Long-term outcomes of a primary complete endoscopic resection strategy for short-segment Barrett’s esophagus with high-grade dysplasia and/or early esophageal adenocarcinoma

doi:10.1016/j.gie.2015.04.044

Gastrointestinal Endoscopy

Volume 83, Issue 1, January 2016, Pages 68-77

https://doi.org/10.1016/j.gie.2015.04.044 Get rights and content

Background and Aims

Complete endoscopic resection (CER) of Barrett’s esophagus (BE) with high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EEA) is a comprehensive and precise staging tool and may produce a sustained treatment response, preventing metachronous disease. There are limited data on long-term clinical outcomes and the sustainability of dysplasia eradication after CER. We aimed to describe long-term outcomes of a primary CER strategy of BE with HGD/EEA.

Methods

Patients with biopsy-proven HGD and EEA in short-segment BE (≤3 cm in circumferential length and ≤5 cm in maximal length) underwent staged CER by multiband mucosectomy or the cap method. The primary endpoint was remission of HGD or EEA (complete resection of HGD/EEA), dysplasia (complete resection of any dysplasia), and complete resection of intestinal metaplasia.

Results

Of 153 patients (126 HGD, 27 EEA; 83.7% male, median age of 66 years) considered suitable for CER, 138 met all inclusion criteria. CER was technically successful in all patients and was established after a median of 2 sessions. Covert synchronous EEA was found in 1 patient. At a mean follow-up of 40.7 months by intention-to-treat analysis, complete remission of HGD/EEA, dysplasia, and intestinal metaplasia was achieved in 98.5%, 89.1%, and 71.0%, respectively. In 47.1% of patients, CER changed the histological grade compared with pretreatment biopsies (28.1% downstaged and 19.0% upstaged). Esophageal dilation was performed in 36.8% in a mean of 2.5 sessions. At the end of follow-up, 96.4% of patients had no or minimal dysphagia and 90.6% of patients found CER an acceptable treatment.

Conclusions

On long-term follow-up, a primary CER strategy was a highly effective, safe, and durable treatment for HGD and EEA. Despite the need for post-CER dilation in one-third of patients, the majority found it an acceptable treatment on long-term follow-up.

Section snippets

Data collection

Data were prospectively collected for patients referred to 2 Australian tertiary referral centers for endoscopic management of biopsy-proven HGD and EEA between January 2004 and January 2014. Follow-up of these patients was extended to May 2014. The same data collection form was used at both study centers. In a minority of patients (7 patients), data such as lesion location and histology was not recorded. For all of these patients, medical records, endoscopy, and histology reports were

Results

The flow of patients is depicted in Figure 1. Patient baseline characteristics of patients considered for CER are shown in Table 1.

During the study period (January 2004 to January 2014), 246 patients were referred for management of HGD/EEA; 153 patients were considered suitable for treatment by CER. Focal ER was performed in 19 patients who were suspected of having invasive carcinoma. Fourteen patients were found to have high-risk histological features and were referred for surgical

Discussion

Our study demonstrated that CER is a highly effective strategy to eliminate residual BE after focal ER. It is durable, safe, and acceptable to patients. We have documented outcomes in a large, prospective, and well-characterized cohort of patients with short-segment BE and early neoplasia. The mean follow-up time of our CER cohort is more than 40 months. Clinicians not uncommonly encounter patients with HGD/EEA, and currently there is limited high-level evidence of the optimal management of the

Acknowledgment

The authors acknowledge the work of Karen Byth, PhD, who assisted with the statistical analysis of the study.

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Endoscopic resection (ER) allows optimal staging with potential cure of early-stage luminal malignancies while maintaining organ preservation. ER and surgery are non-competing but complementary therapeutic options. In addition, histological examination of ER specimens can either confirm or refine the pre-procedure diagnosis. ER is used for the treatment of Barrett's related early carcinomas and dysplasias, early-esophageal squamous cell carcinomas and dysplasias, early gastric carcinomas and dysplasia, as well as low-risk submucosal invasive carcinomas (LR-SMIC) and, large laterally spreading adenomas of the colon. For invasive lesions, histological risk factors predict risk of lymph node metastasis and residual disease at the ER site. Important pathological risk factors predictive of lymph node metastasis are depth of tumor invasion, poor differentiation, and lymphovascular invasion. Complete resection with negative margins is critical to avoid local recurrences. For non-invasive lesions, complete resection is curative. Therefore, a systematic approach for handling and assessing ER specimens is recommended to evaluate all above key prognostic features appropriately. Correct handling starts with pinning the specimen before fixation, meticulous macroscopic assessment with orientation of appropriate margins, systematic sectioning, and microscopic assessment of the entire specimen. Microscopic examination should be thorough for accurate assessment of all pathological risk factors and margin assessment. Site-specific issues such as duplication of muscularis mucosa of the esophagus, challenges of assessing ampullectomy specimens and site-specific differences of staging of early carcinomas throughout the gastrointestinal tract (GI) tract should be given special consideration. Finally, a standard, comprehensive pathology report that allows optimal staging with potential cure of early-stage malignancies or better stratification and guidance for additional treatment should be provided.
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Endoscopic Submucosal Dissection: Indications and Application in Western Endoscopy Practice
2018, Gastroenterology
Citation Excerpt :
After resection of an early Barrett’s cancer, the remaining Barrett’s mucosa shows recurrent lesions in 30% within 3 years.18,19 In expert hands, stepwise endoscopic resection of the whole Barrett’s esophagus using piecemeal EMR has been shown to be effective in reducing the number of recurrences during follow-up.20–25 In addition, combining endoscopic resection with radiofrequency ablation is now considered the preferred route because radiofrequency ablation is highly effective in completely eradicating all Barrett’s mucosa, maintains the functional integrity of the esophagus, is easier to perform, and has a lower rate of esophageal stenosis compared to the stepwise endoscopic resection approach.23,26,27
Endoscopic submucosal dissection was developed in Japan, early in this century, to provide a minimally invasive yet curative treatment for the large numbers of patients with early gastric cancer identified by the national screening program. Previously, the majority of these patients were treated surgically at substantial cost and with significant risk of short- and long-term morbidity. En-bloc excision of these early cancers, most with a limited risk of nodal metastasis, allowed complete staging of the tumor, stratification of the subsequent therapeutic approach, and potential cure. This transformative innovation changed the nature of endoscopic treatment for superficial mucosal neoplasia and, ultimately, for the first time allowed endoscopists to assert that the early cancer had been definitively cured. Subsequently, Western endoscopists have increasingly embraced the therapeutic possibilities offered by endoscopic submucosal dissection, but with some justifiable scientific caution. Here we provide an evidence-based critical appraisal of the role of endoscopic submucosal dissection in advanced endoscopic tissue resection.
Endoscopic submucosal dissection compared to endoscopic mucosal resection for early Barrett esophagus neoplasia
2018, Techniques in Gastrointestinal Endoscopy
Citation Excerpt :
Hence, in patients with flat BE, RFA alone may be an appropriate strategy whereas EMR should be reserved to patients in whom visible raised lesions are identified. A strategy of wide-field EMR targeting all BE epithelium (with and without visible abnormalities) has been previously described [37,38]. This strategy is appealing as it removes all BE epithelium with the potential added advantage of reducing the risk of missing any invasive component not appreciated on endoscopy and by eliminating the need for adjunct ablative therapy.
Endoscopic resection has become an invaluable diagnostic and therapeutic tool in the evaluation and management of early Barrett esophagus (BE) neoplasia. While endoscopic mucosal resection (EMR) is the current standard of care for the resection of nodular early BE neoplasia, endoscopic submucosal dissection (ESD) has been recently introduced as part of the armamentarium in the treatment of these lesions. The potential advantages of ESD compared to EMR include higher en-bloc and R0 resection rates, decreased local recurrence, and the procurement of large en-bloc specimens that may facilitate pathologic staging. On the other hand, EMR is less time-consuming and has been traditionally associated with a lower incidence of serious adverse events when compared to ESD. At present, the choice of the endoscopic resection technique hinges on operator’s preferences, patient and lesions characteristics and available local expertise. Future high-quality studies comparing clinical outcomes between ESD and EMR are needed to better define their roles in the management of early BE neoplasia.
Efficacy and safety outcomes of multimodal endoscopic eradication therapy in Barrett's esophagus-related neoplasia: a systematic review and pooled analysis
2017, Gastrointestinal Endoscopy
Focal EMR followed by radiofrequency ablation (f-EMR + RFA) and stepwise or complete EMR (s-EMR) are established strategies for eradication of Barrett's esophagus (BE)-related high-grade dysplasia (HGD) and/or esophageal adenocarcinoma (EAC)/intramucosal carcinoma (IMC). The objective of this study was to derive pooled rates of efficacy and safety of individual methods in a large cohort of patients with BE and to indirectly compare the 2 methods.
PubMed, Embase, Web of Science, Cochrane, and major conference proceedings were searched. A systematic review and pooled analysis were carried out to determine the following outcomes in patients with BE undergoing either f-EMR + RFA or s-EMR: (1) complete eradication rates of neoplasia (CE-N) and intestinal metaplasia (CE-IM); (2) recurrence rates of cancer (EAC), dysplasia, and IM; (3) incidence rates of adverse events. Mixed logistic regression was performed as an exploratory analysis to examine differences in outcomes between the 2 methods.
Nine studies (774 patients) of f-EMR + RFA and 11 studies (751 patients) of s-EMR were included. Patients undergoing f-EMR + RFA had high BE eradication rates (CE-N, 93.4%; CE-IM, 73.1%), whereas strictures occurred in 10.2%, bleeding in 1.1%, and perforations in 0.2% of patients. Recurrence of EAC, dysplasia, and IM was 1.4%, 2.6%, and 16.1%, respectively, in this group. Patients undergoing s-EMR also showed high BE eradication rates (CE-N, 94.9%; CE-IM, 79.6%) but a higher rate of adverse events (strictures in 33.5%, bleeding in 7.5%, and perforation in 1.3%). Recurrence of EAC, dysplasia, and IM was 0.7%, 3.3%, and 12.1%, respectively, in the s-EMR group. Mixed logistic regression showed that patients undergoing s-EMR might be more likely to develop esophageal strictures (odds ratio [OR], 4.73; 95% confidence interval [CI], 1.61-13.85; P = .005), perforation (OR, 7.00; 95% CI, 1.56-31.33; P = .01), and bleeding (OR, 6.88; 95% CI, 2.19-21.62; P = 0.001) compared with f-EMR + RFA.
In patients with HGD/EAC, f-EMR followed by RFA seems to be equally effective as and safer than s-EMR.
Prevention of strictures after endoscopic resection of esophageal neoplasia
2016, Gastrointestinal Endoscopy

View all citing articles on Scopus

: DISCLOSURE: All authors disclosed no financial relationships relevant to this article. Drs Bahin, Jayanna, and Whiteman were supported by grants from the National Health and Medical Research Council of Australia (NHMRC). The Cancer Institute of New South Wales (CINSW) provided funding for a research nurse and data manager to assist with the administration of the study. There was no influence from the NHMRC or the CINSW on study design or conduct, data collection and management, analysis, interpretation, and preparation and review or approval of the manuscript.

: See CME section; p. 212.

: If you would like to chat with an author of this article, you may contact Dr Bourke at [email protected].

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Original articleClinical endoscopyLong-term outcomes of a primary complete endoscopic resection strategy for short-segment Barrett’s esophagus with high-grade dysplasia and/or early esophageal adenocarcinoma

Background and Aims

Methods

Results

Conclusions

Section snippets

Data collection

Results

Discussion

Acknowledgment

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Clin Gastroenterol Hepatol

Gastroenterology

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Esophageal adenocarcinoma incidence: are we reaching the peak?

Cancer Epidemiol Biomarkers Prev

Pro: esophagectomy is the treatment of choice for high-grade dysplasia in Barrett's esophagus

Am J Gastroenterol

Endoscopic resection for Barrett's high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit

Am J Gastroenterol

Original article
Clinical endoscopy
Long-term outcomes of a primary complete endoscopic resection strategy for short-segment Barrett’s esophagus with high-grade dysplasia and/or early esophageal adenocarcinoma