New Options for the Therapy of Barrett’s High-Grade Dysplasia and Intramucosal Adenocarcinoma: Endoscopic Mucosal Resection and Ablation versus Vagal-Sparing Esophagectomy

Abstract

Adenocarcinoma of the esophagus has the fastest rising incidence of any cancer in the United States and develops as a consequence of chronic gastroesophageal reflux disease [1]. Barrett’s esophagus is the precursor lesion from which adenocarcinoma develops, and surveillance programs have led to the detection of highgrade dysplasia and early-stage adenocarcinoma in an increasing number of patients. High-grade dysplasia and intramucosal adenocarcinoma, although potentially lethal, are both curable lesions in most patients [2‐4]; however, cure is dependent on complete removal of the neoplastic tissue. Until recently, this was reliably accomplished only with esophagectomy, but new technologies have been developed that allow endoscopic mucosal resection and ablation with preservation of the esophagus. The aim of this article is to explore current options for the management of Barrett’s high-grade dysplasia and intramucosal adenocarcinoma. The first fundamental issue in the treatment of highgrade dysplasia and intramucosal adenocarcinoma is to cure the patient of the disease. Patients with only highgrade dysplasia are uniformly cured with esophagectomy because invasive cancer has not developed and will not develop after removal of all of the Barrett’s mucosa. However, a number of surgical series have demonstrated that despite extensive pre-resection biopsies, in 30% to 50% of patients thought only to have high-grade dysplasia, the resected specimen will in fact have an invasive cancer [5, 6]. In the absence of a visible ulcer or nodule on endoscopy, these occult adenocarcinomas have always been limited to the mucosa in our experience [5]. In contrast, if a lesion of any sort is seen endoscopically within the columnar-lined portion of the esophagus, that lesion is at high risk to be a cancer. Further, any visible lesion that on biopsy shows adenocarcinoma cannot be assumed to be limited to the mucosa, regardless of the size or appearance of the lesion. Even very small lesions may penetrate into the submucosa, thus the endoscopic appearance of the lesion cannot be used to determine the T stage. It was hoped that endoscopic ultrasound imaging would allow accurate determination of intramucosal vs submucosal tumor invasion, but even high-frequency 20-MHz probes have not provided acceptable differentiation of these lesions [7]. The only method currently able to accurately determine the depth of invasion of a small visible lesion is endoscopic mucosal resection. This technique enables endoscopic excision of lesions sized up to 1.5 cm along with the adjacent mucosa and submucosa down to the muscularis propria and thereby allows the precise depth of invasion of the tumor to be pathologically determined. We have previously shown the accuracy of endoscopic resection as a staging procedure for early esophageal cancer, and we use it routinely for patients with a visible lesion within the Barrett’s mucosa [8].