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Endoscopy 2007; 39(12): 1086-1091
DOI: 10.1055/s-2007-966788
Original article

© Georg Thieme Verlag KG Stuttgart · New York

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

A.  Larghi1 , C.  J.  Lightdale2 , A.  S.  Ross1 , P.  Fedi2 , J.  Hart3 , H.  Rotterdam4 , A.  Noffsinger3 , L.  Memeo4 , G.  Bhagat4 , I.  Waxman1
  • 1Section of Endoscopy and Therapeutics and the Cancer Research Center, The University of Chicago, Chicago, Illinois, USA
  • 2Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York, USA
  • 3Department of Pathology, The University of Chicago, Chicago, Illinois, USA
  • 4Department of Pathology, Columbia University, College of Physicians and Surgeons, New York, USA
Further Information

Publication History

submitted 16 July 2006

accepted after revision 11 June 2007

Publication Date:
15 August 2007 (online)

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Commentaire de travail de A. Larghi et al., pp. 1086Endoscopy 2007; 39(12): 86-87
DOI: 10.1055/s-0032-1308894

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
    CrossrefPubMedSearch in Google Scholar
  • 2 Sampliner R E. Managing Barrett’s esophagus: what is new in 2005?.  Dis Esophagus. 2005;  18 17-20
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 9 Pech O, May A, Gossner L. et al . Barrett’s esophagus: endoscopic resection.  Gastrointest Endosc Clin N Am. 2003;  13 505-512
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 37 Dye C, Kinney T, Chi K. et al . Holmium laser assisted mucosectomy (HLAM).  Gastrointest Endosc. 2004;  59 P90
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 40 Oyama T, Tomori A, Hotta K. et al . Endoscopic submucosal dissection of early esophageal cancer.  Clin Gastroenterol Hepatol. 2005;  3 S67-S70
    CrossrefPubMedSearch in Google Scholar
  • 41 Larghi A, Waxman I. Endoscopic mucosal resection: treatment of neoplasia.  Gastrointest Endosc Clin N Am. 2005;  15 431-454
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar

I. Waxman, MD

The University of Chicago, Section of Gastroenterology

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Email: iwaxman@medicine.bsd.uchicago.edu