Early Barrett's Cancer Research Articles

Expert assessment of infiltration depth and recommendation of endoscopic resection technique in early Barrett cancer.

Early Barrett cancer can be curatively treated by endoscopic resection. The choice of the resection technique, however-endoscopic mucosal resection (EMR) or submucosal dissection (ESD)-largely depends on the assumed infiltration depth as judged by the endoscopist. However, the accuracy of endoscopic diagnosis of the degree of cancer infiltration is not known. Three to four high-quality images (both in overview and close-up) from 202 of early Barrett esophagus cancer cases (82% men, mean age 66.9years) were selected from our endoscopy database (73.3% stage T1a and 26.7% in stage T1b). Images were shown to 9 Barrett esophagus experts, with patients' clinical data (age, sex, Barrett esophagus length) and biopsy results. The experts were asked to predict infiltration depth (T1b vs. T1a), and to suggest the appropriate endoscopic resection technique (EMR or ESD, or surgery). Interobserver variability (kappa values) was also determined for these parameters. Overall positive (PPV) and negative predictive values (NPV) to diagnose T1b versus T1a infiltration were 40.7% (95% CI: 36.7, 44.8) and 79.8% (95% CI: 77.5, 81.9), respectively; kappa value was 0.41. Paris classification (kappa 0.51) and suggested treatment also varied between experts. In a post hoc analysis, only the correlation between lesions classified as invisible or flat according to the Paris classification (IIB; 25% of all cases) and the suggested resection technique was better: In this subgroup, EMR was recommended in >80% of cases, with a high complete (basal R0) resection rate (mean of 88.1%). Precise endoscopic distinction between mucosal and submucosal involvement of Barrett esophagus cancer by experts as a basis for choosing the resection technique has limited predictive values and high interobserver variability. It seems that mainly invisible/flat lesions may result in good resection outcomes when treated by EMR, but this stratification strategy has to be assessed in further studies.

Current status in Barrett's esophagus

Barrett's esophagus has been an important issue in clinical medicine for many years. In the 70 s of the last century, the association between gastroesophageal reflux disease and BE was detected. Only ten years later, the association between BE and adenocarcinoma of the esophagus was reported. Starting in the 90s in Europe, endoscopic resection and ablation have seen an expanding role in the management of BE. In analogy with other diseases, patients are undergoing individualized surveillance and treatment strategies. In non-neoplastic Barrett's esophagus, surveillance intervals are clearly defined by national and European guidelines. Only in case of malignant transformation of BE which may range from low-grade dysplasia to high-grade dysplasia and early Barrett's cancer, endoscopic therapy is indicated. At present, there are emerging techniques of artificial intelligence. Due to these rapid developments in BE management, it is important to keep an eye on the current status of BE management.

Quantitative analysis of submucosal excision depth in endoscopic resection for early Barrett's cancer.

BACKGROUND : Following endoscopic resection of early-stage Barrett's esophageal adenocarcinoma (BEA), further oncologic management then fundamentally relies upon the accurate assessment of histopathologic risk criteria, which requires there to be sufficient amounts of submucosal tissue in the resection specimens. METHODS : In 1685 digitized tissue sections from endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) performed for 76 early BEA cases from three experienced centers, the submucosal thickness was determined, using software developed in-house. Neoplastic lesions were manually annotated. RESULTS : No submucosa was seen in about a third of the entire resection area (mean 33.8 % [SD 17.2 %]), as well as underneath cancers (33.3 % [28.3 %]), with similar results for both resection methods and with respect to submucosal thickness. ESD results showed a greater variability between centers than EMR. In T1b cancers, a higher rate of submucosal defects tended to correlate with R1 resections. CONCLUSION : The absence of submucosa underneath about one third of the tissue of endoscopically resected BEAs should be improved. Results were more center-dependent for ESD than for EMR. Submucosal defects can potentially serve as a parameter for standardized reports.

Radiofrequency ablation for Barrett's esophagus-related neoplasia.

Barrett's esophagus (BE) is a premalignant condition associated with increased risk of developing esophageal adenocarcinoma. In the past, BE patients with high-grade intraepithelial neoplasia (IEN) or early adenocarcinoma (EAC) were indicated for esophagectomy. With the recent advance in endoscopy, endoscopic techniques have surpassed esophagectomy in the treatment of Barrett's esophagus-related neoplasia and minimized the treatment-related morbidity. Patients with IEN are candidates for endoscopic treatment - endoscopic mucosal resection (ER) of visible lesions and/or ablation therapy of flat Barrett's mucosa. ER combined with radiofrequency ablation (RFA) is now considered as a gold standard for treatment of patients with early Barrett's cancer. RFA is currently the most effective method of ablation used in the treatment of low-grade intraepithelial neoplasia/high-grade intraepithelial neoplasia without visible lesions and for ablation of residual Barrett's mucosa following ER/ESD of EAC or HGIN aiming to achieve complete eradication of Barrett's surface and thus, decreasing the risk of recurrent dysplasia or cancer. The rates of complete remission of neoplasia and metaplasia after completion of endoscopic treatment are 81-92.6% and 75-88.2%, respectively. The aim of this article is to review the principles, techniques, indications, efficacy and safety of this ablative method and surveillance of patients after successful treatment with RFA.

Predictive features for early cancer detection in Barrett's esophagus using Volumetric Laser Endomicroscopy

The incidence of Barrett cancer is increasing rapidly and current screening protocols often miss the disease at an early, treatable stage. Volumetric Laser Endomicroscopy (VLE) is a promising new tool for finding this type of cancer early, capturing a full circumferential scan of Barrett's Esophagus (BE), up to 3-mm depth. However, the interpretation of these VLE scans can be complicated, due to the large amount of cross-sectional images and the subtle grayscale variations. Therefore, algorithms for automated analysis of VLE data can offer a valuable contribution to its overall interpretation. In this study, we broadly investigate the potential of Computer-Aided Detection (CADe) for the identification of early Barrett's cancer using VLE. We employ a histopathologically validated set of ex-vivo VLE images for evaluating and comparing a considerable set of widely-used image features and machine learning algorithms. In addition, we show that incorporating clinical knowledge in feature design, leads to a superior classification performance and additional benefits, such as low complexity and fast computation time. Furthermore, we identify an optimal tissue depth for classification of 0.5–1.0 mm, and propose an extension to the evaluated features that exploits this phenomenon, improving their predictive properties for cancer detection in VLE data. Finally, we compare the performance of the CADe methods with the classification accuracy of two VLE experts. With a maximum Area Under the Curve (AUC) in the range of 0.90–0.93 for the evaluated features and machine learning methods versus an AUC of 0.81 for the medical experts, our experiments show that computer-aided methods can achieve a considerably better performance than trained human observers in the analysis of VLE data.

Submucosal invasion and risk of lymph node invasion in early Barrett's cancer: potential impact of different classification systems on patient management

Due to the high mortality and morbidity rates of esophagectomy, endoscopic mucosal resection (EMR) is increasingly used for the curative treatment of early low risk Barrett's adenocarcinoma. This retrospective cohort study aimed to assess the prevalence of lymph node metastases (LNM) in submucosal (T1b) esophageal adenocarcinomas (EAC) in relation to the absolute depth of submucosal tumor invasion and demonstrate the efficacy of EMR for low risk (well and moderately differentiated without lymphovascular invasion) EAC with sm1 invasion (submucosal invasion ≤500 µm) according to the Paris classification. The pathology reports of patients undergoing endoscopic resection and surgery from January 1994 until December 2013 at one center were reviewed and 54 patients with submucosal invasion were included. LNM were evaluated in surgical specimens and by follow up examinations in case of EMR. No LNM were observed in 10 patients with sm1 adenocarcinomas that underwent endoscopic resection. Three of them underwent supplementary endoscopic eradication therapy with a median follow up of 27 months for patients with sm1 tumors. In the surgical series two patients (29%) with sm1 invasion according to the pragmatic classification (subdivision of the submucosa into three equal thirds), staged as sm2-3 in the Paris classification, had LNM. The rate of LNM for surgical patients with low risk sm1 tumors was 10% according to the pragmatic classification and 0% according to Paris classification. Different classifications of the tumor invasion depth lead to different LNM risks and treatment strategies for sm1 adenocarcinomas. Patients with low risk sm1 adenocarcinomas appear to be suitable candidates for EMR.

Tu1568 EMR vs ESD for Early Barrett's Cancer: Is It a Case of Horses for Courses?

Tu1568 EMR vs ESD for Early Barrett's Cancer: Is It a Case of Horses for Courses?

Quality of life after operation for early Barrett's cancer: a prospective comparison of Ivor Lewis resection versus modified Merendino resection

Quality of life after operation for early Barrett's cancer: a prospective comparison of Ivor Lewis resection versus modified Merendino resection

Endoscopic submucosal dissection for superficial Barrett's esophageal cancer in the Japanese state and perspective.

The incidence of Barrett's esophageal cancer is one of the most rapidly increasing among all cancers in the West, and it is also expected to increase in Japan. The optimal treatment for early Barrett's esophageal cancer remains controversial. En bloc esophagectomy with regional lymph node dissection has been considered the standard therapy. Endoscopic therapies are currently being evaluated as alternatives to esophagectomy because they can provide the least postoperative morbidity and the best quality of life. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) allow for removal of visible lesions and histopathologic review of resected tissue, which help in diagnostic staging of the disease. EMR is limited with respect to resection size, and large lesions must be resected in several fragments. Piecemeal resection of lesions is associated with high local recurrence rates, probably because of minor remnants of neoplastic tissue being left in situ. ESD provides larger specimens than does EMR in patients with early Barrett's neoplasia. This in turn allows for more precise histological analysis and higher en bloc and curative resection rates, potentially reducing the incidence of recurrence. Detailed endoscopic examination to determine the invasion depth and spread of Barrett's esophageal cancer is essential before ESD. The initial inspection is usually conducted with white-light imaging followed by narrow-band imaging. The ESD procedure is similar to that for lesions in other parts of the gastrointestinal tract. However, the narrow space of the esophagogastric junction and contraction of the lower esophageal sphincter sometimes disturb the visual field and endoscopic control. Skilled endoscope handling, sometimes including retroflexion, is required during ESD for Barrett's esophageal cancer. Previous reports have shown that ESD achieves en bloc resection in >80% of lesions. Although promising short-term results are reported, a long-term, large-scale study is required for better understanding of ESD for Barrett's esophageal cancer.

Endoscopic Resection of a Flat (Type IIb) Early Barrett's Cancer with a Reusable Ligation Device

Endoscopic resection (ER) is an accepted curative treatment of early neoplastic lesions in Barrett's esophagus. Long-term results in large patient cohorts have shown excellent outcome and safety of ER in patients with high-grade dysplasia and mucosal cancer. ER can be performed either with a transparent cap at the tip of the endoscope or with a ligation device. Both methods have shown to be equivalent. This article is part of an expert video encyclopedia.

Argon Plasma Coagulation in Barrett's Esophagus

In the present case, thermal ablation of the Barrett's remainder by argon plasma coagulation (APC) is shown in a patient recently cured of early Barrett's cancer by endoscopic resection. Ablation is carried out in order to reduce the risk of metachronous neoplasia in the residual nonneoplastic Barrett's esophagus.APC is applied dynamically in longitudinal and circumferential stripes, and a wattage of 50 is used. In this patient, the Barrett's segment is completely ablated in one session. This article is part of an expert video encyclopedia.

Endoscopic Imaging of a Flat (Type IIb) Early Barrett's Cancer

A careful inspection of the esophagogastric junction is crucial in order to detect subtle neoplastic lesions in Barrett's esophagus. Advanced imaging techniques like virtual chromoendoscopy and acetic acid staining can be used to improve the detection of subtle neoplastic lesions. This article is part of an expert video encyclopedia.

Good handling and pathological examination of endoscopic resections of early Barrett's cancer

Handling and pathological examination of endoscopic resections of early Barrett's cancer is very important since it provides the basis for deciding whether subsequent surgical treatment is necessary or not. It is recommended that (i) the resected specimens should be unfolded and pinned to a cork mat; (ii) the margins of resection should be identified by marking with Indian ink, and (iii) the entire specimen must be strip-sectioned and embedded prior to histological evaluation.For the histological evaluation the following information is needed: (i) depth of infiltration, differentiated as m1–m4 and sm1–sm3; (ii) evaluation of the resection margins, lateral and deep (R0/R1); (iii) degree of differentiation (G1–G4) and (iv) invasion of lymphatic or blood vessels.Current information in the literature regarding the risk for regional lymphogenic metastatic spread identify ‘low risk’ as G1/G2, m1–m4 (possibly sm1 absent further risk factors), L0, V0, R0 and ‘high risk’ as G3/G4, sm2, sm3, L1, V1.

How is Early Barrett's Cancer Currently Diagnosed and Treated in Western Europe? Results of a Survey at 52 University Hospitals in Eight Western European Countries

Endoscopic treatment is increasingly being accepted for early Barrett's cancer (EBC), as it is associated with few complications, excellent long-term results, and almost no mortality. This study investigated current standards and treatment strategies for EBC in eight countries in Western Europe. A standardized questionnaire with questions on the endoscopic diagnosis, staging, and treatment of EBC was developed and sent to 107 university gastroenterology departments. The data were analyzed anonymously. The response rate was 49 % (52/107). For work-up of early Barrett's neoplasia, 67 % of hospitals use high-resolution endoscopes, with routine four-quadrant and targeted biopsies of visible lesions in 94 % of the cases. Narrow-band imaging and chromoendoscopy are used in 67 % of the cases, and other advanced imaging and staining techniques in 65 %. Before treatment, 63 % of the respondents recommended conventional endosonography, 6 % miniprobe endosonography, and 19 % both. Endoscopic resection is carried out at 98 % of the hospitals. Argon plasma coagulation is used for ablation in 52 % of the cases and radiofrequency ablation in 27 %. An 80-year-old patient with localized mucosal EBC would be treated endoscopically in all of the hospitals. Endoscopic therapy was recommended for 50-year-old patients with mucosal EBC by 87 % of the hospitals; esophageal resection was recommended for multifocal EBC by 15 % in 80-year-old patients, by 63 % in 50-year-old patients and by 44 % in patients with incipient submucosal infiltration. About two-thirds of the university hospitals use high-resolution endoscopy and advanced imaging. Endoscopic therapy is the accepted standard for treating localized mucosal Barrett's cancer in Western Europe; esophageal resection is recommended by the majority (63 %) for a young patient with multifocal EBC.

PWE-192 Efficacy and safety of extensive endomucosal resection for complete Barrett's eradication in early Barrett's neoplasia: a meta-analysis

IntroductionThe efficacy of complete Barrett's eradication by extensive endomucosal resection (E-EMR) of Barrett's oesophagus with early cancer ranges from 60% to 100% with a post-resection stricture rate of up to...

Tu1584 Early Barrett's Cancer With Invasion Into the Mid Third of the Submucosa (Sm2): Are We Really Beyond the External Frontier of Endoscopic Resection With a Curative Intent?

Endoscopic Resection (ER) is widely considered as the treatment of choice in early Barrett's cancer (EBC) limited to the mucosa. A prerequisite for any endoscopic treatment approach with a curative intent is a very low risk of lymph-node (LN) metastasis of the neoplastic lesion. Surgical series have indicated that there may be a relevant risk of LN metastasis in EBC invading at least the mid third of the submucosa (sm2).

Tu1635 Multimodality Endoscopic Therapy for Early Barrett's Cancer: A Single Center Experience

Tu1635 Multimodality Endoscopic Therapy for Early Barrett's Cancer: A Single Center Experience

Tu1580 Early Barrett's Cancer With Incipient Submucosal Invasion (SM1): Results of Endoscopic Resection and Surgery

Tu1580 Early Barrett's Cancer With Incipient Submucosal Invasion (SM1): Results of Endoscopic Resection and Surgery

Sa1544 How Is Early Barrett's Cancer Currently Diagnosed and Treated Throughout Western Europe? Results of a Survey At 107 University Hospitals in 8 Western European Countries

Endoscopic therapy (ET) of early Barrett's cancer (EBC) is gaining increasing acceptance because it is associated with a low complication rate and an almost absent mortality rate in combination with excellent long-term results. Radical surgical resection of the esophagus carries a significant risk for morbidity and mortality. Aim of this study was to investigate current standards and treatment strategies of early Barrett's cancer throughout Western Europe. A standardised questionnaire was developed consisting of 11 “multiple choice questions” asking for the respective hospital's diagnostic and therapeutic standard in patients with early Barrett's cancer. It included case histories with different stages of disease. The questionnaire was sent to the departments of gastroenterology at 108 University hospitals in 8 Western European countries. Data analysis was carried out anonymously. The percentage of returned questionnaires was 49% (52/107). Diagnostics: 94% of hospitals use quadrant-biopsies as well as targeted biopsies. NBI/FICE is utilised in 67% and other advanced imaging techniques in 65% (acetic acid and methylene blue staining). Prior treatment 63% of the hospitals recommend conventional endosonography (EUS), 6% are using miniprobe-EUS and 19% are combining both methods. Treatment: Endoscopic resection is carried out at 98% of all responding University hospitals. 80% are using argon plasma coagulation or radiofrequency ablation. Photodynamic therapy is only used in 32% of departments. An 80-year old patient with localised mucosal Barrett's carcinoma would be treated by 100% of polled hospitals endoscopically. However, ET in a 50-year old patient with mucosal EBC is recommended by 87%. In case of multifocal EBC 15% (80 year old patient) and 63% (50 year old patient) of all respondents, respectively, would recommend esophageal resection. By now ET is accepted as the therapeutic standard of localised mucosal Barrett's cancer in Western Europe. If there are multifocal lesions of mucosal Barrett's cancer the majority of the polled departments would still recommend surgical resection of the esophagus. The use of high-resolution endoscopes and of advanced imaging techniques is standard in most of the European academic GI departments.

Sa1527 Outcomes of Endoscopic Therapy in a Large Cohort of Patients With Barrett's Early Cancer With “Low-Risk” Submucosal Invasion

BackgroundEndoscopic resection (ER) may be associated with favourable outcomes not only in mucosal Barrett's cancer, but also in case of “low risk” submucosal Barrett's cancer which has been shown to carry a very low risk of lymph-node metastasis. Nevertheless, large clinical trials have not been reported up to now.MethodsFrom 1996 to 2010, the suspicion or definite diagnosis of Barrett's cancer with submucosal invasion was made in 240 patients referred to our department. Of those, 123 patients (104 male (85%), mean age 64±10 yrs) had submucosal cancer only invading the upper third of the submucosa (sm1 lesions). 67/123 patients (55%) fulfilled the definition of “low risk” sm1 cancer: absence of infiltration into lymphatic (nor blood) vessels, histological grade G1/2, and macroscopic type I/II. ET was carried out using ER with the suck-and-cut technique with/without additive ablation of non-neoplastic remnants of Barrett's esophagus.ResultsSix of the 67 patients (9%) were excluded from the analysis due to ongoing endoscopic treatment. 52 of the remaining 61 patients (85%) with low-risk sm1 cancer achieved complete remission by means of ER. During a mean follow-up of 49 months, metachronous lesions were found in 11 patients (16%). No tumor-related death occurred. In 9 of the 61 patients, tumor-freedom was not achieved, and the patients were referred to surgery or treated with a palliative intent if not suitable for surgery.ConclusionsIn the majority of patients with early Barrett's cancer showing “low-risk” submucosal invasion complete remission can be achieved by means of ER. BackgroundEndoscopic resection (ER) may be associated with favourable outcomes not only in mucosal Barrett's cancer, but also in case of “low risk” submucosal Barrett's cancer which has been shown to carry a very low risk of lymph-node metastasis. Nevertheless, large clinical trials have not been reported up to now. Endoscopic resection (ER) may be associated with favourable outcomes not only in mucosal Barrett's cancer, but also in case of “low risk” submucosal Barrett's cancer which has been shown to carry a very low risk of lymph-node metastasis. Nevertheless, large clinical trials have not been reported up to now. MethodsFrom 1996 to 2010, the suspicion or definite diagnosis of Barrett's cancer with submucosal invasion was made in 240 patients referred to our department. Of those, 123 patients (104 male (85%), mean age 64±10 yrs) had submucosal cancer only invading the upper third of the submucosa (sm1 lesions). 67/123 patients (55%) fulfilled the definition of “low risk” sm1 cancer: absence of infiltration into lymphatic (nor blood) vessels, histological grade G1/2, and macroscopic type I/II. ET was carried out using ER with the suck-and-cut technique with/without additive ablation of non-neoplastic remnants of Barrett's esophagus. From 1996 to 2010, the suspicion or definite diagnosis of Barrett's cancer with submucosal invasion was made in 240 patients referred to our department. Of those, 123 patients (104 male (85%), mean age 64±10 yrs) had submucosal cancer only invading the upper third of the submucosa (sm1 lesions). 67/123 patients (55%) fulfilled the definition of “low risk” sm1 cancer: absence of infiltration into lymphatic (nor blood) vessels, histological grade G1/2, and macroscopic type I/II. ET was carried out using ER with the suck-and-cut technique with/without additive ablation of non-neoplastic remnants of Barrett's esophagus. ResultsSix of the 67 patients (9%) were excluded from the analysis due to ongoing endoscopic treatment. 52 of the remaining 61 patients (85%) with low-risk sm1 cancer achieved complete remission by means of ER. During a mean follow-up of 49 months, metachronous lesions were found in 11 patients (16%). No tumor-related death occurred. In 9 of the 61 patients, tumor-freedom was not achieved, and the patients were referred to surgery or treated with a palliative intent if not suitable for surgery. Six of the 67 patients (9%) were excluded from the analysis due to ongoing endoscopic treatment. 52 of the remaining 61 patients (85%) with low-risk sm1 cancer achieved complete remission by means of ER. During a mean follow-up of 49 months, metachronous lesions were found in 11 patients (16%). No tumor-related death occurred. In 9 of the 61 patients, tumor-freedom was not achieved, and the patients were referred to surgery or treated with a palliative intent if not suitable for surgery. ConclusionsIn the majority of patients with early Barrett's cancer showing “low-risk” submucosal invasion complete remission can be achieved by means of ER. In the majority of patients with early Barrett's cancer showing “low-risk” submucosal invasion complete remission can be achieved by means of ER.