EUS and EMR/ESD: Is EUS in patients with Barrett’s esophagus with high-grade dysplasia or intramucosal adenocarcinoma necessary prior to endoscopic mucosal resection?

The management of patients with HGD in BE remains controversial, largely because the natural history of this condition is so poorly defined. For example, Reid et al. reported a 59 % 5-yr cumulative cancer incidence among 76 patients with HGD in BE [1],whereas Schnell et al. found that only 12 (16 %) of their 75 patients with HGD developed adenocarcinoma during a mean follow-up period of 7.3 yr [2]. Four management options have been proposed for patients with HGD in BE: (1) esophagectomy, (2) endoscopic ablative therapies, (3) EMR, and (4) intensive endoscopic surveillance, in which invasive therapy is withheld until biopsy specimens show evidence of invasion [3]. Clearly, there are risks associated with all of these approaches, and all would benefit from accurate staging of the neoplasia.

References

• 1 Reid B J, Levine D S, Longton G. et al . Predictors of progression to cancer in Barrett’s esophagus: Baseline histology and flow cytometry identify low- and high-risk patient subsets.  Am J Gastroenterol. 2000;  95 1669-1676
• 2 Schnell T G, Sontag S J, Chejfec G. et al . Long-term nonsurgical management of Barrett’s esophagus with high-grade dysplasia.  Gastroenterology. 2001;  120 1607-1619
• 3 Spechler S J. Dysplasia in Barrett’s esophagus: Limitations of current management strategies.  Am J Gastroenterol. 2005;  100 927-935
• 4 Saitoh Y, Obara T, Einami K, Nomura M, Taruishi M, Ayabe T. et al . Efficacy of high-frequency ultrasound probes for the preoperative staging of invasion depth in flat and depressed colorectal tumors.  Gastrointest Endosc. 1996;  44 (1) 34-39
• 5 Murata Y, Suzuki S, Ohta M, Mitsunaga A, Hayashi K, Yoshida K. et al . Small ultrasonic probes for determination of the depth of superficial esophageal cancer.  Gastrointest Endosc. 1996;  44 (1) 23-28
• 6 Akahoshi K, Chijiiwa Y, Hamada S, Harada N, Nawata H. Endoscopic ultrasonography: a promising method for assessing the prospects of endoscopic mucosal resection in early gastric cancer.  Endoscopy. 1997;  29 (7) 614-619
• 7 Akahoshi K, Chijiwa Y, Hamada S, Sasaki I, Nawata H, Kabemura T. et al . Pretreatment staging of endoscopically early gastric cancer with a 15 MHz ultrasound catheter probe.  Gastrointest Endosc. 1998;  48 (5) 470-476
• 8 Murata Y, Suzuki S, Mitsunaga A, Iizuka Y, Uchiyama M, Uchida K. et al . Endoscopic ultrasonography in diagnosis and mucosal resection for early esophageal cancer.  Endoscopy. 1998;  30 (Suppl 1) A44-46
• 9 Kida M, Tanabe S, Watanabe M, Kokutou M, Kondou I, Yamada Y. et al . Staging of gastric cancer with endoscopic ultrasonography and endoscopic mucosal resection.  Endoscopy. 1998;  30 (Suppl 1) A64-68
• 10 Yanai H, Matsumoto Y, Harada T, Nishiaki M, Tokiyama H, Shigemitsu T. et al . Endoscopic ultrasonography and endoscopy for staging depth of invasion in early gastric cancer: a pilot study.  Gastrointest Endosc. 1997;  46 (3) 212-216
• 11 Rembacken B J, Gotoda T, Fujii T, Axon A T. Endoscopic mucosal resection.  Endoscopy. 2001;  33 (8) 709-718
• 12 Soetikno R M, Gotoda T, Nakanishi Y, Soehendra N. Endoscopic mucosal resection.  Gastrointest Endosc. 2003;  57 567 (4)-79
• 13 Kato H, Haga S, Endo S, Hashimoto M, Katsube T, Oi I. et al . Lifting of lesions during endoscopic mucosal resection (EMR) of early colorectal cancer: implications for the assessment of resectability.  Endoscopy. 2001;  33 (7) 568-573
• 14 Ishiguro A, Uno Y, Ishiguro Y, Munakata A, Morita T. Correlation of lifting versus non-lifting and microscopic depth of invasion in early colorectal cancer.  Gastrointest Endosc. 1999;  50 (3) 329-333
• 15 Uno Y, Munakata A. The non-lifting sign of invasive colon cancer.  Gastrointest Endosc. 1994;  40 (4) 485-489
• 16 Tada M. Endoscopic mucosal resection of the stomach: initial description.  Gastrointest Endosc Clin N Am. 2001;  11 (3) 499-510
• 17 Lightdale C J, Larghi A, Rotterdam H, Okpara N. Endoscopic ultrasonography (EUS) and endoscopic mucosal resection (EMR) for staging and treatment of high-grade dysplasia (HGD) and early adenocarcinoma (EAC) in Barrett"s esophagus (BE). Gastrointest Endosc (abstract AB90( 2004 59(5)
• 18 Falk G W, Catalano M F, Sivak Jr M V. et al . Endosonography in the evaluation of patients with Barrett’s esophagus and high-grade dysplasia.  Gastrointest Endosc. 1994;  40 207-212
• 19 Srivastava A K, Vanagunas A, Kamel P. et al . Endoscopio ultrasound in the evaluation of Barrett’s esophagus: A preliminary report.  Am J Gastroenterol. 1994;  89 2192-2195
• 20 Scotiniotis I A, Kochman M L, Lewis J D. et al . Accuracy of EUS in the evaluation of Barrett’s esophagus and high-grade dysplasia or intramucosal carcinoma.  Gastrointest Endosc. 2001;  54 689-696
• 21 Kimmey M B, Martin R W, Silverstein F E. Endoscopic ultrasound probes.  Gastrointest Endosc. 1990;  36 S40-46
• 22 Adrain A L, Ter H C, Cassidy M J. et al . High-resolution endoluminal sonography is a sensitive modality for the identification of Barrett’s metaplasia.  Gastrointest Endosc. 1997;  46 147-151
• 23 Waxman I, Raju G S, Critchlow J. et al .High-Frequency Probe Ultrasonography Has Limited Accuracy for Detecting Invasive Adenocarcinoma in Patients with Barrett’s Esophagus and High-Grade Dysplasia or Intramucosal Carcinoma: A Case Series. Am J of Gastroenterol 2006: (in press)
• 24 Parent J, Levine D S, Haggitt R C. et al . Role of endoscopic ultrasound in patients with Barrett’s esophagus and high grade dysplasia.  Gastrointest Endosc. 1997;  45 A76
• 25 May A, Gunter E, Roth F. et al . Accuracy of staging in early oesophageal cancer using high resolution endoscopy and high resolution endosonography: A comparative, prospective, and blinded trial.  Gut. 2004;  53 634-640
• 26 Shami V, Villaverde A, Stearns L. et al . Impact of EUS and EUS-FNA in patients with Barrett’s Esophagus and High-grade dysplasia or intramucosal adenocarcinoma referred for endoscopic therapy.  Endoscopy. 2006;  38 157-161
• 27 Bollschweiler E, Baldus S E, Schroder W. et al . High rate of lymph-node metastasis in submucosal esophageal squamous-cell carcinoma and adenocarcinoma.  Endoscopy. 2006;  38 149-156
• 28 Vieth M, Rosch T. Endoscopic mucosal resection and the risk of lymph-node metastases: Indications revisited.  Endoscopy. 2006;  38 175-179