Endoscopic and Surgical Treatment of Mucosal (T1a) Esophageal Adenocarcinoma in Barrett's Esophagus

Abstract

Background and Aims Endoscopic therapy is emerging as an alternative to surgical therapy in patients with mucosal (T1a) esophageal adenocarcinoma (EAC) given the low likelihood of lymph node metastases. Long term outcomes of patients treated endoscopically and surgically for mucosal EAC are unknown. We compared long term outcomes of patients with mucosal EAC treated endoscopically and surgically. Methods Patients treated for mucosal EAC between 1998 and 2007 were included. Patients were divided into an ENDO group (treated endoscopically) and a SURG group (treated surgically). Vital status information was queried using an institutionally approved internet research and location service. Statistical analysis was performed using Kaplan Meier curves and Cox proportional hazards ratios. Results 176 patients were included of which 132 (74 %) were in the ENDO group and 46 (26 %) were in the SURG group. Mean follow up was 64 months (SEM 4.8) in the SURG group and 43 months (SEM 2.8) in the ENDO group. Cumulative mortality in the ENDO group (17%) was comparable to the SURG group (20 %) (p=0.75). Overall survival was also comparable using the Kaplan Meier method. Treatment modality was not a significant predictor of survival on multivariable analysis. Recurrent carcinoma was detected in 12% of patients in the ENDO group, all successfully re-treated without impact on overall survival. Conclusions Overall survival in patients with mucosal EAC when treated endoscopically appears to be comparable to that of patients treated surgically. Recurrent carcinoma occurs in a limited proportion of patients, but can be managed endoscopically.

Update on management of Barrett's esophagus

“…Endoscopic ablation of residual BE is currently recommended after completion of EMR of all visible HGD/T1a lesions. Several case series have reported recurrence of neoplasia if any residual BE is left untreated (11% to 30%, with a mean followup of 3 years) [32,58] , and ablation of the residual BE is associated with a lower recurrence [20,36,40,41,61,62] . Consequently, RFA is currently the best available technique for the treatment of flat HGD and for eradicating residual BE after EMR [3,29,63] .…”

“…Therefore, since HGD is not associated with metastatic nodal spread when the existence of a deeper invasion has been excluded by EMR, endoscopic treatment is preferred over surgery in most patients with BE and HGD [32,33,3840] . But, on the other hand, endoscopic therapies are associated with a higher rate of recurrence of the HGD [3234,38,41] , although it can usually be treated endoscopically [3234,42] . Because of that, surgical resection should be reserved until the endoscopic treatment fails [3234] .…”

Endoscopic diagnosis and therapies for Barrett esophagus: a review

“…Increasing surgeon experience may similarly favorably impact operative mortality (188)(189)(190)(191).…”

Epithelial mesenchymal transition and cancer stem cells in esophageal adenocarcinoma originating from Barrett’s esophagus

“…The pathology assessment was performed according to our protocol as previously published (14). The diagnosis of EAC was confirmed by at least two experienced gastrointestinal pathologists.…”