Depth of resection using two different endoscopic mucosal resection techniques

Background and study aims: Endoscopic mucosal resection (EMR) has been carried out for high-grade dysplasia (HGD) and intramucosal carcinoma (IMCA) in Barrett’s esophagus using two different cap-assisted techniques, the ”inject, suck, and cut“ and the ”band and snare.“ Previous work has demonstrated comparable specimen diameters. However, the two techniques have not been previously compared with respect to depth of resection.

Patients and methods: From a database of patients with Barrett’s esophagus, we identified 40 consecutive specimens removed using EMR from patients with HGD or IMCA, 20 each from the ”inject, suck, and cut” and the ”band and snare” techniques. Specimens were evaluated and measured separately by two pathologists for greatest diameter and depth, and for the presence of submucosa and muscularis propria at the deepest margin of resection. Follow-up data were collected regarding clinical outcome and stricture formation.

Results: The mean depth of the specimens from the two techniques was not significantly different (0.51 cm vs. 0.50 cm, P = 0.76). All specimens contained substantial submucosa, allowing accurate staging of the neoplastic lesions resected. Muscularis propria was identified at the base of 65 % of the ”band and snare” and 50 % of the ”inject, suck, and cut” specimens (P = 0.52).

Conclusions: The ”inject, suck, and cut” and ”band and snare” techniques both yield equivalent adequate depth of histological specimens from Barrett’s esophagus with HGD or IMCA, and both provide accurate pathological staging.

References

• 1 Rouvelas I, Zeng W, Lindblad M. et al . Survival after surgery for oesophageal cancer: a population-based study.  Lancet Oncol. 2005;  6 864-870
• 2 Conio M, Cameron A J, Chak A. et al . Endoscopic treatment of high-grade dysplasia and early cancer in Barrett’s oesophagus.  Lancet Oncol. 2005;  6 311-321
• 3 Bergman J J. Diagnosis and therapy of early neoplasia in Barrett’s esophagus.  Curr Opin Gastroenterol. 2005;  21 466-471
• 4 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
• 5 Ell C, May A, Pech O. et al . Curative endoscopic resection of early esophageal adenocarcinomas (Barrett’s cancer).  Gastrointest Endosc. 2007;  65 3-10
• 6 Mariette C, Piessen G, Balon J M, V . et al . Surgery alone in the curative treatment of localised oesophageal carcinoma.  Eur J Surg Oncol. 2004;  30 869-876
• 7 Birkmeyer J D, Stukel T A, Siewers A E. et al . Surgeon volume and operative mortality in the United States.  N Engl J Med. 2003;  349 2117-2127
• 8 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
• 9 Bollschweiler E, Baldus S E, Schroder W. et al . High rate of lymph-node metastasis in submucosal esophageal squamous-cell carcinomas and adenocarcinomas.  Endoscopy. 2006;  38 149-156
• 10 Liu L, Hofstetter W L, Rashid A. et al . Significance of the depth of tumor invasion and lymph node metastasis in superficially invasive (T1) esophageal adenocarcinoma.  Am J Surg Pathol. 2005;  29 1079-1085
• 11 Eguchi T, Nakanishi Y, Shimoda T. et al . Histopathological criteria for additional treatment after endoscopic mucosal resection for esophageal cancer: analysis of 464 surgically resected cases.  Mod Pathol. 2006;  19 475-480
• 12 Ell C, May A, Gossner L. et al . Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett’s esophagus.  Gastroenterology. 2000;  118 670-677
• 13 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
• 14 Larghi A, Lightdale C J, Memeo L. et al . EUS followed by EMR for staging of high-grade dysplasia and early cancer in Barrett’s esophagus.  Gastrointest Endosc. 2005;  62 16-23
• 15 Inoue H. Endoscopic mucosal resection for the entire gastrointestinal mucosal lesions.  Gastrointest Endosc Clin North Am. 2001;  11 459-478
• 16 Conio M, Ponchon T, Blanchi S, Filiberti R. Endoscopic mucosal resection.  Am J Gastroenterol. 2006;  101 653-663
• 17 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
• 18 May A, Gossner L, Behrens A. et al . A prospective randomized trial of two different endoscopic resection techniques for early stage cancer of the esophagus.  Gastrointest Endosc. 2003;  58 167-175