Long-term follow-up of complete Barrett’s eradication endoscopic mucosal resection (CBE-EMR) for the treatment of high grade dysplasia and intramucosal carcinoma

Background and study aims: In patients with Barrett’s esophagus (BE), targeted endoscopic mucosal resection (EMR) of visible lesions of high grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC) is effective, but carries the risk of leaving in place synchronous lesions and Barrett’s epithelium with the potential for recurrent disease. We evaluated the safety and long-term efficacy of complete Barrett’s eradication EMR (CBE-EMR) for the treatment of patients with HGD or IMC, independently of the presence of macroscopically visible lesions or surgical risk.

Patients and methods: 26 consecutive patients with BE and HGD or IMC underwent CBE-EMRs, which were performed with the endoscopic cap suction method and/or a 2.3-mm monofilament mucosectomy snare. Endoscopic follow up after completion of resection was carried out to assess the rate of residual or recurrent BE with or without HGD or IMC.

Results: 24 patients completed the study. They underwent a total of 44 EMR sessions with a median of 3 pieces (range 1-8) removed per session. Two patients with immediate bleeding were successfully managed endoscopically. Three patients developed an early esophageal stricture that was completely resolved with a single endoscopic dilation. After a median follow-up of 28 months (range 15-51 months), persistent endoscopic and histologic eradication of BE was demonstrated in 21 patients (87.5 %). In two patients, Barrett’s epithelium was detected beneath the neosquamous epithelium 3 months after completion of the resection. In the remaining patient, IMC was found in a nodule seen and removed by EMR at 12-month surveillance endoscopy.

Conclusions: CBE-EMR is a safe and highly effective long-term treatment that should be offered to all patients with Barrett’s esophagus with HGD and IMC.

References

• 1 Shaheen N J. Advances in Barrett’s esophagus and esophageal adenocarcinoma.  Gastroenterology. 2005;  128 1554-1566
• 2 Sampliner R E. Managing Barrett’s esophagus: what is new in 2005?.  Dis Esophagus. 2005;  18 17-20
• 3 Heitmiller R F, Redmond M, Hamilton S R. Barrett’s esophagus with high-grade dysplasia. An indication for prophylactic esophagectomy.  Ann Surg. 1996;  224 66-71
• 4 Holscher A H, Bollschweiler E, Schroder W. et al . Prognostic differences between early squamous-cell and adenocarcinoma of the esophagus.  Dis Esophagus. 1997;  10 179-184
• 5 Birkmeyer J D, Siewers A E, Finlayson E V. et al . Hospital volume and surgical mortality in the United States.  N Engl J Med. 2002;  346 1128-1137
• 6 O’Connor J B, Falk G W, Richter J E. The incidence of adenocarcinoma and dysplasia in Barrett’s esophagus: report on the Cleveland Clinic Barrett’s Esophagus Registry.  Am J Gastroenterol. 1999;  94 2037-2042
• 7 Hulscher J B, van Sandick J W, de Boer A G. et al . Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.  N Engl J Med 2002. 21;  347 1662-1669
• 8 Kitajima M, Kitagawa Y. Surgical treatment of esophageal cancer. The advent of the era of individualization.  N Engl J Med. 2002;  347 1705-1709
• 9 Pech O, May A, Gossner L. et al . Barrett’s esophagus: endoscopic resection.  Gastrointest Endosc Clin N Am. 2003;  13 505-512
• 10 Ell C, May A, Gossner L, Pech O. et al . Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett’s esophagus.  Gastroenterology. 2000;  118 670-677
• 11 Nijhawan P K, Wang K K. Endoscopic mucosal resection for lesions with endoscopic features suggestive of malignancy and high-grade dysplasia within Barrett’s esophagus.  Gastrointest Endosc. 2000;  52 328-332
• 12 Waxman I, Saitoh Y. Clinical outcome of endoscopic mucosal resection for superficial GI lesions and the role of high-frequency US probe sonography in an American population.  Gastroenterol Endosc. 2000;  52 322-327
• 13 Buttar N S, Wang K K, Lutzke L S. et al . Combined endoscopic mucosal resection and photodynamic therapy for esophageal neoplasia within Barrett’s esophagus.  Gastrointest Endosc. 2001;  54 682-688
• 14 May A, Gossner L, Pech O. et al . Intraepithelial high-grade neoplasia and early adenocarcinoma in short-segment Barrett’s esophagus (SSBE): curative treatment using local endoscopic treatment techniques.  Endoscopy. 2002;  34 604-610
• 15 May A, Gossner L, Pech O. et al . Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett’s oesophagus: acute-phase and intermediate results of a new treatment approach.  Eur J Gastroenterol Hepatol. 2002;  14 1085-1091
• 16 Pacifico R J, Wang K K, Wongkeesong L. et al . Combined endoscopic mucosal resection and photodynamic therapy versus esophagectomy for management of early adenocarcinoma in Barrett’s esophagus.  Clin Gastroenterol Hepatol. 2003;  1 252-257
• 17 Peters F P, Kara M A, Rosmolen W D. et al . Endoscopic treatment of high-grade dysplasia and early stage cancer in Barrett’s esophagus.  Gastrointest Endosc. 2005;  61 506-514
• 18 Larghi A, Lightdale J C, Memeo L. et al . Endoscopic ultrasonography followed by endoscopic mucosal resection for staging of high-grade dysplasia and early adenocarcinoma in Barrett’s esophagus.  Gastrointest Endosc. 2005;  62 16-23
• 19 Mino-Kenudson M, Brugge W R, Puricelli W P. et al . Management of superficial Barrett’s epithelium-related neoplasms by endoscopic mucosal resection: clinicopathologic analysis of 27 cases.  Am J Surg Pathol. 2005;  29 680-686
• 20 Ell C, May A, Pech O. et al . Curative endoscopic resection of early esophageal adenocarcinomas (Barrett’s cancer).  Gastrointest Endosc. 2007;  65 3-10
• 21 Seewald S, Akaraviputh T, Seitz U. et al . Circumferential EMR and complete removal of Barrett’s epithelium: a new approach to management of Barrett’s esophagus containing high-grade intraepithelial neoplasia and intramucosal carcinoma.  Gastrointest Endosc. 2003;  57 854-859
• 22 Giovannini M, Bories E, Pesenti C. et al . Circumferential endoscopic mucosal resection in Barrett’s esophagus with high-grade intraepithelial neoplasia or mucosal cancer. Preliminary results in 21 patients.  Endoscopy. 2004;  36 782-787
• 23 Peters F P, Kara M A, Rosmolen W D. et al . Stepwise radical endoscopic resection is effective for complete removal of Barrett’s esophagus with early neoplasia: a prospective study.  Am J Gastroenterol. 2006;  101 1449-1457
• 24 Inoue H, Takeshita K, Hori H. et al . Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach, and colon mucosal lesions.  Gastrointest Endosc. 1993;  39 58-62
• 25 Soehendra N, Binmoeller K F, Bohnacker S. et al . Endoscopic snare mucosectomy in the esophagus without any additional equipment: a simple technique for resection of flat early cancer.  Endoscopy. 1997;  29 380-383
• 26 Heitmiller R F, Redmond M, Hamilton S R. Barrett’s esophagus with high-grade dysplasia. An indication for prophylactic esophagectomy.  Ann Surg. 1996;  224 66-71
• 27 Cameron A J, Carpenter H A. Barrett’s esophagus, high-grade dysplasia, and early adenocarcinoma: a pathological study.  Am J Gastroenterol. 1997;  92 586-591
• 28 Falk G W, Rice T W, Goldblum J R. et al . Jumbo biopsy forceps protocol still misses unsuspected cancer in Barrett’s esophagus with high-grade dysplasia.  Gastrointest Endosc. 1999;  49 170-176
• 29 Rice T W, Zuccaro Jr G, Adelstein D J. et al . Esophageal carcinoma: depth of tumor invasion is predictive of regional lymph node status.  Ann Thorac Surg. 1998;  65 787-792
• 30 Nigro J J, Hagen J A, DeMeester T R. et al . Prevalence and location of nodal metastases in distal esophageal adenocarcinoma confined to the wall: implications for therapy.  J Thorac Cardiovasc Surg. 1999;  117 16-23
• 31 Stein H J, Feith M, Mueller J. et al . Limited resection for early adenocarcinoma in Barrett’s esophagus.  Ann Surg. 2000;  232 733-742
• 32 Buskens C J, Westerterp M, Lagarde S M. et al . Prediction of appropriateness of local endoscopic treatment for high-grade dysplasia and early adenocarcinoma by EUS and histopathologic features.  Gastrointest Endosc. 2004;  60 703-710
• 33 Seewald S, Groth S, Brand B. et al . Circumferential EMR - future endoscopic management of HGIN and IMC in Barrett’s esophagus? Preliminary results of an ongoing study.  Gastrointest Endosc. 2004;  5 AB101
• 34 Macey N, Le Dreau G, Volant A. et al . Adenocarcinoma of the esophago-gastric junction arising after endoscopic laser photocoagulation ablation of the short segment of Barrett’s esophagus.  Gastroenterol Clin Biol. 2001;  25 204-206
• 35 Shand A, Dallal H, Palmer K. et al . Adenocarcinoma arising in columnar lined oesophagus following treatment with argon plasma coagulation.  Gut. 2001;  48 580-581
• 36 van Hillegersberg R, Haringsma J, ten Kate F J. et al . Invasive carcinoma after endoscopic ablative therapy for high-grade dysplasia in Barrett’s oesophagus.  Dig Surg. 2003;  20 440-444
• 37 Dye C, Kinney T, Chi K. et al . Holmium laser assisted mucosectomy (HLAM).  Gastrointest Endosc. 2004;  59 P90
• 38 Rajan E, Gostout C J, Feitoza A B. et al . Widespread EMR: a new technique for removal of large areas of mucosa.  Gastrointest Endosc. 2004;  60 623-627
• 39 Rosch T, Sarbia M, Schumacher B. et al . Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series.  Endoscopy. 2004;  36 788-801
• 40 Oyama T, Tomori A, Hotta K. et al . Endoscopic submucosal dissection of early esophageal cancer.  Clin Gastroenterol Hepatol. 2005;  3 S67-S70
• 41 Larghi A, Waxman I. Endoscopic mucosal resection: treatment of neoplasia.  Gastrointest Endosc Clin N Am. 2005;  15 431-454
• 42 Soehendra N, Seewald S, Groth S. et al . Use of modified multiband ligator facilitates circumferential EMR in Barrett’s esophagus.  Gastrointest Endosc. 2006;  63 847-852
• 43 Katada C, Muto M, Manabe T. et al . Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions.  Gastrointest Endosc. 2003;  57 165-169
• 44 Rajan E, Gostout C, Feitoza A. et al . Widespread endoscopic mucosal resection of the esophagus with strategies for stricture prevention: a preclinical study.  Endoscopy. 2005;  37 1111-1115