Endoscopic resection for mucosal esophageal adenocarcinoma is safe and highly effective, and should be the new standard of care.
That’s according to Dr. Oliver Pech, whose study in the March issue of Gastroenterology showed a complete remission rate of 93.8% over nearly 5 years of follow-up (doi: 10.1053/j.gastro.2013.11.006).
Dr. Pech, of the University of Regensburg, Germany, and his colleagues looked at 1,000 consecutive patients (mean age, 69 years; 861 men) with mucosal adenocarcinoma of the esophagus, who were referred to a single center between October 1996 and September 2010.
All patients had mucosal Barrett’s carcinoma; lesions judged resectable were first subjected to diagnostic endoscopic resection for staging, even when the macroscopic appearance suggested submucosal disease. Patients with low-grade dysplasia, high-grade dysplasia, and submucosal or more advanced cancer (T1 or greater) were excluded.
In total, 481 patients had short-segment Barrett’s esophagus, and the remainder had long-segment Barrett’s. The majority (n = 493) had intraepithelial adenocarcinoma, according to staging by endoscopic resection, while 240 patients had adenocarcinoma invading the tunica propria, 124 had invasion of the first layer of the muscularis mucosae, and the remaining 143 had disease of the second layer of the muscularis mucosae.
En bloc resection was performed in 508 patients and piecemeal resection in the rest.
The authors found that complete remission, defined as an R0 resection plus one normal surveillance endoscopy, was achieved in 963 (96.3%) of the 1,000 patients in the study.
Among these, recurrence of neoplasia (high-grade dysplasia or adenocarcinoma) was detected in 14.5% of the patients (140 out of the 963) after a median 26.5 months; 115 were successfully retreated with additional endoscopic resection.
That translated to a long-term complete remission rate of 93.8% (mean, 56.6 months) and a 5-year survival rate of 91.5%.
Looking at safety, Dr. Pech reported that 15 patients experienced major complications, including bleeding with a corresponding drop in hemoglobin of at least 2 g/dL (in 14 cases) and perforation (in 1).
He added that the relatively minor complication of stenosis requiring dilation occurred in 13 cases, all of which were managed endoscopically. Finally, in an analysis of which patients were more likely to have successful endoscopic treatment, the authors determined that long-segment Barrett’s as well as poorly differentiated mucosal adenocarcinoma (as opposed to well-differentiated lesions) had a significantly higher risk for failure (P less than .0001 for both).
The authors conceded that referral bias cannot be excluded in this cohort, "because it is possible that only patients with early Barrett’s carcinoma that was endoscopically well treatable may have been referred."
Additionally, over the long course of the study, best practices for Barrett’s esophagus and high grade-dysplasia have evolved considerably, "moving away from multimodal therapy for early Barrett’s carcinoma using a combination of [endoscopic resection], photodynamic therapy, [argon plasma coagulation], and laser toward a strict and purely resectional form of treatment."
Nevertheless, "the data presented here on the largest series published to date on endoscopic therapy for mucosal adenocarcinomas in 1,000 patients confirm the safety of endoscopic resection," the authors wrote.
"Endoscopic therapy for mucosal Barrett’s carcinoma should therefore become the international gold standard for treatment," they added.
The authors stated that they had no conflicts of interest to disclose. They disclosed no funding.
