Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, USA.
Division of Gastroenterology and Hepatology, Department of Medicine, Saint Louis University School of Medicine, St. Louis, USA.
Ann Surg Oncol. 2019 Mar;26(3):714-731. doi: 10.1245/s10434-018-07118-5. Epub 2019 Jan 3.
Esophageal adenocarcinoma (EAC) develops as a consequence of gastroesophageal reflux disease and Barrett's esophagus (BE). While combination therapy with chemotherapy or concurrent chemoradiotherapy followed by esophagectomy improves survival in more advanced tumors, the optimal treatment strategy for early-stage EAC is undefined. Endoscopic eradication therapy, consisting of endoscopic resection and mucosal ablation, has revolutionized therapy for superficial (T1a) EAC in BE and allows for esophageal preservation in appropriate patients at low risk for lymph node metastasis (LNM). This review critically examines the literature regarding evaluation, treatment, and outcomes in patients with T1 EAC.
The literature was queried via the PubMed database to include articles published between 1990 and 2017. Search terms were generated from the key statements "Endoscopic eradication therapy results in equivalent overall survival when compared to esophagectomy for clinical T1aN0 EAC" and "Esophagectomy provides better overall survival than endoscopic eradication therapy for cT1b EAC". Abstracts were reviewed and included according to predefined selection and exclusion criteria, and were then assessed according to the GRADE system.
In patients with T1aN0 EAC, overall survival with endoscopic eradication therapy is equal to esophagectomy. Given the substantial risk of LNM in patients with submucosal (T1b) EAC, esophagectomy remains the standard of care for surgical candidates. In the case of inoperability or low-risk lesions, endoscopic resection may be considered adequate therapy. Chemotherapy and radiation can be offered as primary therapy for non-surgical candidates with lesions not amenable to endoscopic therapy, but does not have a clear role in the adjuvant setting after either endoscopic or surgical resection.
食管腺癌（EAC）是胃食管反流病和 Barrett 食管（BE）的后果。虽然化疗或同步放化疗联合手术切除可提高晚期肿瘤患者的生存率，但早期 EAC 的最佳治疗策略尚未确定。由内镜切除术和黏膜消融组成的内镜消除治疗已经彻底改变了 BE 中浅表性（T1a）EAC 的治疗方法，并允许在淋巴结转移（LNM）风险低的合适患者中保留食管。本文批判性地审查了有关 T1 EAC 患者评估、治疗和结局的文献。
通过 PubMed 数据库检索文献，纳入 1990 年至 2017 年发表的文章。检索词来源于关键语句“与 T1aN0 EAC 的食管切除术相比，内镜消除治疗的总生存率相当”和“与内镜消除治疗相比，cT1b EAC 的食管切除术提供更好的总生存率”。根据预先设定的选择和排除标准审查摘要并纳入，并根据 GRADE 系统进行评估。
在 T1aN0 EAC 患者中，内镜消除治疗的总生存率与食管切除术相当。鉴于黏膜下（T1b）EAC 患者存在 LNM 的高风险，食管切除术仍然是手术候选者的标准治疗方法。对于无法手术或低风险病变的患者，如果内镜治疗不可行或病变适合内镜治疗，内镜切除术可能被认为是充分的治疗方法。对于不适合内镜治疗的非手术候选者，可给予化疗和放疗作为初始治疗，但在内镜或手术切除后的辅助治疗中，其作用并不明确。
