Endoscopic submucosal dissection of a minute intramucosal adenocarcinoma in Barrett's esophagus

Endoscopic diagnosis and treatment of esophageal adenocarcinoma: introduction of Japan Esophageal Society classification of Barrett's esophagus

Endoscopic surveillance of Barrett's esophagus has become a foundation of the management of esophageal adenocarcinoma (EAC). Surveillance for Barrett's esophagus commonly involves periodic upper endoscopy with biopsies of suspicious areas and random four-quadrant biopsies. However, targeted biopsies using narrow-band imaging can detect more dysplastic areas and thus reduce the number of biopsies required. Several specific mucosal and vascular patterns characteristic of Barrett's esophagus have been described, but the proposed criteria are complex and diverse. Simpler classifications have recently been developed focusing on the differentiation between dysplasia and non-dysplasia. These include the Japan Esophageal Society classification, which defines regular and irregular patterns in terms of mucosal and vascular shapes. Cancer invasion depth is diagnosed by endoscopic ultrasonography (EUS); however, a meta-analysis of EUS staging of superficial EAC showed favorable pooled values for mucosal cancer staging, but unsatisfactory diagnostic results for EAC at the esophagogastric junction. Endoscopic resection has recently been suggested as a more accurate staging modality for superficial gastrointestinal cancers than EUS. Following endoscopic resection for gastrointestinal cancers, the risk of metastasis can be evaluated based on the histology of the resected specimen. European guidelines describe endoscopic resection as curative for well- or moderately differentiated mucosal cancers without lymphovascular invasion, and these criteria might be extended to lesions invading the submucosa (≤ 500 μm), i.e., to low-risk, well- or moderately differentiated tumors without lymphovascular involvement, and < 3 cm. These criteria were confirmed by a recent study in Japan.

Laser Imaging Facilitates Early Detection of Synchronous Adenocarcinomas in Patients with Barrett's Esophagus

Barrett's adenocarcinoma may occur in multiple sites, and recurrence and metachronous lesions are the major problems with endoscopic resection. Therefore, early detection of such lesions is ideal to achieve complete resection and obtain improved survival rates with minimally invasive treatment. Laser imaging systems allow multiple modalities of endoscopic imaging by using white light laser, flexible spectral imaging color enhancement (FICE), blue laser imaging (BLI), and linked color imaging even at a distant view. However, the usefulness of these modalities has not been sufficiently reported regarding Barrett's adenocarcinoma. Here, we report on a patient with three synchronous lesions followed by one metachronous lesion in a long segment with changes of Barrett's esophagus, all diagnosed with this new laser endoscopic imaging system and enhanced by using FICE and/or BLI with high contrast compared with the surrounding mucosa. Laser endoscopic imaging may facilitate the detection of malignancies in patients with early Barrett's adenocarcinoma.

Endoscopic submucosal dissection for superficial Barrett's esophageal cancer in the Japanese state and perspective

The incidence of Barrett's esophageal cancer is one of the most rapidly increasing among all cancers in the West, and it is also expected to increase in Japan. The optimal treatment for early Barrett's esophageal cancer remains controversial. En bloc esophagectomy with regional lymph node dissection has been considered the standard therapy. Endoscopic therapies are currently being evaluated as alternatives to esophagectomy because they can provide the least postoperative morbidity and the best quality of life. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) allow for removal of visible lesions and histopathologic review of resected tissue, which help in diagnostic staging of the disease. EMR is limited with respect to resection size, and large lesions must be resected in several fragments. Piecemeal resection of lesions is associated with high local recurrence rates, probably because of minor remnants of neoplastic tissue being left in situ. ESD provides larger specimens than does EMR in patients with early Barrett's neoplasia. This in turn allows for more precise histological analysis and higher en bloc and curative resection rates, potentially reducing the incidence of recurrence. Detailed endoscopic examination to determine the invasion depth and spread of Barrett's esophageal cancer is essential before ESD. The initial inspection is usually conducted with white-light imaging followed by narrow-band imaging. The ESD procedure is similar to that for lesions in other parts of the gastrointestinal tract. However, the narrow space of the esophagogastric junction and contraction of the lower esophageal sphincter sometimes disturb the visual field and endoscopic control. Skilled endoscope handling, sometimes including retroflexion, is required during ESD for Barrett's esophageal cancer. Previous reports have shown that ESD achieves en bloc resection in >80% of lesions. Although promising short-term results are reported, a long-term, large-scale study is required for better understanding of ESD for Barrett's esophageal cancer.

Clinical outcomes of endoscopic submucosal dissection for superficial Barrett's adenocarcinoma

BACKGROUND

Advances in diagnostic techniques have allowed early stage detection of superficial Barrett's adenocarcinoma (SBA) as well as resection by endoscopic submucosal dissection (ESD). Few reports exist, however, on the safety and efficacy of ESD for SBA.

OBJECTIVE

To analyze outcomes of ESD for SBA in relation to clinicopathological features of the lesions.

DESIGN

Retrospective study.

SETTING

University hospital.

PATIENTS

Twenty-three patients (21 men, 2 women; mean age, 63 years) with 26 SBAs.

INTERVENTION ESD MAIN OUTCOME MEASUREMENTS

We examined outcomes of ESD in relation to the clinicopathological features of SBAs. The main outcomes assessed were en bloc resection rate, operation time, adverse event rates, additional resection rate, and time between ESD and any recurrence.

RESULTS

Twenty lesions (87%) derived from short-segment Barrett's esophagus, and 3 lesions (13%) derived from long-segment Barrett's esophagus. The majority of SBAs (54%) were located in the 0 to 3 o'clock circumferential quadrant. Median tumor size was 15 mm (range 5-60 mm). Macroscopic types were flat elevated (n = 13, 50%), depressed (n = 12, 46%), and protruded (n = 1, 4%). The SBAs appeared red (n = 23, 88%) or normally pale (n = 3, 12%). Under magnifying narrow-band imaging, all SBAs showed an irregular mucosal pattern and an irregular vascular pattern. The endoscopic en bloc resection rate was 100% (26/26), and the pathological en bloc resection rate was 85% (22/26). The median procedure time was 95 minutes (range, 30-210 minutes). Delayed bleeding occurred in 1 case, but there was no perforation. The SBAs were of the differentiated type (n = 25, 96%) or poorly differentiated type (n = 1, 4%). The tumor had invaded the superficial muscularis mucosa (n = 3, 12%), lamina propria mucosa (n = 5, 19%, deep muscularis mucosa (n = 9, 34%), SM1 (n = 3, 12%), and SM2 (n = 6, 23%). Additional surgical resection after ESD was performed in 9 cases, and there were no residual tumors, but 1 lymph node metastasis was found. There were no recurrent tumors; however, 1 metachronous adenocarcinoma was diagnosed 42 months after ESD.

LIMITATIONS

Single-center, retrospective study.

CONCLUSIONS

ESD appears to be a safe and effective treatment strategy for early stage SBA.

Magnifying endoscopy with narrow-band imaging findings in the diagnosis of Barrett's esophageal adenocarcinoma spreading below squamous epithelium

It has been described that most cases of Barrett's esophageal adenocarcinoma in Japan are cases of Barrett's esophageal adenocarcinoma on a background of short-segment Barrett's esophagus, frequently occurring rostrad to Barrett's epithelium, adjacent to the squamous epithelium of the right wall of the esophagogastric junction. Barrett's esophageal adenocarcinoma may spread below the squamous epithelium when the tumor is situated adjacent to the squamocolumnar junction, so that it is usually difficult to diagnose its presence and extent by conventional endoscopy alone. We have noted that the spread of Barrett's esophageal adenocarcinoma below the squamous epithelium is recognizable as annular vascular formations (AVF) by magnifying endoscopy with narrow-band imaging (ME-NBI), and have verified it by 3-D stereo-reconstruction using serial sections from a specimen of the same lesion. When horizontal cross-sections of the tissue were viewed from the surface, AVF emerged at a depth of approximately 100 μm from the surface and disappeared at a depth of approximately 300 μm. Therefore, it would be presumed to be difficult to visualize the characteristic structural features by ME-NBI if the carcinomatous glandular ducts were situated deeper than approximately 300 μm underneath a thick layer of squamous epithelium. Thickness of the overlying squamous epithelium may be a limiting factor for whether or not the characteristic structural features can be detected.

Safety, efficacy, and long-term outcomes for endoscopic submucosal dissection of early esophagogastric junction cancer

BACKGROUND

Early esophagogastric junction (EGJ) cancer is currently being treated in the same way as early gastric cancer, by endoscopic submucosal dissection (ESD), but long-term outcomes are still unknown. Our aim was to retrospectively evaluate the safety and efficacy of ESD in treating early EGJ cancer and compare risk factors in curative and non-curative resection cases.

METHODS

Forty-four cases of early EGJ cancer, defined as a Siewert's type II tumor, in 44 patients with a mean age of 70.0 years and a male/female ratio of 90.9:9.1 % were treated by ESD between January 2004 and June 2010. There were 30 standard indication cases; the remaining 14 cases were expanded indication cases.

RESULTS

Mean resected specimen and tumor sizes were 35 and 17 mm, respectively, and median procedure time was 121 min, with no bleeding or perforation complications. All cases were resected en bloc with an 84.1 % curative resection rate (37/44). The curative resection rates in the standard and expanded indication cases were 90.0 % (27/30) and 71.4 % (10/14), respectively. There were no significant differences in tumor location, tumor morphology, tumor size, histology of biopsy specimens, or standard versus expanded indication cases with regard to risk factors for curative and non-curative resections. However, submucosal invasion, positive tumor margins, lymphovascular invasion, and some components of poorly differentiated adenocarcinomas in just the submucosal layer were significantly more common in the non-curative resection cases.

CONCLUSIONS

ESD was a safe, effective, and minimally invasive treatment for early EGJ cancer. For tumors without any submucosal invasion findings, therefore, ESD is an acceptable treatment option, in addition to also being suitable for diagnostic purposes in evaluating the need for surgery.

Management of Barrett's esophageal carcinoma

Barrett's esophagus (BE) is the premalignant lesion from which esophageal adenocarcinoma near the esophagogastric junction arises. The management of BE and the treatment of Barrett's esophageal adenocarcinoma (BEA) are important clinical issues in Europe and the United States. As the Helicobacter pylori infection rate in Japan is decreasing in the younger population, the incidence of BE and adenocarcinoma arising from BE may start increasing. Thus, we review the current status of BEA and its management. Magnifying endoscopy with narrow-band imaging is important for diagnosing dysplasia arising from BE. In Japan, adenocarcinoma arising from BE is managed the same way as squamous cell carcinoma in the same location. Strategies to prevent BEA may include medication such as non-steroidal anti-inflammatory drugs and proton pump inhibitors, and anti-reflux surgery. Understanding the pathophysiology of BE will help to reduce the incidence of BEA.

Endoscopic ablation therapy for gastrointestinal superficial neoplasia

AIM

  In Japan, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been widely accepted and standardized for the treatment of gastrointestinal superficial neoplasia.

METHODS

  In contrast, mucosal ablation techniques are more common in Western countries and a variety of endoscopic ablation modalities, including argon plasma coagulation (APC), photodynamic therapy (PDT) and lasers, are used.

RESULTS

  Recently developed modalities such as radiofrequency ablation (RFA) and cryotherapy are also available for the treatment of superficial lesions such as dysplasia of Barrett's esophagus.

CONCLUSION

  Although we should understand that the completeness of destruction of neoplastic tissue can only be judged at follow up, endoscopic ablation is a viable alternative to endoscopic resection for dysplasia and early-stage malignancies, especially for poor candidates of surgery or endoscopic resection.

State of the art in the endoscopic imaging and ablation of Barrett's esophagus

Barrett's esophagus is the result of long-term acid reflux and is a precursor to esophageal adenocarcinoma. Surgical resection of the esophagus has been the mainstay of treatment for high grade dysplasia and early cancer. However, recent advances in the endoscopic imaging and ablation technologies have made esophagectomy avoidable in patients with dysplasia and superficial neoplasia. In this article, we review the most relevant endoscopic imaging technologies, such as chromoendoscopy, narrow band and autofluorescence imaging, and confocal laser endomicroscopy. We also review the various endoscopic ablation technologies, such as endoscopic mucosal resection, photodynamic therapy, radiofrequency ablation, and cryotherapy. Finally, we focus on the studies that evaluate the efficacy of these imaging and ablation technologies in finding and eradicating neoplastic Barrett's esophagus.