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Barrett's esophagus: Treatment of high-grade dysplasia or early cancer with endoscopic resection

Author
Jacques J Bergman, MD, PhD
Section Editor
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF

INTRODUCTION

Barrett's esophagus (BE) is thought to be a complication of longstanding gastroesophageal reflux, resulting in the replacement of the normal squamous lining of the distal esophagus by columnar epithelium containing specialized intestinal metaplasia. (See "Barrett's esophagus: Epidemiology, clinical manifestations, and diagnosis".)

Endoscopic surveillance is recommended for patients with Barrett's esophagus because of its malignant potential in the hope of detecting dysplasia before it progresses to adenocarcinoma. Esophagectomy has traditionally been recommended for patients found to have high-grade dysplasia or early cancer. (See "Management of Barrett's esophagus".)

Endoscopic therapy has been proven to be a safe, effective, and less invasive alternative to surgery for treating such patients.

Endoscopic resection (ER) is an endoscopic approach in which the neoplastic epithelium is excised, thus allowing for a definitive histologic diagnosis while also potentially being curative. ER has been applied not only to Barrett's esophagus with high-grade dysplasia but also to early cancer in which the risk of lymph node involvement or hematogenous dissemination is low enough to justify a relatively conservative approach compared with esophagectomy [1-8].

Several studies have demonstrated that ER is safe and effective for complete resection of superficial lesions and offers the advantage of histopathologic verification [9-12].

                         

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Literature review current through: Apr 2015. | This topic last updated: Mar 18, 2015.
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References
Top
  1. Fernando HC, Luketich JD, Buenaventura PO, et al. Outcomes of minimally invasive esophagectomy (MIE) for high-grade dysplasia of the esophagus. Eur J Cardiothorac Surg 2002; 22:1.
  2. Nigro JJ, Hagen JA, DeMeester TR, et al. Occult esophageal adenocarcinoma: extent of disease and implications for effective therapy. Ann Surg 1999; 230:433.
  3. Nigro JJ, Hagen JA, DeMeester TR, et al. Prevalence and location of nodal metastases in distal esophageal adenocarcinoma confined to the wall: implications for therapy. J Thorac Cardiovasc Surg 1999; 117:16.
  4. Peters JH, Clark GW, Ireland AP, et al. Outcome of adenocarcinoma arising in Barrett's esophagus in endoscopically surveyed and nonsurveyed patients. J Thorac Cardiovasc Surg 1994; 108:813.
  5. Rice TW, Blackstone EH, Goldblum JR, et al. Superficial adenocarcinoma of the esophagus. J Thorac Cardiovasc Surg 2001; 122:1077.
  6. Ruol A, Merigliano S, Baldan N, et al. Prevalence, management and outcome of early adenocarcinoma (pT1) of the esophago-gastric junction. Comparison between early cancer in Barrett's esophagus (type I) and early cancer of the cardia (type II). Dis Esophagus 1997; 10:190.
  7. Stein HJ, Feith M, Mueller J, et al. Limited resection for early adenocarcinoma in Barrett's esophagus. Ann Surg 2000; 232:733.
  8. van Sandick JW, Baak JP, van Lanschot JJ, et al. Computerized quantitative pathology for the grading of dysplasia in surveillance biopsies of Barrett's oesophagus. J Pathol 2000; 190:177.
  9. Ell C, May A, Gossner L, et al. Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett's esophagus. Gastroenterology 2000; 118:670.
  10. Nijhawan PK, Wang KK. Endoscopic mucosal resection for lesions with endoscopic features suggestive of malignancy and high-grade dysplasia within Barrett's esophagus. Gastrointest Endosc 2000; 52:328.
  11. Vieth M, Ell C, Gossner L, et al. Histological analysis of endoscopic resection specimens from 326 patients with Barrett's esophagus and early neoplasia. Endoscopy 2004; 36:776.
  12. Pech O, Behrens A, May A, et al. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus. Gut 2008; 57:1200.
  13. Bennett C, Vakil N, Bergman J, et al. Consensus statements for management of Barrett's dysplasia and early-stage esophageal adenocarcinoma, based on a Delphi process. Gastroenterology 2012; 143:336.
  14. Schlemper RJ, Riddell RH, Kato Y, et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut 2000; 47:251.
  15. Skacel M, Petras RE, Gramlich TL, et al. The diagnosis of low-grade dysplasia in Barrett's esophagus and its implications for disease progression. Am J Gastroenterol 2000; 95:3383.
  16. Hulscher JB, Haringsma J, Benraadt J, et al. Comprehensive Cancer Centre Amsterdam Barrett Advisory Committee: first results. Neth J Med 2001; 58:3.
  17. Schnell TG, Sontag SJ, Chejfec G, et al. Long-term nonsurgical management of Barrett's esophagus with high-grade dysplasia. Gastroenterology 2001; 120:1607.
  18. Kara MA, Peters FP, Rosmolen WD, et al. High-resolution endoscopy plus chromoendoscopy or narrow-band imaging in Barrett's esophagus: a prospective randomized crossover study. Endoscopy 2005; 37:929.
  19. Kara MA, Smits ME, Rosmolen WD, et al. A randomized crossover study comparing light-induced fluorescence endoscopy with standard videoendoscopy for the detection of early neoplasia in Barrett's esophagus. Gastrointest Endosc 2005; 61:671.
  20. Curvers WL, Singh R, Song LM, et al. Endoscopic tri-modal imaging for detection of early neoplasia in Barrett's oesophagus: a multi-centre feasibility study using high-resolution endoscopy, autofluorescence imaging and narrow band imaging incorporated in one endoscopy system. Gut 2008; 57:167.
  21. Sharma P, Dent J, Armstrong D, et al. The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria. Gastroenterology 2006; 131:1392.
  22. Pech O, Gossner L, Manner H, et al. Prospective evaluation of the macroscopic types and location of early Barrett's neoplasia in 380 lesions. Endoscopy 2007; 39:588.
  23. Reid BJ, Blount PL, Feng Z, Levine DS. Optimizing endoscopic biopsy detection of early cancers in Barrett's high-grade dysplasia. Am J Gastroenterol 2000; 95:3089.
  24. Curvers WL, Bergman JJ. Multimodality imaging in Barrett's esophagus: looking longer, seeing better, and recognizing more. Gastroenterology 2008; 135:297.
  25. ASGE Standards of Practice Committee, Evans JA, Early DS, et al. The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointest Endosc 2013; 77:328.
  26. Larghi A, Lightdale CJ, Memeo L, et al. EUS followed by EMR for staging of high-grade dysplasia and early cancer in Barrett's esophagus. Gastrointest Endosc 2005; 62:16.
  27. Mino-Kenudson M, Hull MJ, Brown I, et al. EMR for Barrett's esophagus-related superficial neoplasms offers better diagnostic reproducibility than mucosal biopsy. Gastrointest Endosc 2007; 66:660.
  28. Peters FP, Brakenhoff KP, Curvers WL, et al. Histologic evaluation of resection specimens obtained at 293 endoscopic resections in Barrett's esophagus. Gastrointest Endosc 2008; 67:604.
  29. Buskens CJ, Westerterp M, Lagarde SM, et al. Prediction of appropriateness of local endoscopic treatment for high-grade dysplasia and early adenocarcinoma by EUS and histopathologic features. Gastrointest Endosc 2004; 60:703.
  30. Bergman JJ, Fockens P. Endoscopic ultrasonography in patients with gastro-esophageal cancer. Eur J Ultrasound 1999; 10:127.
  31. Fockens P, Van den Brande JH, van Dullemen HM, et al. Endosonographic T-staging of esophageal carcinoma: a learning curve. Gastrointest Endosc 1996; 44:58.
  32. May A, Günter E, Roth F, et al. Accuracy of staging in early oesophageal cancer using high resolution endoscopy and high resolution endosonography: a comparative, prospective, and blinded trial. Gut 2004; 53:634.
  33. Heeren PA, van Westreenen HL, Geersing GJ, et al. Influence of tumor characteristics on the accuracy of endoscopic ultrasonography in staging cancer of the esophagus and esophagogastric junction. Endoscopy 2004; 36:966.
  34. Pouw RE, Heldoorn N, Alvarez Herrero L, et al. Do we still need EUS in the workup of patients with early esophageal neoplasia? A retrospective analysis of 131 cases. Gastrointest Endosc 2011; 73:662.
  35. Inoue H, Fukami N, Yoshida T, Kudo SE. Endoscopic mucosal resection for esophageal and gastric cancers. J Gastroenterol Hepatol 2002; 17:382.
  36. Alvarez Herrero L, Pouw RE, van Vilsteren FG, et al. Safety and efficacy of multiband mucosectomy in 1060 resections in Barrett's esophagus. Endoscopy 2011; 43:177.
  37. May A, Gossner L, Behrens A, et al. A prospective randomized trial of two different endoscopic resection techniques for early stage cancer of the esophagus. Gastrointest Endosc 2003; 58:167.
  38. Peters FP, Kara MA, Curvers WL, et al. Multiband mucosectomy for endoscopic resection of Barrett's esophagus: feasibility study with matched historical controls. Eur J Gastroenterol Hepatol 2007; 19:311.
  39. Pouw RE, van Vilsteren FG, Peters FP, et al. Randomized trial on endoscopic resection-cap versus multiband mucosectomy for piecemeal endoscopic resection of early Barrett's neoplasia. Gastrointest Endosc 2011; 74:35.
  40. Yamamoto H, Sekine Y, Higashizawa T, et al. Successful en bloc resection of a large superficial gastric cancer by using sodium hyaluronate and electrocautery incision forceps. Gastrointest Endosc 2001; 54:629.
  41. Miyamoto S, Muto M, Hamamoto Y, et al. A new technique for endoscopic mucosal resection with an insulated-tip electrosurgical knife improves the completeness of resection of intramucosal gastric neoplasms. Gastrointest Endosc 2002; 55:576.
  42. Ohkuwa M, Hosokawa K, Boku N, et al. New endoscopic treatment for intramucosal gastric tumors using an insulated-tip diathermic knife. Endoscopy 2001; 33:221.
  43. Hirasawa K, Kokawa A, Oka H, et al. Superficial adenocarcinoma of the esophagogastric junction: long-term results of endoscopic submucosal dissection. Gastrointest Endosc 2010; 72:960.
  44. Chevaux JB, Piessevaux H, Jouret-Mourin A, et al. Clinical outcome in patients treated with endoscopic submucosal dissection for superficial Barrett's neoplasia. Endoscopy 2015; 47:103.
  45. Choi IJ, Kim CG, Chang HJ, et al. The learning curve for EMR with circumferential mucosal incision in treating intramucosal gastric neoplasm. Gastrointest Endosc 2005; 62:860.
  46. Ohyama T, Kobayashi Y, Mori K, et al. Factors affecting complete resection of gastric tumors by the endoscopic mucosal resection procedure. J Gastroenterol Hepatol 2002; 17:844.
  47. Deprez PH, Bergman JJ, Meisner S, et al. Current practice with endoscopic submucosal dissection in Europe: position statement from a panel of experts. Endoscopy 2010; 42:853.
  48. van Vilsteren FG, Pouw RE, Herrero LA, et al. Learning to perform endoscopic resection of esophageal neoplasia is associated with significant complications even within a structured training program. Endoscopy 2012; 44:4.
  49. Takubo K, Sasajima K, Yamashita K, et al. Double muscularis mucosae in Barrett's esophagus. Hum Pathol 1991; 22:1158.
  50. Prasad GA, Wang KK, Lutzke LS, et al. Frozen section analysis of esophageal endoscopic mucosal resection specimens in the real-time management of Barrett's esophagus. Clin Gastroenterol Hepatol 2006; 4:173.
  51. Prasad GA, Buttar NS, Wongkeesong LM, et al. Significance of neoplastic involvement of margins obtained by endoscopic mucosal resection in Barrett's esophagus. Am J Gastroenterol 2007; 102:2380.
  52. Ormsby AH, Petras RE, Henricks WH, et al. Observer variation in the diagnosis of superficial oesophageal adenocarcinoma. Gut 2002; 51:671.
  53. American Joint Committee on Cancer Staging Manual, 7th, Edge SB, Byrd DR, Compton CC, et al (Eds), Springer, New York 2010. p.103.
  54. Manner H, May A, Pech O, et al. Early Barrett's carcinoma with "low-risk" submucosal invasion: long-term results of endoscopic resection with a curative intent. Am J Gastroenterol 2008; 103:2589.
  55. Alvarez Herrero L, Pouw RE, van Vilsteren FG, et al. Risk of lymph node metastasis associated with deeper invasion by early adenocarcinoma of the esophagus and cardia: study based on endoscopic resection specimens. Endoscopy 2010; 42:1030.
  56. Ciocirlan M, Lapalus MG, Hervieu V, et al. Endoscopic mucosal resection for squamous premalignant and early malignant lesions of the esophagus. Endoscopy 2007; 39:24.
  57. Esaki M, Matsumoto T, Hirakawa K, et al. Risk factors for local recurrence of superficial esophageal cancer after treatment by endoscopic mucosal resection. Endoscopy 2007; 39:41.
  58. May A, Gossner L, Pech O, et al. Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett's oesophagus: acute-phase and intermediate results of a new treatment approach. Eur J Gastroenterol Hepatol 2002; 14:1085.
  59. Ell C, May A, Pech O, et al. Curative endoscopic resection of early esophageal adenocarcinomas (Barrett's cancer). Gastrointest Endosc 2007; 65:3.
  60. Prasad GA, Wu TT, Wigle DA, et al. Endoscopic and surgical treatment of mucosal (T1a) esophageal adenocarcinoma in Barrett's esophagus. Gastroenterology 2009; 137:815.
  61. Chennat J, Konda VJ, Ross AS, et al. Complete Barrett's eradication endoscopic mucosal resection: an effective treatment modality for high-grade dysplasia and intramucosal carcinoma--an American single-center experience. Am J Gastroenterol 2009; 104:2684.
  62. Moss A, Bourke MJ, Hourigan LF, et al. Endoscopic resection for Barrett's high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit. Am J Gastroenterol 2010; 105:1276.
  63. Pech O, Bollschweiler E, Manner H, et al. Comparison between endoscopic and surgical resection of mucosal esophageal adenocarcinoma in Barrett's esophagus at two high-volume centers. Ann Surg 2011; 254:67.
  64. Wu J, Pan YM, Wang TT, et al. Endotherapy versus surgery for early neoplasia in Barrett's esophagus: a meta-analysis. Gastrointest Endosc 2014; 79:233.
  65. Chung A, Bourke MJ, Hourigan LF, et al. Complete Barrett's excision by stepwise endoscopic resection in short-segment disease: long term outcomes and predictors of stricture. Endoscopy 2011; 43:1025.
  66. Yamada M, Oda I, Nonaka S, et al. Long-term outcome of endoscopic resection of superficial adenocarcinoma of the esophagogastric junction. Endoscopy 2013; 45:992.
  67. Pech O, May A, Manner H, et al. Long-term efficacy and safety of endoscopic resection for patients with mucosal adenocarcinoma of the esophagus. Gastroenterology 2014; 146:652.
  68. Konda VJ, Gonzalez Haba Ruiz M, Koons A, et al. Complete endoscopic mucosal resection is effective and durable treatment for Barrett's-associated neoplasia. Clin Gastroenterol Hepatol 2014; 12:2002.
  69. Leggett CL, Lewis JT, Wu TT, et al. Clinical and histologic determinants of mortality for patients with Barrett's esophagus-related T1 esophageal adenocarcinoma. Clin Gastroenterol Hepatol 2015; 13:658.
  70. Chadwick G, Groene O, Markar SR, et al. Systematic review comparing radiofrequency ablation and complete endoscopic resection in treating dysplastic Barrett's esophagus: a critical assessment of histologic outcomes and adverse events. Gastrointest Endosc 2014; 79:718.
  71. Manner H, Rabenstein T, Pech O, et al. Ablation of residual Barrett's epithelium after endoscopic resection: a randomized long-term follow-up study of argon plasma coagulation vs. surveillance (APE study). Endoscopy 2014; 46:6.
  72. Phoa KN, Pouw RE, van Vilsteren FG, et al. Remission of Barrett's esophagus with early neoplasia 5 years after radiofrequency ablation with endoscopic resection: a Netherlands cohort study. Gastroenterology 2013; 145:96.
  73. Peters FP, Kara MA, Rosmolen WD, et al. Stepwise radical endoscopic resection is effective for complete removal of Barrett's esophagus with early neoplasia: a prospective study. Am J Gastroenterol 2006; 101:1449.
  74. Seewald S, Akaraviputh T, Seitz U, et al. Circumferential EMR and complete removal of Barrett's epithelium: a new approach to management of Barrett's esophagus containing high-grade intraepithelial neoplasia and intramucosal carcinoma. Gastrointest Endosc 2003; 57:854.
  75. Giovannini M, Bories E, Pesenti C, et al. Circumferential endoscopic mucosal resection in Barrett's esophagus with high-grade intraepithelial neoplasia or mucosal cancer. Preliminary results in 21 patients. Endoscopy 2004; 36:782.
  76. Deprez P, Aouattah T, Piessevaux P, et al. Can piecemeal mucosectomy completely remove Barrett's esophagus with high-grade dysplasia or adenocarcinoma? (abstract). Gastrointest Endosc 2005; 61:AB129.
  77. Pouw RE, Seewald S, Gondrie JJ, et al. Stepwise radical endoscopic resection for eradication of Barrett's oesophagus with early neoplasia in a cohort of 169 patients. Gut 2010; 59:1169.
  78. van Vilsteren FG, Pouw RE, Seewald S, et al. Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett's oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial. Gut 2011; 60:765.
  79. Lewis JJ, Rubenstein JH, Singal AG, et al. Factors associated with esophageal stricture formation after endoscopic mucosal resection for neoplastic Barrett's esophagus. Gastrointest Endosc 2011; 74:753.
  80. Gerke H, Siddiqui J, Nasr I, et al. Efficacy and safety of EMR to completely remove Barrett's esophagus: experience in 41 patients. Gastrointest Endosc 2011; 74:761.
  81. Soetikno RM, Gotoda T, Nakanishi Y, Soehendra N. Endoscopic mucosal resection. Gastrointest Endosc 2003; 57:567.
  82. Peters FP, Kara MA, Rosmolen WD, et al. Endoscopic treatment of high-grade dysplasia and early stage cancer in Barrett's esophagus. Gastrointest Endosc 2005; 61:506.
  83. Katada C, Muto M, Manabe T, et al. Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions. Gastrointest Endosc 2003; 57:165.
  84. Larghi A, Lightdale CJ, Ross AS, et al. Long-term follow-up of complete Barrett's eradication endoscopic mucosal resection (CBE-EMR) for the treatment of high grade dysplasia and intramucosal carcinoma. Endoscopy 2007; 39:1086.
  85. Qumseya B, Panossian AM, Rizk C, et al. Predictors of esophageal stricture formation post endoscopic mucosal resection. Clin Endosc 2014; 47:155.