Post-EMR Surveillance of GE-Junction Mucosal Lesions with EUS

Abstract

Purpose: Introduction: Endoscopic mucosal resection (EMR) has become the standard of care for the endoscopic management of early neoplastic lesions of the GE-Junction. Lesions that are effectively removed with clear resection margins are uniformly felt to be endoscopic cures and are followed with surveillance endoscopies. The exact surveillance guidelines for following post-resection lesions are not well established. Case Report: A 52 y/o man with dyspepsia was found to have a GE-Junction nodule with high grade dsyplasia. EUS demonstrated that it was confined to the mucosa (T1 N0). EMR was done and the resected specimen showed carcinoma in situ with clear margins. Follow up endoscopies and biopsies were done at 2 and 5 months, and were normal without residual dysplasia. At that point, the patient was followed annually with surveillance EUS. At the 5 year surveillance EUS, the GE-Junction again appeared normal endoscopically with normal biopsies. EUS, however, revealed new local adenopathy, with a 1.3 cm perigastric LN, found to be adenocarcinoma by FNA. An oncologic evaluation showed no evidence of metastatic disease, or of a second primary. The patient underwent adjuvant chemotherapy, followed by an esophagectomy, with the pathology showing 8 of 23 LN's positive for disease, as well as a focus of adenocarcinoma in the peri-esophageal fat. Conclusion: The exact guidelines for following early GE-Junction neoplastic lesions which have been resected endoscopically are not well established. This case demonstrates that resected superficial T1 lesions can present with delayed local nodal spread in the absence of mucosal recurrence. This case suggests that resected neoplastic GE-Junction lesions should be followed for at least five years after endoscopic resection, and that EUS should be part of the surveillance to detect extraluminal recurrence.