Mo1292 EFFICACY AND OUTCOMES OF ENDOSCOPIC MUCOSAL RESECTION IN T1B ESOPHAGEAL ADENOCARCINOMA: CAN ESOPHAGECTOMY BE AVOIDED IN SELECT PATIENTS?

Abstract

The incidence of esophageal adenocarcinoma (EAC) has continued to increase over the past several decades. While endoscopic mucosal resection (EMR) is highly effective for intramucosal EAC (T1a lesions), there is limited data on outcomes of patients following EMR with T1b EAC in the era of modern chemoradiation and cryotherapy modalities. While the current standard of care for T1b EAC relies on esophagectomy, with its high risk of morbidity and mortality, it remains uncertain whether select patients with T1b EAC can be definitively treated with EMR along with chemoradiation or additional endoscopic therapies. The aim of this study is to evaluate the outcomes of patients with T1b EAC after initial EMR. A retrospective cross-sectional study was performed using a prospective electronic endoscopy database at a tertiary care academic medical center. All patients who underwent esophageal EMR for T1b EAC between February 2015 and September 2019 were included. Data on patient and disease characteristics were collected. The primary outcome was presence of residual disease (local or metastatic) during follow-up. A total of 13 patients with T1b EAC who underwent EMR were identified. The mean age was 71 years and 85% were male. Seven of these patients (54%) underwent esophagectomy while 6 patients had endoscopic and clinical surveillance. Patients who underwent esophagectomy and endoscopic surveillance had similar characteristics except that patients who underwent esophagectomy had a lower Charlson comorbidity index (5.7 vs. 7.8, P = 0.04). In patients who underwent endoscopic surveillance, 67% were deemed too high-risk for surgery, while 33% refused surgery. Among the 6 patients who underwent endoscopic surveillance after EMR, 3 were additionally treated with cryotherapy, 1 was treated with radiofrequency ablation (RFA) and 1 underwent chemoradiation. One of these 6 patients was found to have residual disease at a mean follow-up of 478 days. Among the 7 patients who underwent esophagectomy after EMR, 3 (43%) had residual tumor on surgical pathology, however none of these 7 patients underwent chemoradiation prior to surgery. Of all 13 T1b EAC patients who underwent EMR, 69.2% (N = 9) had no evidence of subsequent residual disease with a follow-up of 739 days. None of the patients with residual disease underwent prior chemoradiation. These results suggest that select patients with T1b EAC who are at high-risk for esophagectomy may be successfully managed with local therapy of EMR followed by the addition of chemoradiation and alternative endoscopic treatment modalities. Further prospective studies are needed to validate these findings and guide optimal patient selection.View Large Image Figure ViewerDownload Hi-res image Download (PPT)