4Endoscopic treatment of high-grade intraepithelial neoplasia and early cancer in Barrett oesophagus
Section snippets
Work-up for patients with HGIN or EC in Barrett oesophagus
Three aspects need to be taken into consideration regarding the work-up of Barrett oesophagus patients with HGIN or EC: the histopathological evaluation, the endoscopic work-up, and the staging of the lesions.
Endoscopic therapy for HGIN and EC in Barrett oesophagus
Endoscopic therapy for early oesophageal neoplasia can be subdivided into two categories: endoscopic resection (ER) techniques and endoscopic ablation therapy. ER has been shown to be a safe and effective method for complete resection of superficial lesions, with the advantage of histopathological verification.43, 44, 45 Larger lesions, however, are less suitable for ER since piece-meal resection is often necessary, making it impossible to be conclusive about the radicality of the resection at
Endoscopic resection techniques
A variety of different ER techniques have been described for the oesophagus. The most of these techniques were originally developed and clinically applied in Japan primarily for oesophageal squamous neoplasia. For treatment of Barrett neoplasia the most widely practiced ER technique is the ER-cap technique after submucosal lifting (Figure 1, Figure 2).46 With this technique, the target lesion is first lifted by injection of a fluid, usually diluted adrenaline (1:100 000), into the submucosal
New endoscopic resection techniques
Currently, new endoscopic resection techniques are being explored. Japanese endoscopists have used specially designed needle knifes for en-bloc dissection of large oesophageal lesions.49, 50, 51 These dissection techniques are usually performed after submucosal injection with viscous substances, such as hyaluronidate, that provide a prolonged submucosal lifting.49, 50, 51 Experience in Barrett oesophagus patients is still limited and a high-level of endoscopic expertise seems to be required for
Complications and limitations of ER for HGIN and EC in Barrett oesophagus
ER of HGIN or EC in Barrett oesophagus is a safe procedure and serious complications are rare.43 Minor complications, such as minor bleedings, occur in 9% of the cases and usually are easily managed endoscopically.52 Depending on the definition of a post-ER bleeding, this complication may, however, occur in as much as 46% of procedures.53 We suggest that immediate bleedings should only be regarded as complications if they resulted in clinical consequences such as a drop in haemoglobin level,
Success rate of endoscopic resection for HGIN and EC in Barrett oesophagus patients
There is only a small number of series available on the efficacy of ER as monotherapy for treatment of HGIN or EC in Barrett oesophagus patients. The largest series comes from the Wiesbaden group who treated 64 Barrett oesophagus patients with EC (61 patients) or HGIN (three patients). Thirty-five patients were classified as having ‘low risk’ lesions, defined as macroscopic types I, IIa, IIb, and IIc, a lesion diameter up to 20 mm, limited to the mucosa, and histological grades G1 or G2. The
Endoscopic ablation therapy with photodynamic therapy
Photodynamic therapy (PDT) is an endoscopic ablative therapy that may eradicate HGIN or EC in Barrett oesophagus patients. It requires the administration of a photosensitizing drug that accumulates in the target tissue, application of light (usually laser light) with an appropriate wavelength, and the presence of oxygen. In the presence of these three factors, a photodynamic reaction takes place that generates oxygen radicals causing delayed cell death; usually becoming apparent after 12–24
Future prospects and unresolved issues
Radical endoscopic resection of the entire Barrett oesophagus is, in our opinion, the most promising alternative for treating selected Barrett oesophagus patients with HGIN and EC. First, it allows complete removal of the whole mucosa at risk, thus by definition, leaving no residual Barrett tissue. Second, it provides tissue samples for optimal histopathological diagnosis. Third, the risk of buried Barrett may be reduced. Finally, radical endoscopic resection may also reduce the likelihood of
Summary
In the past years, sufficient evidence has accumulated to support the endoscopic treatment of HGIN/EC in Barrett oesophagus as an alternative to surgery in selected patients. Optimal management of these patients requires referral to a centre with expertise in this field. The endoscopic work-up requires high-quality endoscopic equipment and expertise of the endoscopist in the use of different imaging techniques for the detection of subtle mucosal abnormalities. Reliable histopathological
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Cited by (20)
Safety of Prior Endoscopic Mucosal Resection in Patients Receiving Radiofrequency Ablation of Barrett's Esophagus
2012, Clinical Gastroenterology and HepatologyCitation Excerpt :EMR is an important component of endoscopic ablative therapy of esophageal neoplasia in BE; it is a tissue acquiring technique.6 EMR enables proper patient selection on the basis of the histologic assessment of the resection specimen.14–19 Because EMR results in removal of focal lesions, further ablative therapy in the form of RFA can then be used to remove the remaining areas of dysplasia or metaplasia.
Endoscopic approaches to Barrett's oesophagus with high-grade dysplasia/early mucosal cancer
2008, Best Practice and Research: Clinical GastroenterologyCitation Excerpt :The tissue is then exposed to wavelength-specific light, triggering a photochemical reaction that generates oxygen radicals which lead to cell death. Technical details of PDT application have been well described.61 Biomedical lasers are the most common source of light energy, as laser light can be adjusted to specific wavelength and power to optimise results.
Place of photodynamic treatment in therapeutics
2008, Gastroenterologia y Hepatologia ContinuadaThe endoscopic diagnosis and staging of oesophageal adenocarcinoma
2006, Best Practice and Research: Clinical GastroenterologyCitation Excerpt :For submucosal tumours located at the gastro-oesophageal junction or with infiltration of the first third of the submucosa, however, the diagnostic accuracy of both techniques is not yet satisfactory. This again underlines the importance of using an endoscopic resection technique as the primary treatment modality in these patients (allowing for histological examination) and that the use of ablation techniques should ideally be restricted to an adjuvant setting after EMR of the most involved area.57 The diagnostic accuracy of EUS pertaining to lymph node involvement has been reported to range from 68% to 86%.39–41
Sixteen-year follow-up of barrett’s esophagus, endoscopically treated with argon plasma coagulation
2014, United European Gastroenterology Journal