Single-Center-Erfahrung mit der Endoskopischen Submukosa-Dissektion (ESD) bei Barrett-Frühkarzinomen

Zusammenfassung

Einleitung: Derzeit stellen die endoskopische Mukosaresektion (EMR) bzw. die operative Therapie die Standardtherapieverfahren des Barrett-Frühkarzinoms dar. Ein neues endoskopisches Resektionsverfahren ist die endoskopische Submukosa-Dissektion (ESD). Diese wurde in Japan entwickelt und gewinnt weltweit zunehmend an Bedeutung. Die ESD ermöglicht im Gegensatz zur EMR eine En-bloc-Resektion von Läsionen größer 2 cm und eine komplette histologische Aufarbeitung des resezierten Präparates inklusive der Beurteilung der Resektionsränder. Die Erfahrungen mit der ESD bei Barrett-Frühkarzinomen sind in Deutschland noch sehr begrenzt. Ziel der vorliegenden Studie ist die Darstellung der Ergebnisse von 34 ESDs bei Vorliegen eines Barrett-Frühkarzinoms eines deutschen Endoskopiezentrums.

Material und Methodik: Zwischen November 2009 und August 2015 wurden 34 ESDs (30 Männer, 4 Frauen, mittleres Alter: 63,52 Jahre) bei Patenten mit einem Barrett-Frühkarzinom durchgeführt. Es wurde die technische Erfolgsrate, die Rate der En-bloc-, der R0- und der R0 En-bloc-Resektionen, die Komplikationsrate, die Rate kurativer endoskopischer ESDs sowie die lokale Rezidivrate im Follow-up ermittelt.

Ergebnisse: Die technische Erfolgsrate der ESD lag bei 100 %. Die postinterventionellen histologischen Ergebnisse ergaben 24 gut differenzierte und 6 mäßig differenzierte mukosale Barrett-Frühkarzinome sowie 4 Submukosakarzinome, davon 2 gut differenzierte und 2 mäßig differenzierte Barrett-Frühkarzinome. Die En-bloc-, R0-, R0 En-bloc- und die kurative Resektionsrate lag bei 97,1, 85,3, 85,3 bzw. 76,5 %. Die Komplikationsrate lag bei 17,6 % (n = 2 Blutungen, n = 1 Perforationen, n = 3 Stenosen nach zirkumferenzieller Resektion). Nach kurativer R0 En-bloc-Resektion betrug die Lokalrezidivrate nach einem mittleren Follow-up von 1,68 Jahren 8 %.

Diskussion: Die vorliegenden Daten unterstreichen trotz der kleinen Fallzahl und des bislang kurzen Follow-up die Wertigkeit der ESD in der Therapie von Barrett-Frühkarzinomen, insbesondere bei R0 En-bloc-Resektionen. Langzeitergebnisse dieser neuen Methode müssen jedoch abgewartet werden. Insbesondere ist bei vielfach unterminierendem Wachstum von Barrett-Frühkarzinomen auf einen ausreichenden Sicherheitsabstand zu achten. Aufgrund des technisch anspruchsvollen Eingriffes sollte die ESD von Barrett-Frühkarzinomen großen Endoskopiezentren vorbehalten bleiben.

Abstract

Introduction: So far endoscopic mucosal resection (EMR) or radical surgical resection are the standard treatment options for patients with early Barrett’s adenocarcinoma. Endoscopic submucosal dissection (ESD) of neoplastic lesions of the gastrointestinal tract is a rather new endoscopic technique, which was developed in Japan and becomes increasing importance. The ESD allows in contrast to EMR an endoscopic en-bloc resection of lesions greater than 2 cm with a complete histological evaluation of the resected specimen. In Germany the experience with ESD in patients with early Barrett’s carcinoma is still limited. Therefore the aim of the present study is to describe the results of 34 ESDs in patients with early Barrett’s carcinoma performed in a German tertiary referral center.

Material and methods: Between November 2009 and August 2015 ESDs were performed in 34 patients (30 men, 4 women; mean age 63.52 years) with histologically proven Barrett’s adenocarcinoma. Data were given for the en-bloc, the R0, the R0 en-bloc and the curative resection rate as well as for the complication and the local recurrence rate after a follow-up period.

Results: ESD was technically possible in all of the 34 patients. Thirty of the resected neoplastic lesions showed an adenocarcinoma limited to the mucosa. Of these lesions, 24 were histopathologically defined as well-differentiated adenocarcinoma and 6 as moderately differentiated adenocarcinoma based on a Barrett’s mucosa. In contrast only 4 of the resected lesions showed an adenocarcinoma with submucosal invasion. 2 were histopathologically defined as well-differentiated adenocarcinoma and 2 as moderately differentiated adenocarcinoma. The en-bloc, R0, R0 en-bloc and curative resection rates were 97.1 %, 85.3 %, 85.3 % resp. 76.5 %. Complication rate was 17.6 % (perforation n = 1, delayed bleeding n = 2, esophageal stenosis n = 3). In case of curative tumor resection only 2 local tumor recurrence (8 %) occurred after a medium follow-up of 1.68 years.

Discussion: Despite the small number of patients and a relatively short follow-up, the present data underline the value of ESD especially in case of curative resections in the definite as well as less invasive therapy of early Barrett´s carcinoma. Special attention should be drawn towards subsquamous extension of Barrett´s adenocarcinoma requiring a sufficient safety margin as an obligate condition for tumor-free lateral resection margins. Due to the required learning curve and the management of potential complications ESD should be restricted to greater endoscopic centers.

Schlüsselwörter

endoskopische Submukosa-Dissektion - ESD - Barrett-Frühkarzinome - endoskopische Tumorresektion

Key words

endoscopic submucosal dissection - ESD - early Barrett’s carcinoma - endoscopic tumor resection

• Literatur

• 1 Peitz U, Malfertheiner P. Barrett Carcinoma – Diagnosis, Screening, Surveillance, Endoscopic Treatment,Prevention. Z Gastroenterol 2007; 45: 1264-1272
• 2 Sharma P. Clinical practice. Barrett’s esophagus. N Engl J Med 2009; 361: 2548-2556
• 3 Sharma P, Falk G, Weston A et al. Dysplasia and Cancer in a Large Multicenter Cohort of Patients With Barrett’s Esophagus. Clin Gastroenterol Hepatol 2006; 4: 566-572
• 4 Kubo A, Corley D, Jensen C et al. Dietary factors and the risks of oesophageal adenocarcinoma and Barrett’s oesophagus. Nutr Res Rev 2010; 23 (02) 230-246
• 5 Pech O, Bollschweiler E, Manner H et al. Comparison between endoscopic and surgical resection of mucosal esophageal adenocarcinoma in Barrett´s esophagus at two high-volume centers. Ann Surg 2011; 254: 67-72
• 6 Probst A, Golder D, Arnholdt H et al. Endoscopic submucosal dissection of early cancers, flat adenomas, and submucosal tumors in the gastrointestinal tract. Clin Gastroenterol Hepatol 2009; 7: 149-155
• 7 Wang K, Prasad G, Tian J. Endoscopic mucosal resection and endoscopic submucosal dissection in esophageal and gastric cancers. Curr Opin Gastroenterol 2010; 26: 453-458
• 8 Yamamoto H, Sunada K. Successful en-bloc-resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small caliber-tip-transparent hood. Endoscopy 2003; 35: 690-694
• 9 Ono S, Fujishiro M, Koike K. Endoscopic submucosal dissection for superficial esophageal neoplasms. World J Gastrointest Endosc 2012; 4: 162-166
• 10 Miyamoto S, Muto M, Hamamoto Y et al. A new technique for endoscopic mucosal resection with an insulated-tip electrosurgical knife improves the completeness of resection of intramucosal gastric neoplasms. Gastrointest Endosc 2002; 55: 576-581
• 11 Hochberger J, Köhler P, Kruse E et al. Endoskopische Submukosadissektion. Internist 2013; 54: 287-301
• 12 Hongo M, Nagasaki Y, Shoji T. Epidemiology of esophageal cancer: Orient to Occident. Effects of chronology, geography and ethnicity. J Gastroenterol Hepatol 2009; 24: 729-735
• 13 Ell C, May A, Pech O et al. Curative endoscopic resection of early esophageal adenocarcinoma (Barrett’s cancer). Gastrointest Endosc 2007; 65: 3-10
• 14 Ell C, May A, Pech O et al. Curative Endoscopic Therapy in early Adenocarcinoma of the Esophagus. Dtsch Arztebl 2003; 21: 1438-1448
• 15 Pech O, May A, Manner H et al. Long-term Efficacy and Safety of Endoscopic Resection for Patients With Mucosal Adenocarcinoma of the Esophagus. Gastroenterology 2014; 146: 652-660
• 16 Chung A, Bourke M, Hourigan L et al. Complete Barrett's excision by stepwise endoscopic resection in short-segment disease: long term outcomes and predictors of stricture. Endoscopy 2011; 12: 1025-1032
• 17 Anders M, Bähr C, El-Masry M et al. Long-term recurrence of neoplasia and Barrett's epithelium after complete endoscopic resection. Gut 2014; 63: 1535-1543
• 18 Phoa K, Pouw R, van Vilsteren F et al. Remission of Barrett’s esophagus with early neoplasia 5 years after radiofrequency ablation with endoscopic resection: a Netherlands cohort study. Gastroenterology 2013; 145: 96-104
• 19 Gupta M, Iyer P, Lutzke L et al. Recurrence of esophageal intestinal metaplasia after endoscopic mucosal resection and radiofrequency ablation of Barrett's esophagus: results from a US Multicenter Consortium. Gastroenterology 2013; 145: 79-86
• 20 Pouw R, Wirths K, Eisendrath P et al. Efficacy of radiofrequency ablation combined with endoscopic resection for Barrett’s esophagus with early neoplasia. Clin Gastroenterol Hepatol 2010; 8: 23-29
• 21 Hirasawa K, Kokawa A, Oka H et al. Superficial adenocarcinoma of the esophagogastric junction: long-term results of endoscopic submucosal dissection. Gastrointest Endosc 2010; 72: 960-966
• 22 Kagemoto K, Oka S, Tanaka S et al. Clinical outcomes of endoscopic submucosal dissection for superficial Barrett’s adenocarcinoma. Gastrointest Endosc 2014; 80: 239-245
• 23 Probst A, Aust D, Märkl B et al. Early esophageal cancer in Europe: endoscopic treatment by endoscopic submucosal dissection. Endoscopy 2015; 47: 113-121
• 24 Chevaux J, Piessevaux H, Jouret-Mourin A et al. Clinical outcome in patients treated with endoscopic submucosal dissection for superficial Barrett’s neoplasia. Endoscopy 2015; 47: 103-112
• 25 Neuhaus H, Terheggen G, Rutz E et al. Endoscopic submucosal dissection plus radiofrequency ablation of neoplastic Barrett’s esophagus. Endoscopy 2012; 44: 1105-1113
• 26 Hoteya S, Matsui A, Iizuka T et al. Comparison of the clinicopathological characteristics and results of endoscopic submucosal dissection for esophagogastric junction and non-junctional cancers. Digestion 2013; 87: 29-33
• 27 Höbel S, Baumbach R, Dautel P et al. Single centre experience of endoscopic submucosal dissection (ESD) in premalignant and malignant gastrointestinal neoplasia. Z Gastroenterol 2014; 52: 193-199
• 28 Asano M. Endoscopic submucosal dissection and surgical treatment for gastrointestinal cancer. World J Gastrointest Endosc 2012; 4: 438-447
• 29 Anders M, Lucks Y, El-Masry M et al. Subsquamous extension of intestinal metaplasia is detected in 98% of cases of neoplastic Barrett’s esophagus. Clin Gastroenterol Hepatol 2014; 12: 405-410
• 30 Ono S, Fujishiro M, Niimi K et al. Long-term outcomes of endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms. Gastrointest Endosc 2009; 70: 860-866
• 31 Ishii N, Horiki N, Itoh T et al. Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife is a safe and effective treatment for superficial esophageal neoplasias. Surg Endosc 2010; 24: 335-342
• 32 Repici A, Hassan C, Carlino A et al. Endoscopic submucosal dissection in patients with early esophageal squamous cell carcinoma: results from a prospective Western series. Gastrointest Endosc 2010; 71: 715-721
• 33 Fujishiro M, Kodashima S. Indications, techniques, and outcomes of endoscopic submucosal dissection for esophageal squamous cell carcinoma. Esophagus 2009; 6: 143-148
• 34 Fujishiro M, Yahagi N, Kakushima N et al. Endoscopic submucosal dissection of esophageal squamous cell neoplasms. Clin Gastroenterol Hepatol 2006; 4: 688-694
• 35 Höbel S, Dautel P, Baumbach R et al. Single center experience of endoscopic submucosal dissection (ESD) in early Barrett’s adenocarcinoma. Surg Endosc 2015; 29: 1591-1597