T1a Esophageal Adenocarcinoma Research Articles

Targeted detection of Barrett’s neoplasia: A case report

Barrett’s esophagus (BE) is a precursor condition for esophageal adenocarcinoma (EAC). This case report describes the in vivo use of a fluorescently-labeled peptide heterodimer specific for epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor (HER2) to identify residual neoplasia in a 52-year-old female patient with BE. This targeted contrast agent was topically administered after an incomplete endoscopic mucosal resection of high-grade dysplasia with carcinoma in situ. A flexible fiber-coupled multi-modal scanning fiber endoscope was used to capture near-infrared fluorescence images. This instrument was passed through the working channel of a standard upper endoscope for use as an accessory. Increased fluorescence intensity was observed from nodular mucosa as a real-time “red flag” to identify the presence of neoplasia. Pathologic tests were conducted on the resected tissues, confirming the presence of stage T1a EAC. The expression EGFR and HER2 was confirmed by immunohistochemistry ex vivo. These findings support integrated imaging as a potential strategy to detect Barrett’s neoplasia.

A158 FINDINGS FROM A MULTIDISCIPLINARY DATABASE FOR PATIENTS WITH BARRETT'S ESOPHAGUS AND EARLY ESOPHAGEAL ADENOCARCINOMA

Abstract Background Previously, Barrett’s esophagus (BE) with high grade dysplasia (HGD) or neoplasia was treated with esophagectomy; however, recent guidelines support the use of endoscopic mucosal resection (EMR) for T1a esophageal adenocarcinoma (EAC) and potentially T1b EAC. Long term data for outcomes from EMR are lacking and these treatments are often provided with minimal collaboration between gastroenterologists and thoracic surgeons. Purpose Our primary aim was to describe the findings from our multidisciplinary database of patients with Barrett’s esophagus and EAC undergoing endoscopic treatment. Secondary aims were to compare the overall survival and recurrence-free survival of patients undergoing endoscopic resection to those undergoing esophagectomy. Method For the endoscopic resection cohort, a combined retrospective and prospective database was created containing demographic, clinical, and oncologic variables for patients undergoing endoscopic resection for early stage EAC from 2009 to 2021. For the esophagectomy cohort, a pre-existing retrospective database including patients undergoing esophagectomy for esophageal cancer from 2012 to 2018 at a single institution was used. A multivariate cox proportional hazards model was developed for recurrence-free survival and overall survival using a hypothesis driven approach. A kaplan-meier (KM) curve with associated log-rank test was created to evaluate recurrence-free survival and overall survival stratified by treatment modality. Result(s) A total of 108 patients were included in the analysis (73 EMR, 35 esophagectomy). Baseline characteristics including age, sex, and co-morbidities were similar among the two groups. KM curves stratified by treatment modality are provided in Figure 1. Esophagectomy was associated with greater DFS on univariate log-rank test (p = 0.0127), but no difference in OS (p = 0.9306). There was no significant difference between esophagectomy and endoscopic resection in the cox-model for OS (HR 1.03, 95% CI 0.45-2.32, p = 0.914). Endoscopic resection was associated with increased hazards of disease recurrence in the cox model for DFS (HR 2.56, 95% CI 1.1-6.0, p = 0.032). In the logistic regression model, high grade disease (OR 5.43, 95% CI 1.1 – 26.1, p = 0.035) and submucosal involvement (OR 7.8, 1.9-31.4, p = 0.004) were identified as significant predictors of positive margin necessitating esophagectomy after initial endoscopic resection. All patients who experienced a positive margin after endoscopic therapy were evaluated by a thoracic surgeon and proceeded to esophagectomy. Conclusion(s) In this largely retrospective analysis, our multidisciplinary approach was shown to be highly efficacious in the treatment of BE with EAC. Through optimizing collaboration between thoracic surgeons and gastroenterologists, patients receive the best therapeutic approach for their unique condition, taking into account oncologic factors and clinical comorbidities. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Socioeconomic Disparities Affect Outcomes in Early-Stage Esophageal Adenocarcinoma: A SEER Analysis

Socioeconomic determinants of health are understudied in early stage esophageal adenocarcinoma. We aimed to assess how socioeconomic status influences initial treatment decisions and survival outcomes in patients with T1a esophageal adenocarcinoma. We performed an observational study using the 2018 submission of the Surveillance, Epidemiology, and End Results-18 database. A total of 1526 patients from 2004 to 2015 with a primary T1aN0M0 esophageal adenocarcinoma were subdivided into 3 socioeconomic tertiles based on their median household income. Endoscopic trends over time, rates of endoscopic and surgical treatment, 2- and 5-year overall survival, cancer-specific mortality, and non-cancer-specific mortality were calculated. Statistical analysis was performed using R-studio. Patients within the lowest median household income tertile ($20,000-$54,390) were associated with higher cancer-specific mortality at 2 years (P < .01) and 5 years (P < .02), and lower overall survival at 2 and 5 years (P < .01) compared with patients in higher income tertiles. Patients with a higher income had a decreased hazard ratio for cancer-specific mortality (hazard ratio, 0.66; 95% CI, 0.45-0.99) in a multivariate Cox proportional hazards regression model. Patients within the higher income tertile were more likely to receive endoscopic intervention (P < .001), which was associated with improved cancer-specific mortality compared with patients who received primary surgical intervention (P= .001). The South had lower rates of endoscopy compared with other regions. Lower median household income was associated with higher rates of cancer-specific mortality and lower rates of endoscopic resection in T1aN0M0 esophageal adenocarcinoma. Population-based strategies aimed at identifying and rectifying possible etiologies for these socioeconomic and geographic disparities are paramount to improving patient outcomes in early esophageal cancer.

Impact of neoadjuvant chemoradiation in early stage esophageal and gastro-esophageal junction adenocarcinoma

Background: Esophageal adenocarcinoma (EAC) poses a therapeutic challenge due to late-stage presentation, requiring multimodal management, with ensuing high-mortality, despite our best efforts. Current guidelines recommend use of neoadjuvant chemoradiation on patients with T1a EAC patients due to reported increased rates of R0 resection attained. However, recent literature has challenged the morbidity and survival benefits of the use of neoadjuvant radiation.

A127 ENDOSCOPIC MUCOSAL RESECTION FOR DYSPLASTIC AND NEOPLASTIC BARRETT’S ESOPHAGUS: FINDINGS FROM A FOREGUT NEOPLASIA MULTIDISCIPLINARY DATABASE

Abstract Background Previously, Barrett’s esophagus with high grade dysplasia (HGD) or neoplasia was treated with esophagectomy, which is associated with a high postoperative morbidity and mortality rate. Recent guidelines support the use of endoscopic mucosal resection (EMR) for T1a esophageal adenocarcinoma (EAC) and potentially T1b EAC; however, data on long term outcomes of endoscopic treatment is lacking. We created a combined prospective and retrospective multidisciplinary database to monitor outcomes of patients with Barrett’s esophagus undergoing endoscopic treatment. Aims Our primary aim was to compare outcomes of EMR and esophagectomy in patients presenting with BE and HGD, and/or early EAC. Methods A collaboration of gastroenterologists, general surgeons and thoracic surgeons from the University of Alberta, Edmonton, Alberta, provided input on the development of the database. All patients referred to the Northern Alberta Endoscopic Ablation Program from 2009–2021 who received at least one endoscopic treatment were included. A sub-analysis of all patients with pathologic confirmation of HGD, and/or early EAC was conducted to compare outcomes of EMR and esophagectomy. Results A total of 212 patients have been entered into the database. The most common findings were HGD, low grade dysplasia (LGD), and adenocarcinoma, respectively. All patients (n=48) who had at least LGD reached complete eradication of dysplasia (CE-D) and 95.8% reached complete eradication of intestinal metaplasia (CE-IM). Of those patients that reached CE-D, 8.3% developed recurrence of dysplasia (n=4). In the sub-analysis, 74 patients (76.3%) received endoscopic therapy while 23 patients (23.7%) received endoscopic therapy then ultimately an esophagectomy. There were significantly more T1b lesions in the esophagectomy group compared to the EMR group ( p&amp;lt;0.0001). Of all the patients in the EMR group, only 5.4% (n=4) had treatment related complications. Of patients receiving an esophagectomy, 60.9% (n=14) experienced treatment related complications. The mean length of stay for patients in the EMR group was 1.03 +/- 0.2 days, compared to 16.5 +/- 11.8 days for esophagectomy ( p&amp;lt;0.0001). Conclusions EMR provides definitive and durable treatment for BE lesions classified as T1b or less severe, with fewer complications and a shorter length of hospital stay than esophagectomy. Funding Agencies Alberta Innovates Health Solutions

Endoscopic submucosal dissection vs. endoscopic mucosal resection for early Barrett's neoplasia in the West: a retrospective study.

The difference in clinical outcomes after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for early Barrett's esophagus (BE) neoplasia remains unclear. We compared the recurrence/residual tissue rates, resection outcomes, and adverse events after ESD and EMR for early BE neoplasia. We included patients who underwent EMR or ESD for BE-associated high grade dysplasia (HGD) or T1a esophageal adenocarcinoma (EAC) at eight academic hospitals. We compared demographic, procedural, and histologic characteristics, and follow-up data. A time-to-event analysis was performed to evaluate recurrence/residual disease and a Kaplan-Meier curve was used to compare the groups. 243 patients (150 EMR; 93 ESD) were included. EMR had lower en bloc (43 % vs. 89 %; P < 0.001) and R0 (56 % vs. 73 %; P = 0.01) rates than ESD. There was no difference in the rates of perforation (0.7 % vs. 0; P > 0.99), early bleeding (0.7 % vs. 1 %; P > 0.99), delayed bleeding (3.3 % vs. 2.1 %; P = 0.71), and stricture (10 % vs. 16 %; P = 0.16) between EMR and ESD. Patients with non-curative resections who underwent further therapy were excluded from the recurrence analysis. Recurrent/residual disease was 31.4 % [44/140] for EMR and 3.5 % [3/85] for ESD during a median (interquartile range) follow-up of 15.5 (6.75-30) and 8 (2-18) months, respectively. Recurrence-/residual disease-free survival was significantly higher in the ESD group. More patients required additional endoscopic resection procedures to treat recurrent/residual disease after EMR (EMR 24.2 % vs. ESD 3.5 %; P < 0.001). ESD is safe and results in more definitive treatment of early BE neoplasia, with significantly lower recurrence/residual disease rates and less need for repeat endoscopic treatments than with EMR.

S0344 Endoscopic Resection of T1b Esophageal Adenocarcinoma Is Comparable to Esophagectomy: A Surveillance, Epidemiology, and End Results Database Study

INTRODUCTION: Current guidelines recommend consideration of endoscopic therapy when treating T1a esophageal adenocarcinoma. However, it remains unclear if endoscopy is appropriate for treating T1b lesions with and without lymph node metastasis. Our study aims to compare survival outcomes following surgical resection and endoscopy in treating T1b esophageal adenocarcinoma. METHODS: We performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results database from 2000 to 2016 of patients with T1b esophageal adenocarcinoma treated with endoscopic resection or esophagectomy. Kaplan Meier estimations and cox proportional hazards models were used to assess survival outcomes. RESULTS: A total of 603 patients with T1b esophageal carcinoma were identified, of whom 87.7% were male. Median age at diagnosis was 67 ± 10.6 years. Overall, males had a higher prevalence of T1b esophageal carcinoma compared to females (87.7% vs. 12.1 per 100,000 per year). Tumors were most common among White patients (95.2%). Most tumors were moderately differentiated (45%), followed by poorly differentiated (33%), well differentiated (10.4%), and undifferentiated (1.0%). Most tumors occurred in the distal third of the esophagus (83.4%) followed by the mid esophagus (8.6%) and the proximal third (1.8%). About 84 (13.9%) underwent endoscopic resection and 367 (60.9%) underwent esophagectomy. One, 3- and 5-year survival for cancer-specific death was associated with survival rates of 91%, 78%, and 74%, respectively, for endoscopic resection. Esophagectomy was associated with 1-, 3 and 5-year survival rates of 91%, 85%, and 73%, respectively. Subgroup analysis showed that in patients with lymph node metastasis (LMN), no significant difference in mortality was observed following surgical and endoscopic resection (Log Rank test = 0.903). Adjusted hazard models indicated that LMN was associated with 2 times higher mortality [HR 2.16, 95% CI 1.250-23.742, P = 0.0.006], and surgical intervention was associated with a non-significant reduction in mortality [HR 0.78, 95% CI 0.414-1.480, P = 0.451]. CONCLUSION: Endoscopic resection was associated with similar cancer-specific survival outcomes compared with esophagectomy in stage T1b esophageal adenocarcinoma, regardless of lymph node metastasis. Endoscopic removal of T1b esophageal adenocarcinoma is an effective strategy for patients including those either refusing esophagectomy or not a candidate for surgical intervention.Figure 1.: Survival following endoscopic resection (ER) and surgical resection (SR).

355 Endoscopic Submucosal Dissection vs. Endoscopic Mucosal Resection for Treatment of Barrett’s Related Superficial Esophageal Neoplasia

INTRODUCTION: The difference in long-term outcomes of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for Barrett’s related superficial neoplasia remains unclear. We aimed to compare the rates of local and metachronous recurrence of ESD and EMR in patients with clinically staged BE-associated high-grade dysplasia (HGD) and T1a esophageal adenocarcinoma (EAC). METHODS: Multicenter study at six academic hospitals in the U.S. including patients who underwent ESD for BE-HGD or T1a EAC. Primary outcome was a composite of metastasis and local recurrence rate. A time-to-event analysis was performed to evaluate recurrence. A Kaplan-Meier plot was constructed, and a log-rank test was used to compare the groups. A Cox hazard ratio regression analysis was performed to identify predictors of recurrence. RESULTS: A total of 241 patients were included. 154 underwent EMR, while 84 underwent ESD (Table 1). ESD had higher en bloc (96% vs 33%, P &lt; 0.0001), R0 (76% vs 54%, P = 0.0009) and curative resection rates (75% vs 32%, P &lt; .0001) when compared to EMR. The 24-month local recurrence rate for EMR and ESD was 43% and 11%, respectively (P = 0.0007) (Figure 1). Significantly more endoscopic resection procedures were required to treat recurrence after EMR compared to after ESD (Table 1). EMR, piecemeal resection, positive margins, and non-curative resection were identified as predictors of recurrence on univariate analysis. En bloc resection remained significant after multivariate analysis (Table 2). CONCLUSION: This multicenter study showed that ESD results in more definitive treatment of BE-associated early neoplasia than EMR, with significant lower recurrence rates and less need for repeat endoscopic therapeutic procedures than EMR.

Endoscopic Therapy for Dysplastic Barrett Esophagus and Intramucosal Cancer

Barrett esophagus (BE) is a common premalignant condition that may evolve from nondysplastic intestinal metaplasia to low-grade dysplasia (LGD), high-grade dysplasia (HGD), and ultimately to esophageal adenocarcinoma (EAC). This review addresses the range of endoscopic approaches for treating dysplastic BE and early EAC. Endoscopic treatment is favored for most patients with LGD, although endoscopic surveillance continues to be an alternative. Endoscopic eradication is definitively recommended for patients with HGD. Radiofrequency ablation is the preferred technique for ablation of dysplastic BE, although there is also strong support for endoscopic mucosal resection as a first-line therapy. Cryotherapy is emerging as a valid alternative ablative approach. Endoscopic resection by endoscopic mucosal resection or endoscopic submucosal dissection is recommended as the first-line therapy for nodular BE and T1a EAC. Post-eradication endoscopic surveillance is indicated at intervals that depend on the category of pretreatment dysplasia. Because of advances in endoscopic therapy, surgery is now indicated only when endoscopic ablation or resection has failed or in the setting of more advanced EAC. This review contains 8 figures, 2 tables, and 55 references. Key Words: cryotherapy, endoscopic mucosal resection, esophageal adenocarcinoma, esophagectomy, high-grade dysplasia, low-grade dysplasia, nodular Barrett esophagus, radiofrequency ablation

Impact of the development of an endoscopic eradication program for Barrett's esophagus with high grade dysplasia or early adenocarcinoma on the frequency of surgery.

Background and aims The impact of the advent of an institutional endoscopic eradication therapy (EET) program on surgical practice for Barrett’s esophagus (BE)-associated high grade dysplasia (HGD) or suspected T1a esophageal adenocarcinoma (EAC) is unknown. The aims of this study are to evaluate the different endoscopic modalities used during development of our EET program and factors associated with the use of EET or surgery for these patients after its development. Methods Patients who underwent primary endoscopic or surgical treatment for BE-HGD or early EAC at our hospital between January 1992 and December 2014 were retrospectively identified. They were categorized by their initial modality of treatment during the first year, and the impact over time for choice of therapy was assessed by multivariable logistic regression. Results We identified 386 patients and 80 patients who underwent EET and surgery, respectively. EET included single modality therapy in 254 (66 %) patients and multimodal therapy in 132 (34 %) patients. Multivariable logistic regression showed that, for each subsequent study year, EET was more likely to be performed in patients who were older ( P = 0.0009), with shorter BE lengths ( P < 0.0001), and with a pretreatment diagnosis of HGD ( P = 0.0054) compared to surgical patients. The diagnosis of EAC did not increase the utilization of EET compared to surgery as time progressed ( P = 0.8165). Conclusion The introduction of an EET program at our hospital increased the odds of utilizing EET versus surgery over time for initial treatment of patients who were older, had shorter BE lengths or the diagnosis of BE-HGD, but not in patients with EAC.

Endoscopic Therapy for Dysplastic Barrett Esophagus and Intramucosal Cancer

Barrett esophagus (BE) is a common premalignant condition that may evolve from nondysplastic intestinal metaplasia to low-grade dysplasia (LGD), high-grade dysplasia (HGD), and ultimately to esophageal adenocarcinoma (EAC). This review addresses the range of endoscopic approaches for treating dysplastic BE and early EAC. Endoscopic treatment is favored for most patients with LGD, although endoscopic surveillance continues to be an alternative. Endoscopic eradication is definitively recommended for patients with HGD. Radiofrequency ablation is the preferred technique for ablation of dysplastic BE, although there is also strong support for endoscopic mucosal resection as a first-line therapy. Cryotherapy is emerging as a valid alternative ablative approach. Endoscopic resection by endoscopic mucosal resection or endoscopic submucosal dissection is recommended as the first-line therapy for nodular BE and T1a EAC. Post-eradication endoscopic surveillance is indicated at intervals that depend on the category of pretreatment dysplasia. Because of advances in endoscopic therapy, surgery is now indicated only when endoscopic ablation or resection has failed or in the setting of more advanced EAC. This review contains 8 figures, 2 tables, and 55 references. Key Words: cryotherapy, endoscopic mucosal resection, esophageal adenocarcinoma, esophagectomy, high-grade dysplasia, low-grade dysplasia, nodular Barrett esophagus, radiofrequency ablation

Esophagectomy versus endoscopic resection for patients with early-stage esophageal adenocarcinoma: A National Cancer Database propensity-matched study

ObjectivesEndoscopic resection has been rapidly adopted in the treatment of early-stage esophageal tumors. We compared the outcomes after esophagectomy or endoscopic resection for stage T1a adenocarcinoma. MethodsWe queried the National Cancer Database for patients with T1a esophageal adenocarcinoma who underwent esophagectomy or endoscopic resection and generated a balanced cohort with 735 matched pairs using propensity-score matching. We then performed a multivariable Cox regression analysis on the matched and unmatched cohorts. ResultsWe identified 2173 patients; 1317 (60.6%) underwent esophagectomy, and 856 (39.4%) underwent endoscopic resection. In the unmatched cohort, patients who underwent esophagectomy were younger, more often not treated in academic settings, and more likely to have comorbidities (30.4% vs 22.5%, P = .002). They had longer hospital stays and more readmissions than patients who underwent endoscopic resection. Factors positively affecting overall survival were younger age, resection at an academic medical center, and lower Charlson–Deyo comorbidity score. In the matched cohort, patients who underwent esophagectomy had longer hospital stays and were more likely to be readmitted within 30 days (7.0% vs 0.6%, P < .001). When a time period–specific partition was applied, endoscopic resection had a lower death hazard 0 to 90 days after resection (hazard ratio, 0.15; P = .003), but this was reversed for survival greater than 90 days (hazard ratio, 1.34; P = .02). ConclusionsIn patients with early-stage esophageal adenocarcinoma, survival appears equivalent after endoscopic resection or esophagectomy, but endoscopic resection is associated with shorter hospital stays, fewer readmissions, and less 90-day mortality. In patients surviving more than 90 days, esophagectomy may provide better overall survival.

Surgical vs Endoscopic Management of T1 Esophageal Adenocarcinoma: A Modeling Decision Analysis

Although treatment of T1a esophageal adenocarcinoma (EAC) is shifting from esophagectomy to endoscopic therapy, T1b EACs are considered too high risk to be treated endoscopically. We investigated the effectiveness and cost effectiveness of esophagectomy vs endoscopic therapy for T1a and T1b EACs, and the effects of age and comorbidities, using a decision analytic Markov model. We developed a model to simulate a hypothetical cohort of men 75 years old with Charlson comorbidity index scores of 0 and either T1aN0M0 or T1bN0M0 EAC, as a base case. We used the model to compare the effects of esophagectomy vs serial endoscopic therapy. We performed sensitivity analyses based on age at diagnosis of 60-85 years, comorbidity indices of 0-2, andutilities. Post-procedure cancer-specific mortality was derived from the Surveillance, Epidemiology, and End Results Medicare database. In the T1a base case, esophagectomy yielded more unadjusted life years than endoscopic therapy (6.97 vs 6.81), but fewer quality-adjusted life years (QALYs, 4.95 for esophagectomy vs 5.22 for endoscopic therapy). In the T1b base case, esophagectomy yielded more unadjusted life years than endoscopic therapy (5.73 vs 5.01) and QALYs (4.07 vs 3.85 for endoscopic therapy), but was not cost effective (incremental cost-effectiveness ratio $156,981). Sensitivity analysesshowed endoscopic therapy optimized QALYs for patients more than 80years old with a comorbidity index of 1 or 2, or if the ratio of post-esophagectomy to post-endoscopic therapy utilities was below 0.875. In a Markov model, we showed that endoscopic therapy of T1a EAC yields more QALYs and is more cost effective than esophagectomy for patients of all ages and comorbidity indices tested. In contrast, selection of therapy for T1b EAC depends on age and comorbidities, due to surgical mortality and the competing risk of non-cancer death.

Ablation Therapy for Barrett's Esophagus: New Rules for Changing Times.

In this review, we discuss different endoscopic techniques in the eradication of Barrett's esophagus (BE) as well as some controversies in the field of treatment. Patients with T1a esophageal adenocarcinoma and BE of high-grade dysplasia should undergo endoscopic ablative therapy. The most studied technique to date is radiofrequency ablation. It can be combined with endoscopic mucosal resection in cases containing nodular and flat lesions. Cryotherapy and APC have shown promise with good efficacy and safety profiles so far, but are not mainstream as more studies are needed. Surveillance is still required post-ablation since recurrence is common. Low-grade dysplasia can be treated with either endo-ablative therapy or surveillance. Non-dysplastic BE treatment is controversial and so far, only surveillance is recommended. Research is ongoing to better risk stratify these patients. Our ability to diagnose and treat BE has come a long way in the past few years with the goal of preventing its progression into malignancy. The advent of endoscopic techniques in the eradication of BE has provided a less invasive and safer modality of treatment as compared to surgical esophagectomy. Data in the form of randomized trials and high-volume registries has provided good evidence to support the efficacy of these techniques and their long-term durability.

Outcomes after Endoscopic Mucosal Resection for T1a Esophageal Adenocarcinoma with Suggested Algorithm for Management

BACKGROUND: Esophageal adenocarcinoma (EAC) is a well-known complication of Barrett’s esophagus (BE). The ASGE, AGA, and ACG have established guidelines regarding the diagnosis, management and surveillance of patients diagnosed with BE. Endoscopic mucosal resection (EMR) is an acceptable therapeutic option for T1a EAC versus esophagectomy. However, no clear guidelines exist regarding the management and follow up of patients with early EAC after EMR. The purpose of this study is: (1) to better define the outcome of EMR for T1a EAC; (2) to analyze the characteristics of our BE patients that underwent EMR for EAC; 3) to evaluate repeat EMR for positive margins of EAC in initial resection specimens. METHODS: A retrospective cohort study was conducted of patients at a tertiary care center with BE patients with early EAC who underwent EMR. The electronic medical record was reviewed to collect the following data: age, sex, age at diagnosis of BE and EAC, length of BE segment, pathology results, and imaging. RESULTS: 31 patients with BE who underwent EMR for early EAC were assessed. 29 (93.55%) were male. The median age was 67 ± 9.7 years. The median ages at BE and EAC diagnoses were 63 ± 10.5 years and 63 ± 10.3 years, respectively. The length of BE segments ranged from < 1 cm to 14cm and 17 (54.84%) patients had short segment BE. 19 (61.29%) patients had EAC diagnosed on their first EGD at our institution. On pathology, 8 (25.81%) EMR specimens had margins positive for EAC. 7 (87.5%) of these patients underwent repeat EMR; 5 were successful and 1 required esophagectomy for persistently positive margins. 26 (83.86%) patients had PET/CT after EMR, 4 (15.38%) of which were positive. Overall, 2 (6.45%) patients had EAC recurrence, occurring at 70 and 71 months; both had successful repeat EMR. Mean length of follow up at our institution was 29.1 ± 21.9 months (range 2-87 months). CONCLUSIONS: BE is a known risk factor for EAC. Our study suggests BE patients with early EAC who undergo EMR have a low rate of EAC recurrence. In our population, short segment BE also carried a risk for EAC and should not be de-emphasized. EMR specimens with margins positive for EAC can be successfully managed with repeat EMR.

Role of EUS in patients with suspected Barrett’s esophagus with high-grade dysplasia or early esophageal adenocarcinoma: impact on endoscopic therapy

Endoscopic therapy is the standard treatment for high-grade dysplasia and some cases of T1a esophageal adenocarcinoma (EAC), but it is not appropriate for deeply invasive disease. Data on the value of EUS for patient selection for endoscopic or surgical resection are conflicting. We investigated the outcome of esophageal EUS for the staging and treatment selection of patients with treatment-naive, premalignant Barrett's esophagus (BE) and suspected superficial EAC. We retrospectively reviewed consecutive patients who underwent EUS for staging of treatment-naive, suspected premalignant BE and superficial EAC from January 2006 to June 2014. All patients referred for endoscopic therapy routinely underwent EUS. Patients with esophageal masses, squamous cell cancers, previous neoadjuvant therapy, or unrelated pathologies were excluded. Each patient's final diagnosis was verified by EMR, esophagectomy, or forceps biopsy sampling. Test characteristics of EUS were calculated. Three hundred thirty-five patients (mean age, 68 years; 86% male) with BE, a Prague C mean of 2.8 cm, and a Prague M mean of 4.5 cm were staged (pT0, 78% [6% nondysplastic, 24% low-grade dysplasia, 42% high-grade dysplasia]; pT1a, 14%; pT1b, 7%; and pT2, 1%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for patient selection to endoscopic (T1aN0 or less) or surgical therapy with EUS TN staging were 50%, 93%, 40%, 95%, and 90%, respectively. Comparable rates were achieved for patients with nodular BE. Overstaging occurred in 7% of patients, and EUS selected 11% for incorrect treatment modalities compared with pathologic staging. This study confirms the limited value of EUS suggested in the latest American College of Gastroenterology guidelines for BE management.

Sa1273 Long Term Outcome After Endoscopic Mucosal Resection (EMR) for T1a Esophageal Adenocarcinoma in Barrett's Esophagus

Sa1273 Long Term Outcome After Endoscopic Mucosal Resection (EMR) for T1a Esophageal Adenocarcinoma in Barrett's Esophagus

ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus.

Barrett's esophagus (BE) is among the most common conditions encountered by the gastroenterologist. In this document, the American College of Gastroenterology updates its guidance for the best practices in caring for these patients. These guidelines continue to endorse screening of high-risk patients for BE; however, routine screening is limited to men with reflux symptoms and multiple other risk factors. Acknowledging recent data on the low risk of malignant progression in patients with nondysplastic BE, endoscopic surveillance intervals are attenuated in this population; patients with nondysplastic BE should undergo endoscopic surveillance no more frequently than every 3-5 years. Neither routine use of biomarker panels nor advanced endoscopic imaging techniques (beyond high-definition endoscopy) is recommended at this time. Endoscopic ablative therapy is recommended for patients with BE and high-grade dysplasia, as well as T1a esophageal adenocarcinoma. Based on recent level 1 evidence, endoscopic ablative therapy is also recommended for patients with BE and low-grade dysplasia, although endoscopic surveillance continues to be an acceptable alternative. Given the relatively common recurrence of BE after ablation, we suggest postablation endoscopic surveillance intervals. Although many of the recommendations provided are based on weak evidence or expert opinion, this document provides a pragmatic framework for the care of the patient with BE.

Tu1575 Successful Eradication of Stage T1a Esophageal Adenocarcinoma Using Radiofrequency Ablation in Conjunction With Photodynamic Therapy

Tu1575 Successful Eradication of Stage T1a Esophageal Adenocarcinoma Using Radiofrequency Ablation in Conjunction With Photodynamic Therapy

Clinical and Histologic Determinants of Mortality for Patients With Barrett’s Esophagus–Related T1 Esophageal Adenocarcinoma

Superficial (T1) esophageal adenocarcinoma (EAC) commonly is treated by endoscopic resection, yet little is known about factors that predict outcomes of this approach. We assessed clinical and histologic variables associated with the overall survival times of patients with T1 EAC who received therapy. In a retrospective analysis, we collected data from patients who underwent endoscopic mucosal resection (EMR) for T1 EAC (194 patients with T1a and 75 patients with T1b) at the Mayo Clinic, from 1995 through 2011. EMR specimens were reviewed systematically for depth of invasion, presence of lymphovascular invasion, grade of differentiation, and status of resection margins. Kaplan-Meier curves and proportional hazards regression models were used in statistical analyses. Demographic characteristics were similar between patients with T1a and T1b EAC. Overall survival at 5 years after EMR was 74.4% for patients with T1a (95% confidence interval [CI], 67.6%-81.8%) and 53.2% for patients with T1b EAC (95% CI, 40.3%-70.1%). Of surviving patients with T1a EAC, 94.1% remained free of cancer (95% CI, 89.8%-98.5%), and 94.7% of surviving patients with T1b EAC remained free of cancer (95% CI, 85.2%-100%). A multivariable model associated older age (per 10-year increment), evidence of lymphovascular invasion, and deep margin involvement with reduced overall survival in patients with T1 EAC. Systematic assessment of EMR specimens can help predict mortality and potentially guide treatment options for patients with T1 EAC.