endoscopic treatment and surveillance of esophageal cancer...
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Endoscopic Treatment and Surveillance of Esophageal Cancer: GI Perspective
Charles J. Lightdale, MD
Columbia University
New York, NY
Barrett's
metaplasia
Chronic
inflammation
Squamous
esophagus Injury
Acid & bile reflux
Genetics
Gender, race,
Evolution of
Barrett’’’’s esophagus
Adenocarcinoma
High-grade
dysplasia
Low-grade
dysplasia
Accumulate
Genetic
Changes
1.0%/yr
<0.5%/yr
Hvid-Jensen, et al. N Engl J Med 2011;365:1375-83
Barrett’s Prevalence Estimates
• 1.6% of general adult population (3.3 M)– Ronkainen J, et al. Prevalence of BE; Gastroenterology
2005;129:1825-31.
• 6.8% of persons over age 40 (8.7 M)– Rex DK, et al. Screening for Barrett’s... Gastroenterology 2003;
125:1670-77.
• Majority without GERD – Gerson LB, et al. Prevalence of Barrett’s;Gastroenterology
2002;123:461-7.
3
Accuracy and Acceptability of
Cytology Sponge with IHC for TFF3
• 501/504 patients swallowed sponge
capsule
• Compared to endoscopy and biopsy:• Compared to endoscopy and biopsy:
>1 cm BE >2 cm BE
Sensitivity 73.3% 90.0%
Specificity 93.8% 93.5%
Kadri, et al. BMJ 2010;341:4372
Corley, et al. Gastroenterology 2002;123:633-640
Technique of Biopsy in Endoscopic SurveillanceTechnique of Biopsy in Endoscopic Surveillance
BE With and Without Dysplasia: Confounding Factors
• Endoscopic Biopsy Sampling Error
– Persists even with “Seattle Protocol”
• Pathology Interpretation • Pathology Interpretation
– LGD: Κ = 0.32 (fair)
– HGD/IMC: Κ = 0.65 (substantial)
– HGD vs IMC: Κ = 0.42 (fair)Ormsby AH, et al. Gut 2002;51:671-76
Montgomery, Canto. CG & H 2006;4:1434-39
Adherence to Surveillance Biopsy Guidelines by Year
56.3%
44.7%49.9% 48.3%
54.8% 55.5%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Pe
rce
nta
ge
0.0%
10.0%
20.0%
30.0%
40.0%
2002 2003 2004 2005 2006 2007
Year
Pe
rce
nta
ge
Abrams JA, et al. Clin Gastroenterol Hepatol 2009;736-42
Optical Contrast EndoscopyOptical Contrast Endoscopy
WLE NBI
Mucosal Patterns:
Regular/Irregular
3708
Confocal Probe BE
IM
HGD
Wide Area Transepithelial Sample (WATS)
15
WATS method is
designed to decrease
biopsy sampling
Flat HGD and
IMCA can occur
in a mosaic
pattern missed
by 4-Q biopsy
biopsy sampling
error
17
Early Esophageal Adenocarcinoma
Risk of lymph node metastases:
• Tis (intraepithelial) 0
• T1a (intramucosal) 2%• T1a (intramucosal) 2%
• T1b (submucosal) 25% Nigro, et al. J Thorac Cardiovasc Surg 1999;117:16-25
Stein, et al. Ann Surg 2000;232:733-742
Rice, et al. J Thorac Cardiovasc Surg 2001;122:1077-90
Hulscher, et al. N Engl J Med 2002;347:1662-1669
EMR Techniques
• INJECTION ASSISTED:– Inject and snare (saline-assisted polypectomy)
– Inject, lift, and cut with snare (2-channel scope)
• CAP ASSISTED:• CAP ASSISTED:– inject, endoscopic suction, and snare
• LIGATION ASSISTED:– Band and snare
• ENDOSCOPIC SUBMUCOSAL DISSECTION) (ESD)– Inject and cut with free-hand knife for en-bloc resection
EMR for HGD/Early Carcinomain Barrett’s Esophagus
• Outpatient procedure
• Major risk is bleeding, usually mild, < 5%
• Perforation is rare, < 1%• Perforation is rare, < 1%
• Pathology specimen for evaluation of tumor depth and margins.
Ell. Gastroenterology 2000;118:670-7.
Alvarez Herrero. Endoscopy 2011;43:177-83.
Mino-Kenudson. Gastrointest Endosc 2007;66:660-6.
Peters. Gastrointest Endosc 2008;67:604-9.
Moss. Am J Gastroenterol 2010;105:1276-83.
Good Risk Lesions For EMR in Early Esophageal Adenocarcinoma
• Non-ulcerated lesions, < 2.0 cm in diameter
• Invasion limited to mucosa• Invasion limited to mucosa
• No lympho-vascular invasion
• No poorly differentiated histology
Ell et al. Gastrointest Endosc 2007;65:3-10.
EMR in HGD/T1a complicating
Barrett’s esophagus
• 100 patients, 144 resections
• No major complications; 11 mild bleeding
• Complete local remission in 99% after a • Complete local remission in 99% after a maximum of 3 resections
• 11% recurred in 36.7 months, all successfully retreated with EMR
Ell. Gastrointest Endosc 2007;65:3-10
Complete Removal of BE with EMR:Radical Sequential EMR
• Length of Barrett’s segment is a major factor
• SSBE < 3 cm has best results• SSBE < 3 cm has best results
• Strictures >50% if >3.0 cm length or > ¾ circumference of lumen
• Longer segments: focal EMR + ablationPeters et al. Am J Gastroenterol 2006;101:1449-57.
Larghi et al. Endoscopy 2007; 39:1086-91.
Van Vilsteren, et al. Gut 2011;60:765-73
Currently Available Endoscopic Ablation Techniques for BE
• Argon Plasma Coagulation (APC)
• Multipolar Electrocoagulation (MPEC)
• Heat Probe• Heat Probe
• Lasers (Nd:YAG, KTP, Argon)
• Photodynamic Therapy (PDT)
• Cryotherapy
• Radiofrequency Ablation (RFA)
Prasad, et al. Gastroenterology 2007;132:1226-1233
Radiofrequency Ablation Balloon
Focal Radiofrequency Ablation Device
RFA versus Surveillance at 1-YearShaheen, et al. N Engl J Med 2009;360:2277-88
RFA ComplicationsShaheen, et al. N Engl J Med 2009;360:2277-88
Serious Adverse Events:
3/84 (3.6%). 1 UGI bleed, 2 chest pain
Strictures:
5/84 patients (6%) resolved:mean 2.6 dilations5/84 patients (6%) resolved:mean 2.6 dilations
Subsquamous intestinal metaplasia:
RFA Surveillance
Baseline 25% 26%
1-year 5% 40%
Longterm Durability of Ablation
38Shaheen, et al. Gastroenterology 2011:141:460-468.
EMR+RFA vs. Esophagectomy
in BE with HGD/IMC
• All patients treated at USC 2001-2010
EMR+RFA(40)
Esophagectomy(61)Esophagectomy(61)
Survival (3 yr) 94% 94% ns
Morbidity 0% 39% p <
0.0001
Zehetner, et al. J Thorac Cardiovasc Surg 2011;141:39-47.
Conclusions
• Low-cost screening for BE may become feasible.
• New methods may improve surveillance.
• Need for better risk stratification in BE.• Need for better risk stratification in BE.
• EMR for staging of all focal dysplastic lesions.*
• HGD/IMCA: Endoscopic Therapy (EMR, Ablation)
preferred in most patients to esophagectomy.**AGA Medical Position Statement on the Management of BE
Gastroenterology 2011;140:1084-1091.