Advancing Approaches for Superficial Esophageal Adenocarcinoma: Shifting Toward More Patient-tailored Therapy

The incidence of superficial esophageal adenocarcinoma (EAC) is rising and warrants awareness. Invasive surgery with lymph node dissection was long standard treatment for EAC. However, endoscopic resection techniques, such as cap-based endoscopic resection or endoscopic submucosal dissection (ESD), have proven to be safe and effective alternatives for removal of superficial EAC. Therefore, endoscopic resection is now the cornerstone of management for superficial EAC, for both diagnostic and therapeutic purposes. Current guidelines advise use of the cap-based approach for small, flat lesions, whereas ESD is recommended for large and bulky lesions, lesions with suspected submucosal invasion, or lesions in scarred areas. The histopathological assessment after a resection, evaluating histological risk factors for lymph node metastases, plays a key role in the decision about whether additional surgery is indicated. Until recently, all submucosal and/or high-risk EAC had an indication for additional (prophylactic) surgery because of the assumed high risk for lymph node metastases. However, this risk appears lower than initially assumed, and endoscopic management for low-risk submucosal EAC is gaining acceptance. Ongoing prospective trials will help to determine whether a watchful waiting strategy could be an alternative to surgery in patients with submucosal and/or high-risk EAC. In the future, the distinction between patients who can safely be followed with a watchful waiting strategy and patients who might benefit from additional surgery could become more unambiguous, resulting in more optimal patient-tailored management for patients with superficial EAC.