Endoscopic eradication therapy for patients with Barrett’s esophagus–associated dysplasia and intramucosal cancer

Abstract

Barrett's esophagus (BE) is defined by the replacement of the normal squamous epithelium of the distal esophagus with metaplastic intestinal-type columnar epithelium. 1-3 BE is an adverse event of chronic GERD and the only identifiable premalignant condition for esophageal adenocarcinoma (EAC), a cancer that continues to increase in incidence. In 2014 there were approximately 18,170 incident cases of esophageal cancer in the United States, nearly 60% of which were EAC. [4][5][6] Although uncommon, EAC is a highly lethal cancer associated with a poor 5year survival rate of 15% to 20% and an overall median survival of <1 year in cases with advanced disease. [5][6][7] It is estimated that BE is present in 1% to 2% of the general adult population. 8,9 The stepwise and hypothesized progression of BE to invasive EAC is believed to occur through the histopathologic stages of intestinal metaplasia to low-grade dysplasia (LGD) to high-grade dysplasia (HGD) to intramucosal EAC and finally to invasive EAC. 3,[10][11][12][13] Endoscopic eradication therapy (EET) has significantly changed the management of patients with BE-related neoplasia and allows a minimally invasive treatment approach that avoids the morbidity and mortality associated with esophagectomy. Contemporary EET, supported by published literature, entails endoscopic mucosal resection (EMR) of visible lesions within the Barrett's segment and ablative techniques that include radiofrequency ablation (RFA) and cryotherapy. Several studies, including randomized controlled trials (RCTs), large observational studies, and population-based studies, have demonstrated the efficacy, effectiveness, and safety of EET to achieve complete eradication of intestinal metaplasia (CE-IM) and neoplasia while maintaining disease remission. [14][15][16][17][18][19][20][21][22] In addition, population-based studies report comparable outcomes between esophagectomy and EET in the management of BE-related HGD and mucosal EAC. 23 Available data suggest that EET is being performed not only at academic and tertiary care centers but also among community practices. 14,18 AIMS/SCOPEThe aim of this document is to offer evidence-based recommendations and clinical guidelines addressing key issues related to EET in the management of BE-related neoplasia. This document addresses the following clinical questions: 1. What is the role of confirmation of diagnosis by an expert GI pathologist or by a panel of pathologists in BE patients with dysplasia or intramucosal EAC referred for EET? 2. Comparing EET with surveillance, what is the optimal management strategy in BE patients with dysplasia (HGD and LGD) and intramucosal EAC? 3. Comparing EET with esophagectomy, what is the optimal management strategy in BE patients with HGD and intramucosal EAC? 4. What is the role of EMR in BE patients with a visible lesion detected during screening or surveillance? 5. What is the role of ablation of the remaining BE segment after EMR of all visible lesions in BE patients referred for EET? 6. Comparing EMR of visibl...

Treatment pattern and overall survival in esophageal cancer during a 13-year period: A nationwide cohort study of 6,354 Korean patients

“…Endoscopic resection for early esophageal cancer without lymphadenopathy is recommended as alternative to esophagectomy in The National Comprehensive Cancer Network (NCCN) guidelines and the Society of Thoracic Surgeons Guidelines. [6,7] Also NCCN for locally advanced esophageal SCC without distant metastasis recommends for definitive concurrent chemoradiotherapy (CCRT), neoadjucant therapy with surgery or esophagectomy alone. [6] However, health insurance databases or the KCCR are difficult to obtain detailed information regarding cancer stage, clinical characteristics, and treatment modality with outcomes.…”

Anatomic location of Barrett’s esophagus recurrence after endoscopic eradication therapy: development of a simplified surveillance biopsy strategy

“…Endoscopic eradication therapy (EET) is a safe and effective treatment for Barrett's esophagus (BE)-related dysplasia and intramucosal esophageal adenocarcinoma (EAC). [1][2][3][4] EET typically involves a combination of therapies including EMR to remove any areas of nodularity or visible focal lesions followed by radiofrequency ablation (RFA) to treat the remaining flat BE with the goal of achieving complete eradication of intestinal metaplasia (CE-IM). However, recurrence of IM, dysplasia, and/or EAC remains a challenge.…”

“…7 Based on this well-established risk of recurrence after achieving CE-IM, current guidelines recommend that these patients undergo surveillance endoscopies at regular intervals. [1][2][3] During endoscopy, sampling of any visible lesions followed by systematic, 4-quadrant random biopsy sampling every 1 to 2 cm through the length of the original BE segment is suggested. 2,3 These random biopsy specimens serve to identify nonvisible recurrence, which may include microscopic foci of BE or "buried" or subsquamous BE.…”

“…[1][2][3] During endoscopy, sampling of any visible lesions followed by systematic, 4-quadrant random biopsy sampling every 1 to 2 cm through the length of the original BE segment is suggested. 2,3 These random biopsy specimens serve to identify nonvisible recurrence, which may include microscopic foci of BE or "buried" or subsquamous BE. However, the current tissue sampling protocols are based on expert opinion only.…”

Endoscopic submucosal dissection is associated with less pathologic uncertainty than endoscopic mucosal resection in diagnosing and staging Barrett's‐related neoplasia

“…In patients with BN, endoscopic resection is the preferred therapeutic approach . While both endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have demonstrated similar efficacy in removal of neoplastic lesions in the esophagus, significant controversy exists over the preferred resection technique and there is a paucity of direct comparisons between the two for the treatment of BN . Several authors have demonstrated no technical advantage of ESD vs. EMR while noting higher rates of complications .…”