An 81-Year-Old Healthy Male is Found to Have a 12-cm Long Segment Barrett´s Esophagus and Several Tiny, Raised Lesions. Biopsy Shows Moderate- to High-Grade Dysplasia in One Location. How Should I Advise This Patient About This Prognosis? Which Surgical or Endoscopic Therapies Would Be Appropriate to Consider? How Can I Tell Whether or Not a Small Cancer Has Been Missed in the Biopsy?
Paulo
Sakai,
MD, PhD, FASGE
Fauze
Maluf-Filho,
MD, PhD
Barrett’s esophagus (BE) is defined as the presence of specialized columnar metaplasia at the distal esophagus in response to the chronic reflux of gastroduodenal content into the esophagus.
Compared to other patients with gastroesophageal reflux disease, patients with BE present with longer acid and bile exposure. It has been recently acknowledged that the risk of adenocarcinoma associated with BE was overestimated. One case of cancer for approximately 300 patients with BE per year is expected. Long segments of BE (>3 cm) mean a higher risk of cancer when compared to shorter segments. Endoscopic surveillance with routine biopsies is recommended for early detection of adenocarcinoma in these patients. The presence of cellular atypia confined to the epithelium is called dysplasia and is considered to be a marker for the development of invasive adenocarcinoma in BE. When high-grade dysplasia (HGD) is detected and confirmed by a senior pathologist, the patient should be made aware of the 30% to 40% risk that an invasive adenocarcinoma was missed in the endoscopy. The incidence of cancer after diagnosis of HGD may be in approximately 28% to 30% of the patients, which definitely is an indication for treatment.1 Controversy exists regarding the optimal management of BE with HGD. There are two options: 1) esophagectomy to prevent cancer and cure early cancer and 2) endoscopic ablation and resection to remove the neoplastic mucosa to prevent cancer and cure mucosal cancer.
For some investigators, particularly among surgeons, BE with HGD has been considered an indication for esophagectomy because of the increased risk of cancer. The patient should be referred to high-volume surgical consultation centers where more than 50 esophagectomies are performed every year. In these centers, the mortality rate related to this extensive surgery is lower than 5%. However, the endoscopic therapy may be an attractive and less invasive treatment alternative since the risk of lymph node involvement or hematogenous dissemination is absent in HGD and negligible in early stage cancer. Endoscopic therapy may be performed through local endoscopic mucosal resection or through endoscopic ablation using photodynamic therapy (PDT), argon plasma coagulation (APC), or radiofrequency ablation (RFA).
Endoscopic mucosal resection (EMR) is safe and effective for complete HGD local resection and early BE cancer. Usually two endoscopic techniques are applied: cap-technique and band-ligation technique (Figure 1-1). In both techniques, piecemeal resection is required when the lesion is larger than 10 to 15 mm. More recently, another technique called endoscopic submucosal dissection (ESD) is being used for the resection of a large lesion en bloc, but specific accessories and training are required for this procedure. For BE more than 3 cm in length, the complete circumferential removal of the mucosa may cause an esophageal stricture. One of the most frequently studied endoscopic therapies for HGD in BE is photodynamic therapy. It is an expensive method of limited availability, and long-term results are not well described. There is a 40% rate of esophageal stenosis, and small foci of invasive cancer may be left untreated. Ablative therapy such as PDT and APC do not provide a specimen for histopathological evaluation, and usually the depth of eradication is limited. Residual BEs under restored squamous epithelium after endoscopic tissue ablative therapy may occur in 20% to 30% of cases. The use of RFA seems to be very effective, but long-term evaluation is not yet available.2
Figure 1-1. (A) Long segment of BE with HGD lesion, (B, C) band-ligation mucosectomy and (D) final aspect of local resection.
With a 12-cm long segment BE and several raised lesions with HGD in a healthy person, the esophagectomy could be considered. Although preoperative morbidity is significant, surgical resection of HGD in BE may provide excellent long-term survival with acceptable quality of life.3 On the other hand, the endoscopic resection may be another option. All lesions may be locally resected although in the remaining BE, approximately 11% of patients will have a recurrence or development of metachronous HGD or an early stage cancer in a long-term follow-up, and these can be treated again through endoscopic resection.4 Therefore, we emphasize the importance of a strict endoscopic follow-up in order to detect and treat any recurrent lesion. Ideally, all possible columnar mucosa with intestinal metaplasia should be eradicated and this approach would be recommended in patients with invisible or multiple neoplastic areas in a shorter BE.
In conclusion, we can offer for this patient two options: 1) esophagectomy as a definite treatment and 2) endoscopic resection of HGD lesions with less morbidity but with the need for a strict endoscopic follow-up.
Reference
1. Wang KK, Wongkeesong M, Buttar NS. American Gastroenterological Association medical position statement: Role of the gastroenterologist in the management of esophageal carcinoma. Gastroenterology. 2005;128:1468-1470.
2. Sharma VK, Wang KK, Overholt BF, et al. Balloon-based, circumferential, endoscopic radiofrequency ablation of Barrett´s esophagus: 1-year follow-up of 100 patients. Gastrointest Endosc. 2007;65:185-195.
3. Headrick JR, Nichols III FC, Miller DL, et al. High-grade esophageal dysplasia: long-term survival and quality of life after esophagectomy. Ann Thorac Surg. 2002;73:1697-1703.
4. Ell C, May A, Pech O, et al. Curative endoscopic resection of early esophageal adenocarcinomas (Barrett´s cancer). Gastrointest Endosc. 2007;65:3-10.