Intramucosal Esophageal Adenocarcinoma Research Articles

Endoscopic submucosal dissection for early esophageal adenocarcinoma: low rates of metastases in mucosal cancers with poor differentiation

Background and aimsEndoscopic resection (ER) is accepted as standard treatment for intramucosal esophageal adenocarcinoma (EAC) with well or moderate differentiation. Poor differentiation (PD) is judged as a risk factor for lymph node metastasis (LNM) and surgery is recommended. However, the evidence for this recommendation is weak. Study aim was to analyze the clinical course of patients after ER of EAC with PD. Patients and methodsPatients undergoing endoscopic submucosal dissection for EAC were included from 16 German centers. Inclusion criteria were PD in the resection specimen, R0 resection and endoscopic follow-up. Primary outcome was the metastasis rate during follow-up. Analysis was performed retrospectively in a prospectively collected database. Results25 patients with PD as single risk factor (group A) and 15 patients with PD and additional risk factors (submucosal invasion and/or lymphovascular invasion) were included. The metastasis rate was was 1/25 (4.0%; 95%CI 0.4-17.2) in group A and 3/15 (20.0%; 95%CI 6.0-44.4%) in group B, respectively (p=0.293). The rate of EAC-associated deaths was 1/25 (4%; 95%CI 0.4-17.2%) versus 3/15 (20%; 95%CI 6.0-44.4%) in group B (p=0.293) while the overall death rate was 7/25 (28.0%; 95%CI 13.5-47.3%) versus 3/15 (20%; 95%CI 6.0-44.4%) (p=0.715). Median follow-up was 30 months (IQR 15-53). ConclusionsDuring long-term follow-up the risk of metastasis is low after ER of mucosal EAC with PD as single risk factor. A conservative approach seems justified in this small patient group. However, the treatment strategy has to be determined on an individualized basis until further prospective data are available.

Multicenter Randomized Controlled Trial of Surveillance Versus Endoscopic Therapy for Barrett’s Esophagus With Low-grade Dysplasia: The SURVENT Trial: Study Rationale, Methodology, Innovation, and Implications

Multicenter Randomized Controlled Trial of Surveillance Versus Endoscopic Therapy for Barrett’s Esophagus With Low-grade Dysplasia: The SURVENT Trial: Study Rationale, Methodology, Innovation, and Implications

Impact of bariatric surgery on surveillance and treatment outcomes of Barrett's esophagus: A stage-matched cohort study.

Obesity could increase the risk of Barrett's esophagus (BE). Roux-en-Y gastric bypass (RYGB) could alter the natural course of BE. Data on BE progression after RYGB are scarce. To study endoscopic surveillance and endoscopic eradication therapy (EET) outcomes of BE in post-RYGB patients versus controls with obesity. Academic referral centers, a retrospective cohort study. Patients who underwent RYGB with biopsy-proven BE or intramucosal esophageal adenocarcinoma (IM-EAC) with an endoscopic follow-up of at least 12 months were identified from a prospectively maintained database between January 1992 and February 2019 at 3 tertiary care centers. RYGB patients were matched 1-to-2 to patients with obesity (body mass index > 30 kg/m2) by the initial BE stage at diagnosis. Surveillance and EET outcomes were compared. A total of 147 patients were included (49 RYGB and 98 BE stage-matched controls with obesity). For endoscopic surveillance, the rate of disease progression to high-grade dysplasia /IM-EAC was significantly lower in the RYGB patients than controls (2.6% versus 40.2%, respectively; P < .0001), with a comparable median follow-up time (85 months versus 80 months, respectively). This effect persisted in a multivariate analysis, with a hazard ratio of .09 (95% confidence interval, .01-.69). For EET, no difference in the rate of achieving complete remission of intestinal metaplasia was observed between the RYGB and control groups (71.2% versus 81.3%, respectively; P = .44). RYGB appears to be a protective factor for disease progression to neoplastic BE during endoscopic surveillance. However, disease progression was still observed after RYGB, warranting continuing endoscopic surveillance. EET appeared to be equally effective between RYGB patients and controls with obesity.

S0442 Natural History of Barrett’s Esophagus in Cirrhotic Patients Undergoing Liver Transplantation

INTRODUCTION: Barrett’s esophagus (BE) is incidentally diagnosed in patients with liver cirrhosis who undergo upper endoscopy for esophageal variceal screening and surveillance. The management of BE in this context is poorly described and higher rates of progression have been reported. A prevailing concern is the use of immunosuppression in cirrhotic patients with BE undergoing transplantation, with reported accelerated progression to esophageal adenocarcinoma (EAC). We aimed to assess the natural history of BE in patients undergoing liver transplantation (LT) to better understand whether immunosuppression affects progression in BE. METHODS: Patients were identified from an academic medical center according to ICD-10 codes. Only patients with confirmed liver cirrhosis and both endoscopic and histologic confirmation of BE were included in the study. Review of the EMR was conducted to abstract clinical variables. Prevalent dysplasia was defined as dysplasia diagnosed at index endoscopy and incident dysplasia as dysplasia diagnosed during endoscopic surveillance. RESULTS: A total of 40 patients met inclusion criteria. Of these, BE was diagnosed pre-LT in 27 (67.5%) and post-LT in 13 (32.5%). Median follow up after LT and BE diagnosis was 8.2 and 7.9 years, respectively. Post-LT BE was diagnosed at a median of 7 years after LT. Clinical characteristics are presented in Table 1. BE-related and demographic characteristics did not significantly differ between those diagnosed with BE before or after LT. Dysplasia was found in 5 patients (12.5%), of which it was prevalent in 3 and incident in 2. Progression to high-grade dysplasia (HGD) or EAC only occurred in 3 patients. A fourth patient experienced progression from non-dysplastic BE to low-grade dysplasia. Both post-LT progressors were found to have intramucosal EAC and underwent endoscopic resection. All other patients with dysplasia were treated endoscopically and achieved complete eradication of dysplasia and intestinal metaplasia. CONCLUSION: BE-related neoplasia occurs in cirrhotic patients with similar frequency to historical data for non-cirrhotics. In this cohort of patients undergoing LT with long-term follow up, the risk of progression to HGD/EAC does not appear to be increased by iatrogenic immunosuppression. No cases of invasive or metastatic EAC were encountered and all patients were safely and effectively managed with endoscopic therapy. These data support the application of current BE management guidelines to cirrhotic patients undergoing LT.Table 1.: Clinical characteristics in the study population

Mo1239 COMPARATIVE OUTCOMES OF CAP ASSISTED ENDOSCOPIC RESECTION AND ENDOSCOPIC SUBMUCOSAL DISSECTION IN PATIENTS WITH DYSPLASTIC BARRETT'S ESOPHAGUS AND INTRAMUCOSAL ADENOCARCINOMA

Endoscopic eradication therapy (EET) is the standard of care for the treatment of Barrett’s Esophagus (BE) with dysplasia and intramucosal esophageal adenocarcinoma (EAC). Cap assisted endoscopic resection (cEMR) leads to piecemeal resection in larger lesions. Endoscopic submucosal dissection (ESD) allows for the en bloc removal of larger lesions. Both approaches are followed by mucosal ablation to achieve complete eradication of dysplasia and intestinal metaplasia. Limited data is available for the efficacy of these two approaches followed by mucosal ablation. We studied the outcomes of patients treated with these modalities at our institution, focusing on rates of complete remission of intestinal metaplasia (CRIM) and dysplasia (CRD). We queried a prospectively maintained database of all patients at our institution undergoing EMR and ESD for dysplastic/neoplastic BE and abstracted relevant demographic and clinical data. Only patients with at least one endoscopic follow up were included. Our primary outcome was the achievement of CRIM, defined as the absence of intestinal metaplasia on at least one follow up EGD at 2 years. Secondary outcomes included rates of complete remission of dysplasia (CRD), defined as the absence of dysplastic BE on at least one follow up EGD and rates of complications. All pathology was read by expert gastrointestinal pathologists. Time dependent analyses were conducted to compare outcomes in the two groups. A total of 633 patients, of whom 447 that underwent cEMR and 89 that underwent ESD were included. 447 (100%) and 59 (66.3%) in the cEMR group and ESD groups underwent ablation (either radiofrequency ablation or cryotherapy) post endoscopic resection. Demographic and clinical variables are displayed in Table 1. The ESD group had a higher proportion of EAC patients (48.3% vs 20.1%, p<0.05) but proportions of HGD+EAC were similar in both groups. More complications were associated with the EMR group, driven mainly by post-procedural bleeding rates. Rates of CRD were lower in the EMR group at 6 months but were comparable at 12 and 24 months (see table 1 and Figure 1). Rates of CRIM were comparable between the two groups at 12 and 24 months. A multivariate model (adjusting for age, gender, BMI, smoking status, length of BE, presence of hiatal hernia, and initial histology) showed that EMR was associated with a lower likelihood of achieving CRD (HR 0.487, 95% CI: 0.337-0.703, p <0.0001), but not CRIM at 2 years (HR 0.895, 95% CI: 0.537-1.491, p=.67). EMR and ESD both appear to be effective in the treatment of BE related neoplasia. ESD is safe when performed by expert endoscopists. While there is a higher likelihood of achieving CRD earlier in patients with ESD, both resection techniques when combined with endoscopic ablation appear equally efficacious in achieving CRIM at 24 months.Comparison of baseline characteristics and outcomes (CRIM, CRD and complications) in the two groups.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Mo1292 EFFICACY AND OUTCOMES OF ENDOSCOPIC MUCOSAL RESECTION IN T1B ESOPHAGEAL ADENOCARCINOMA: CAN ESOPHAGECTOMY BE AVOIDED IN SELECT PATIENTS?

The incidence of esophageal adenocarcinoma (EAC) has continued to increase over the past several decades. While endoscopic mucosal resection (EMR) is highly effective for intramucosal EAC (T1a lesions), there is limited data on outcomes of patients following EMR with T1b EAC in the era of modern chemoradiation and cryotherapy modalities. While the current standard of care for T1b EAC relies on esophagectomy, with its high risk of morbidity and mortality, it remains uncertain whether select patients with T1b EAC can be definitively treated with EMR along with chemoradiation or additional endoscopic therapies. The aim of this study is to evaluate the outcomes of patients with T1b EAC after initial EMR. A retrospective cross-sectional study was performed using a prospective electronic endoscopy database at a tertiary care academic medical center. All patients who underwent esophageal EMR for T1b EAC between February 2015 and September 2019 were included. Data on patient and disease characteristics were collected. The primary outcome was presence of residual disease (local or metastatic) during follow-up. A total of 13 patients with T1b EAC who underwent EMR were identified. The mean age was 71 years and 85% were male. Seven of these patients (54%) underwent esophagectomy while 6 patients had endoscopic and clinical surveillance. Patients who underwent esophagectomy and endoscopic surveillance had similar characteristics except that patients who underwent esophagectomy had a lower Charlson comorbidity index (5.7 vs. 7.8, P = 0.04). In patients who underwent endoscopic surveillance, 67% were deemed too high-risk for surgery, while 33% refused surgery. Among the 6 patients who underwent endoscopic surveillance after EMR, 3 were additionally treated with cryotherapy, 1 was treated with radiofrequency ablation (RFA) and 1 underwent chemoradiation. One of these 6 patients was found to have residual disease at a mean follow-up of 478 days. Among the 7 patients who underwent esophagectomy after EMR, 3 (43%) had residual tumor on surgical pathology, however none of these 7 patients underwent chemoradiation prior to surgery. Of all 13 T1b EAC patients who underwent EMR, 69.2% (N = 9) had no evidence of subsequent residual disease with a follow-up of 739 days. None of the patients with residual disease underwent prior chemoradiation. These results suggest that select patients with T1b EAC who are at high-risk for esophagectomy may be successfully managed with local therapy of EMR followed by the addition of chemoradiation and alternative endoscopic treatment modalities. Further prospective studies are needed to validate these findings and guide optimal patient selection.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Workload, Recurrence, Quality of Life and Long-term Efficacy of Endoscopic Therapy for High-grade Dysplasia and Intramucosal Esophageal Adenocarcinoma

To review the workload, type and frequency of recurrence, long-term quality of life (QOL), and late oncologic outcomes with endoscopic therapy. The short-term oncologic efficacy of endoscopic resection (ER) and ablation for patients with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC) is well-established in the literature. A retrospective chart review was performed of the initial 40 patients who had endoscopic therapy from 2001 to 2010 at 1 center by 1 physician. Initial pathology was HGD in 22 and IMC in 18 patients, but 9 patients (41%) with HGD progressed to invasive cancer during endotherapy. The median follow-up was 82 months. Four patients had an esophagectomy, and in the remaining 36 patients, 70 ERs and 111 ablations were performed. The median number of endoscopic sessions was 4 in patients with short segment compared with 7 in patients with long-segment Barrett's. Complete resolution of intestinal metaplasia (CRIM) was achieved in 30 patients (83%) at a median of 21 months. In 18 patients (60%), CRIM was maintained, whereas 12 patients developed recurrence at a median of 14 months. Additional endotherapy (n = 11) led to CRIM again in 10 patients (83%). There were no cancer deaths when CRIM was achieved. Overall survival with endotherapy was 73% at 5 years and 67% at 10 years. Quality of life (QOL) was below population means in 4 of 8 areas, but alimentary satisfaction was good after endotherapy. Endotherapy is successful in most patients, but multiple sessions are usually required and disease progression can occur. Once CRIM is achieved, recurrence is common and mandates continued endoscopic follow-up. QOL is impaired with endotherapy, but alimentary satisfaction and oncologic outcomes support esophageal preservation with endotherapy for patients with HGD or IMC.

Antibodies against human papillomavirus proteins in Barrett's dysplasia and intramucosal esophageal adenocarcinoma.

High-risk human papillomavirus (HPV) types 16/18 have been associated with Barrett's dysplasia (BD)/esophageal adenocarcinoma (EAC). Nevertheless, no data exist in relation to serological analysis for HPV antibodies in BD/EAC with site-specific viral DNA status. We prospectively examined antibodies to multiple HPV types in 438 patients representing hospital/reflux controls and Barrett's metaplasia (BM)/BD/intramucosal EAC. Antibody responses to HPV6/11/16/18/31/33/45/52/58 were analyzed using multiplex serology, including antibodies to E6/E7/E1/E2 and L1 antigens. Seropositivity for individual HPV proteins was infrequent in both cases and controls and was ≤10.2%. There was no difference in the seroprevalence of antibodies to any HPV antigen/antibody combination between reclassified cases (BD/EAC) and controls (hospital/reflux/BM) or between HPV16 or HPV18 DNA cases and controls, respectively. Among HPV16 DNA-positive BD/EAC cases, antibodies to HPV16 E7 were significantly more prevalent (3/26, 11.5%) than in hospital and reflux controls plus BM (5/328, 1.5%) (adjusted OR=10.12, 95% CI: 1.61-63.73, P=0.014). Among HPV18 DNA-positive cases, antibodies to HPV18 E1 were present in 3/6 (50%) cases versus 5/328 (1.5%) controls (adjusted OR=44.28, 95% CI: 6.10-321.47, P=0.0002). Although antibodies against HPV were generally uncommon in cases and controls, immune responses against two early proteins of HPV16/18 were significantly more frequent in viral DNA-positive BD/intramucosal EAC.

AGA Clinical Practice Update on Endoscopic Treatment of Barrett’s Esophagus With Dysplasia and/or Early Cancer: Expert Review

The purpose of this best practice advice article is to describe the role of Barrett's endoscopic therapy (BET) in patients with Barrett's esophagus (BE) with dysplasia and/or early cancer and appropriate follow-up of these patients. The best practice advice provided in this document is based on evidence and relevant publications reviewed by the committee. BEST PRACTICE ADVICE 1: In BE patients with confirmed low-grade dysplasia, a repeat examination with high-definition white-light endoscopy should be performed within 3-6 months to rule out the presence of a visible lesion, which should prompt endoscopic resection. BEST PRACTICE ADVICE 2: Both BET and continued surveillance are reasonable options for the management of BE patients with confirmed and persistent low-grade dysplasia. BEST PRACTICE ADVICE 3: BET is the preferred treatment for BE patients with high-grade dysplasia (HGD). BEST PRACTICE ADVICE 4: BET should be preferred over esophagectomy for BE patients with intramucosal esophageal adenocarcinoma (T1a). BEST PRACTICE ADVICE 5: BET is a reasonable alternative to esophagectomy in patients with submucosal esophageal adenocarcinoma (T1b) with low-risk features (<500-μm invasion in the submucosa [sm1], good to moderate differentiation, and no lymphatic invasion) especially in those who are poor surgical candidates. BEST PRACTICE ADVICE 6: In all patients undergoing BET, mucosal ablation should be applied to 1) all visible esophageal columnar mucosa; 2) 5-10 mm proximal to the squamocolumnar junction and 3) 5-10 mm distal to the gastroesophageal junction, as demarcated by the top of the gastric folds (ie, gastric cardia) using focal ablation in a circumferential fashion. BEST PRACTICE ADVICE 7: Mucosal ablation therapy should only be performed in the presence of flat BE without signs of inflammation and in the absence of visible abnormalities. BEST PRACTICE ADVICE 8: BET should be performed by experts in high-volume centers that perform a minimum of 10 new cases annually. BEST PRACTICE ADVICE 9: BET should be continued until there is an absence of columnar epithelium in the tubular esophagus on high-definition white-light endoscopy and preferably optical chromoendoscopy. In case of complete endoscopic eradication, the neosquamous mucosa and the gastric cardia are sampled by 4-quadrant biopsies. BEST PRACTICE ADVICE 10: If random biopsies obtained from the neosquamous epithelium demonstrate intestinal metaplasia/dysplasia or subsquamous intestinal metaplasia, a repeat endoscopy should be performed and visible islands or tongues should undergo targeted focal ablation. BEST PRACTICE ADVICE 11: Intestinal metaplasia of the gastric cardia (without residual columnar epithelium in the tubular esophagus) should not warrant additional ablation therapy. BEST PRACTICE ADVICE 12: When consenting patients for BET, the most common complication of therapy to be quoted is post-procedural stricture formation, occurring in about 6% of cases. Bleeding and perforation occur at rates <1%. BEST PRACTICE ADVICE 13: After complete eradication (endoscopic and histologic) of intestinal metaplasia has been achieved with BET, surveillance endoscopy with biopsies should be performed at the following intervals: for baseline diagnosis of HGD/esophageal adenocarcinoma: at 3, 6, and 12 months and annually thereafter; and baseline diagnosis of low-grade dysplasia: at 1 and 3 years. BEST PRACTICE ADVICE 14: Endoscopic surveillance post therapy should be performed with high-definition white-light endoscopy, including careful inspection of the neosquamous mucosal and retroflexed inspection of the gastric cardia. BEST PRACTICE ADVICE 15: The approach to recurrent disease is similar to that of the initial therapy; visible recurrent nodular lesions require endoscopic resection, whereas flat areas of columnar mucosa in the tubular esophagus can be treated with mucosal ablation. BEST PRACTICE ADVICE 16: Patients should be counseled on cancer risk in the absence of BET, as well as after BET, to allow for informed decision-making between the patient and the physician.

Desmoplasia and Detached Papillae in Early Esophageal Adenocarcinoma: A Histologic Study on Endoscopic Submucosal Dissection Specimens.

BackgroundDesmoplasia and detached papillae were only rarely mentioned in intramucosal adenocarcinoma of esophagus or stomach. This study aimed to examine these two features in early esophageal adenocarcinoma.MethodsAll endoscopic submucosal dissections specimens performed for Barrett’s esophagus neoplasm during the year 2013 to 2016 were reviewed. These 44 cases included in this study were eight Barrett’s esophagus with high-grade dysplasia, 21 intramucosal adenocarcinoma, and 15 submucosally or beyond invasive adenocarcinoma.ResultsDesmoplasia occurred in 73% submucosally or beyond invasive adenocarcinoma, higher than intramucosal adenocarcinoma (24%) and high-grade dysplasia (0%) (P < 0.00001 for each). The frequency of detached papillae in intramucosal adenocarcinoma and submucosally or beyond invasive adenocarcinoma specimens was 71.4% and 73.3%, higher than high-grade dysplasia (0%, P < 0.0001 for both). Univariate analysis identified desmoplasia as risk factors for lymphovascular invasion in intramucosal adenocarcinoma specimens (odds ratio 12, P = 0.048), and desmoplasia and tumor thickness for lymphovascular invasion in intramucosal adenocarcinoma and submucosally or beyond invasive adenocarcinoma specimens combined (odds ratio 9.0, P = 0.005; odds ratio 2.7, P = 0.01, respectively). Age, gender, the largest dimension and the average thickness of endoscopic submucosal dissection specimens, tumor size, detached papillae, and poor differentiation were not associated with lymphovascular invasion (P ≥ 0.05 for all). Multivariate analysis confirmed that only desmoplasia was predictive of lymphovascular invasion (odds ratio 8.0, P = 0.02) in intramucosal adenocarcinoma and submucosally or beyond invasive adenocarcinoma specimens combined.ConclusionsIn conclusion, desmoplasia occurs in about a quarter of esophageal intramucosal adenocarcinomas and three quarters of submucosally or beyond invasive adenocarcinomas, and is associated with lymphovascular invasion in early esophageal adenocarcinoma.

Tu1218 - Efficacy of Endoscopic Eradication Therapy for Intramucosal Esophageal Adenocarcinoma: A Single Center us Experience

Tu1218 - Efficacy of Endoscopic Eradication Therapy for Intramucosal Esophageal Adenocarcinoma: A Single Center us Experience

Outcome with Primary En-bloc Esophagectomy for Submucosal Esophageal Adenocarcinoma.

Intramucosal esophageal adenocarcinoma can be reliably treated endoscopically. Controversy exists about the use of endotherapy versus esophagectomy for submucosal tumors. Increasingly endotherapy is considered for submucosal tumors in part because of the presumed high mortality with esophagectomy and the perceived poor prognosis in patients with nodal disease. This study was designed to assess survival following primary en bloc esophagectomy (EBE) in patients with submucosal esophageal adenocarcinoma (EAC). This is a retrospective review of all patients who underwent EBE for submucosal EAC between 1998 and 2015. No patient had neoadjuvant therapy. There were 32 patients (28M/4F; median age 64years). The median tumor size was 1.5cm (0.4-8.0), and the median number of resected nodes was 48 (23-85). There was one perioperative death. Lymph node metastases were present in 7 patients (22%). There was one involved node in four patients and 2, 3, and 31 nodes in one patient each. The one N3 patient received adjuvant therapy. The median follow-up was 87months. Overall survival at 5 and 10years was 84 and 70% respectively. Disease-specific survival at 10years was 90%. Eight patients died, but only three deaths (9%) were related to EAC. Disease-specific survival at 10years in node-positive patients was 71%. Survival after primary en bloc esophagectomy for submucosal adenocarcinoma was excellent even in node-positive patients. Mortality with esophagectomy was low and far less than the 22% risk of node metastases in patients with submucosal tumor invasion. Esophagectomy should remain the preferred treatment for T1b esophageal adenocarcinoma.

Endoscopic mucosal ablation and resection of Barrett's esophagus and related diseases.

The prevalence of gastroesophageal reflux disease as well as the incidence of Barrett's esophagus (BE) has increased in the Western world over the last decades. The chronic reflux of gastric secretions injuries the esophageal mucosa and triggers cellular and molecular changes inducing the transformation of the normal squamous mucosa into columnar metaplastic epithelium. BE is a premalignant condition that can progress to low-grade dysplasia, high-grade dysplasia and ultimately esophageal adenocarcinoma. An early diagnosis of dysplastic changes and the adoption of appropriate therapeutic approaches are essential to improve patient outcomes and survival. Endoscopic therapies such as radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR) have been developed to treat dysplastic changes and mucosal abnormalities suspicious of malignancy. RFA has shown to be safe and effective for the treatment of low and high-grade dysplasia. EMR is diagnostic for mucosal lesions and potentially therapeutic for high-grade dysplasia or intramucosal adenocarcinoma. Proficient endoscopic skills and frequent practice are essential elements for a successful result. Here, we describe patient selection, the pre- and post-operative management, and the surgical technique for RFA and EMR in patients with the diagnosis of dysplastic BE and intramucosal esophageal adenocarcinoma.

Barrett's esophagus: best practices for treatment and post-treatment surveillance.

Barrett's esophagus (BE) is a premalignant condition that increases the risk of esophageal adenocarcinoma (EAC). Significantly more common in the Western world, risk factors include increased age, male sex, white race, gastro-esophageal reflux disease (GERD), central obesity, and cigarette smoking. The rates of progression to cancer depend on the grade of Barrett's dysplasia. Screening for BE is recommended in patients with GERD and additional risk factors. Endoscopic surveillance of patients with BE likely improves overall outcomes. Advanced endoscopic imaging can help increase the efficiency of current endoscopic surveillance. Endoscopic therapy is safe and effective for the treatment of dysplastic BE and intramucosal EAC, but ongoing surveillance following treatment is necessary. This review will cover screening, surveillance, advanced imaging, chemoprevention, endoscopic treatment, and post-treatment surveillance of BE.

Current Endoscopic Approaches for the Treatment of Barrett Esophagus.

Barrett esophagus (BE) is the only identifiable premalignant condition for esophageal adenocarcinoma (EAC), a cancer associated with a poor 5-year survival rate. The stepwise pathologic progression of BE to invasive cancer provides an opportunity to halt progression and potentially decrease incidence and ultimately the morbidity and mortality related to this lethal cancer. Endoscopic eradication therapy (EET) in patients at increased risk of progression to invasive EAC (intramucosal EAC, high-grade dysplasia, and low-grade dysplasia) is a practice that is endorsed by multiple societies and has replaced esophagectomy as the standard of care for these patients. Although the effectiveness, safety, and durability of EET have been demonstrated in several studies, this review addresses the several challenges with EET that need to be considered to optimize patient outcomes. Finally, the critical role of training, competence, and quality indicators in EET are emphasized in this era of value-based health care practice.

Endoscopic Treatment of High-Grade Dysplasia and Intramucosal Esophageal Adenocarcinoma.

The endoscopic management of Barrett's esophagus (BE) has changed with the emergence of novel endoscopic technologies and new data informing the care of dysplastic BE and early adenocarcinoma. These changes include an expanded use of endoscopic ablative therapy as well new recommendations for surveillance intervals. For most patients with BE and high-grade dysplasia (HGD), endoscopic ablative therapy is the preferred treatment strategy. Ablation has consistently been shown to be effective, with less morbidity compared with surgery. The best approach to treatment of adenocarcinoma with submucosal invasion is not clear as relevant data are conflicting. Traditionally, submucosal invasion was a contradiction to endoscopic therapy of esophageal adenocarcinoma, but recent data suggest that both endoscopic resection with ablation and esophagectomy may be acceptable treatment options in some settings. At present, surveillance for patients with baseline HGD or intramucosal carcinoma is suggested every 3 months in the first year following complete eradication of intestinal metaplasia, every 6 months in the second year, and annually thereafter.

Incidence of Esophageal Adenocarcinoma and Causes of Mortality After Radiofrequency Ablation of Barrett’s Esophagus

Radiofrequency ablation (RFA) is commonly used to treat Barrett's esophagus (BE). We assessed the incidence of esophageal adenocarcinoma (EAC) after RFA, factors associated with the development of EAC, and EAC-specific and all-cause mortality. We collected data for outcomes of patients who underwent RFA for BE from July 2007 through July 2011 from US multicenter RFA Patient Registry. Patients were followed until July 2014. Kaplan-Meier curves of EAC incidence were stratified by baseline histology. Crude EAC incidence and mortality (all-cause and EAC-specific) were calculated, and adjusted all-cause mortality was assessed. Logistic regression models were constructed to assess predictors of EAC and all-cause mortality. Among 4982 patients, 100 (2%) developed EAC (7.8/1000 person-years [PY]) and 9 patients (0.2%) died of EAC (0.7/1000 PY) in a mean 2.7 ± 1.6 years. The incidence of EAC in nondysplastic BE was 0.5/1000 PY. Overall, 157 patients (3%) died during follow-up (all-cause mortality, 11.2/1000 PY). On multivariate logistic regression, baseline BE length (odds ratio, 1.1/ cm) and baseline histology (odds ratios, 5.8 and 50.3 for low-grade dysplasia and high-grade dysplasia [HGD] respectively) predicted EAC incidence. Among 9 EAC deaths, 6 (67%) had baseline HGD, and 3 (33%) had baseline intramucosal EAC. The most common causes of death were cardiovascular (15%) and extraesophageal cancers (15%). No deaths were associated with RFA. Based on analysis of a multicenter registry of patients who underwent RFA of BE, less than 1% died from EAC. The incidence of EAC was markedly lower in this study than in other studies of disease progression, with the greatest absolute benefit observed in patients with HGD.

Sa1083 The Prevalence of Lymph-Node Metastases in Patients With Intramucosal Esophageal Adenocarcinoma: A Population-Based Assessment

Sa1083 The Prevalence of Lymph-Node Metastases in Patients With Intramucosal Esophageal Adenocarcinoma: A Population-Based Assessment

Good Results with Ablation of Barrett Esophagus with Low-Grade Dysplasia

For high-grade dysplasia and intramucosal esophageal adenocarcinoma (EAC), endoscopic resection of visible lesions followed by radiofrequency ablation

Tumeurs et pseudotumeurs digestives dont on parle rarement. Cas no 3 : polype muqueux/sous-muqueux allongé

The purpose of this best practice advice article is to describe the role of Barrett’s endoscopic therapy (BET) in patients with Barrett’s esophagus (BE) with dysplasia and/or early cancer and appropriate follow-up of these patients.The best practice advice provided in this document is based on evidence and relevant publications reviewed by the committee.In BE patients with confirmed low-grade dysplasia, a repeat examination with high-definition white-light endoscopy should be performed within 3–6 months to rule out the presence of a visible lesion, which should prompt endoscopic resection.Both BET and continued surveillance are reasonable options for the management of BE patients with confirmed and persistent low-grade dysplasia.BET is the preferred treatment for BE patients with high-grade dysplasia (HGD).BET should be preferred over esophagectomy for BE patients with intramucosal esophageal adenocarcinoma (T1a).BET is a reasonable alternative to esophagectomy in patients with submucosal esophageal adenocarcinoma (T1b) with low-risk features (<500-μm invasion in the submucosa [sm1], good to moderate differentiation, and no lymphatic invasion) especially in those who are poor surgical candidates.In all patients undergoing BET, mucosal ablation should be applied to 1) all visible esophageal columnar mucosa; 2) 5–10 mm proximal to the squamocolumnar junction and 3) 5–10 mm distal to the gastroesophageal junction, as demarcated by the top of the gastric folds (ie, gastric cardia) using focal ablation in a circumferential fashion.Mucosal ablation therapy should only be performed in the presence of flat BE without signs of inflammation and in the absence of visible abnormalities.BET should be performed by experts in high-volume centers that perform a minimum of 10 new cases annually.BET should be continued until there is an absence of columnar epithelium in the tubular esophagus on high-definition white-light endoscopy and preferably optical chromoendoscopy. In case of complete endoscopic eradication, the neosquamous mucosa and the gastric cardia are sampled by 4-quadrant biopsies.If random biopsies obtained from the neosquamous epithelium demonstrate intestinal metaplasia/dysplasia or subsquamous intestinal metaplasia, a repeat endoscopy should be performed and visible islands or tongues should undergo targeted focal ablation.Intestinal metaplasia of the gastric cardia (without residual columnar epithelium in the tubular esophagus) should not warrant additional ablation therapy.When consenting patients for BET, the most common complication of therapy to be quoted is post-procedural stricture formation, occurring in about 6% of cases. Bleeding and perforation occur at rates <1%.After complete eradication (endoscopic and histologic) of intestinal metaplasia has been achieved with BET, surveillance endoscopy with biopsies should be performed at the following intervals: for baseline diagnosis of HGD/esophageal adenocarcinoma: at 3, 6, and 12 months and annually thereafter; and baseline diagnosis of low-grade dysplasia: at 1 and 3 years.Endoscopic surveillance post therapy should be performed with high-definition white-light endoscopy, including careful inspection of the neosquamous mucosal and retroflexed inspection of the gastric cardia.The approach to recurrent disease is similar to that of the initial therapy; visible recurrent nodular lesions require endoscopic resection, whereas flat areas of columnar mucosa in the tubular esophagus can be treated with mucosal ablation.Patients should be counseled on cancer risk in the absence of BET, as well as after BET, to allow for informed decision-making between the patient and the physician.