challenges faced by the pathologist to accurately identify the submucosal invasion depth on the ER specimen.…”

“…The importance of experienced pathology in deciding whether endotherapy is likely to be curative or not is critical, since not only the depth of invasion but features of the tumour (lymphatic or vascular invasion, degree of differentiation) are thought to be important in the decision-making process 238. Free deep resection margins on the ER specimen (R0), together with an absence of lymphovascular invasion (LVI−) and good differentiation (G1) are all indicative of a good prognosis for early cancer 230. Lymphovascular space invasion and lymph node metastases have been reported in 17% and 10% of patients, respectively, with invasion into the duplicated muscularis mucosae, although these are technically intramucosal 235…”

“…This may lead to overstaging by misinterpreting the space between duplicated muscularis as submucosa, and in some instances it may not even be possible to determine if true submucosa is present (see online supplementary appendix 4). The largest and most recent studies suggest that invasion into the space between the duplicated muscularis mucosae has a similar low risk of lymph node metastases to lamina propria invasion if other features (lymphovascular invasion and poor differentiation) are absent230 247 (Evidence grade III). In addition, it is important to be aware of entrapped glands and submucosal glands that may mimic submucosal adenocarcinoma.…”

“…In the latter instance, it may be more appropriate to state that submucosal invasion is present and then measure the depth of invasion beyond the muscularis mucosae. In the colon, depth of invasion beyond the submucosa is widely used as a marker of likely lymph node metastases, but studies in OAC have been conflicting, with differences between surgical and ER series 229 230. Measurement of the distance from the tumour to the nearest deep margin is recommended to document the adequacy of resection.…”