Gastroenterology

Gastroenterology

Volume 137, Issue 3, September 2009, Pages 815-823
Gastroenterology

Clinical—Alimentary Tract
Endoscopic and Surgical Treatment of Mucosal (T1a) Esophageal Adenocarcinoma in Barrett's Esophagus

https://doi.org/10.1053/j.gastro.2009.05.059Get rights and content

Background & Aims

Endoscopic therapy is emerging as an alternative to surgical therapy in patients with mucosal (T1a) esophageal adenocarcinoma (EAC) given the low likelihood of lymph node metastases. Long-term outcomes of patients treated endoscopically and surgically for mucosal EAC are unknown. We compared long-term outcomes of patients with mucosal EAC treated endoscopically and surgically.

Methods

Patients treated for mucosal EAC between 1998 and 2007 were included. Patients were divided into an endoscopically treated group (ENDO group) and a surgically treated group (SURG group). Vital status information was queried using an institutionally approved internet research and location service. Statistical analysis was performed using Kaplan–Meier curves and Cox proportional hazard ratios.

Results

A total of 178 patients were included, of whom 132 (74%) were in the ENDO group and 46 (26%) were in the SURG group. The mean follow-up period was 64 months (standard error of the mean, 4.8 mo) in the SURG group and 43 months (standard error of the mean, 2.8 mo) in the ENDO group. Cumulative mortality in the ENDO group (17%) was comparable with the SURG group (20%) (P = .75). Overall survival also was comparable using the Kaplan–Meier method. Treatment modality was not a significant predictor of survival on multivariable analysis. Recurrent carcinoma was detected in 12% of patients in the ENDO group, all successfully re-treated without impact on overall survival.

Conclusions

Overall survival in patients with mucosal EAC when treated endoscopically appears to be comparable with that of patients treated surgically. Recurrent carcinoma occurs in a limited proportion of patients, but can be managed endoscopically.

Section snippets

Study Design

This was a retrospective cohort study. Patients were either referred for endoscopic treatment of mucosal EAC to the Barrett's Esophagus Unit by physicians or were under surveillance for high-grade dysplasia (HGD) in the BE Unit. All patients seen in the BE Unit for endoscopic therapy had received consultation either with thoracic surgeons at the Mayo Clinic or at their local hospitals. Patients referred for esophagectomy usually were referred directly by their physicians or were elected to

Results

A total of 132 patients underwent endoscopic therapy (ENDO group) and 46 patients underwent esophagectomy (SURG group) for mucosal EAC between 1998 and 2007 at the Mayo Clinic (Rochester, MN) and were included in this study. The baseline characteristics of these patients are summarized in Table 1. As is evident from Table 1, patients treated endoscopically were older and had more medical comorbidities than those treated surgically. In addition, patients in the SURG group also had a longer BE

Discussion

Early stage EAC (T1 stage disease confined to the mucosa or submucosa) comprises approximately 20% of all cases of EAC diagnosed in the United States.21, 22 Endoscopic therapy of mucosal EAC has been proposed as an alternative to surgical resection given the low risk of metastatic lymphadenopathy in these patients.6 In this large cohort study we studied outcomes after the endoscopic and surgical treatment of mucosal (T1a) EAC and found that overall survival and cumulative mortality rates were

Acknowledgments

The authors appreciate the assistance of Ross Dierkhising, MS (Division of Biostatistics) for statistical analysis, and Yutaka Tomizawa, MD (Division of Gastroenterology) for assistance with data extraction.

References (35)

  • J.D. Luketich et al.

    Minimally invasive resection and mechanical cervical esophagogastric anastomotic techniques in the management of esophageal cancer

    J Gastrointest Surg

    (2004)
  • O. Pech et al.

    Long-term results of photodynamic therapy with 5-aminolevulinic acid for superficial Barrett's cancer and high-grade intraepithelial neoplasia

    Gastrointest Endosc

    (2005)
  • C.C. Chang et al.

    Metachronous esophageal cancer and colon cancer treated by endoscopic mucosal resection

    J Formos Med Assoc

    (2007)
  • C. Ell et al.

    Curative endoscopic resection of early esophageal adenocarcinomas (Barrett's cancer)

    Gastrointest Endosc

    (2007)
  • R.E. Pouw et al.

    Eradication of Barrett esophagus with early neoplasia by radiofrequency ablation, with or without endoscopic resection

    J Gastrointest Surg

    (2008)
  • H. Pohl et al.

    The role of overdiagnosis and reclassification in the marked increase of esophageal adenocarcinoma incidence

    J Natl Cancer Inst

    (2005)

  • Surveillance Epidemiology and End Results

    • Cited by (0)

    Conflicts of interest The authors disclose no conflicts.

    Funding Supported by National Institutes of Health grants R01CA111603-01A1 (K.K.W.), R01CA097048 (K.K.W.), R21CA122426-01 (K.K.W.), and R03CA135991-01 (G.A.P.), and the Shirley and Miles Fiterman Digestive Disease Center.

    View full text
    Copyright © 2009 AGA Institute. Published by Elsevier Inc. All rights reserved.