Endoscopic Mucosal Ablation Research Articles

A case of esophageal cancer with chronic renal failure undergoing hemodialysis treatment showing long-term complete response with docetaxel chemotherapy and salvage endoscopic treatment

Chemotherapy for hemodialysis patients is not yet well codified, and the selection of individual patients remains difficult. We report the case of a 71-year-old hemodialyzed man who was successfully treated with docetaxel for squamous cell carcinoma of the esophagus. He had received radiotherapy for squamous cell carcinoma of the esophagus 6 years earlier. Metachronous esophageal cancer had developed at the upper third of the esophagus. He was treated tri-weekly with docetaxel at a dose of 60 mg/body in combination with hemodialysis three times a week. He achieved complete response after five cycles of chemotherapy. A small elevated lesion was diagnosed at the anal edge of the scar 26 months after initial treatment, and endoscopic mucosal resection and ablation was performed. Chemotherapy with docetaxel was continued up to 50 months without significant toxicity. The patient died of infection resulting from diabetic gangrene at 60 months after the initial chemotherapy, but no signs of recurrence have been observed until then. Docetaxel may be an effective anticancer agent for patients undergoing hemodialysis.

Review: Diagnosis and management of Barrett’s esophagus for the endoscopist

In Barrett's esophagus, the stratified squamous epithelium lining the esophagus is replaced by specialized intestinal-type columnar epithelium. The prevalence of Barrett's esophagus has ranged from 0.9% to 4.5%. The rate of progression from Barrett's esophagus to esophageal adenocarcinoma is 0.5% per patient-year. Proton-pump inhibitors are the mainstay of symptom control in Barrett's patients. Nondysplastic Barrett's and Barrett's with low-grade dysplasia (LGD) are typically managed by periodic surveillance. Radiofrequency ablation is being evaluated as a modality for managing nondysplastic Barrett's and Barrett's with LGD. The options for the management of Barrett's patients with high-grade dysplasia (HGD) include endoscopic therapy, surgery, and intensive surveillance until biopsy reveals adenocarcinoma. Endoscopic therapy involves endoscopic mucosal resection (EMR) and ablation. More aggressive techniques such as endoscopic submucosal dissection and larger segment endoscopic mucosal resection are under study. In this review, we discuss the diagnosis and management of Barrett's esophagus. The recommendations from the major gastroenterologic societies and the current and investigational endoscopic modalities for the management of Barrett's esophagus with and without dysplasia are reviewed.

S1502: Features of Sub-Epithelial Glandular Structures on Three-Dimensional Endoscopic Optical Coherence Tomography (3D-EOCT) After Endoscopic Mucosal Ablation

S1502: Features of Sub-Epithelial Glandular Structures on Three-Dimensional Endoscopic Optical Coherence Tomography (3D-EOCT) After Endoscopic Mucosal Ablation

Treatment of Barrett’s esophagus with high-grade dysplasia and intramucosal adenocarcinoma

High-grade dysplasia and intramucosal adenocarcinoma are premalignant and malignant lesions of the esophagus. The incidence of lymphatic or systemic metastases is low and esophagectomy is curative in most patients. Until recently, complete removal of the neoplastic tissue was reliably accomplished with only esophagectomy. New technologies have been developed that allow endoscopic mucosal resection and ablation with preservation of the esophagus for these lesions. Optimal treatment of the patient requires consideration of not only the stage of the lesion but also the pathophysiology of the esophagus and the severity of the underlying reflux disease. Only with this approach can outcomes be optimized for both the dysplasia or cancer and the patient’s reflux disease and long-term quality of life. In this article, we summarize the experience from a surgical center’s perspective.

The Society of Thoracic Surgeons Practice Guideline Series: Guidelines for the Management of Barrett's Esophagus With High-Grade Dysplasia

The management of Barrett's esophagus with high-grade dysplasia is controversial. The standard of care has traditionally been esophagectomy. However, a number of treatment options aimed at esophageal preservation are increasingly being utilized by many centers. These esophageal-sparing approaches include endoscopic surveillance, mucosal ablation, and endoscopic mucosal resection. In this guideline we review the best evidence supporting these commonly used strategies for high-grade dysplasia to better define management and guide future investigation.

A korai Barrett-carcinomák sebészi kezeléser

Adenocarcinomas in Barrett's oesophagus are more commonly diagnosed at an early stage due to effective surveillance programmes. Subtotal oesophagectomy with extended lymphadenectomy is considered the best curative treatment for patients with early adenocarcinoma of the oesophagus. However, such treatment carries substantial morbidity and compromises quality of life. Limited resection, minimal invasive surgical procedures or endoscopic mucosal ablation have been proposed as less invasive alternatives. A comparison of treatment associated morbidity, recurrence rate, long-term survival and functional outcome suggests that none of these alternative methods can be universally recommended. An individualized strategy should be employed based on staging (tumour penetration into the mucosa/submucosa, presence of lymph node metastasis), multicentricity, length of the underlying Barrett mucosa and risk factors of the patient. Surgical resection (radical or limited) remains the treatment of choice for tumours invading the submucosa, or multicentric and recurrent tumours after endoscopic mucosectomy.

Surveillance in Barrett's Esophagus: A Failed Premise

It is recommended that patients in whom Barrett's esophagus is diagnosed undergo surveillance endoscopy. However, multiple issues regarding the efficacy and feasibility of surveillance remain. Quantitative techniques were used to examine surveillance in patients with Barrett's esophagus. A retrospective case-control study was performed to determine whether surveillance endoscopy prolonged survival in a cohort of U.S. veterans diagnosed with esophageal adenocarcinoma. Cost-effectiveness analysis was employed to compare competing strategies of management for patients with Barrett's esophagus to determine whether surveillance strategies using alternative biomarkers could out-perform dysplasia based surveillance, and whether new techniques for eradicating Barrett's metaplasia would constitute cost-effective strategies. Surveillance did not improve long-term survival among veterans diagnosed with esophageal adenocarcinoma. Lead-time bias has confounded previous reports claiming the efficacy of endoscopic surveillance. Cost-effectiveness analysis revealed that while screening 50-year old Caucasian males with heartburn may be cost-effective, surveillance even at 5 year intervals among patients with Barrett's esophagus without dysplasia exceeded the threshold of cost-effective care. If a biomarker were developed whose sensitivity and specificity to predict cancer development exceeded 80%, this could represent a more viable strategy than dysplasia-based surveillance and overcome the inherent inter- and intra-observer variations in dysplasia diagnosis that currently limit the effectiveness of surveillance programs. Finally, techniques that reduce cancer incidence such as endoscopic mucosal resection or ablation will likely be more cost-effective than current surveillance strategies that rely on early detection of cancer. Current recommendations for the management of patients with Barrett's esophagus are flawed. Future guidelines should include alternative markers of cancer risk and focus on strategies that reduce cancer incidence instead of cancer detection.

Update on the Diagnosis and Treatment of Barrett Esophagus and Related Neoplastic Precursor Lesions

At present, Barrett esophagus is the most common cause of esophageal adenocarcinoma. In the past 20 years, the incidence of esophageal adenocarcinoma in white males has exceeded that of tumors of the colorectum, lung, prostate, and skin. To (1) provide an evidence-based review of the diagnosis, classification, and histologic differentiation of Barrett esophagus from gastric carditis, (2) provide a summary of the key pathologic features of precursor lesions, such as dysplasia, and (3) evaluate adjunctive markers of dysplasia and predictive markers for the development of cancer. The natural history and risk of cancer in patients with Barrett esophagus is also reviewed. For this review, selected published peer reviewed articles were chosen from a search through PubMed between the years 1970 and 2007. The current definition of Barrett esophagus is partially flawed because not all cases are endoscopically recognizable, nongoblet epithelium is biologically intestinalized, and determination of the presence or absence of goblet cells is susceptible to sampling error. Differentiation of ultrashort segment Barrett esophagus from chronic gastric carditis can be accomplished, in a minority of cases, by evaluating for the presence or absence of histologic features that are known to be associated with Barrett esophagus. Dysplasia in Barrett esophagus begins in the crypt bases and then extends more superficially to include the upper portions of the crypts and surface epithelium. Low- and high-grade dysplasia are distinguished by the presence of marked cytologic and/or architectural abnormalities in the latter compared with the former. There are few, if any, reliable adjunctive diagnostic techniques that can help differentiate nondysplastic from dysplastic epithelium. However, alpha-methylacyl coenzyme A racemase staining has been shown to be useful in 2 separate studies. Both low- and high-grade dysplasia are progressive lesions, and in general, the extent of dysplasia, particularly low grade, is a strong risk factor for progression to carcinoma. Of all the biologic and genetic biomarkers studied to date, evaluation of DNA content is the most reliable and specific. The management of patients with dysplasia is variable among institutions and ranges from aggressive surveillance, endoscopic mucosal resection, mucosal ablation, or total esophagectomy.

Combined endoscopic trans-anal rectal mucosal ablation and laparoscopic partial proctectomy for ulcerative colitis – a new procedure

A case is reported in which endoscopic trans-anal rectal mucosal ablation (ETARMA) was employed in combination with laparoscopic partial proctectomy in order to decrease complications associated with open surgery.

Prophylactic Use of Covered Metal Stent to Prevent Stricture Formation after Long Segment Circumferential EMR

Purpose: Endoscopic mucosal resection (EMR) and ablation are alternatives to surgery for Barrett's esophagus (BE) with high grade dysplasia (HGD) and intramucosal carcinoma. Endoscopic therapies may have an advantage over esophagectomy given the associated mortality and morbidity. But circumferential EMR of the esophagus for long segment BE with HGD has been shown to be complicated by stricture formation. We describe a case of circumferential EMR with prophylactic covered stent placement. Methods: A 57 y/o with coronary artery disease was diagnosed with long segment Barrett's (8 cm) with HGD. EUS showed no invasion into the muscularis mucosa or lymph adenopathy. The patient declined surgery and elected EMR. He underwent circumferential EMR of the BE from 42 cm to 34 cm. The BE mucosa was suctioned up into a band ligator to create pseudoplyps. These pseudopolyps were resected with a hot snare. A Roth net was then used to retrieve the tissue and bands. 40 cc of saline mixed with 10 cc of epinephrine was flushed into the lumen to decrease oozing. A 22 × 120 mm alveolus stent was placed over a guide wire positioned parallel to the scope, under direct endoscopic visualization. The patient complained of severe heart burn in the post procedural period and hence the stent was pulled proximally to have distal tip lay above the GE junction with the proximal tip at 23 cm. He later complained of chest pain. In spite of narcotic treatment, he continued to experience moderate pain requiring removal of the stent on Day# 5. Results: The patient recovered well after the stent removal and had no further pain. On follow up at 5 weeks, he had no significant strictures despite extensive EMR. Some residual BE mucosa was again resected to achieve what appeared to be a complete removal of BE mucosa. Patient remains asymptomatic after 3 months on a regular diet. Conclusion: Prophylactic stent placement after circumferential EMR has not been reported to our knowledge. Most common complications of EMR include bleeding, perforation and stricture formation. Strictures when they occur are usually treated with bouginage. Complete loss of lumen will be more difficult to treat. A case of complete esophageal stenosis which eventually required esophagectomy is described (ref). Prophylactic temporary stent placement, even short term, may be an effective way to prevent stricture formation. It should be noted that our patient experienced significant pain requiring stent removal after 5 days. Further experience on a larger patient population is needed to prove efficacy of this strategy.

Surgical Efficiency or Eradication Sufficiency

The management of local and early mucosal cancer of the esophagus is an enormous challenge. There is a change in the practice developing with the establishment of endoscopic mucosal resection and other ablative techniques. Das et al. in this issue have used the Surveillance Epidemiology and End Results (SEER) database of the National Cancer Institute data to compare survival of 99 patients treated using endotherapy (endoscopic mucosal resection, thermal ablation, and photodynamic therapy), with 742 patients treated with surgical resection. Using the Cox proportional hazards model, there was no survival difference between the groups. The survival predictors were the age at diagnosis and the absence of radiotherapy. Although many patients are unsuitable for surgical excision and are offered alternative therapy, these data provide evidence that endotherapy may be an equally effective alternative for many patients with early esophageal cancer. It supports the need for randomized data where this can be achieved. These population-based data open up the possibility of wider acceptance of endoscopic techniques.

Current practice in management of high-grade dysplasia in Barrett's oesophagus: The real problem

The management of high-grade dysplasia within Barrett's oesophagus is highly topical and indeed controversial. It is becoming clear that radical surgery may be excessive treatment for many patients. This is because the natural history is not understood with some indicating of rapid degeneration to cancer, others demonstrating a low rate of degeneration over many years. Early detection and optical diagnosis has allowed minimally invasive destruction using endoscopic mucosal resection, thermal ablation and photodynamic therapy. Long-term eradication is possible and is real alternative to surgical excision. The current practice is variable and there is a requirement for randomised evidence comparing endoscopic therapy with surgical excision. This is becoming more appropriate with the development of minimally invasive oesophagectomy.

Endoscopic mucosal ablation for the treatment of gastric antral vascular ectasia with the HALO 90 system: a pilot study

Gastric antral vascular ectasia (GAVE) often results in GI bleeding and chronic anemia. Treatment options are limited and include medical, endoscopic, and surgical therapies. To assess the utility of endoscopic mucosal ablative therapy by using the HALO(90) system for patients with GAVE and recurrent bleeding. Prospective open-label case series. Tertiary referral center. Six consecutive patients with GAVE, bleeding, and blood transfusion dependence. Comparison of preablation and postablation Hb levels and transfusion requirements. To assess the number of ablation sessions needed to stabilize the Hb level and eliminate the need for blood transfusion. Six patients, (4 men, mean age 58 years, range 47-65 years) underwent endoscopic mucosal ablation of antral lesions (mean procedure time 29 minutes; mean treatments 1.7, range 1-3). The mean Hb level improved from 8.6 to 10.2 g/dl (mean 2 months after the last ablation). Five of 6 patients are no longer dependent on blood transfusions to maintain a stable Hb level. This is a pilot study, with a small number of patients at a single center, with limited patient follow-up. This study suggests that endoscopic mucosal ablation by using the HALO(90) system is a promising treatment option for chronic bleeding related to GAVE.

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

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].

Endoscopic Mucosal Ablation for the Treatment of Gastric Antral Vascular Ectasia (GAVE) Using the HALO90 System: A Pilot Study

Endoscopic Mucosal Ablation for the Treatment of Gastric Antral Vascular Ectasia (GAVE) Using the HALO90 System: A Pilot Study

Limited Surgical Resection and Jejunal Interposition for Early Adenocarcinoma of the Distal Esophagus

The need for radical resection and extensive lymphadenectomy for early adenocarcinoma of the distal esophagus has recently been challenged. Limited surgical resection and endoscopic mucosal ablation techniques are increasingly proposed and used as less invasive alternatives. Available data indicate that a limited resection of the distal esophagus and esophagogastric junction with jejunal interposition is associated with less morbidity and mortality, provides similar oncologic results, and offers a better quality of life as compared with radical esophagectomy. In contrast, endoscopic ablation and mucosectomy techniques are still plagued by high tumor recurrence rates, particularly in patients with incomplete removal of the underlying Barrett's mucosa, multicentric tumors, or tumors invading into the submucosa. Attention to technical details of limited resection and jejunal interposition is, however, required to avoid complications, poor functional results, and the need for reintervention.

Limitierte chirurgische Resektion versus lokale endoskopische Therapie beim Frühkarzinom des ösophagogastralen Übergangs

Adenocarcinomas of the esophagogastric junction (especially Barrett's cancers) are increasingly diagnosed at early stages. The current standard treatment - radical resection with extensive lymphadenectomy - has been challenged. Limited resection or endoscopic mucosal ablation have been proposed as less invasive alternatives. Available data regarding limited surgical resections and endoscopic interventional procedures are evaluated with respect to short- and long-term results (mortality, morbidity, oncologic adequacy, quality of life). Limited resection of the esophagogastric junction has been proven as safe (low morbidity and mortality) and oncologically adequate procedure (low rate of recurrence/excellent long-term survival) with good quality of life. The procedure meets the oncological requirements (R0-resection, complete resection of potentially tumor-infiltrated lymph nodes and the entire precancerous Barrett's esophagus). Reconstruction with interposition of a pedicled isoperistaltic jejunal loop prevents reflux and is crucial for achieving good postoperative quality of life. In contrast, endoscopic mucosal resection (EMR) carries the risk of high recurrence rates (at least 30 %). This has to be regarded as an effect of the frequent incomplete resection, multicentric tumor growth, the persistence of precancerous Barrett's mucosa and persistence of gastroesophageal reflux. Consequently, from the oncological view point, EMR is only suited for unicentric mucosal tumors (T1a) in short segments of Barrett's esophagus. Reliable preoperative identification of such tumors is, however, currently not possible. For adequately selected patients with early Barrett's cancer, limited resection of the esophagogastric junction is an appropriate procedure. Endoscopic mucosa resection (EMR) might gain importance as staging tool.

A case report of mucosal Barrett's cancer with vessel involvement, with special reference to indications for endoscopic mucosal ablation therapy

We present a 72-year-old female patient with mucosal Barrett's cancer. Although preoperative diagnosis suggested tumor invasion throughout the mucosal layer, she was treated by endoscopic mucosal resection at her preference. The tumor invasion depth was “m-3.” However, tumor cells were observed along the endothelium of a small vein. Following endoscopic treatment, ultimately the patient underwent radical surgery. Neither residual tumor nor lymph node metastasis was found in the resected specimens. We also reviewed published reports regarding the relationship between tumor depth and vessel involvement in early-stage Barrett's cancer. In Barrett's cancer with a tumor invasion of m-3 where tumor had invaded throughout the mucosal layer, blood or lymphatic vessel invasion was observed in 12.5% of cases (6/48). However, no lymph node metastasis was found. Therefore, we considered that endoscopic mucosal ablation therapy may be applicable to treat intramucosal Barrett's cancer with a tumor invasion depth of m-3.

Endoscopic Transanal Rectal Mucosal Ablation in the Surgical Treatment of Ulcerative Colitis: Preliminary Results of a Novel Technique

We describe a new technique that endoscopically eradicates rectal stump mucosa after total colectomy for ulcerative colitis. Seven patients (5 males; median age, 56 (range, 36-72) years) underwent attempted endoscopic transanal rectal mucosal ablation using the 28-French-gauge urologic resectoscope, either at the time of total colectomy and ileostomy for failed medical therapy (5 patients) or as an alternative to completion proctectomy (2 patients) with rectal stump discharge. All had declined restorative proctocolectomy. Clinical, endoscopic, and histologic follow-up was undertaken during a mean of 15 (range, 3-28) months. The operative technique evolved during these cases; mucosal ablation was successfully performed leaving a denuded muscular rectal tube in situ in six patients. Mean operative time was 45 minutes. Postoperative endoscopic surveillance has not demonstrated any viable rectal mucosa in these six patients, with only granulation tissue detected histologically. Narrowing of the rectal tube has occurred in two patients. Although all patients report insignificant rectal discharge, urinary and sexual function have remained unchanged. Diathermy ablation of the rectal mucosa via endoscopic transanal rectal mucosal ablation avoids the complications of pelvic dissection and might offer an effective alternative to proctectomy for ulcerative colitis.

Photodynamic therapy and endoscopic mucosal resection for Barrett's dysplasia and early esophageal adenocarcinoma.

Endoscopic mucosal resection (EMR) and endoscopic ablation with porfimer sodium photodynamic therapy (PDT) have recently been combined to improve the accuracy of histologic staging and remove superficial carcinomas. All patients with Barrett's esophagus and high-grade dysplasia were evaluated with computed tomography and endosonography. Patients with nodular or irregular folds underwent EMR followed by PDT. In three patients, endoscopic mucosal resection upstaged the diagnosis to mucosal adenocarcinoma (T1N0M0). PDT successfully ablated the remaining glandular mucosa. Complications were limited to transient chest discomfort and odynophagia. The use of EMR resection in Barrett's high-grade dysplasia patients with mucosal irregularities resulted in histologic upstaging to mucosal adenocarcinoma, requiring higher laser light doses for PDT. PDT after EMR appears to be safe and effective for the complete elimination of Barrett's mucosal adenocarcinoma. EMR should be strongly considered for Barrett's dysplasia patients being evaluated for endoscopic ablation therapy.