Endoscopy
Endoscopic Resection and Ablation in Barrett’s Oesophagus Hendrik Manner and Oliver Pech Department of Internal Medicine, HSK Wiesbaden
Abstract
Endoscopic therapy has been shown to be safe and highly effective with long-term complete remission rates of more than 94% in early neoplasia in Barrett’s oesophagus (high-grade intra-epithelial neoplasia [HGIN] and mucosal adenocarcinoma). All visible lesions should be treated by endoscopic resection (ER) for histological confirmation of the neoplastic lesion rather than by ablative techniques. Nevertheless, there is a role for ablative techniques: after successful ER of all visible and localisable HGIN and mucosal cancer, ablative treatment of the remaining Barrett’s epithelium at risk should be performed in order to reduce the rate of recurrent or metachronous neoplasia.
Keywords Endoscopic resection, ablation, Barrett’s oesophagus, early Barrett's cancer
Disclosure: The authors have no conflicts of interest to declare. Received: 14 January 2011 Accepted: 20 April 2011 Citation: European Gastroenterology & Hepatology Review, 2011;7(2):133–8 Correspondence: Hendrik Manner, Department of Gastroenterology, HSK Wiesbaden, Ludwig-Erhard-Str 100, 65199 Wiesbaden, Germany. E:
hendrik.manner@
hsk-wiesbaden.de
Barrett’s adenocarcinoma is increasing in incidence, and it has a high mortality rate unless detected early. The sequence of events from Barrett’s oesophagus to adenocarcinoma goes through several steps, encompassing both low- and high-grade intra-epithelial neoplasia (LGIN and HGIN, respectively). Endoscopy has seen an expanding role in the management of early Barrett’s neoplasia, especially throughout the last decade. Detection of early neoplasias has become more frequent as a result of improved endoscopic imaging technology, surveillance programmes and increasing experience of endoscopists.
Even though radical oesophageal resection was considered to be the treatment of choice for early Barrett’s neoplasia for many years, it is known to be associated with significant mortality and morbidity. For these reasons, local treatment methods such as endoscopic resection (ER) have been introduced and investigated in several studies on cancers that carry a negligible risk of lymph node metastasis.
In general, patients are ideal candidates for endoscopic treatment if they are at no risk of lymph node metastasis or lower risk for developing lymph node metastasis compared with the risk of mortality from surgery. This risk of lymph node involvement depends on the depth of tumour invasion and other histological criteria of the lesion.
Unlike ablative methods such as photodynamic therapy (PDT), argon plasma coagulation (APC) or radiofrequency ablation (RFA), ER allows complete pathological assessment of the resected specimen including depth of cancer invasion, tumour differentiation and involvement of lymphatics or vessels (L/V status). This pathological staging is crucial as it allows the risk of lymph node metastasis to be predicted and further treatment to be refined.
Accurate evaluation of patients and careful staging of lesions is mandatory before ER with a curative intent, as well as a strict follow-up programme after endoscopic treatment in order to be able
© TOUCH BRIEFINGS 2011
to detect recurrent lesions in an early stage. The vast majority of recurrent and metachronous lesions in Barrett’s early cancer can again be treated endoscopically.
Staging of Early Neoplasia in Barrett’s Oesophagus
Accurate staging is mandatory before ER of early gastric or oesophageal cancer. The most important part of the staging procedure is careful evaluation of the neoplasia (according to the Japanese classification; see Figure 1) and the borders of the lesion using a high-resolution endoscope and searching for multifocal neoplasia. For evaluation of early neoplastic lesions in Barrett’s oesophagus, acetic acid spraying or virtual chromoendoscopy (e.g. Flexible spectral Imaging Color Enhancement [FICE, Fujinon], narrow-band imaging [NBI], or i-scan) have shown promising results1 and are widely used.
Four-quadrant Random Biopsies and Chromoendoscopy
HGIN and early carcinoma (EC) are often discrete (see Figure 2) or even macroscopically occult at standard surveillance endoscopy. Therefore, a comprehensive endoscopic biopsy protocol with systematic four-quadrant random biopsies (4QBs) every 1–2cm along the length of the Barrett’s segment according to the Seattle protocol is recommended as the gold standard for surveillance.
Additional use of virtual and conventional chromoendoscopy with acetic acid2
might further optimise detection of mucosal abnormalities by enhancement of mucosal contrast and plasticity. A recently published study has shown that advanced imaging technology is able to identify the vast majority of early neoplasia in Barrett’s oesophagus.2
Therefore, at least in high-volume centres,
limiting endoscopic surveillance to chromoendoscopy-guided biopsies is justified.
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