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Complete endoscopic mucosal resection is an effective, durable, and relatively safe treatment for Barrett’s esophagus with high-grade dysplasia, findings from a series of 107 patients suggest.
A particular benefit of endoscopic mucosal resection is that it provides large and intact tissue specimens that allow for accurate staging, according to a report by Dr. Vani J.A. Konda of the University of Chicago and her colleagues in the December issue of Clinical Gastroenterology and Hepatology (doi:10.1016/j.cgh.2014.04.010).
Based on an intention-to-treat analysis, the approach resulted in complete eradication of Barrett’s esophagus in 86 of the 107 patients (80%) who were referred to the Center for Endoscopic Research and Therapeutics at the University of Chicago between August 2003 and December 2012 for Barrett’s esophagus with suspected high-grade dysplasia or intramucosal carcinoma. Based on a per-protocol analysis, the approach resulted in complete eradication in 79 of 80 patients (98.8%), the investigators reported.
Endoscopic mucosal resection resulted in a change in the diagnosis in 27 cases (25.2%), which were upstaged based on assessment of the resection specimens. Four of the cases in which the diagnosis was changed were initially diagnosed as high-grade dysplasia on biopsy and were found on endoscopic mucosal resection to have evidence of submucosal invasion, they said.
Patients included in the series had a mean lesion length of 3.6 cm. All patients underwent complete endoscopic mucosal resection performed on an outpatient basis by a single endoscopist and were followed through January 2014 for a median of 33 months. Most (78.5%) were treated using the cap-assisted technique, while 8.4% were treated using band ligation, 2.8% were treated using a mixed band ligation and cap technique, and 11.2% were treated using an injection-assisted, free-hand technique. Two patients with suspected submucosal invasion underwent a combination of endoscopic submucosal dissection and endoscopic mucosal resection.
Esophageal strictures occurred in 44 patients (41.1%) and 40 were symptomatic; strictures required an average of 2.3 dilations. Symptomatic dysphagia developed in 37.3% of patients, and perforations occurred in two patients, suggesting a need for surgical back-up for patients undergoing endoscopic mucosal resection, the investigators said.High-grade dysplasia and intramucosal carcinoma each recurred in one patient, and both were treated successfully with endoscopic mucosal resection, they reported.
At the most recent analysis, 53 of 74 patients (71.6%) in a durability cohort were in complete remission from intestinal metaplasia, and all were in complete remission from high-grade dysplasia or intramucosal carcinoma, they noted.
Endoscopic therapy is now preferred over esophagectomy in most cases of Barrett’s esophagus with high-grade dysplasia or intramucosal carcinoma, and the current findings show that complete endoscopic mucosal resection is an effective and durable method to treat Barrett’s-associated neoplasia, the investigators concluded, adding that the results support the replacement of esophagectomy by endoscopic therapy for the condition.
“The most commonly encountered complication of esophageal stricture formation can be addressed with endoscopic dilation,” the investigators said.
However, long-term outcomes, particularly in those with advanced pathology who undergo endoscopic management, are still needed, as is an improved understanding of the behavior of the disease following treatment with specific modalities in order to optimize endoscopic therapy, they added.
This study was supported by the Francis L. Lederer Foundation. The authors reported having no disclosures.
Localized treatments aimed at the eradication of dysplasia, early cancer, and surrounding mucosa in Barrett’s esophagus have been a major advancement in gastroenterology. Although radiofrequency ablation (RFA) has become the procedure of choice, debate exists regarding the role of other mucosal extirpative procedures. The work by Dr. Konda and her colleagues gives life to another proposed procedure, complete endoscopic mucosal resection (EMR) of dysplastic and Barrett’s mucosa. In this study, complete EMR led to results comparable with previous reports on RFA (Gastroenterology 2013;145:96-104). EMR also has theoretical advantages over RFA, including avoidance of promoting protumorigenic mutations and clonal expansion in remaining mucosa (Am. J. Gastroenterol. 2013;108:1584-92).
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| Dr. David A. Katzka |
EMR, like RFA, however, is not risk free; perforations occurred in three patients (one during dilation) and 38% developed symptomatic strictures. Furthermore, the endoscopic skill required to complete this protocol also necessitated expertise in cap technique, band ligation, injection-assisted free-hand technique, focal RFA, and endoscopic submucosal dissection. In other words, performing complete EMR is for a select group of endoscopic intensivists only. Unfortunately, endoscopic eradication of Barrett’s mucosa remains a procedure that is betwixt and between. It is between the mucosal and submucosal layer but is betwixt because of limitations on the depth of penetration of RFA (around 0.7 mm) and EMR (Dig. Dis. 2009;26:280-4) needed to eradicate the elusive Barrett’s stem cell, coupled with the increasing chance of esophageal stricture formation with these deeper levels of injury. Nevertheless, work such as this from Dr. Konda and her colleagues allows us to continue to claim at least a partial victory over Barrett’s dysplasia. It is hoped that with future techniques, we may come up with a “kinder” and easier method of removing all Barrett’s mucosa without the provocation of a substantial fibrotic reaction of the remaining esophageal wall.
Dr. David A. Katzka is in the department of gastroenterology and hepatology, Mayo Clinic, Rochester, Minn. He has no conflicts of interest.
Localized treatments aimed at the eradication of dysplasia, early cancer, and surrounding mucosa in Barrett’s esophagus have been a major advancement in gastroenterology. Although radiofrequency ablation (RFA) has become the procedure of choice, debate exists regarding the role of other mucosal extirpative procedures. The work by Dr. Konda and her colleagues gives life to another proposed procedure, complete endoscopic mucosal resection (EMR) of dysplastic and Barrett’s mucosa. In this study, complete EMR led to results comparable with previous reports on RFA (Gastroenterology 2013;145:96-104). EMR also has theoretical advantages over RFA, including avoidance of promoting protumorigenic mutations and clonal expansion in remaining mucosa (Am. J. Gastroenterol. 2013;108:1584-92).
|
| Dr. David A. Katzka |
EMR, like RFA, however, is not risk free; perforations occurred in three patients (one during dilation) and 38% developed symptomatic strictures. Furthermore, the endoscopic skill required to complete this protocol also necessitated expertise in cap technique, band ligation, injection-assisted free-hand technique, focal RFA, and endoscopic submucosal dissection. In other words, performing complete EMR is for a select group of endoscopic intensivists only. Unfortunately, endoscopic eradication of Barrett’s mucosa remains a procedure that is betwixt and between. It is between the mucosal and submucosal layer but is betwixt because of limitations on the depth of penetration of RFA (around 0.7 mm) and EMR (Dig. Dis. 2009;26:280-4) needed to eradicate the elusive Barrett’s stem cell, coupled with the increasing chance of esophageal stricture formation with these deeper levels of injury. Nevertheless, work such as this from Dr. Konda and her colleagues allows us to continue to claim at least a partial victory over Barrett’s dysplasia. It is hoped that with future techniques, we may come up with a “kinder” and easier method of removing all Barrett’s mucosa without the provocation of a substantial fibrotic reaction of the remaining esophageal wall.
Dr. David A. Katzka is in the department of gastroenterology and hepatology, Mayo Clinic, Rochester, Minn. He has no conflicts of interest.
Localized treatments aimed at the eradication of dysplasia, early cancer, and surrounding mucosa in Barrett’s esophagus have been a major advancement in gastroenterology. Although radiofrequency ablation (RFA) has become the procedure of choice, debate exists regarding the role of other mucosal extirpative procedures. The work by Dr. Konda and her colleagues gives life to another proposed procedure, complete endoscopic mucosal resection (EMR) of dysplastic and Barrett’s mucosa. In this study, complete EMR led to results comparable with previous reports on RFA (Gastroenterology 2013;145:96-104). EMR also has theoretical advantages over RFA, including avoidance of promoting protumorigenic mutations and clonal expansion in remaining mucosa (Am. J. Gastroenterol. 2013;108:1584-92).
|
| Dr. David A. Katzka |
EMR, like RFA, however, is not risk free; perforations occurred in three patients (one during dilation) and 38% developed symptomatic strictures. Furthermore, the endoscopic skill required to complete this protocol also necessitated expertise in cap technique, band ligation, injection-assisted free-hand technique, focal RFA, and endoscopic submucosal dissection. In other words, performing complete EMR is for a select group of endoscopic intensivists only. Unfortunately, endoscopic eradication of Barrett’s mucosa remains a procedure that is betwixt and between. It is between the mucosal and submucosal layer but is betwixt because of limitations on the depth of penetration of RFA (around 0.7 mm) and EMR (Dig. Dis. 2009;26:280-4) needed to eradicate the elusive Barrett’s stem cell, coupled with the increasing chance of esophageal stricture formation with these deeper levels of injury. Nevertheless, work such as this from Dr. Konda and her colleagues allows us to continue to claim at least a partial victory over Barrett’s dysplasia. It is hoped that with future techniques, we may come up with a “kinder” and easier method of removing all Barrett’s mucosa without the provocation of a substantial fibrotic reaction of the remaining esophageal wall.
Dr. David A. Katzka is in the department of gastroenterology and hepatology, Mayo Clinic, Rochester, Minn. He has no conflicts of interest.
Complete endoscopic mucosal resection is an effective, durable, and relatively safe treatment for Barrett’s esophagus with high-grade dysplasia, findings from a series of 107 patients suggest.
A particular benefit of endoscopic mucosal resection is that it provides large and intact tissue specimens that allow for accurate staging, according to a report by Dr. Vani J.A. Konda of the University of Chicago and her colleagues in the December issue of Clinical Gastroenterology and Hepatology (doi:10.1016/j.cgh.2014.04.010).
Based on an intention-to-treat analysis, the approach resulted in complete eradication of Barrett’s esophagus in 86 of the 107 patients (80%) who were referred to the Center for Endoscopic Research and Therapeutics at the University of Chicago between August 2003 and December 2012 for Barrett’s esophagus with suspected high-grade dysplasia or intramucosal carcinoma. Based on a per-protocol analysis, the approach resulted in complete eradication in 79 of 80 patients (98.8%), the investigators reported.
Endoscopic mucosal resection resulted in a change in the diagnosis in 27 cases (25.2%), which were upstaged based on assessment of the resection specimens. Four of the cases in which the diagnosis was changed were initially diagnosed as high-grade dysplasia on biopsy and were found on endoscopic mucosal resection to have evidence of submucosal invasion, they said.
Patients included in the series had a mean lesion length of 3.6 cm. All patients underwent complete endoscopic mucosal resection performed on an outpatient basis by a single endoscopist and were followed through January 2014 for a median of 33 months. Most (78.5%) were treated using the cap-assisted technique, while 8.4% were treated using band ligation, 2.8% were treated using a mixed band ligation and cap technique, and 11.2% were treated using an injection-assisted, free-hand technique. Two patients with suspected submucosal invasion underwent a combination of endoscopic submucosal dissection and endoscopic mucosal resection.
Esophageal strictures occurred in 44 patients (41.1%) and 40 were symptomatic; strictures required an average of 2.3 dilations. Symptomatic dysphagia developed in 37.3% of patients, and perforations occurred in two patients, suggesting a need for surgical back-up for patients undergoing endoscopic mucosal resection, the investigators said.High-grade dysplasia and intramucosal carcinoma each recurred in one patient, and both were treated successfully with endoscopic mucosal resection, they reported.
At the most recent analysis, 53 of 74 patients (71.6%) in a durability cohort were in complete remission from intestinal metaplasia, and all were in complete remission from high-grade dysplasia or intramucosal carcinoma, they noted.
Endoscopic therapy is now preferred over esophagectomy in most cases of Barrett’s esophagus with high-grade dysplasia or intramucosal carcinoma, and the current findings show that complete endoscopic mucosal resection is an effective and durable method to treat Barrett’s-associated neoplasia, the investigators concluded, adding that the results support the replacement of esophagectomy by endoscopic therapy for the condition.
“The most commonly encountered complication of esophageal stricture formation can be addressed with endoscopic dilation,” the investigators said.
However, long-term outcomes, particularly in those with advanced pathology who undergo endoscopic management, are still needed, as is an improved understanding of the behavior of the disease following treatment with specific modalities in order to optimize endoscopic therapy, they added.
This study was supported by the Francis L. Lederer Foundation. The authors reported having no disclosures.
Complete endoscopic mucosal resection is an effective, durable, and relatively safe treatment for Barrett’s esophagus with high-grade dysplasia, findings from a series of 107 patients suggest.
A particular benefit of endoscopic mucosal resection is that it provides large and intact tissue specimens that allow for accurate staging, according to a report by Dr. Vani J.A. Konda of the University of Chicago and her colleagues in the December issue of Clinical Gastroenterology and Hepatology (doi:10.1016/j.cgh.2014.04.010).
Based on an intention-to-treat analysis, the approach resulted in complete eradication of Barrett’s esophagus in 86 of the 107 patients (80%) who were referred to the Center for Endoscopic Research and Therapeutics at the University of Chicago between August 2003 and December 2012 for Barrett’s esophagus with suspected high-grade dysplasia or intramucosal carcinoma. Based on a per-protocol analysis, the approach resulted in complete eradication in 79 of 80 patients (98.8%), the investigators reported.
Endoscopic mucosal resection resulted in a change in the diagnosis in 27 cases (25.2%), which were upstaged based on assessment of the resection specimens. Four of the cases in which the diagnosis was changed were initially diagnosed as high-grade dysplasia on biopsy and were found on endoscopic mucosal resection to have evidence of submucosal invasion, they said.
Patients included in the series had a mean lesion length of 3.6 cm. All patients underwent complete endoscopic mucosal resection performed on an outpatient basis by a single endoscopist and were followed through January 2014 for a median of 33 months. Most (78.5%) were treated using the cap-assisted technique, while 8.4% were treated using band ligation, 2.8% were treated using a mixed band ligation and cap technique, and 11.2% were treated using an injection-assisted, free-hand technique. Two patients with suspected submucosal invasion underwent a combination of endoscopic submucosal dissection and endoscopic mucosal resection.
Esophageal strictures occurred in 44 patients (41.1%) and 40 were symptomatic; strictures required an average of 2.3 dilations. Symptomatic dysphagia developed in 37.3% of patients, and perforations occurred in two patients, suggesting a need for surgical back-up for patients undergoing endoscopic mucosal resection, the investigators said.High-grade dysplasia and intramucosal carcinoma each recurred in one patient, and both were treated successfully with endoscopic mucosal resection, they reported.
At the most recent analysis, 53 of 74 patients (71.6%) in a durability cohort were in complete remission from intestinal metaplasia, and all were in complete remission from high-grade dysplasia or intramucosal carcinoma, they noted.
Endoscopic therapy is now preferred over esophagectomy in most cases of Barrett’s esophagus with high-grade dysplasia or intramucosal carcinoma, and the current findings show that complete endoscopic mucosal resection is an effective and durable method to treat Barrett’s-associated neoplasia, the investigators concluded, adding that the results support the replacement of esophagectomy by endoscopic therapy for the condition.
“The most commonly encountered complication of esophageal stricture formation can be addressed with endoscopic dilation,” the investigators said.
However, long-term outcomes, particularly in those with advanced pathology who undergo endoscopic management, are still needed, as is an improved understanding of the behavior of the disease following treatment with specific modalities in order to optimize endoscopic therapy, they added.
This study was supported by the Francis L. Lederer Foundation. The authors reported having no disclosures.
Key clinical point: Endoscopic therapy should replace esophagectomy for Barrett’s-associated neoplasia.
Major finding: Barrett’s esophagus was completely eradicated in 86 of 107 patients (80%) on intention-to-treat analysis.
Data source: A series of 107 cases.
Disclosures: This study was supported by the Francis L. Lederer Foundation. The authors reported having no disclosures.
