Original Article
EUS followed by EMR for staging of high-grade dysplasia and early cancer in Barrett's esophagus

https://doi.org/10.1016/S0016-5107(05)00319-6Get rights and content

Background

Accurate staging of high-grade dysplasia and of early cancer in Barrett's esophagus is important in the selection of patients for endoscopic therapy.

Methods

Patients with Barrett's esophagus and biopsy specimen proven high-grade dysplasia and adenocarcinoma in focal nodular lesions or in endoscopically unapparent flat lesions in short-segment Barrett's esophagus were initially staged with EUS. In patients with disease limited to the mucosa on EUS, cap-assisted EMR was performed. The depth of tumor invasion on EMR specimens was classified in a similar manner to squamous-cell cancer of the esophagus: m1 (epithelial layer, dysplasia), m2 (lamina propria invasion), m3 (muscularis mucosae invasion), sm (submucosal invasion).

Results

EUS was performed in 48 consecutive patients (27 with focal nodular lesions and 21 with microscopic lesions), and submucosal invasion was diagnosed in 8 (confirmed in 7/8 at surgery). EMR was carried out in the remaining 40 patients without significant complications. In the 25 patients with high-grade dysplasia on prior biopsy specimens, EMR confirmed m1 disease in 19; whereas in 6 (24%), invasive adenocarcinoma was detected (to m2 in 4; to m3 in 2). In the 15 patients with invasive cancer on prior biopsy specimens and staged as intramucosal cancer on EUS, intramucosal carcinoma was confirmed in 9 (m2 in 3; m3 in 6); whereas, in 6 patients (40%), submucosal invasion was found. Overall, EUS provided accurate staging in 41/48 patients (85%) with one patient overstaged and 6 patients understaged compared with pathologic staging obtained by surgery or EMR. Of the 34 patients with m1 to m3 staging after EMR, 29 were treated endoscopically and had no evidence of cancer after a mean follow-up of 22.9 months(standard deviation 9.2 months).

Conclusions

EMR provides pathologic staging information that, in addition, may be helpful after EUS if a stage-determined approach is used in the management of high-grade dysplasia and of early cancer in Barrett's esophagus. EMR may be particularly useful for staging of focal nodules or in short-segment Barrett's esophagus with microscopic lesions when endoscopic therapy is an option.

Section snippets

Patients and methods

The patients in this study were all referred to a single investigator (C.J.L.) for management of BE with HGD or presumed EC of the esophagus or of the esophagogastric junction. Since June 1999, we have carried out a protocol in these patients, beginning with the performance of endoscopy with repeat biopsies and EUS. Consecutive patients were included in the study if HGD and EC, on biopsy, was found in SSBE (<3 cm in length in either circumferential or tongue extension) or in focal nodular

Results

Initial EUS was performed on 48 consecutive patients (36 men, 12 women) with HGD (25 patients) and possible EC (23 patients) complicating BE (Figs. 2A and 2B). The mean age of the patients was 69 years (range 36-87 years). EUS examination diagnosed submucosal invasion in 8 patients (two with suspicion of regional lymph-node metastases adjacent to the tumor), and these 8 patients underwent esophagectomy and lymph-node dissection. EUS was accurate compared with surgical pathology in 7 of these 8

Discussion

Endoscopic therapy has shown considerable promise as a minimally invasive approach to patients with BE and HGD (previously called carcinoma in situ, Tis) or adenocarcinoma confined to the mucosa (T1m).25, 26 The aim of endoscopic therapy is to achieve a curative effect similar to surgery because of the extremely low incidence of lymph-node metastasis in these early stages27, 28, 29 while avoiding the considerably higher rates of mortality and morbidity associated with esophagectomy.30, 31, 32

References (36)

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Presented, in part, at the annual meeting of the American Society for Gastrointestinal Endoscopy, Digestive Diseases Week, May 15-20, 2004, New Orleans, Louisiana (Gastrointest Endosc 2004;59:AB90).

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