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Multidisciplinary treatment of T1a adenocarcinoma in Barrett’s esophagus: contemporary comparison of endoscopic and surgical treatment in physiologically fit patients

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Abstract

Background

Previous reports comparing endoscopic therapy (ET) and surgical therapy (ST) have predominantly assessed patients with high-grade dysplasia. The study aim was to compare ET to ST in physiologically fit patients with cT1a adenocarcinoma (EAC).

Methods

Review of two prospective databases yielded 100 patients presenting with clinical cT1a EAC between 2000 and 2013. Only physiologically fit patients who were candidates for either treatment were analyzed.

Results

Presenting patient characteristics were similar between ET (n = 36) and ST groups (n = 49). Surgical patients were less likely to be staged with EMR (43 vs 100 %) and were associated with mass lesions >1 cm at EGD (p = 0.01), multifocal EAC (p = 0.03), and positive margins for EAC on EMR (p < 0.05). On multivariate analysis, only multifocal HGD was an independent factor for surgery. Following esophagectomy, R0 resection rates for Barrett’s esophagus and cancer were 100 %. Incidence of surgery decreased over the study period from 85 to 25 %. All ET patients had EMR, and 28 patients underwent additional ablative therapies for Barrett’s esophagus. Following ET, eradication rates of EAC, dysplasia, and BE were 92, 81, and 53 %, respectively. Morbidity rates were comparable between groups (ST 51 % vs ET 39 %, p = 0.31). In-hospital mortality rate was zero in each group. Recurrence rates in ST and ET group were 2 and 11 % (p = 0.08). In the ET group, two patients with endoluminal cancer recurrence after complete eradication underwent esophagectomy. Age-adjusted overall survival was comparable.

Conclusion

In high-volume esophageal centers, ST and ET provide equally safe and effective treatment for cT1a EAC in medically fit patients. While the results of this study provide a historical perspective and clearly demonstrate an evolution toward ET over time, the appropriate treatment modality is best selected in a multidisciplinary fashion with EMR providing the most accurate staging. In endoscopically treated patients, indefinite endoscopic follow-up required, however, standardized long-term follow-up protocols are needed.

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Authors and Affiliations

  1. Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA

    Henner M. Schmidt, Kamran Mohiuddin, Artur M. Bodnar, Mustapha El Lakis, Stephen Kaplan & Donald E. Low

  2. Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA

    Shayan Irani, Ian Gan & Andrew Ross

Authors
  1. Henner M. Schmidt
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  2. Kamran Mohiuddin
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  3. Artur M. Bodnar
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  4. Mustapha El Lakis
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  7. Ian Gan
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  9. Donald E. Low
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Correspondence to Donald E. Low.

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Disclosures

Henner M. Schmidt, Kamran Mohiuddin, Artur M. Bodnar, Mustapha El Lakis, Stephen Kaplan, Shayan Irani, Ian Gan, Andrew Ross, and Donald E. Low have no conflicts of interest or financial ties to disclose.

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Schmidt, H.M., Mohiuddin, K., Bodnar, A.M. et al. Multidisciplinary treatment of T1a adenocarcinoma in Barrett’s esophagus: contemporary comparison of endoscopic and surgical treatment in physiologically fit patients. Surg Endosc 30, 3391–3401 (2016). https://doi.org/10.1007/s00464-015-4621-z

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  • DOI: https://doi.org/10.1007/s00464-015-4621-z

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