Low Rate of Invasive Cancer in Patients Undergoing Mucosectomy for Barrett's Esophagus (BE) and High Grade Dysplasia (HGD) Or Intramucosal Carcinoma (IMC)

Abstract

Background: The literature reports vastly different rates of invasive esophageal adenocarcinoma (IEAC) discovered at esophagectomy in patients with Barrett's esophagus (BE) and high-grade dysplasia (HGD) and often approximates a rate of around 40%. Our analysis of the literature using strict pathological definitions revealed a prevalence of occult IEAC at 12%. [1] The risk of occult IEAC in patients with BE with HGD and intramucosal carcinoma (IMC) is critical to properly evaluate options as endoscopic treatments emerge for BE. Aim: To determine the prevalence of IEAC in patients who underwent complete Barrett's eradication endoscopic mucosal resection (CBE-EMR) for BE with HGD or IMC in order to assess the rate of occult IEAC with current endoscopic technology. Methods: A retrospective analysis of a prospective database of all patients undergoing CBE-EMR at a single tertiary center was performed. We define IEAC as tumor with submucosal invasion or beyond. Non-visible lesions are those not detected with white light endoscopy. Results: 44 patients (34 male) with BE with HGD or IMC underwent CBE-EMR from August 1, 2003 to November 15, 2007. 25 patients had short segment BE, and 20 had no visible lesion. 13 patients had IMC, and the rest had HGD. IEAC was found in EMR specimens in 6.8% (3) of the patients. 2 patients had evidence of submucosal invasion and 1 had evidence of IMC with mucosal lymphatic invasion; these patients were referred for esophagectomy. All IEAC patients had visible lesions seen on endoscopy. None of the patients with non-visible lesions had IEAC. 21 patients have completed the CBE-EMR treatment and are in surveillance; no cases of IEAC have been identified during intensive endoscopic surveillance (median remission time 18 months, up to 51 months). One patient died of unrelated causes. 18 patients are still undergoing CBE-EMR treatment; however, no additional cases of invasive adenocarcinoma have been identified. Conclusions: In BE patients presenting with HGD or IMC, our series demonstrates a rate of occult IEAC at 6.8% in the resection specimens. Furthermore, in the absence of visible lesions, the prevalence was 0%. Further work should clarify what factors, such as visible lesions, improve the diagnosis of IEAC. EMR appears to be a promising treatment modality for BE with HGD or IMC since EMR is less invasive than esophagectomy, and still provides pathologic specimens to gauge success or need for further treatment. [1] Konda, Ross, Ferguson, et al. Is the Risk of Concomitant Invasive Esophageal Cancer in High Grade Dysplasia in Barrett's Esophagus Overestimated? Clin Gastroenterol Hepatol. In press.