Clinical outcome in patients treated with endoscopic submucosal dissection for superficial Barrett’s neoplasia

Background and study aims: The role of endoscopic submucosal dissection (ESD) in Barrett’s neoplasia is ill-defined, although it might provide a higher curative resection rate and better histologic assessment than endoscopic mucosal resection (EMR). We aimed to assess efficacy, safety, and long-term results of ESD.

Patients and methods: A retrospective analysis was done of 75 consecutive patients with Barrett’s esophagus who underwent ESD between January 2007 and February 2014. ESD was performed for visible lesions that were multiple, larger than 15 mm, or poorly lifting, or suspected of submucosal infiltration. The primary end point was the rate of curative resection of carcinoma.

Results: Median patient age was 68 years (interquartile range [IQR] 61 – 76), median follow-up was 20 months (IQR 8.5 – 37.5), and median maximum specimen diameter was 52.5 mm (IQR 43 – 71). En bloc resection rate was 90 % (66 /73), and rates of curative resection of carcinoma and high grade dysplasia/carcinoma were 85 % (47 /55) and 64 % (42 /66), respectively. G3 differentiation and invasion to greater than pT1m2 were observed in 25 % (14 /55) and 67 % (37 /55) of patients with adenocarcinoma, respectively. There were 5 early ( < 48 hours) adverse events (2 delayed hemorrhages and 3 perforations), all treated endoscopically. No ESD-specific death occurred. Esophageal strictures developed in 60 % of patients, all treated endoscopically. Additional treatment (median sessions 2 [IQR 2 – 3]) for residual Barrett’s esophagus were recommended to 62 % (42 /68). At latest follow-up, complete remission of neoplasia and intestinal metaplasia was found in 92 % (54 /59) and 73 % (43 /59) of patients, respectively.

Conclusion: ESD appears to be safe and effective, with a high rate of curative resection of carcinoma. ESD should be considered for patients with Barrett’s neoplasia at risk of incomplete resection or poor pathologic assessment with conventional EMR.

• References

• 1 de Jonge PJ, van Blankenstein M, Looman CW et al. Risk of malignant progression in patients with Barrett’s oesophagus: a Dutch nationwide cohort study. Gut 2010; 59: 1030-1036
• 2 Dubecz A, Solymosi N, Stadlhuber RJ et al. Does the incidence of adenocarcinoma of the esophagus and gastric cardia continue to rise in the twenty-first century? - a SEER database analysis. J Gastrointest Surg 2014; 18: 124-129
• 3 Bennett C, Vakil N, Bergman J et al. Consensus statements for management of Barrett’s dysplasia and early-stage esophageal adenocarcinoma, based on a Delphi process. Gastroenterology 2012; 143: 336-346
• 4 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
• 5 Alvarez Herrero L, Pouw RE, van Vilsteren FG et al. Risk of lymph node metastasis associated with deeper invasion by early adenocarcinoma of the esophagus and cardia: study based on endoscopic resection specimens. Endoscopy 2010; 42: 1030-1036
• 6 Manner H, Pech O, Heldmann Y et al. Efficacy, safety, and long-term results of endoscopic treatment for early stage adenocarcinoma of the esophagus with low-risk sm1 invasion. Clin Gastroenterol Hepatol 2013; 11: 630-635
• 7 Moss A, Bourke MJ, Hourigan LF et al. Endoscopic resection for Barrett’s high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit. Am J Gastroenterol 2010; 105: 1276-1283
• 8 Mino-Kenudson M, Brugge WR, Puricelli WP et al. Management of superficial Barrett’s epithelium-related neoplasms by endoscopic mucosal resection: clinicopathologic analysis of 27 cases. Am J Surg Pathol 2005; 29: 680-686
• 9 Pech O, Behrens A, May A et al. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett’s oesophagus. Gut 2008; 57: 1200-1206
• 10 Ell C, May A, Pech O et al. Curative endoscopic resection of early esophageal adenocarcinomas (Barrett’s cancer). Gastrointest Endosc 2007; 65: 3-10
• 11 Prasad GA, Wang KK, Buttar NS et al. Long-term survival following endoscopic and surgical treatment of high-grade dysplasia in Barrett’s esophagus. Gastroenterology 2007; 132: 1226-1233
• 12 Pech O, May A, Manner Hl et al. Long-term efficacy and safety of endoscopic resection for patients with mucosal adenocarcinoma of the esophagus. Gastroenterology 2014; 146: 652-660
• 13 Gossner L, Stolte M, Sroka R et al. Photodynamic ablation of high-grade dysplasia and early cancer in Barrett’s esophagus by means of 5-aminolevulinic acid. Gastroenterology 1998; 114: 448-455
• 14 Shaheen NJ, Greenwald BD, Peery AF et al. Safety and efficacy of endoscopic spray cryotherapy for Barrett’s esophagus with high-grade dysplasia. Gastrointest Endosc 2010; 71: 680-685
• 15 van Laethem JL, Jagodzinski R, Peny MO et al. Argon plasma coagulation in the treatment of Barrett’s high-grade dysplasia and in situ adenocarcinoma. Endoscopy 2001; 33: 257-261
• 16 Pouw RE, Wirths K, Eisendrath P et al. Efficacy of radiofrequency ablation combined with endoscopic resection for Barrett’s esophagus with early neoplasia. Clin Gastroenterol Hepatol 2010; 8: 23-29
• 17 Pouw RE, Seewald S, Gondrie JJ et al. Stepwise radical endoscopic resection for eradication of Barrett’s oesophagus with early neoplasia in a cohort of 169 patients. Gut 2010; 59: 1169-1177
• 18 van Vilsteren FG, Pouw RE, Seewald S et al. Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett’s oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial. Gut 2011; 60: 765-773
• 19 Cao Y, Liao C, Tan A et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy 2009; 41: 751-757
• 20 Sgourakis G, Gockel I, Lang H. Endoscopic and surgical resection of T1a/T1b esophageal neoplasms: a systematic review. World J Gastroenterol 2013; 19: 1424-1437
• 21 Endoscopic Classification Review Group. Update on the Paris classification of superficial neoplastic lesions in the digestive tract. Endoscopy 2005; 37: 570-578
• 22 Sharma P, Dent J, Armstrong D et al. The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C & M criteria. Gastroenterology 2006; 131: 1392-1399
• 23 Schlemper RJ, Riddell RH, Kato Y et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut 2000; 47: 251-255
• 24 Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 2011; 14: 113-123
• 25 Yonemura Y, Endou Y, Tabachi K et al. Evaluation of lymphatic invasion in primary gastric cancer by a new monoclonal antibody, D2-40. Hum Pathol 2006; 37: 1193-1199
• 26 Kakushima N, Yahagi N, Fujishiro M et al. Efficacy and safety of endoscopic submucosal dissection for tumors of the esophagogastric junction. Endoscopy 2006; 38: 170-174
• 27 Neuhaus H, Terheggen G, Rutz EM et al. Endoscopic submucosal dissection plus radiofrequency ablation of neoplastic Barrett’s esophagus. Endoscopy 2012; 44: 1105-1113
• 28 Hoteya S, Matsui A, Iizuka T et al. Comparison of the clinicopathological characteristics and results of endoscopic submucosal dissection for esophagogastric junction and non-junctional cancers. Digestion 2013; 87: 29-33
• 29 Sato H, Inoue H, Kobayashi Y et al. Control of severe strictures after circumferential endoscopic submucosal dissection for esophageal carcinoma: oral steroid therapy with balloon dilation or balloon dilation alone. Gastrointest Endosc 2013; 78: 250-257
• 30 Alvarez Herrero L, Pouw RE, van Vilsteren FG et al. Safety and efficacy of multiband mucosectomy in 1060 resections in Barrett’s esophagus. Endoscopy 2011; 43: 177-183
• 31 Deprez PH, Bergman JJ, Meisner S et al. Current practice with endoscopic submucosal dissection in Europe: position statement from a panel of experts. Endoscopy 2010; 42: 853-858
• 32 Goda K, Singh R, Oda I et al. Current status of endoscopic diagnosis and treatment of superficial Barrett’s adenocarcinoma in Asia-Pacific region. Dig Endosc 2013; 25: 146-150
• 33 Komanduri S, Deprez PH, Atasoy A et al. Barrett’s esophagus: treatments of adenocarcinomas. Ann N Y Acad Sci 2011; 1232: 248-264
• 34 Takahashi H, Arimura Y, Masao H et al. Endoscopic submucosal dissection is superior to conventional endoscopic resection as a curative treatment for early squamous cell carcinoma of the esophagus (with video). Gastrointest Endosc 2010; 72: 255-264
• 35 Isomoto H, Yamaguchi N, Minami H et al. Management of complications associated with endoscopic submucosal dissection / endoscopic mucosal resection for esophageal cancer. Dig Endosc 2013; 25: 29-38
• 36 Kagemoto K, Oka S, Tanaka S et al. Clinical outcomes of endoscopic submucosal dissection for superficial Barrett’s adenocarcinoma. Gastrointest Endosc 2014; 80: 239-245
• 37 Boerwinkel DF, Swager A, Curvers WL et al. The clinical consequences of advanced imaging techniques in Barrett’s esophagus. Gastroenterology 2014; 146: 622-629
• 38 Anders M, Lucks Y, El-Masry MA et al. Subsquamous extension of intestinal metaplasia is detected in 98% of cases of neoplastic Barrett’s esophagus. Clin Gastroenterol Hepatol 2014; 12: 405-410
• 39 Nagata K, Shimizu M. Pathological evaluation of gastrointestinal endoscopic submucosal dissection materials based on Japanese guidelines. World J Gastrointest Endosc 2012; 4: 489-499
• 40 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
• 41 Orman ES, Li N, Shaheen NJ. Efficacy and durability of radiofrequency ablation for Barrett’s esophagus: systematic review and meta-analysis. Clin Gastroenterol Hepatol 2013; 11: 1245-1255
• 42 Chadwick G, Groene O, Markar SR et al. Systematic review comparing radiofrequency ablation and complete endoscopic resection in treating dysplastic Barrett’s esophagus: a critical assessment of histologic outcomes and adverse events. Gastrointest Endosc 2014; 79: 718-731
• 43 Peters FP, Kara MA, Rosmolen WD et al. Stepwise radical endoscopic resection is effective for complete removal of Barrett’s esophagus with early neoplasia: a prospective study. Am J Gastroenterol 2006; 101: 1449-1457
• 44 Tomizawa Y, Iyer PG, Wong Kee Song LM et al. Safety of endoscopic mucosal resection for Barrett’s esophagus. Am J Gastroenterol 2013; 108: 1440-1447
• 45 Pouw RE, Peters FP, Sempoux C et al. Stepwise radical endoscopic resection for Barrett’s esophagus with early neoplasia: report on a Brussels cohort. Endoscopy 2008; 40: 892-898
• 46 Ono S, Fujishiro M, Niimi K et al. Predictors of postoperative stricture after esophageal endoscopic submucosal dissection for superficial squamous cell neoplasms. Endoscopy 2009; 41: 661-665
• 47 Mizuta H, Nishimori I, Kuratani Y et al. Predictive factors for esophageal stenosis after endoscopic submucosal dissection for superficial esophageal cancer. Dis Esophagus 2009; 22: 626-631
• 48 Deprez PH. Esophageal strictures after extensive endoscopic resection: hope for a better outcome?. Gastrointest Endosc 2013; 78: 258-259
• 49 Van Den Eynde M, Jouret-Mourin A, Sempoux C et al. Endoscopic mucosal or submucosal resection of early neoplasia in Barrett’s esophagus after antireflux surgery. Gastrointest Endosc 2010; 72: 855-861