Endoscopic approaches to Barrett's oesophagus with high-grade dysplasia/early mucosal cancer

Treatment of early stage (T1) esophageal adenocarcinoma: Personalizing the best therapy choice

Esophagectomy is considered the primary form of management for esophageal adenocarcinoma (EAC); however, the surgery is associated with high rates of morbidity and mortality. For patients with early-stage EAC, endoscopic resection (ER) presents a potential curative treatment option that is less invasive and carries fewer risks procedure related risks, but it is associated with higher rates of cancer recurrence following the procedure. For some patients, age and comorbidities may prevent them from having esophagectomy as a treatment option, while other patients may be operative candidates but do not wish to undergo esophagectomy for a variety of reasons related to their values and preferences. Furthermore, while anxiety of cancer recurrence following ER may significantly diminish a patient’s quality of life (QOL), so might the morbidity surrounding esophagectomy. In addition to considering health status, patient preferences, and impacts on QOL, physicians and patients must also consider what treatments would be both beneficial and available to the patient, considering esophagectomy methods-minimally invasive vs open-or the use of chemoradiotherapy in addition to ER. Our article reviews and summarizes available treatment options for patients with early EAC and their potential effects on the health and wellbeing of patients based on the current data. We conclude with a request for more research of available options for early EAC patients, the conditions that determine when each option should be employed, and their effects not only on patient health but also QOL.

Esophageal cancer: A Review of epidemiology, pathogenesis, staging workup and treatment modalities

Esophageal cancer is a serious malignancy with regards to mortality and prognosis. It is a growing health concern that is expected to increase in incidence over the next 10 years. Squamous cell carcinoma is the most common histological type of esophageal cancer worldwide, with a higher incidence in developing nations. With the increased prevalence of gastroesophageal reflux disease and obesity in developed nations, the incidence of esophageal adenocarcinoma has dramatically increased in the past 40 years. Esophageal cancer is staged according to the widely accepted TNM system. Staging plays an integral part in guiding stage specific treatment protocols and has a great impact on overall survival. Common imaging modalities used in staging include computed tomography, endoscopic ultrasound and positron emission tomography scans. Current treatment options include multimodality therapy mainstays of current treatment include surgery, radiation and chemotherapy. Tumor markers of esophageal cancer are an advancing area of research that could potentially lead to earlier diagnosis as well as playing a part in assessing tumor response to therapy.

Endoscopic therapy for Barrett's esophagus: a review of its emerging role in optimal diagnosis and endoluminal therapy

Barrett's esophagus (BE) is a premalignant lesion known to sequentially progress to esophageal adenocarcinoma. Management of BE has changed significantly over the last 5 years with the development of endoscopic resection and ablation, which has replaced esophagectomy as the treatment of choice in BE with high-grade dysplasia. The aim of this review is to discuss the details of these new endotherapies in regards to response and durability and to define the role of these new therapies in the current management of BE.

Staging of early adenocarcinoma in Barrett's esophagus

The main goal in the staging of patients with early neoplasia arising in the context of Barrett's esophagus (BE) is to identify individuals who are eligible for endoscopic therapy and differentiate them from those who require surgical management. To make the proper patient selection a combined staging strategy consisting of endoscopy evaluation, endoscopic ultrasonography, and endoscopic mucosal resection is necessary. In this article, the authors summarize the evidence behind each different staging modality in the setting of early BE adenocarcinoma and propose a staging approach that helps to select patients who are suitable for endoscopic therapy.

New endoscopic and surgical treatment options for early esophageal adenocarcinoma

Although the outcome for advanced stage esophageal cancer is poor, the early detection and treatment of early stage disease is usually associated with a much better outcome. Until recently, esophagectomy has been the treatment of choice in fit patients. However, morbidity is significant, and this has encouraged the development of newer endoscopic treatments that preserve the esophagus. These techniques include ablation and mucosal resection. Promising results are described, and endoscopic methods might provide a reasonable alternative for the treatment of early esophageal cancer. However, follow-up remains short and endoscopic treatment does not deal with potential lymphatic spread. Hence, careful selection is required. Minimally invasive techniques for esophageal resection have also been shown to be feasible, although there is only limited evidence that they reduce postoperative morbidity. Better data are still required to demonstrate improved outcomes from endoscopic treatment and minimally invasive esophagectomy.

Variation in Barrett's esophageal wall thickness: is it associated with histology or segment length?

GOALS

To measure esophageal wall thickness (EWT) with endoscopic ultrasound (EUS) in patients with and without Barrett's esophagus (BE).

BACKGROUND

Segment length and histology are used to evaluate BE. The development of varying depths of ablation therapy has renewed interest in using EUS for BE.

STUDY

In this prospective study, EWT measurements were taken from the balloon-mucosal interface to the outer most hyper-echoic line. These measurements were correlated with the highest grade of BE dysplasia and segment length, and then compared with the measurements from control group.

RESULTS

Between 2004 to 2007, 76 BE patients (69 men, mean age 68 y, 4 ND, 14 low-grade dysplasia, 52 high-grade dysplasia, 6 carcinoma in situ) and 53 normal controls (18 men, mean age 60 y) underwent EUS. The mean EWT was 2.4 mm for controls, 3.1 mm for nondysplastic BE, 3.2 mm for low-grade dysplasia, 3.4 mm for high-grade dysplasia, and 3.9 mm for carcinoma in situ. In the control group of 53 patients, the mean EWT was 2.4 mm. Compared with normal controls, the mean EWT was significantly greater in all histologic subgroups of BE patients (P<0.001). No statistically significant correlation was seen between EWT and BE histology grade. There were no correlations between age, gender, or BE segment length and EWT (P=0.55).

CONCLUSIONS

EWT is greater among patients with BE compared with control patients; however, there were no systematic differences in EWT were found among BE patients, based on histology and segment length.

Endoscopic mucosal resection for staging and therapy of adenocarcinoma of the esophagus, gastric cardia, and upper gastric third

Minamally invasive endoscopic resection techniques allow definitive histological staging for dysplasia and early cancer and in many cases curative treatment. In Barrett's esophagus with High Grade Dysplasia (HGD) or early mucosal cancer, endoscopic mucosal resection (EMR) should be considered both as diagnostic and therapeutic first line procedure, with the possibility to repeat the procedure in case of residual Barrett's dysplasia or mucosal cancer. In early cancer of the the submucosa, surgical resection should be discussed. Endoscopic submucosal dissection (ESD) is a useful therapeutic option for HGD or early cancer in the squamous epithelium of the esophagus or in the stomach when en bloc resection is needed in large lesions.