Chan Man Wai, Nieuwenhuis Esther A, Pouw Roos E
Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology Endocrinology & Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
Visc Med. 2022 Jun;38(3):196-202. doi: 10.1159/000524285. Epub 2022 Apr 25.
Given the limitation that endoscopic resection only enables local intraluminal treatment without lymphadenectomy, the standard treatment of esophageal adenocarcinoma (EAC) with invasion of the submucosa (T1b) has long been surgical esophageal resection. However, in recent literature, the risk of lymph node metastases (LNM) associated with T1b EAC appears to be lower than previously assumed, and endoscopic management is increasingly being considered a valid and less invasive alternative to surgery.
Surgical esophageal resection performed after radical endoscopic resection of T1b EAC often does not show any residual tumor or LNM in the resected specimen. Given the morbidity and mortality associated with surgical esophageal resection, endoscopic management with strict surveillance protocols has been more widely applied provided that the initial tumor was radically removed by endoscopic resection, reserving surgery for those cases where the additional risk of surgical esophageal resection is justified. These are the cases where intraluminal recurrent neoplasia is found that cannot be retreated endoscopically or cases with locoregional LNM detected during follow-up. In the future, selection of patients who can safely be managed endoscopically and those who may benefit from additional surgery after endoscopic resection of T1b EAC may become more tailored, using risk prediction calculators or sentinel node navigated surgery.
Management of patients with T1b EAC is shifting from surgical treatment to less invasive endoscopic treatment strategies, including watchful waiting approaches. The risk of LNM of T1b EAC appears to be lower than long assumed. In the future, management of T1b EAC may become more individualized based on tools to predict LNM risk per patient case.
鉴于内镜切除仅能进行局部腔内治疗而无法进行淋巴结清扫，对于侵犯黏膜下层（T1b）的食管腺癌（EAC），标准治疗方法长期以来一直是手术切除食管。然而，近期文献表明，与T1b期EAC相关的淋巴结转移（LNM）风险似乎低于先前的假设，内镜治疗越来越被视为一种有效且侵入性较小的手术替代方案。
在对T1b期EAC进行根治性内镜切除后进行的手术食管切除，在切除标本中通常未显示任何残留肿瘤或LNM。鉴于手术食管切除相关的发病率和死亡率，如果最初的肿瘤通过内镜切除被根治性切除，那么采用严格监测方案的内镜治疗已得到更广泛应用，而手术则保留给那些手术食管切除额外风险合理的病例。这些病例包括发现腔内复发性肿瘤无法通过内镜治疗或在随访期间检测到局部区域LNM的情况。未来，使用风险预测计算器或前哨淋巴结导航手术，选择能够安全接受内镜治疗的患者以及那些在内镜切除T1b期EAC后可能从额外手术中获益的患者可能会更加精准。
T1b期EAC患者的管理正从手术治疗转向侵入性较小的内镜治疗策略，包括观察等待方法。T1b期EAC的LNM风险似乎低于长期以来的假设。未来，基于预测每位患者LNM风险的工具，T1b期EAC的管理可能会更加个体化。
