Endoscopic Resection for Solitary Nodular Lesions After Ablation of Esophageal Dysplasia and Carcinoma

Abstract

Purpose: Nodular lesions in Barrett's esophagus [BE] are suspicious for harboring invasive carcinoma. Endoscopic resection [ER] is of diagnostic and therapeutic importance for the removal and histologic staging of these lesions. There are few data available, however, regarding the safety and utility of ER for nodular lesions detected at surveillance endoscopy after ablation therapy. Methods: After IRB approval, patients with solitary nodular lesions detected after ablation therapy were identified. Medical records were abstracted for demographics, pre-ablation histology and endoscopic ultrasound [EUS] findings, ablation technique and ER procedure details including complications and disease recurrence. Results: Twelve patients with solitary nodular lesions were identified between 2001-08 after previous endoscopic ablation using porfimer sodium photodynamic therapy (PsPDT) or radiofrequency ablation (RFA) (10 were men; mean age 72 years [range: 43-82]). PsPDT was performed for Barrett's high grade dysplasia (7 pts); esophageal adenocarcinoma (1 pt) and squamous cell carcinoma (1 pt), both T1N0MX by EUS staging. RFA was performed for Barrett's high grade dysplasia in 3 pts. At follow up endoscopy, (median 335 days after endoscopic ablation; range: 105-1843 days) nodular mucosa suspicious for disease recurrence was detected. EUS findings were T1sm1 or less in each case and pts were referred for ER that was successful in 11/12 patients using either Wilson Cook Duette or Olympus cap technique with no complications. ER was unsuccessful in one patient (no lift sign). ER specimen histopathology found BE-HGD (3 pts), T1m adenocarcinoma (3 pt) and benign, hypertrophic glandular mucosa (5 pts). ER findings prompted further therapy (repeat endoscopic ablation in 3 pts, esophageal resection surgery in 1 pt, and failed esophageal resection in 1 pt due to adhesions from a previous surgery). Mean follow up after successful ER and negative adenocarcinoma in need of surgical resection was 303 days (27-676 days) with no further complications or disease recurrence. The patient who had an attempted but unsuccessful EMR due to lack of lift sign was later found to have adenocarcinoma and underwent esophagectomy as repeat PsPDT followed by liquid nitrogen cryotherapy treatment was unsuccessful. Conclusion: In our series of patients with nodular lesions detected at surveillance endoscopy after endoscopic therapy for esophageal dysplasia or carcinoma, ER was safely performed in most patients (11/12) and detected dysplasia or carcinoma in 6/11 patients leading to further ablation therapy and surgery.