Early Barrett's Cancer Research Articles

Sentinel node detection in Barrett's and cardia cancer.

Because of surveillance strategies in patients with known Barrett's esophagus, more patients with high-grade dysplasia or early cancer in the distal esophagus and at the esophagogastric junction are identified. The need for and extent of lymphadenectomy in such patients are controversial. The technique of sentinel lymph node dissection (SLND) to diagnose early lymphatic spread is applied increasingly in tumors of the gastrointestinal tract. The poorly defined lymphatic drainage of the esophagogastric junction has so far prevented many investigators from performing SLND in tumors of this anatomic region. We report the first results of SLND in Barrett's and cardia cancer. The preliminary experience indicates that the method is, even in this anatomical area, feasible and yields good results in early tumors. In advanced tumors, the method lacks sensitivity. Mapping should be done with blue dye and a radiocolloid. The concept of sentinel lymph node mapping and detection thus may open the door to individualized therapy for patients with high-grade dysplasia in a Barrett's esophagus or with early Barrett's and cardia cancer.

Approach to early Barrett's cancer.

Because of effective surveillance programs in patients with known Barrett's esophagus, adenocarcinoma of the distal esophagus is increasingly diagnosed at early stages. With the introduction of limited surgical and endoscopic treatment modalities, the need for radical esophagectomy and extensive lymphadenectomy in such patients has been questioned. When selecting the approach to early Barrett's cancer, the precancerous nature of the underlying Barrett's esophagus, the frequent multicentricity of neoplastic alterations within the Barrett mucosa, the inaccuracy of current staging modalities, and the presence of lymph node metastases should be taken into account. Invasiveness and morbidity of the procedures, as well as quality of life aspects, should also be considered. From an oncologic point of view the minimum extent of a resection for early Barrett's cancer should include a full-thickness removal of the entire segment of the distal esophagus covered by intestinal metaplasia together with a regional lymphadenectomy. In appropriately selected patients this can be achieved by a limited surgical procedure involving transhiatal resection of the distal esophagus, but not by endoscopic mucosal ablation or endoscopic mucosa resection. Our experience with 49 limited surgical resections with regional lymphadenectomy indicates that this procedure is oncologically adequate and safe. Reconstruction with an interposed jejunal loop prevents postoperative gastroesophageal reflux and is associated with good quality of life. In contrast, endoscopic interventions are plagued by a high tumor recurrence rate, probably from persistence of Barrett's mucosa and gastroesophageal reflux.

Pattern of lymphatic spread of Barrett's cancer.

As in squamous cell esophageal cancer, the presence and number of lymph node metastases constitutes the major prognostic factor in patients with adenocarcinoma of the distal esophagus (the so-called Barrett's cancer) who have had complete tumor resection (R0 resection). In contrast to squamous cell esophageal cancer, however, lymphatic spread in patients with Barrett's cancer appears to follow certain rules. Lymphatic spread is closely correlated with the pT category of the primary tumor; it starts only after infiltration of the basal membrane, and initially it is limited to the regional lymph nodes. Lymph node metastases at distant locations-i.e., the upper mediastinum and the celiac axis-are found almost exclusively in patients with multiple positive regional nodes. Skipping of regional lymph node stations occurs in less than 5% of the patients. These observations set the stage for individualized and tailored lymphadenectomy strategies. The sentinel lymphadenectomy concept may be applicable to patients with early Barrett's cancer.

Barrett's esophagus: endoscopic resection.

In experienced hands, ER is a safe method of resecting dysplastic lesions and early carcinomas of the GI tract, and it has decisive advantages compared with other local endoscopic treatment procedures (such as thermal destruction and PDT). The opportunity for histological processing of the resected specimen provides information regarding the depth of invasion of the individual layers of the GI tract wall. Additionally, it has advantages regarding excision with healthy margins. This means that even when there is infiltration of the submucosa that has not been detected before treatment--in which case local endoscopic therapy is no longer appropriate--a patient with early Barrett's cancer still is able to undergo surgical resection. As was shown recently, the morbidity and mortality of ER are significantly dependent on the frequency with which esophagectomy is performed in each center. When there were more than 20 procedures of this type per year, the surgical mortality was 8%, whereas in centers conducting fewer than 10 procedures per year the rate was 21%. In view of the consequent claim that ER should only be performed at high-volume centers, curative endoscopic treatment of early esophageal carcinomas also should be performed only in centers with a similar frequency to that of the surgical high-volume centers. It is only in these conditions that the conclusion is defensible that patients with HGIN or mucosal Barrett's carcinoma should undergo ER with curative intent instead of radical ER. Randomized and controlled studies comparing radical esophagectomy with endoscopic therapy are desirable, but they are difficult to conduct, not least because valid 5-year survival data show no significant difference between patients who have undergone endoscopic treatment for early Barrett's cancers and the average German population of the same age and sex.

Endoscopic mucosal resection for early adenocarcinoma arising in Barrett's esophagus

A 58‐year‐old man was diagnosed to have an esophageal adenocarcinoma arising in Barrett's esophagus by screening examination at the previous hospital. Endoscopically, a slightly reddish elevated lesion with a central depressed component was detected in the Barrett's epithelium. Endoscopic ultrasonography showed the thickness of the second layer of the esophagus and no enlarged lymph node. Histological examination of a biopsy specimen revealed well or moderately differentiated adenocarcinoma. From these findings, the lesion was diagnosed as a mucosal esophageal cancer, type IIa + IIc, arising in Barrett's esophagus. As he refused operation, the lesion was resected endoscopically with his informed consent. Histologically, the resected specimens showed moderately differentiated adenocarcinoma arising in Barrett's esophagus. The adenocarcinoma had invaded the superficial muscularis mucosa, but was limited to the deep one with no vessel invasion. Barrett's esophagus often has a double muscularis mucosa. Connective tissues containing vascular and lymphatic vessels exist between them. However, one consideration is whether the existence of vessels between the double muscularis mucosa and the presence of vessel invasion are risk factors for metastasis. In order for a definitive indication for endoscopic mucosal resection, the frequency of lymph node and distant metastasis in cases of early Barrett's cancer needs to be investigated.

Endoscopic Mucosal Resection for High-Grade Dysplasia and Early Barrett's Cancer

The therapeutic approach to patients with Barrett's esophagus (BE) and related high-grade dysplasia (HGD) or early cancer remains problematic.

3514 ENDOSCOPIC MUCOSAL RESECTION OF EARLY CANCER AND HIGH GRADE DYSPLASIA IN BARRETT'S ESOPHAGUS.

Introduction: In the view of the mortality and morbidity rate of esophagectomy and the relatively large group of inoperable patients local therapeutic techniques for high grade dysplasias (HGD) and early Barrett's cancer (EC) are required. Patients&Method: From 10/96 to 4/99 in Wiesbaden 96 Pat. with proven HGD and/or EC in Barrett's esophagus were treated by means of a local therapy after carefull staging (Video-endoscopy including chromoendoscopy, if necessary photodynamic diagnostics, biopsies from all visible lesions and quadrant biopsies every 2 cm, conventional endosonography as well as 20MHz-probe, abdominal ultrasound, X-ray of the thorax, CT of the thorax and upper abdomen). In 64/96 patients EMR was performed. These 64 pat. were divided into 2 groups: group A (n=35) fulfilled "low-risk"-criteria: mucosal lesion, diameter up to 20mm; macroscopic type I, IIa, IIb, IIc and histological grading G1-G2 or HGD. The remaining 29 patients were included in group B ("high risk"). Results: Totally, 120 resections were performed without technical problems. The mean number of treatment sessions per patient was 1.3±0.6 in group A and 2.8±2.0 in group B (p<0.0005). Only one major complication in form of a spurting bleeding was seen, which could be managed endoscopically, no perforation occurred. Complete local remission (CLR) was significantly (p=0.008) earlier achieved in group A than group B. Up to now complete remission was achieved in 97% in group A and in 59% in group B, but 1 resp. 9 patients are still under therapy or the first control has to be expected, so the CLR will be probably higher. During the mean follow-up period of 12±8 months recurrent or metachronous carcinomas were seen in 14%. Conclusions: Mucosectomy of Barrett's early carcinomas shows a promising low morbidity and mortality. Mucosectomy might offer a new minimally invasive therapeutic alternative to esophagectomy especially in "low risk" situations. A comparison with surgery remains to be done until long-term results are available.

Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett's esophagus

Background & Aims: In view of the mortality and morbidity rates of esophagectomy and the relatively large group of inoperable patients, local therapeutic techniques are required for high-grade dysplasia and early Barrett's cancer. Methods: A prospective investigation of endoscopic mucosal resection was conducted in 64 patients (mean age, 65 ± 10 years) who had early carcinoma (61 patients) or high-grade dysplasia (3 patients) in Barrett's esophagus. Thirty-five patients met the criteria for low risk: macroscopic types I, IIa, IIb, and IIc; lesion diameter up to 20 mm; mucosal lesion; and histological grades G1 and G2 and/or high-grade dysplasia (group A). The remaining 29 patients were included in group B (high risk). Results: A total of 120 resections were performed, with no technical problems encountered. The mean number of treatment sessions per patient was 1.3 ± 0.6 in group A and 2.8 ± 2.0 in group B ( P < 0.0005). Only one major complication occurred, a case of spurting bleeding, which was managed endoscopically. Complete local remission was achieved significantly earlier ( P = 0.008) in group A than in group B. In May 1999, complete remission had been achieved in 97% of the patients in group A and in 59% of those in group B; however, 1 patient in group A and 9 in group B are still undergoing treatment or awaiting the first check-up. During a mean follow-up of 12 ± 8 months, recurrent or metachronous carcinomas were found in 14%. Conclusions: Endoscopic mucosal resection of early carcinoma in Barrett's esophagus is associated with promisingly low morbidity and mortality rates. The procedure may offer a new minimally invasive therapeutic alternative to esophagectomy, especially in low-risk situations. Comparisons with surgical results will need to be done when the long-term results of this procedure become available. GASTROENTEROLOGY 2000;118:670-677

Extent of resection and lymphadenectomy in early Barrett's cancer.

The recognition of Barrett's esophagus as a premalignant condition has led to aggressive endoscopic screening protocols aimed at detecting adenocarcinoma in this organ. This policy has resulted in an increasing number of patients who present with 'early Barrett's cancer'. In the existing literature, very little data address patients with these lesions and, therefore, no consistent definition of early Barrett's cancer currently exists. Additionally, the extent of resection and lymphadenectomy that should be performed is not known. We define early Barrett's cancer as clinical T1N0M0 adenocarcinoma. We perform en bloc esophagectomy with radical lymphadenectomy for these lesions because current data suggest that a more radical operation may improve survival in patients with esophageal cancer. It is also the only way to stage adequately the tumour and is associated with morbidity and mortality rates comparable to less radical, 'standard' resections in experienced hands. Barrett's esophagus is associated with invasive adenocarcinoma in 40% of patients who undergo esophagectomy for the preoperative diagnosis of high-grade dysplasia. The existing literature suggests these lesions may represent the earliest subset of Barrett's cancer and that a standard, less radical resection may suffice for these patients.