NEW YORK (Reuters Health) - In patients with Barrett's high-grade dysplasia or early esophageal adenocarcinoma, endoscopic resection improves staging and "dramatically" reduces esophagectomy rates, Australian physicians report.
Esophagectomy, the standard of care, produces high morbidity, and mortality from the procedure ranges from 4% to 20%, according to the researchers. Moreover, the surgery is often done on the basis of biopsy results alone, but biopsy staging is not very accurate.
For these reasons, endoscopic resection is becoming more popular for staging and management, Dr. Michael J. Bourke, from Westmead Hospital in Sydney, and his colleagues say in their article, published online on February 23rd by the American Journal of Gastroenterology.
The researchers studied 75 consecutive patients (ages 45 to 87) who underwent endoscopic resection for biopsy-proven Barrett's high-grade dysplasia or esophageal adenocarcinoma. The mean follow-up was 31 months.
Barrett's mucosa ranged in length from 1 to 16 cm, with a mean of 3.6 cm. In 35 otherwise healthy patients younger than 75, with Barrett's segments no longer than 3 cm, the authors attempted complete excision by 2- to 3-stage radical mucosectomy - which was successful in 33 cases (94%). One patient required esophagectomy; in another, comorbidities interfered.
Among the remaining 40 patients, 8 developed metachronous lesions. Another 5 had esophagectomy because resection revealed submucosal invasion, but there was no recurrence at endoscopic resection sites. Four patients (ages 81 to 92 years) died, but none of the deaths was due to adenocarcinoma.
The authors staged the resections over at least two sessions six weeks apart to minimize the risk of strictures. The number of sessions ranged from one to five per patient, with a median of two resections at the index procedure.
Overall, histologic findings led to changes in grade or stage in nearly half of patients, with lesions downgraded/staged in 21 patients and upgraded/staged in 15. Diagnoses "included the full spectrum of pathology," the authors report, ranging from no dysplasia to submucosal invasive adenocarcinoma. Seventeen patients had only low-grade dysplasia or none at all.
"Nearly one in four patients would have undergone unnecessary esophagectomy if surgery based on biopsy alone was the first-line therapy" in their series, the authors point out.
Unlike biopsy, endoscopic resection also adds data on breadth, depth, and areas of more advanced pathology. Furthermore, because mucosal lesions have a very low rate of nodal involvement, endoscopic resection is likely to be curative, the investigators note.
The absence of serious procedure-related complications in this series "further enhances" the potential utility of endoscopic resection "as a low-risk definitive dysplasia grading and local T-staging tool," Dr. Bourke and associates write.
In conclusion, they say, "We believe it is no longer acceptable to refer patients with early disease for esophagectomy without including endoscopic resection in the preoperative staging strategy."
Reference:
Am J Gastroenterol 2010.
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