Today’s Mistakes and Tomorrow’s Wisdom… in the Management of T1b Barrett’s Adenocarcinoma

Abstract

<b><i>Background:</i></b> Given the limitation that endoscopic resection only enables local intraluminal treatment without lymphadenectomy, the standard treatment of esophageal adenocarcinoma (EAC) with invasion of the submucosa (T1b) has long been surgical esophageal resection. However, in recent literature, the risk of lymph node metastases (LNM) associated with T1b EAC appears to be lower than previously assumed, and endoscopic management is increasingly being considered a valid and less invasive alternative to surgery. <b><i>Summary:</i></b> Surgical esophageal resection performed after radical endoscopic resection of T1b EAC often does not show any residual tumor or LNM in the resected specimen. Given the morbidity and mortality associated with surgical esophageal resection, endoscopic management with strict surveillance protocols has been more widely applied provided that the initial tumor was radically removed by endoscopic resection, reserving surgery for those cases where the additional risk of surgical esophageal resection is justified. These are the cases where intraluminal recurrent neoplasia is found that cannot be retreated endoscopically or cases with locoregional LNM detected during follow-up. In the future, selection of patients who can safely be managed endoscopically and those who may benefit from additional surgery after endoscopic resection of T1b EAC may become more tailored, using risk prediction calculators or sentinel node navigated surgery. <b><i>Key Messages:</i></b> Management of patients with T1b EAC is shifting from surgical treatment to less invasive endoscopic treatment strategies, including watchful waiting approaches. The risk of LNM of T1b EAC appears to be lower than long assumed. In the future, management of T1b EAC may become more individualized based on tools to predict LNM risk per patient case.

Unmet needs in Barret’s esophagus diagnosis and treatment: a narrative review

“…Patient preference and condition factor as well. T1b EAC may have less propensity for lymph node metastases than previously thought and therapy is shifting towards endoscopic resection for lower risk subjects and those who are not good surgical candidates; clinical trials are ongoing ( 61 , 62 ). Piecemeal EMR of larger lesions is problematic because of the significant recurrence rate and ESD is preferred ( 58 , 60 ).…”

Barrett’s Esophagus: Today’s Mistakes and Tomorrow’s Wisdom

“…However, novel insights have demonstrated that also in selected cases of T1b adenocarcinoma, endoscopic management may be a justified alternative to surgery, given a lower risk of lymph node metastases than previously assumed. Chan et al [10] discuss these novel insights in the management of T1b esophageal adenocarcinoma in Chapter 7.…”