Endoscopic Management of High Grade Dysplasia and Intramucosal Carcinoma: Experience in a Large Academic Medical Center

Kyle A Perry, MD, Mario Salazar, MD, Andrew Suzo, Jon Walker, MD, Jeffrey W Hazey, MD, W S Melvin, MD

The Ohio State University Medical Center

BACKGROUND: Traditionally, esophagectomy has been the standard treatment for patients with high grade dysplasia and early esophageal cancer. Recently, endoscopic treatment with endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) has become the preferred approach for the management of these patients in some specialized centers. We report a single institution series of patients undergoing endoscopic management of Barrett’s esophagus (BE) with high grade dysplasia or intramucosal adenocarcinoma.

METHODS: A retrospective review of a prospectively-collected database was conducted for patients undergoing endoscopic treatment for BE with biopsy proven high grade dysplasia or intramucosal carcinoma from 2009 to 2012. Patients with nodular BE were managed with EMR followed by RFA, while those with flat BE received RFA alone. The primary outcome measure was progression of BE necessitating esophagectomy. Secondary outcomes included complete eradication of BE, complete eradication of dysplasia, recurrence or progression of BE or dysplasia, and complications of endoscopic treatment. Patients were followed for a median follow up interval of 8 months following completion of RFA treatment. Data are presented as incidence (%) or median (range) as appropriate.

RESULTS: During the study period, 87 patients underwent RFA for treatment of BE, and 19 met the inclusion criteria for this study. Three (16%) had a presenting diagnosis of intramucosal adenocarcinoma, and 16 (84%) were treated for high grade dysplasia. Twelve (63%) had long segment BE, and the median length of BE was 5 cm. Ten (53%) patients had nodular BE and underwent EMR prior to ablative therapy. Intramucosal cancer was identified in 3 EMR specimens, and a margin negative resection was achieved in each case. Complete eradication of dysplasia was achieved in 89% of patients, and complete eradication of BE was achieved in 58%. A median of 2 (1-7) treatments were required, and there were no immediate post-procedure complications. No patients in this series developed strictures requiring endoscopic dilation following RFA. Three patients (16%) developed recurrent dysplasia following complete eradication of BE, and each case was successfully managed with repeat RFA. Three patients (16%) required esophagectomy within 6 months following RFA treatment. Two of these developed nodules containing adenocarcinoma with subsequent margin positive EMR, and the other had persistent nodular BE with extensive low and high grade dysplasia. A complete surgical resection was achieved in each case, and none of the patients developed lymph node metastases.

CONCLUSIONS: Complete eradication of high grade dysplasia and intramucosal adenocarcinoma can be achieved via endoscopic therapy, thus avoiding esophagectomy in the majority of patients. However, a subset of patients will fail this treatment approach and require surgical resection. With aggressive endoscopic treatment and surveillance, these patients can be identified at an early stage while curative resection is still possible. Long-term follow up studies are required to determine the rate of recurrent BE and progression rate to cancer over time following successful initial endoscopic therapy in this patient population.

Session: Podium Presentation

Program Number: S038

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