Transcript Barrett’s Esophagus and EAC

Endoscopic Management of Barrett’s HighGrade Dysplasia and Early Stage
Esophageal Adenocarcinoma
A literature Review
James L. Wise, MD
Duluth MN
Early Esophageal Adenocarcinoma
with Submucosal Invasion
A literature Review
James L Wise, MD Duluth MN
Background: Esophageal
Adenocarcinoma (EAC)
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Incidence 16,400 cases of esophageal cancer
10,000 cases are EAC
EAC 5 year survival ≤ 15%
Early stage EAC in Barrett’s Esophagus can be
managed endoscopically.
• Several papers detailing the experience in
relatively large cohorts have just been published
in recent years.
• These papers are discussed in the following
slides.
Early EAC with “Low Risk” Submucosal
Invasion
• 80 patients with EUS suspicion or diagnosis of SM stage
EAC.
• Stage defined by EMR/EUS/CT or Surgical resection.
• 21/80 “low risk”: no lymphovascular invasion, low grade
histology, macroscopic type (Japanese criteria both).
• Using EMR on these 19 pts with low risk SM a “CR” was
achieved in 18/19 patients, one died of non-EAC cause.
• Mean of 2.9 EM resections. Mean follow up 5.3 months.
• 5 patients had recurrent or metachronous carcinomas
(25%) 4/5 patients underwent recurrent ET with success
1) Manner H, May A, Pech O, Gossner L, Rabenstein T, Günter E, Vieth M, Stolte
M, Ell C. Early Barrett's carcinoma with "low-risk" submucosal invasion: long-term
results of endoscopic resection with a curative intent. Am J Gastroenterol. 2008
Oct;103(10):2589-97. Epub 2008 Sep 10. 18785950 [uid]
EMR of HGD/ Early EAC for
staging and Benefit
• 75 consecutive pt with HGD/EAC underwent EMR
prospectively.
• EMR for flat, ulcerated, nodular, irregular mucosa.
• Pre-EMR staging for lesions >2.0
• EMR with clear margins were considered for Complete
Barrett’s eradication (CBE)
• CBE for those with who were deemed suitable (3 cm or
less of BE, age ≤ 75, “minimal” comorbidities)
• Those not suitable anyof the above were refered for
surgery or followed if not surgical candidation
2) Moss A, Bourke MJ, Hourigan LF, Gupta S, Williams SJ, Tran K, Swan MP, Hopper
AD, Kwan V, Bailey AA. Endoscopic resection for Barrett's high-grade dysplasia and
early esophageal adenocarcinoma: an essential staging procedure with long-term
therapeutic benefit. Am J Gastroenterol. 2010 Jun;105(6):1276-83. Epub 2010 Feb
23.
20179694 [uid]
EMR of HGD/ Early EAC for
staging and Benefit
• EMR changed grade or stage in 50% (mostly up-staged
early lesions).
• EMR “techinically” successful in 100%
• 3/7 with SM stage underwent esophagectomy.
• 4/7 with SM had a combination of EMR and adjuvant
radiotherapy
• EMR/CBE Complications: 7 with Bleeding, 1 aspiration,
2 with pain, 6 strictures.
• No deaths related to EAC in this cohort.
• Without CBE 23% developed metachronous lesions (3
HGD and 5 EAC)
Moss et Al. Am J Gastro 2010 105:1276-1283
EMR of HGD/ Early EAC for staging
and Benefit
Biopsy proven HGD/EAC
Unsuitable for EMR
Suitable for EMR
EUS Staging
≥ T2
T1N0
EMR
SM invasion
HGD or EAC
Suitable for CBE
Refer to Surgery
Unfit for Surgery
LGD (Repeat Bx)
Not Suitable for CBE
Repeat EMR
XRT+EMR
Moss et Al. Am J Gastro 2010 105:1276-1283
RFA
Radical eradication EMR for HGD
and EAC
• 169 patients in 4 European centers retrospect
• < 5cm BE with early neoplasia not infiltrating
deep SM
• Took T1sm1 stage for endoscopic therapy
meeting G1/G2 histology , no LVI.
• Had eradication with EMR and stepwise radical
mucosal resection (SRMR)
Pouw, RE et al. Gut 2010; 59:1169-77
Radical eradication EMR for HGD
and EAC
• 100% of worst histology was on 1st EMR.
• 7, T1sm1 cancers were effectively treated using
EMR and SRMR.
• One patient died from metastatic adenoCa.
97.6% survival 50% stricture Rate from SRMR.
• APC utilized EMR techniques varied between
centers
3) Pouw RE, Seewald S, Alvarez Herrero L, Sondermeijer CM, Visser M, Ten Kate FJ, Yu
Kim Teng KC, Soehendra N, Rösch T, Weusten BL, Bergman JJ.
Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett's
oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial. Gut.
2011 Jun;60(6):765-73. Epub 2011 Jan 5. 21209124 [uid]
Depth of Mucosal invasion Does Not
Predict Lymph Node Mets
• 1997-2007 retrospective path review
• 80 underwent esophagectomy for HGD/EAC
• Tumors invading muscularis propria and intramucosal tumors were excluded
• Any patient who had neoadjuvant or radiation
treatment were excluded.
• SM1 = Invasion into upper third of SM
• SM2/3 = Invasion into the 2nd third or into the
deep 3rd
4) Badreddine RJ, Prasad GA, Lewis JT, Lutzke LS, Borkenhagen LS, Dunagan
KT, Wang KK. Depth of submucosal invasion does not predict lymph node
metastasis and survival of patients with esophageal carcinoma. Clin Gastroenterol
Hepatol. 2010 Mar;8(3):248-53. Epub 2009 Nov 27. 19948247[uid]
Depth of Mucosal invasion Does Not
Predict Lymph Node Mets
• Roughly 30% SM1 and 70% SM2/3
• SM1 12.9% with LN mets, where SM2/3 20%
with LN mets. (NS)
• LVI: SM1 32% and SM2/3 35% (NS)
• Recurrent cancer SM1 9.6%, SM2 8.2% (NS)
• Identical 5 year overall and cancer free survival
comparing SM1 to SM2/3 groups.
4) Badreddine RJ, Prasad GA, Lewis JT, Lutzke LS, Borkenhagen LS, Dunagan
KT, Wang KK. Depth of submucosal invasion does not predict lymph node
metastasis and survival of patients with esophageal carcinoma. Clin Gastroenterol
Hepatol. 2010 Mar;8(3):248-53. Epub 2009 Nov 27. 19948247[uid]
Cause of Death With SM1 vs SM2/3
Cause of
Death
Recurrence
Post op Comp
Cardiac
SM1 (10)
SM2/3 (21)
3 (30%)
2 (20%)
2 (20%)
5 (23%)
5 (23%)
3 (14%)
Pulmonary
Lung Ca
Head/Neck Ca
Sepsis
2 (20%)
0
0
1 (10%)
5 (23%)
1 (4%)
1 (4%)
1 (4)
4) Badreddine RJ, Prasad GA, Lewis JT, Lutzke LS, Borkenhagen LS, Dunagan
KT, Wang KK. Depth of submucosal invasion does not predict lymph node
metastasis and survival of patients with esophageal carcinoma. Clin Gastroenterol
Hepatol. 2010 Mar;8(3):248-53. Epub 2009 Nov 27. 19948247[uid]
Depth of Mucosal invasion Does
Not Predict Lymph Node Mets
• Endoscopic therapy not advised for tumors
involving SM in operative candidates.
• Esophagectomy is a morbid procedure with
significant peri-operative mortality in this patient
population.
• ?role of adjuvant therapy in the non-operative
candidate.
4) Badreddine RJ, Prasad GA, Lewis JT, Lutzke LS, Borkenhagen LS, Dunagan
KT, Wang KK. Depth of submucosal invasion does not predict lymph node
metastasis and survival of patients with esophageal carcinoma. Clin Gastroenterol
Hepatol. 2010 Mar;8(3):248-53. Epub 2009 Nov 27. 19948247[uid]
Conclusions
• Submucosal Adenocarcinoma is a controversial
stage in caring for patients with Early EAC.
• European studies used Japanese pathologic
criteria for low risk T1sm1 lesions
• If T1 sm-1,2,or,3 at EMR consider surgery vs
adjuvant radiotherapy in non-surgical
candidates.
• The high rates of metachronous neoplasia in
these patients suggest a role for complete
Barrett’s eradication.
T1b lesion GE junction with EMR