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

Abstract

Background & Aims Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have demonstrated similar efficacy in removal of neoplastic esophageal lesions. However, significant controversy exists over the preferred resection technique. Our primary aim was to compare the pathologic specimens produced via EMR and ESD and secondarily gauge their effect on clinical decision making and patient outcomes. Methods Using a retrospective cohort study design, all esophageal Barrett's‐associated neoplastic lesions resected by a single provider from 2012 to 2017 were reviewed. The pathology was re‐reviewed by two blinded authors for diagnosis, margins, and adverse outcomes and recurrence rates were also collected. Results Thirty‐one EMR and 20 ESD cases were identified. Baseline demographics and lesion characteristics were similar. ESD produced more R0 resections and more en bloc resections compared to EMR. EMR produced more equivocal lateral (13/31, 41.9% vs 1/20, 5.0%) and vertical margins (13/31, 41.9% vs. 0/20, 0%, both P < 0.05). This led to an inability to reach a definitive diagnosis in 13/31 EMR vs 0/20 ESD pathology specimens (P = 0.003). Of the 13 EMR specimens with equivocal pathology, 11 were noted to have ‘at least intramucosal adenocarcinoma’. Four of the 11 patients chose to undergo elective esophagectomy with final surgical pathology demonstrating ≤T1a disease in 2, and ≥T1b disease in two. Conclusion Compared to ESD, EMR was associated with greater pathologic uncertainty in Barrett's‐associated neoplasia.

Endoscopic management of Barrett's esophagus: Western perspective of current status and future prospects

“…38 ESD has the additional advantage of carrying superior definitive staging of lesions as it commonly eliminates the pathological uncertainty associated with EMR specimens. 39 It is widely accepted that ESD is more technically demanding and the learning curve to competency is longer. Lessons may be learned by the West from Asia where the learning process is shorter, likely owing to a higher proportion of easier gastric cases and structured tutoring.…”

Endoscopic submucosal dissection for esophageal neoplasia in the West: Are we there yet?

“…A recent study has further called into question the diagnostic accuracy of EMR in BE neoplasia, inasmuch as nearly one third of EMR specimens resulted in equivocal pathologic results with the dreaded diagnosis of "at least intramucosal adenocarcinoma" compared with none with ESD. 4 These findings have profound clinical implications because diagnostic uncertainty can potentially lead to unnecessary esophagectomy in otherwise endoscopically curable disease.…”

“…Importantly, it should be noted that incomplete resection with EMR is not strictly related to piecemeal removal of large lesions, given that equivocal deep resection margins due to limited submucosa or snare-related electrocautery artifact have been reported for EMR of lesions <15 mm. 4 Has esophageal ESD supplanted EMR in the West? Not quite.…”

“…We should not underestimate this because these recurrences can develop into postcolonoscopy colorectal cancer (PCCRC) when SC adherence is suboptimal. [2][3][4][5] Second, short-interval SC is needed after p-EMR to reduce recurrence (5.7% at 6 months and 2.4% at 18 months) but seems insignificant after e-EMR (2.0% at 6 months and 1.0% at 18 months). Therefore, e-EMR prevents recurrence and,…”

Response

“…We should not underestimate this because these recurrences can develop into postcolonoscopy colorectal cancer (PCCRC) when SC adherence is suboptimal. [2][3][4][5] Second, short-interval SC is needed after p-EMR to reduce recurrence (5.7% at 6 months and 2.4% at 18 months) but seems insignificant after e-EMR (2.0% at 6 months and 1.0% at 18 months). Therefore, e-EMR prevents recurrence and,…”