Please provide us with a reasonable definition for curative R0 resection in Barrett’s esophagus neoplasia; which one should we choose?

A resection is considered to be R0 when the pathological examination confirms that the edges of the resected specimen are free of disease. A resection is curative when the patient is cured by the endoscopic treatment without need for further surgery or chemoradiation therapy. In the colon for example, the definition of the curative R0 resection is quite simple: a strict R0 is defined by an 'en bloc' specimen with normal mucosa on the edges when examined histologically. The treatment is considered to be curative if the resection is R0 with an invasion depth less than 1000 µm in the submucosa, without lymphatic or venous emboli, without budding, and with a differentiated carcinoma. The situation is far more complex in the neoplasia developed on Barrett’s esophagus (BE) since different degrees of neoplasia are possible with different prognosis and treatment strategies. At present, we do not have any consensus on the definition of R0 and curative resections for BE neoplasia ([Fig. 1 a]). This editorial aims to discuss various definitions of the R0 resection and their clinical impact. We shall also discuss the literature available to choose the best criteria to define resection curativeness.

Fig. 1 Schematic representation of the different R0 resections. a Neoplasia representation; b Colon-like R0; c Intestinal metaplasia R0; d LGD or less R0; e HGD or less R0; f Flat components R0. IM, intestinal metaplasia; LGD, low grade dysplasia; HGD, high grade dysplasia.

• References

• 1 Shaheen NJ, Overholt BF, Sampliner RE et al. Durability of radiofrequency ablation in Barrett’s esophagus with dysplasia. Gastroenterology 2011; 141: 460-468
• 2 Shaheen NJ, Sharma P, Overholt BF et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. NEJM 2009; 360: 2277-2288
• 3 Pouw RE, Sharma VK, Bergman JJ et al. Radiofrequency ablation for total Barrett’s eradication: a description of the endoscopic technique, its clinical results and future prospects. Endoscopy 2008; 40: 1033-1040
• 4 Phoa KN, van Vilsteren FGI, Weusten BLAM et al. Radiofrequency ablation vs endoscopic surveillance for patients with Barrett esophagus and low-grade dysplasia: a randomized clinical trial. JAMA 2014; 311: 1209-1217
• 5 Fitzgerald RC, di Pietro M, Ragunath K et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut 2014; 63: 7-42
• 6 Mannath J, Subramanian V, Hawkey CJ et al. Narrow band imaging for characterization of high grade dysplasia and specialized intestinal metaplasia in Barrett’s esophagus: a meta-analysis. Endoscopy 2010; 42: 351-359
• 7 Sharma P, Hawes RH, Bansal A et al. Standard endoscopy with random biopsies versus narrow band imaging targeted biopsies in Barrett’s oesophagus: a prospective, international, randomised controlled trial. Gut 2013; 62: 15-21
• 8 Singh R, Anagnostopoulos GK, Yao K et al. Narrow-band imaging with magnification in Barrett’s esophagus: validation of a simplified grading system of mucosal morphology patterns against histology. Endoscopy 2008; 40: 457-463
• 9 Singh R, Shahzad MA, Tam W et al. Preliminary feasibility study using a novel narrow-band imaging system with dual focus magnification capability in Barrett’s esophagus: is the time ripe to abandon random biopsies?. Dig Endosc Off J Jpn Gastroenterol Endosc Soc 2013; 25: 151-156
• 10 Montgomery E, Bronner MP, Goldblum JR et al. Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation. Hum Pathol 2001; 32: 368-378
• 11 Skacel M, Petras RE, Gramlich TL et al. The diagnosis of low-grade dysplasia in Barrett’s esophagus and its implications for disease progression. Am J Gastroenterol 2000; 95: 3383-3387
• 12 Wani S, Falk GW, Post J et al. Risk factors for progression of low-grade dysplasia in patients with Barrett’s esophagus. Gastroenterology 2011; 141: 1179-1186 ; 1186.e1
• 13 Phoa KN, van Vilsteren FGI, Weusten BLAM et al. Radiofrequency ablation vs endoscopic surveillance for patients with Barrett esophagus and low-grade dysplasia: a randomized clinical trial. JAMA 2014; 311: 1209-1217
• 14 Chevaux JB, Piessevaux H, Jouret-Mourin A et al. Clinical outcome in patients treated with endoscopic submucosal dissection for superficial Barrett’s neoplasia. Endoscopy 2015; 47: 103-112
• 15 Dunbar KB, Spechler SJ. The risk of lymph-node metastases in patients with high-grade dysplasia or intramucosal carcinoma in Barrett’s esophagus: a systematic review. Am J Gastroenterol 2012; 107: 850-862 ; quiz 863
• 16 Hölscher AH, Bollschweiler E, Schröder W et al. Prognostic impact of upper, middle, and lower third mucosal or submucosal infiltration in early esophageal cancer. Ann Surg 2011; 254: 802-807 ; discussion 807–808
• 17 Bollschweiler E, Baldus SE, Schröder W et al. High rate of lymph-node metastasis in submucosal esophageal squamous-cell carcinomas and adenocarcinomas. Endoscopy 2006; 38: 149-156
• 18 Manner H, May A, Pech O et al. Early Barrett’s carcinoma with “low-risk” submucosal invasion: long-term results of endoscopic resection with a curative intent. Am J Gastroenterol 2008; 103: 2589-2597
• 19 Manner H, Pech O, Heldmann Y et al. The frequency of lymph node metastasis in early-stage adenocarcinoma of the esophagus with incipient submucosal invasion (pT1b sm1) depending on histological risk patterns. Surg Endosc 2015; 29: 1888-1896