Endoscopic submucosal dissection may effectively treat Barrettâ??s neoplasia

Last Updated: 2017-02-17

By Marilynn Larkin

NEW YORK (Reuters Health) – When performed by an experienced surgeon, endoscopic submucosal dissection (ESD) is effective for resecting early Barrett’s neoplasia, researchers say.

Drs. Sharmila Subramaniam and Pradeep Bhandari of Portsmouth Hospitals NHS Trust, UK, told Reuters Health by email, “Esophageal ESD has traditionally been undertaken in the East, but with the growing incidence and detection of Barrett's cancers in the West a role for it here has been identified. Our data shows encouraging results, both in terms of complete resection and complication rates.”

As reported in Gastrointestinal Endoscopy, online January 31, Drs. Subramaniam and Bhandari and colleagues reviewed outcomes of 143 ESDs performed in 124 patients (97 men; mean age 71) from 2008 to 2016.

Lesions were assessed endoscopically before ESD, and patients underwent staging computed tomography of the chest and abdomen to exclude nodal or metastatic disease before endoscopic resection. Patients were followed up every three months in the first year, every six months in the second year, and yearly thereafter.

All endoscopists had performed more than 50 gastric/rectal ESDs and were proficient in the technique before performing ESD in the esophagus.

A total of 32 (22.4%) procedures were done in patients who had undergone previous endoscopic resection for Barrett’s neoplasia. One patient required ESD for recurrence after esophagectomy and two others for recurrence after radical chemoradiotherapy for advanced cancer.

The mean lesion size was 31.1 mm and median follow-up time was 21.6 months. The en bloc resection rate was 90.8% and the R0 (microscopically margin-negative) resection rate was 79%. The adverse event rate was 3.5% overall (1.4% bleeding, 0% perforation, 2.1% stricture formation).

The expanded curative resection rate was 65.8%, reflecting the R0 resection rate and the proportion of cases with more advanced disease.

Drs. Subramaniam and Bhandari observed, “With a complication rate of just 3.5% in our series, we have demonstrated that this is indeed a safe technique in experienced hands, even in a Western setting. Ultimately, we believe that ESD is a safe and viable method of managing early complex Barrett's cancer in experienced hands, though of course, further large scale randomized controlled trials comparing ESD versus conventional endoscopic mucosal resection (EMR) would be extremely useful."

Dr. Anton Bilchik, chief of medicine and of gastrointestinal research at John Wayne Cancer Institute at Providence Saint John’s Health Center in Santa Monica, California, commented, “Barrett’s esophagus is extremely common in the U.S., probably related to the high incidence of gastroesophageal reflux disease and obesity. This is a precursor to high-grade dysplasia and ultimately cancer. The standard treatment used to be a resection (esophagectomy), which is associated with a high rate of complications.”

“More recently,” he told Reuters Health by email, “less invasive endoscopic approaches have been used, such as EMR. One of the limitations of this approach is the inability to do an en bloc resection and to evaluate all the margins accurately.”

ESD “takes it one step further by removing more tissue using an oncologic approach and therefore allowing the pathologist to evaluate the margins more accurately,” Dr. Bilchik explained. “Because ESD is more complex than EMR, little is known about its benefit and outcome.”

“This study is one of the largest reported and demonstrates that in the hands of experienced endoscopists, it can be done safely with few adverse events reported,” he continued. “However, curative resection was only accomplished in 65.8% of patients and negative margins were only achieved in 79%. These results are inferior to those reported for esophagectomy. Furthermore, the follow up of only 21 months may be too short to fully evaluate the outcomes.”

Dr. Bilchik concluded, “The advantage of a less invasive approach to treat Barrett’s esophagus and early esophageal cancer is obvious, but as the authors mention, it is essential to optimize patient selection for this approach, more prospective studies are needed and it should only be done at high-volume centers by experienced endoscopists.”

SOURCE: http://bit.ly/2m3KRgH

Gastrointest Endosc 2017.