Extending treatment criteria for Barrett’s neoplasia: results of a nationwide cohort of 138 endoscopic submucosal dissection procedures

Abstract

Objective The use of endoscopic submucosal dissection (ESD) is gradually expanding for treatment of neoplasia in Barrett’s esophagus (BE). We aimed to report outcomes of all ESDs for BE neoplasia performed inNL. Design We retrospectively assessed ESD outcomes in NL, where treatment for BE neoplasia is centralized in 9 expert centers with jointly trained endoscopists and pathologists, and treatment/follow-up data collected in a joint database. ESD is restricted for selected cases. Results During median 121 minutes (p25-p75 90-180), 130 complete ESDs were performed with 97% (126/130) removed en-bloc. Pathology was HGD (5%), T1a-EAC (43%) or T1b-EAC (52%; 19%sm1, 33%≥sm2). The combined en-bloc and R0 rate was 87% [95%-CI 77-94%] for HGD/T1a-EAC and 49% [37-62%] for T1b-EAC. Upon R1 resection, 29% had residual cancer, in all cases detected at first follow-up endoscopy, while the remaining 71% had no residual cancer in esophagectomy specimen (n=6) or during median 9 months endoscopic FU (p25-p75 4-22) (n=18). Upon R0 resection, local recurrence rate during median 17 months (8-30) was 0% [0-5%]. Adverse events: 1% perforation [0-4%], 3% post-procedural bleeding [1-7%], 13% strictures [8-20%]. Conclusion In expert hands, ESD is safe and allows for removal of bulky intraluminal neoplasia and submucosal cancer. ESD of the latter is, however, associated with a positive deep resection margin in half of the patients, yet only one third had actual persisting neoplasia at endoscopic FU. To better stratify R1-patients with an indication for additional surgery, repeat endoscopy after healing of the ESD wound may help in predicting residual cancer.

Mechanisms of esophageal stricture after extensive endoscopic resection: a transcriptomic analysis

“…The expanding indications of esophageal ESD result in larger resection specimens and an increased frequency of post-endoscopic esophageal strictures [17,18]. There is no currently…”

“…The expanding indications of esophageal ESD result in larger resection specimens and an increased frequency of post-endoscopic esophageal strictures 17 18 . There is no currently recommended preventive treatment for these strictures, and their management relies on iterative endoscopic dilatation.…”

Vertical tumor-positive resection margins and the risk of residual neoplasia after endoscopic resection of Barrett’s neoplasia: a nationwide cohort with pathology reassessment

“…[1,2] However, residual neoplasia is not always present in the surgical resection specimen of patients with R1v. [5] Moreover, surgical resection is -even in high-volume centers -associated with substantial mortality (0-5%), morbidity (20-50%), and decreased quality of life. [6][7][8] Surgery may thus be unwanted overtreatment in a subset of patients with documented R1v.…”

Combined tubular adenocarcinoma, neuroendocrine carcinoma and adenocarcinoma with enteroblastic differentiation arising in Barrett esophagus

“…Barrett's esophagus (BE), which is characterized by the replacement of normal esophageal squamous cell epithelium with columnar metaplasia, affects approximately 1% of the global population and increases the risk of developing esophageal carcinoma (EC) [1]. Most neoplasms arising in BE are tubular adenocarcinoma (AC) [2], while other tissue types, such as neuroendocrine carcinoma (NEC) or adenocarcinoma with enteroblastic (ENT) differentiation, are rare in BE [3][4][5]. These rare tumors reportedly exhibit more aggressive biology than AC [6,7].…”