High-grade dysplasia and intramucosal adenocarcinoma in Barrett's esophagus: the role of esophagectomy in the era of endoscopic eradication therapy

The role of esophagectomy in the management of Barrett's esophagus with high-grade dysplasia

Barrett's esophagus (BE) with high-grade dysplasia (HGD) has previously been a routine indication for esophagectomy. Recent advances in endoscopic therapy have resulted in a shift away from surgery. Current international guidelines recommend endoscopic therapy for BE with HGD irrespective of recurrence or progression of dysplasia. Current guidelines do not address the ongoing role of esophagectomy as an adjunct in the setting of failed endoscopic therapy. This review examines the role of esophagectomy as an adjunct to endoscopy in the management of patients with BE and HGD, with a specific focus on patients with persistent, progressive, or recurrent disease, disease resistant to endoscopic therapy, in patients with concomitant esophageal pathology, and in those patients in whom lifelong surveillance may not be possible or desired.

Specific Tumor Characteristics Predict Upstaging in Early-Stage Esophageal Cancer

BACKGROUND

Early-stage esophageal cancer (stages 0-1) has been shown to have relatively good outcomes after local endoscopic or surgical resection. For this reason, neoadjuvant chemoradiation usually is reserved for higher-stage disease. Some early tumors, however, are found after resection to be more advanced than predicted based on initial clinical staging, termed pathologic upstaging. Such tumors may have benefited from alternate treatment models had their true stage been known preoperatively. This study aimed to identify high-risk features in early esophageal cancers that might predict tumor upstaging and guide more individualized treatment algorithms.

METHODS

Through retrospective review of a single-institution foregut disease registry, we evaluated patients who underwent esophagectomy for high-grade dysplasia (Tis) or stage 1 esophageal cancer, searching for factors associated with pathologic upstaging.

RESULTS

The review included 110 patients (88% male, median age at diagnosis, 64.5 years) treated between January 2000 and June 2016. Upstaging occurred for 20.9% of the patients, and was more common for patients with angiolymphatic invasion (odds ratio [OR], 11.07; 95% confidence interval [CI], 2.96-41.44; P < 0.001) or signet-ring features (OR, 23.9; 95% CI, 2.6-216.8; P = 0.005). In the absence of other predictors, upstaging was associated with decreased overall survival (P = 0.006).

CONCLUSIONS

Approximately 20% of patients with early-stage esophageal cancer may be upstaged at resection. Angiolymphatic invasion and signet-ring features may predict tumors likely to be upstaged, resulting in decreased overall survival.

Surgical Treatment of High-Grade Dysplasia and Early Esophageal Cancer

BACKGROUND

The treatment of early-stage esophageal cancer and high-grade dysplasia of the esophagus has changed significantly in recent years. Many early tumors that were traditionally treated with esophagectomy can now be resected with endoscopic therapy alone. These new endoscopic modalities can offer similar survival outcomes without the associated morbidity of a major operation. However, a number of these cases may still require surgical intervention as the best treatment option.

METHODS

The current scientific literature, national and international guidelines were reviewed for recommendations regarding optimal treatment of early esophageal malignancy.

RESULTS

The primary advantage of surgery over endoscopic treatment lies in the reduced risk of recurrence as well as the ability to assess harvested lymph nodes for regional disease. We recommend that esophageal tumors that have invaded into the submucosa (T1b) or beyond should be treated with an esophagectomy. In addition, dysplastic lesions and cancers that demonstrate poorly differentiated pathology or lymphovascular or perineural invasion should be surgically resected. Finally, large tumors, multifocal lesions, tumors within a long segment of Barrett's esophagus, tumors adjacent to a hiatal hernia, tumors that cannot be resected enbloc with endoscopic techniques should also be treated with an esophagectomy.

CONCLUSIONS

When performed at high-volume centers in experienced hands, esophagectomy can have consistently good outcomes for high-grade dysplasia and early esophageal cancers, and should be considered as a treatment option.

Advances in the Diagnosis and Treatment of Barrett's Esophagus and Early Esophageal Cancer; Summary of the Kelly and Carlos Pellegrini SSAT/SAGES Luncheon Symposium

BACKGROUND

Patients with Barrett's esophagus (BE) are at increased risk of developing esophageal adenocarcinoma (EAC). The incidence of EAC is rising faster than any other cancer.

DISCUSSION

Patients with BE have a 30- to 40-fold increased risk of EAC. In the past 20 years, there have been dramatic advances in our understanding of the incidence and natural history of BE. Endoscopic treatment of BE is evolving. Even early EAC has been treated without esophagectomy and good oncologic results in the modern era.

Recurrent intestinal metaplasia at the gastroesophageal junction following endoscopic eradication of dysplastic Barrett's esophagus may not be benign

BACKGROUND AND STUDY AIMS

Radiofrequency ablation (RFA) combined with endoscopic mucosal resection (EMR) is effective for eradicating dysplastic Barrett's esophagus. The durability of response is reported to be variable. We aimed to determine the effectiveness and durability of RFA with or without EMR for patients with dysplastic Barrett's esophagus.

PATIENTS AND METHODS

Patients with dysplastic Barrett's esophagus referred to two academic hospitals were assessed with high definition white-light endoscopy, narrow-band imaging, and Seattle protocol biopsies. EMR was performed in visible lesions. RFA was performed at 3-month intervals until complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM) was achieved.

RESULTS

In total, 137 patients received RFA (78 with EMR); 75 with over 12 months follow-up since commencing RFA. Pretreatment histology was intramucosal cancer (IMC) 21 %, high grade dysplasia (HGD) 54 %, low grade dysplasia (LGD) 25 %. CR-D rates were 88 %, 92 %, and 100 % at 1, 2, and 3 years; CR-IM rates were 69 %, 74 %, and 81 %. Kaplan-Meier analysis showed increasing probability of achieving CR-D/CR-IM over time. Of 26 patients maintaining CR-IM for > 12 months, five relapsed with intestinal metaplasia (19 %), and three with dysplasia (12 %). Recurrences occurred in patients with prior HGD/IMC, predominantly at the gastroesophageal junction (GEJ). None relapsed with cancer. Adverse events occurred in 4 % of RFA and 6.5 % of EMR procedures.

CONCLUSIONS

RFA combined with EMR is effective in achieving CR-D/CR-IM in the majority of patients with dysplastic Barrett's esophagus, with an incremental response over time. While durable in the majority, recurrent intestinal metaplasia and dysplasia, frequently occurring at the GEJ, suggest long-term surveillance is warranted in high risk groups.

Long-term outcomes of a primary complete endoscopic resection strategy for short-segment Barrett's esophagus with high-grade dysplasia and/or early esophageal adenocarcinoma

BACKGROUND AND AIMS

Complete endoscopic resection (CER) of Barrett's esophagus (BE) with high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EEA) is a comprehensive and precise staging tool and may produce a sustained treatment response, preventing metachronous disease. There are limited data on long-term clinical outcomes and the sustainability of dysplasia eradication after CER. We aimed to describe long-term outcomes of a primary CER strategy of BE with HGD/EEA.

METHODS

Patients with biopsy-proven HGD and EEA in short-segment BE (≤ 3 cm in circumferential length and ≤ 5 cm in maximal length) underwent staged CER by multiband mucosectomy or the cap method. The primary endpoint was remission of HGD or EEA (complete resection of HGD/EEA), dysplasia (complete resection of any dysplasia), and complete resection of intestinal metaplasia.

RESULTS

Of 153 patients (126 HGD, 27 EEA; 83.7% male, median age of 66 years) considered suitable for CER, 138 met all inclusion criteria. CER was technically successful in all patients and was established after a median of 2 sessions. Covert synchronous EEA was found in 1 patient. At a mean follow-up of 40.7 months by intention-to-treat analysis, complete remission of HGD/EEA, dysplasia, and intestinal metaplasia was achieved in 98.5%, 89.1%, and 71.0%, respectively. In 47.1% of patients, CER changed the histological grade compared with pretreatment biopsies (28.1% downstaged and 19.0% upstaged). Esophageal dilation was performed in 36.8% in a mean of 2.5 sessions. At the end of follow-up, 96.4% of patients had no or minimal dysphagia and 90.6% of patients found CER an acceptable treatment.

CONCLUSIONS

On long-term follow-up, a primary CER strategy was a highly effective, safe, and durable treatment for HGD and EEA. Despite the need for post-CER dilation in one-third of patients, the majority found it an acceptable treatment on long-term follow-up.

Endoscopic mucosal resection for staging and treatment of early esophageal carcinoma: a single institution experience

BACKGROUND

Endoscopic mucosal resection (EMR) has emerged for evaluation and treatment of esophageal nodules. We report our initial experience with EMR for T staging and management of early esophageal cancer.

METHODS

We reviewed patients undergoing EMR for esophageal adenocarcinoma between 2008 and 2013. The primary outcome measure was needed for esophagectomy. Secondary outcomes included complete eradication of adenocarcinoma, recurrence or persistence of cancer, nodal status for those undergoing esophagectomy, and complications of endoscopic treatment.

RESULTS

During the study period, 24 patients underwent EMR demonstrating carcinoma, and a grossly margin negative endoscopic resection was achieved in all cases. Ten patients (42 %) had evidence of submucosal invasion and were referred for esophagectomy. Patients with margin negative EMR (n = 10, 42 %) or positive radial margins (n = 4, 16 %) underwent endoscopic surveillance and treatment with radiofrequency ablation or repeat EMR as needed. Thirteen patients (93 %) with intramucosal cancer (IMC) have been successfully managed with ongoing endoscopic surveillance and treatment with a median follow-up of 15.5 months. One patient underwent esophagectomy due to recurrent IMC in the setting of long-segment multifocal high-grade dysplasia. There were no esophageal perforations, one patient developed a self-limited gastrointestinal hemorrhage following EMR, and one had an esophageal stricture following endoscopic management.

CONCLUSIONS

IMC can be successfully managed endoscopically and thus esophagectomy is avoided in a significant proportion of patients. Endoscopic management may be utilized in the setting of complete resection or radial margin involvement without evidence of submucosal invasion. Close endoscopic follow-up is of paramount importance even in those with negative margins, because recurrent disease may occur following EMR in these patients.

Detection and staging of esophageal cancers within Barrett's esophagus is improved by assessment in specialized Barrett's units

BACKGROUND

Identification and resection of mucosal abnormalities are critical in managing dysplastic Barrett's esophagus (BE) because these areas may harbor esophageal adenocarcinoma (EAC).

OBJECTIVES

To compare mucosal lesion and EAC detection rates in dysplastic BE in the community versus a BE unit and assess the impact of EMR on disease staging and management.

DESIGN

Prospective cohort study.

SETTING

Tertiary referral center.

PATIENTS

Patients with dysplastic BE.

INTERVENTIONS

Reassessment with high-definition white-light endoscopy (HD-WLE), narrow-band imaging (NBI), and Seattle protocol biopsies. EMR performed in lesions thought to harbor neoplasia. Review of referral histology and endoscopies.

MAIN OUTCOME MEASUREMENTS

Mucosal lesion and EAC detection rates in a BE unit versus the community. Impact of EMR on management.

RESULTS

Sixty-nine patients were referred (88% male; median age, 69 years). At referral, HD-WLE/NBI use was 57%/14%, and Seattle protocol adherence was 20%. Eighteen patients had intramucosal cancer. Lesions were detected in 65 patients in the BE unit versus 29 patients at referral (P < .001). EMR was performed in 47 patients. BE unit assessment confirmed EAC in all 18 patients and identified 10 additional patients (56% increased cancer detection, P = .036); all 10 had lesions identified in the BE unit (vs 3 identified at referral). EMR in these patients found submucosal cancer (n = 4) and intramucosal cancer (n = 6), resulting in esophagectomy (n = 4) and chemoradiotherapy (n = 1).

LIMITATION

Academic center.

CONCLUSION

BE assessment at a BE unit resulted in increased lesion and EAC detection. EMR of early cancers was critical in optimizing patient management. These data suggest that BE unit referral be considered in patients with dysplastic BE.

Evidence for enhanced telomerase activity in Barrett's esophagus with dysplasia and adenocarcinoma

BACKGROUND

Dysplasia and adenocarcinoma developing in Barrett's esophagus (BE) are not always endoscopically identifiable. Molecular markers are needed for early recognition of these focal lesions and to identify patients at increased risk of developing adenocarcinoma. The aim of the current study was to correlate increased telomerase activity (TA) with dysplasia and adenocarcinoma occurring in the setting of BE.

MATERIALS AND METHODS

Esophageal mucosal biopsies were obtained from patients (N=62) who had pathologically verified BE at esophagogastroduodenoscopy (EGD). Mucosal biopsies were also obtained from the gastric fundus as controls. Based on histopathology, patients were divided into three groups: 1) BE without dysplasia (n=24); 2) BE with dysplasia (both high grade and low grade, n=13); and 3) BE with adenocarcinoma (n=25). TA was measured by a PCR-based assay (TRAPeze® ELISA Telomerase Detection Kit). Statistical analyses were performed using one-way ANOVA and post-hoc Bonferroni testing.

RESULTS

TA was significantly higher in biopsies of BE with dyplasia and BE with adenocarcinoma than in BE without dysplasia. Subgroup analyses did not reveal any significant correlations between TA and patient age, length of BE, or presence of gastritis.

CONCLUSIONS

Telomerase activity in esophageal mucosal biopsies of BE may constitute a useful biomarker for the early detection of esophageal dysplasia and adenocarcinoma.

Barrett esophagus: diagnostic challenges

The incidence of esophageal adenocarcinoma and associated mortality has risen dramatically over the past several decades, and, thus, it is increasingly important to understand its pathogenesis and risk factors. Barrett esophagus is the established precursor to esophageal adenocarcinoma that progresses through a metaplasia-dysplasia-carcinoma sequence. Its risk of transforming to carcinoma is not as high as previously reported and there appears to be a biological heterogeneity among patients with this disease. The overall prevalence of Barrett esophagus in the United States ranges from 1% to 25% and is closer to 5% in patients with gastroesophageal reflux disease. Because of the frequency of Barrett esophagus and associated implications, it is important for the practicing pathologist to have a thorough understanding of this disease and its diagnostic pitfalls. In this review, we will discuss issues associated with the diagnosis of Barrett esophagus, including the definition of Barrett esophagus and its distinction from carditis with intestinal metaplasia. We will also discuss challenges in the grading of dysplasia and new variants of dysplasia, including crypt dysplasia and foveolar-type dysplasia. Finally, we will touch upon the evaluation of dysplasia in endoscopic mucosal resection specimens.

MicroRNA as a new factor in lung and esophageal cancer

Lung cancer is the most lethal cancer due to late detection in advanced stages; early diagnosis of lung cancer allows surgical treatment and improves the outcome. The prevalence of gastroesophageal reflux-related adenocarcinomas of the esophagus is increasing; repetitive surveillance endoscopies are necessary to detect development of cancer. A blood-based biomarker would simplify the diagnosis and treatment of both diseases. MicroRNAs (miRNAs) are short RNA strands that interfere with protein production. miRNAs play pivotal roles in cell homeostasis, and dysregulation of miRNAs can lead to the development of cancer. miRNAs can be found in all body fluids and have been proposed to serve as messengers between closely localized cells but also distant organs. Cancer cells actively secrete miRNAs, and these miRNA profiles can be found in blood. We outline, here, how these miRNAs may aid in diagnosis and treatment of lung and esophageal cancers, as well as their apparent limitations.

Outcomes in patients who have failed endoscopic therapy for dysplastic Barrett's metaplasia or early esophageal cancer

BACKGROUND

Endoscopic therapy (ablation ± mucosal resection) for esophageal high-grade dysplasia (HGD) or intramucosal carcinoma has demonstrated promising results. Little is known about patients who have persistent or progressive disease despite endotherapy. We compared patients who had successful eradication of their disease with those in whom endotherapy failed to try to identify factors predictive of failure and outcomes after salvage therapy.

METHODS

We performed a single-institution retrospective review of patients treated with endotherapy from 2007 to 2012.

RESULTS

Thirty-eight patients underwent endotherapy: 28 had successful eradication of their disease and endotherapy failed in 10 patients. Patients in whom endotherapy failed were more likely to have high-grade dysplasia (HGD) on initial endoscopy, nodules or ulcers, multifocal dysplasia, and persistent nondysplastic Barrett's metaplasia. Patients in whom endotherapy failed also underwent significantly more endotherapy sessions. Seven patients had persistent dysplasia or progression to cancer, and 3 patients had complete eradication of HGD but presented with intramucosal carcinoma an average of 15 months after eradication. The 10 patients in whom endotherapy failed underwent salvage therapy with esophagectomy (7 patients), definitive chemoradiotherapy (1 patient), and endotherapy (2 patients). Patients treated with esophagectomy were disease free at a mean of 25 months postoperatively.

CONCLUSIONS

HGD on initial endoscopy, multifocal dysplasia, mucosal abnormalities, and failure to eradicate nondysplastic Barrett's metaplasia were associated with failure of endotherapy. Patients with these characteristics should be considered at higher risk for treatment failure, and earlier consideration should be given to esophagectomy if there is persistent, progressive, or recurrent neoplasia. Clinical outcomes are good, even after salvage therapy. Continued endoscopic surveillance is mandatory after successful endotherapy because of the risk of recurrent disease.

Advances in endoluminal therapy for esophageal cancer

Advances in endoscopic therapy have resulted in dramatic changes in the way early esophageal cancer is managed as well as in the palliation of dysphagia related to advanced esophageal cancer. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are effective therapies for accurate histopathologic staging and provide a potential for complete cure. Mucosal ablative techniques (radiofrequency ablation and cryotherapy) are effective adjuncts to EMR and ESD and reduce the occurrence of synchronous and metachronous lesions within the Barrett esophagus. The successes of these techniques have made endoscopic therapy the primary means of management of early esophageal cancer.

Endoscopic therapy of Barrett esophagus

Barrett esophagus (BE) is a well-established premalignant condition for esophageal adenocarcinoma (EAC), a lethal cancer with a dismal survival rate. The current guidelines recommend surveillance of patients with BE to detect dysplasia or early cancer before the development of invasive EAC. Recently, endoscopic eradication therapies have been shown to be safe and effective in the treatment of BE-related high-grade dysplasia and early EAC. This article reviews the various treatment options for BE and discusses the current evidence and gaps in knowledge in the understanding of treatment of this condition. In addition, recommendations are provided in context to the recently published guidelines by the American Gastroenterological Association.

Management strategies of Barrett's esophagus

Barrett’s esophagus is a condition resulting from chronic gastro-esophageal reflux disease with a documented risk of esophageal adenocarcinoma. Current strategies for improved survival in patients with Barrett's adenocarcinoma focus on detection of dysplasia. This can be obtained by screening programs in high-risk cohorts of patients and/or endoscopic biopsy surveillance of patients with known Barrett’s esophagus (BE). Several therapies have been developed in attempts to reverse BE and reduce cancer risk. Aggressive medical management of acid reflux, lifestyle modifications, antireflux surgery, and endoscopic treatments have been recommended for many patients with BE. Whether these interventions are cost-effective or reduce mortality from esophageal cancer remains controversial. Current treatment requires combinations of endoscopic mucosal resection techniques to eliminate visible lesions followed by ablation of residual metaplastic tissue. Esophagectomy is currently indicated in multifocal high-grade neoplasia or mucosal Barrett’s carcinoma which cannot be managed by endoscopic approach.