Endoscopic submucosal dissection: evolving role and position in the management of Barrett’s neoplasia

Endoscopic mucosal resection (EMR) is an integral component of diagnosis, staging, and treatment of Barrett’s neoplasia [1]. EMR can cure the majority of T1a cancers [2]. Conversely, T1b cancers are considered to be better managed with esophagectomy owing to the risk of lymph node metastasis (LNM). Surgery has also been shown to improve overall survival compared with EMR for T1b tumors [3]. While the risk of LNM with T1a cancer is negligible, favoring endoscopic resection due to its low risk of morbidity and mortality, the risk of LNM for T1b cancer is not clear. Previous surgical series have reported an increasing rate of LNM based on invasion depth (sm1 0–22 %, sm2/3 36 %–54 %). However, recent studies based on endoscopic resection data report substantially lower LNM rates for submucosal cancer (0–14 %) [3] [4]. The risk of LNM compared with rates of surgical morbidity has so far dictated the management of T1b esophageal adenocarcinoma (EAC). Therefore, precise rates of LNM are required to guide individual management and this may require use of additional testing, including endoscopic ultrasound and cross-sectional imaging, in addition to precise histopathological assessment of the resected lesion.

“...we anticipate that endoscopic submucosal dissection may offer a curative role for many patients with submucosal esophageal adenocarcinoma (sm1–3) where it can achieve surgery-free cure.”

The role of endoscopic submucosal dissection (ESD) has been expanding in recent years, with data showing cure rates comparable to EMR while offering R0 resection [5]. In patients with Barrett’s esophagus (BE), ESD would be the preferred resection technique for lesions ≥ 30 mm, poorly lifting, and with endoscopic features concerning for submucosal invasion – situations in which EMR would yield suboptimal results. Frequent or piecemeal EMR also increases the risk for recurrence and fibrosis at the site, making future intervention difficult. ESD can decrease pathological uncertainty, achieve R0 resection, and avoid surgery (especially sm1 disease) [6]. However, ESD has a higher rate of adverse events compared with EMR, including the risk of perforation. ESD can also be time-consuming and has a steeper learning curve. Data for its role in sm2/3 disease, as well as for the true risk of LNM with sm2 /3, are limited. It also remains unclear which patients with submucosal invasion will benefit the most and whether they still need to undergo surgery if resection margins are positive (R1). In addition, ESD has not been compared with esophagectomy for T1b disease in a prospective study; however, surgery does offer certain advantages over endoscopic resection including potential surgical cure and ability to sample lymph nodes. The timing of subsequent follow-up after ESD remains uninvestigated as well.

In this issue of Endoscopy, Munster et al. [7] report data on 130 ESD cases (52 % T1b, 43 % T1a) from nine expert centers in the Netherlands, showing a 97 % en bloc resection rate. While the combined R0/en bloc rate was 87 % for T1a EAC, it was only 49 % for submucosal EAC (T1b). Persistent EAC was found in 11 patients (2 had sm1; 9 had sm2/3) at 6–8 weeks follow-up, and 5 underwent surgery. At the first follow-up endoscopy, 108 had no residual neoplasia and underwent follow-up (R1 9 months, R0 17 months), with no local recurrence and 7 metachronous lesions. The rate of immediate complications was low (perforation 1 %, bleeding 3 %) but strictures occurred in 13 %. While these data, which originate from high-volume centers and endoscopists with ESD expertise and in a patient cohort that includes T1a disease (or lower; ~50 %), appear promising, the findings highlight the evolving position of ESD for the management of T1b cancer. Should we start using ESD as the preferred approach over surgery for T1b EAC? While prospective comparison of ESD and surgery are required, ESD should have a role in the management of selected patients with submucosal EAC. Further data on the role of ESD for different invasion depths (sm1–3) and risk of disease progression are required to guide the management. Patients who have “low-risk features” in sm1 disease, are unfit for surgery, place a higher emphasis on quality of life, and accept a higher recurrence risk might prefer ESD over surgery ([Fig. 1]).

Fig. 1 Evolving management algorithm for Barrett’s neoplasia. EMR, endoscopic mucosal resection; ESD, endoscopic submucosal dissection; SM, submucosal invasion; EAC, esophageal adenocarcinoma; LVI, lymphovascular invasion; BET, Barrett’s endoscopic therapy; CE-IM, complete eradication of intestinal metaplasia; HGD, high grade dysplasia.

For further refining and defining of Barrett’s endoscopic therapy (BET), the role of ESD in submucosal invasive EAC (sm1–3) is an important area of research and a step toward minimally invasive BET being preferred over surgery. Just as BET, using a combination of EMR and mucosal ablation, has revolutionized the management of T1a disease by offering complete eradication of BE, we anticipate that ESD may offer a curative role for many patients with submucosal EAC (sm1–3) where it can achieve a surgery-free cure.

Publication History

Article published online:
16 February 2022

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