Multidisciplinary treatment of T1a adenocarcinoma in Barrett's esophagus: contemporary comparison of endoscopic and surgical treatment in physiologically fit patients.

BACKGROUND: Previous reports comparing endoscopic therapy (ET) and surgical therapy (ST) have predominantly assessed patients with high-grade dysplasia. The study aim was to compare ET to ST in physiologically fit patients with cT1a adenocarcinoma (EAC). METHODS: Review of two prospective databases yielded 100 patients presenting with clinical cT1a EAC between 2000 and 2013. Only physiologically fit patients who were candidates for either treatment were analyzed. RESULTS: Presenting patient characteristics were similar between ET (n = 36) and ST groups (n = 49). Surgical patients were less likely to be staged with EMR (43 vs 100 %) and were associated with mass lesions >1 cm at EGD (p = 0.01), multifocal EAC (p = 0.03), and positive margins for EAC on EMR (p < 0.05). On multivariate analysis, only multifocal HGD was an independent factor for surgery. Following esophagectomy, R0 resection rates for Barrett's esophagus and cancer were 100 %. Incidence of surgery decreased over the study period from 85 to 25 %. All ET patients had EMR, and 28 patients underwent additional ablative therapies for Barrett's esophagus. Following ET, eradication rates of EAC, dysplasia, and BE were 92, 81, and 53 %, respectively. Morbidity rates were comparable between groups (ST 51 % vs ET 39 %, p = 0.31). In-hospital mortality rate was zero in each group. Recurrence rates in ST and ET group were 2 and 11 % (p = 0.08). In the ET group, two patients with endoluminal cancer recurrence after complete eradication underwent esophagectomy. Age-adjusted overall survival was comparable. CONCLUSION: In high-volume esophageal centers, ST and ET provide equally safe and effective treatment for cT1a EAC in medically fit patients. While the results of this study provide a historical perspective and clearly demonstrate an evolution toward ET over time, the appropriate treatment modality is best selected in a multidisciplinary fashion with EMR providing the most accurate staging. In endoscopically treated patients, indefinite endoscopic follow-up required, however, standardized long-term follow-up protocols are needed.

Thoracic multidisciplinary tumor board routinely impacts therapeutic plans in patients with lung and esophageal cancer: a prospective cohort study.

BACKGROUND: National and subspecialty guidelines for lung and esophageal cancers recommend treatment decisions to be made in a multidisciplinary tumor board (MTB). This study prospectively analyzes the actual impact of presentation at the thoracic tumor board on decision making in thoracic cancer cases. METHODS: During the electronic submission process for presentation at MTB managing physicians documented their current treatment plan. The initial treatment plan was compared with the MTB final recommendation. Patient demographics, physician's proposed treatment plan, MTB recommendation, and documentation of application of MTB recommendations were prospectively recorded in an Institutional Review Board approved database. RESULTS: Between June 2010 and December 2012, 185 patients with esophageal and 294 patients with lung cancer were presented at the MTB. One hundred sixty-six patients were presented on more than 1 occasion, resulting in 724 assessments of 479 patients. In 48 esophageal cancer patients (26%) and 118 lung cancer patients (40%) MTB recommendations differed from the initial treatment plan. Overall, a differing MTB recommendation from the primary treatment plan occurred in 330 of 724 case presentations (46%). The MTB recommendations changed treatment plans in 40% and staging and assessment plans in 60% of patients. Follow-up in a cohort of 249 patients confirmed that MTB recommendations were followed in 97% of cases. CONCLUSIONS: This study validates the impact of the thoracic MTB. Recommendations will differ from the managing providers' initial plan in 26% to 40% of cases. However, MTB recommendations can be successfully initiated in the majority of patients. Complex thoracic cancer patients will benefit from multidisciplinary review and should ideally be presented at tumor board.

Evolution of standardized clinical pathways: refining multidisciplinary care and process to improve outcomes of the surgical treatment of esophageal cancer.

BACKGROUND: The aim of this study is to determine the effect of the implementation and evolution of a multidisciplinary esophagectomy care pathway on postoperative outcomes over a 20-year experience. STUDY DESIGN: All patients undergoing esophagectomy for cancer between 1991 and 2012 were included. Patients were divided into four groups (Gp1 1991-1996, Gp2 1997-2002, Gp3 2003-2007, and Gp4 2008-2012). RESULTS: Five hundred and ninety-five patients were included (Gp1 92, Gp2 159, Gp3 161, and Gp4 183). Age remained consistent over time; however, a progressive significant increase was observed in BMI and Charlson comorbidity index. Increases were also noted in patients with clinical stage III cancers, in the use of neoadjuvant chemoradiotherapy, in salvage esophagectomy and in the utilization of pretreatment jejunostomy. We observed a significant reduction in estimated blood loss (EBL) and operative room IV fluid administration (ORFA) during the study period. Median ICU stay and length of hospital stay (LOS) (10 (5-50) to 8 (5-115) days) decreased over time. In-hospital mortality (0.3 %) and postoperative complications remained consistent over time. cumulative sum (CUSUM) analysis showed that EBL, ORFA, and LOS all declined during the study period, reaching mean values at case 120, 310, and 175, respectively. CONCLUSIONS: The results of this study show that process improvement within the pathway is likely more significant than the level of comorbidities, application of neoadjuvant chemoradiation, or technical approach in patients undergoing esophagectomy.

Update on clinical impact, documentation, and management of complications associated with esophagectomy.

The assessment and monitoring of complications associated with esophageal resection suffers from the absence of an internationally recognized system for documenting the incidence and severity of complications. The impact of complications is significant, with direct effects being identified on mortality, length of stay, postoperative quality of life, and long-term survival. Newer systems of assessing surgical complication severity and the resources required to treat complications include the Accordion and Clavien grading systems. New endoscopic and interventional approaches to treating anastomotic leak and stricture and chyle leak can selectively decrease length of stay and costs of managing complications.

The impact of neoadjuvant chemoradiotherapy on perioperative outcomes, tumor pathology, and survival in clinical stage II and III esophageal cancer.

BACKGROUND: The purpose of this study was to evaluate the impact of neoadjuvant chemoradiotherapy (NCR) on perioperative outcomes, tumor pathology, and survival following surgical resection of clinical stage II and III esophageal cancer. METHODS: Patients undergoing esophagectomy for clinical stage II and III cancer were divided into two groups: those who received NCR and those who underwent primary surgery (1991-2011). RESULTS: A total of 173 (50.9%) of 340 stage II/III patients received NCR, 108 (31.8%) patients underwent primary surgery, and 59 (17.4%) underwent neoadjuvant chemotherapy followed by surgery. Patients who received NCR were younger but had a similar Charlson comorbidity index and incidence of adenocarcinoma. There were no differences between groups in the incidence of complications, in-hospital mortality, and ICU stay, but patients who received NCR demonstrated a reduced length of hospital stay. NCR was associated with a reduced the incidence of positive pathological lymph node status and positive resection margin (3.1 vs. 21.1%) in stage III esophageal cancer. No overall survival benefit was seen with use of NCR, although a nonsignificant improvement in survival of 22 months (p = 0.06) was noted in patients with adenocarcinoma. Negative resection margin was associated with an improved survival in both stage II and III patients. CONCLUSIONS: This study highlights the importance of planning operations to optimize the opportunity to provide negative surgical resection margins and to identify patients not responding to NCR to allow them to proceed directly to surgery. Additional assessment of the effect of NCR on patients with adenocarcinoma is warranted.