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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.
In this month’s issue of Gastroenterology, Oliver Pech, Christian Ell, and colleagues continue their pioneering work on endoscopic treatment of Barrett’s neoplasia with a study of the long-term efficacy and safety of endoscopic resection for T1a esophageal adenocarcinoma. Based on prior work by this German group and several others around the world, endoscopic resection of nodular high-grade dysplasia followed by ablation or resection of all residual Barrett’s has become the standard of care for high-grade dysplasia. There are fewer data available on endoscopic treatment of T1a lesions, which have a small but nonzero incidence of lymph node spread that needs to be considered in treatment algorithms.
While many therapeutic endoscopy programs have embraced endoscopic treatment of T1a esophageal adenocarcinoma with favorable histology, some skepticism remains, and the current study will go a long way toward justifying endoscopic treatment of these tumors. The scope and magnitude of this study are striking – 1,000 consecutive patients with T1a tumors treated by endoscopic resection were followed for an average of nearly 5 years. The results are outstanding, with a long-term remission rate of 94% and only two deaths from Barrett’s cancer. Major complications were rare and were successfully treated endoscopically. Very few patients ultimately required surgery – for lymphatic infiltration, inability to resect the lesion endoscopically due to scarring, poor wound healing, incorrect assessment of the tumor stage during initial treatment, or additional cancer developing during the study. Even those patients ultimately did well.
Given the well-documented mortality risk of esophagectomy even in expert centers (2%-5%), as well as the high morbidity of surgery, it is clear from this study that endoscopic treatment of T1a esophageal adenocarcinoma needs to be the standard of care.
Dr. Shai Friedland is an associate professor of medicine at Stanford (Calif.) University. He is a consultant for C2 Medical.
In this month’s issue of Gastroenterology, Oliver Pech, Christian Ell, and colleagues continue their pioneering work on endoscopic treatment of Barrett’s neoplasia with a study of the long-term efficacy and safety of endoscopic resection for T1a esophageal adenocarcinoma. Based on prior work by this German group and several others around the world, endoscopic resection of nodular high-grade dysplasia followed by ablation or resection of all residual Barrett’s has become the standard of care for high-grade dysplasia. There are fewer data available on endoscopic treatment of T1a lesions, which have a small but nonzero incidence of lymph node spread that needs to be considered in treatment algorithms.
While many therapeutic endoscopy programs have embraced endoscopic treatment of T1a esophageal adenocarcinoma with favorable histology, some skepticism remains, and the current study will go a long way toward justifying endoscopic treatment of these tumors. The scope and magnitude of this study are striking – 1,000 consecutive patients with T1a tumors treated by endoscopic resection were followed for an average of nearly 5 years. The results are outstanding, with a long-term remission rate of 94% and only two deaths from Barrett’s cancer. Major complications were rare and were successfully treated endoscopically. Very few patients ultimately required surgery – for lymphatic infiltration, inability to resect the lesion endoscopically due to scarring, poor wound healing, incorrect assessment of the tumor stage during initial treatment, or additional cancer developing during the study. Even those patients ultimately did well.
Given the well-documented mortality risk of esophagectomy even in expert centers (2%-5%), as well as the high morbidity of surgery, it is clear from this study that endoscopic treatment of T1a esophageal adenocarcinoma needs to be the standard of care.
Dr. Shai Friedland is an associate professor of medicine at Stanford (Calif.) University. He is a consultant for C2 Medical.
In this month’s issue of Gastroenterology, Oliver Pech, Christian Ell, and colleagues continue their pioneering work on endoscopic treatment of Barrett’s neoplasia with a study of the long-term efficacy and safety of endoscopic resection for T1a esophageal adenocarcinoma. Based on prior work by this German group and several others around the world, endoscopic resection of nodular high-grade dysplasia followed by ablation or resection of all residual Barrett’s has become the standard of care for high-grade dysplasia. There are fewer data available on endoscopic treatment of T1a lesions, which have a small but nonzero incidence of lymph node spread that needs to be considered in treatment algorithms.
While many therapeutic endoscopy programs have embraced endoscopic treatment of T1a esophageal adenocarcinoma with favorable histology, some skepticism remains, and the current study will go a long way toward justifying endoscopic treatment of these tumors. The scope and magnitude of this study are striking – 1,000 consecutive patients with T1a tumors treated by endoscopic resection were followed for an average of nearly 5 years. The results are outstanding, with a long-term remission rate of 94% and only two deaths from Barrett’s cancer. Major complications were rare and were successfully treated endoscopically. Very few patients ultimately required surgery – for lymphatic infiltration, inability to resect the lesion endoscopically due to scarring, poor wound healing, incorrect assessment of the tumor stage during initial treatment, or additional cancer developing during the study. Even those patients ultimately did well.
Given the well-documented mortality risk of esophagectomy even in expert centers (2%-5%), as well as the high morbidity of surgery, it is clear from this study that endoscopic treatment of T1a esophageal adenocarcinoma needs to be the standard of care.
Dr. Shai Friedland is an associate professor of medicine at Stanford (Calif.) University. He is a consultant for C2 Medical.
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.
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.
FROM GASTROENTEROLOGY
Major finding: Endoscopic resection of esophageal adenocarcinoma resulted in a long-term complete remission rate of 93.8%.
Data source: Data from 1,000 consecutive patients with mucosal adenocarcinoma of the esophagus.
Disclosures: The authors stated that they had no conflicts of interest to disclose. They disclosed no funding.