EUS followed by EMR for staging of high-grade dysplasia and early cancer in Barrett's esophagus

• Published in: Gastrointestinal endoscopy 2005-07, Vol.62 (1), p.16-23
• Main Authors: Larghi, Alberto, MD, PhD, Lightdale, Charles J., MD, Memeo, Lorenzo, MD, Bhagat, Govind, MD, Okpara, Nnenna, MD, Rotterdam, Heidrun, MD
• Format: Article
• Language: English
• Subjects: Adenocarcinoma - diagnostic imaging; Adenocarcinoma - pathology; Adenocarcinoma - surgery; Adult; Aged; Aged, 80 and over; Barrett Esophagus - diagnostic imaging; Barrett Esophagus - pathology; Barrett Esophagus - surgery; Biological and medical sciences; Biopsy; Carcinoma, Squamous Cell - diagnostic imaging; Carcinoma, Squamous Cell - pathology; Carcinoma, Squamous Cell - surgery; Digestive system. Abdomen; Disease Progression; Endoscopy; Endosonography; Esophageal Neoplasms - diagnostic imaging; Esophageal Neoplasms - pathology; Esophageal Neoplasms - surgery; Esophagectomy - methods; Esophagoscopy; Esophagus; Female; Follow-Up Studies; Gastroenterology and Hepatology; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Intestinal Mucosa - surgery; Investigative techniques, diagnostic techniques (general aspects); Male; Medical sciences; Middle Aged; Neoplasm Staging; Precancerous Conditions - diagnostic imaging; Precancerous Conditions - pathology; Precancerous Conditions - surgery; Reproducibility of Results; Retrospective Studies; Severity of Illness Index; Stomach, duodenum, intestine, rectum, anus; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the digestive system; Time Factors; Tumors
• ISSN: 0016-5107; 1097-6779
• DOI: 10.1016/S0016-5107(05)00319-6

Background Accurate staging of high-grade dysplasia and of early cancer in Barrett's esophagus is important in the selection of patients for endoscopic therapy. Methods Patients with Barrett's esophagus and biopsy specimen proven high-grade dysplasia and adenocarcinoma in focal nodular lesions or in endoscopically unapparent flat lesions in short-segment Barrett's esophagus were initially staged with EUS. In patients with disease limited to the mucosa on EUS, cap-assisted EMR was performed. The depth of tumor invasion on EMR specimens was classified in a similar manner to squamous-cell cancer of the esophagus: m1 (epithelial layer, dysplasia), m2 (lamina propria invasion), m3 (muscularis mucosae invasion), sm (submucosal invasion). Results EUS was performed in 48 consecutive patients (27 with focal nodular lesions and 21 with microscopic lesions), and submucosal invasion was diagnosed in 8 (confirmed in 7/8 at surgery). EMR was carried out in the remaining 40 patients without significant complications. In the 25 patients with high-grade dysplasia on prior biopsy specimens, EMR confirmed m1 disease in 19; whereas in 6 (24%), invasive adenocarcinoma was detected (to m2 in 4; to m3 in 2). In the 15 patients with invasive cancer on prior biopsy specimens and staged as intramucosal cancer on EUS, intramucosal carcinoma was confirmed in 9 (m2 in 3; m3 in 6); whereas, in 6 patients (40%), submucosal invasion was found. Overall, EUS provided accurate staging in 41/48 patients (85%) with one patient overstaged and 6 patients understaged compared with pathologic staging obtained by surgery or EMR. Of the 34 patients with m1 to m3 staging after EMR, 29 were treated endoscopically and had no evidence of cancer after a mean follow-up of 22.9 months(standard deviation 9.2 months). Conclusions EMR provides pathologic staging information that, in addition, may be helpful after EUS if a stage-determined approach is used in the management of high-grade dysplasia and of early cancer in Barrett's esophagus. EMR may be particularly useful for staging of focal nodules or in short-segment Barrett's esophagus with microscopic lesions when endoscopic therapy is an option.