Original article
Clinical endoscopy
Low prevalence of submucosal invasive carcinoma at esophagectomy for high-grade dysplasia or intramucosal adenocarcinoma in Barrett's esophagus: a 20-year experience

https://doi.org/10.1016/j.gie.2008.05.013Get rights and content

Background

The rate of occult adenocarcinoma at esophagectomy in patients with Barrett's esophagus (BE) and high-grade dysplasia (HGD) has been reported to be approximately 40%. Recently, it has been suggested that this risk may be overestimated.

Objective

Our purpose was to determine the rate of submucosal invasive adenocarcinoma in patients undergoing esophagectomy for BE after biopsy diagnosis of HGD or intramucosal carcinoma (IMC). A secondary aim was to identify clinical risk factors for submucosal invasive adenocarcinoma in these patients.

Design

A retrospective study.

Setting

Tertiary referral center.

Patients

All patients with preoperative BE with HGD or IMC treated with esophagectomy over a 20 year period.

Interventions

Esophagectomy.

Main Outcome Measurements

Submucosal invasive adenocarcinoma at esophagectomy.

Results

Sixty patients were included (41 with preoperative HGD, 19 with preoperative IMC). The overall rate of submucosal invasive carcinoma was 6.7% (95% CI, 1.8%-16.2%) (n = 4), with a 5% rate of submucosal invasion in patients with preoperative HGD and 11% for patients with preoperative IMC. All 4 patients with submucosal invasion at esophagectomy had either nodular or ulcerated mucosa on preoperative endoscopy. The 1-year and 5-year all-cause risks of death for the entire cohort were 1.9% and 10.9%, respectively.

Limitations

Retrospective study.

Conclusions

The rate of submucosal invasive adenocarcinoma at esophagectomy in BE patients with HGD or IMC on biopsy is much lower than 40%. After adequate sampling and staging, patients with BE with HGD and IMC, especially those without endoscopically visible lesions, can potentially be treated by nonsurgical (local) therapies.

Section snippets

Definitions

BE is defined as columnar metaplasia, with goblet cells, identified in biopsy specimens obtained from the esophagus above the gastroesophageal junction.19 HGD in BE shows increased crypt complexity, crowding, irregularity, and branching, with more pronounced nuclear stratification, loss of nuclear polarity, pleomorphism, and mitotic activity.20 IMC is defined as neoplastic epithelium that has invaded beyond the basement membrane into the surrounding lamina propria or muscularis mucosae but not

Results

Sixty patients in total were included in the study, 41 with preoperative HGD and 19 with preoperative IMC. Table 1 summarizes the demographic features. The response rate of the administered survey was 83%. The mean age at diagnosis of HGD or IMC was 61 ± 10 years. Fifty-five (92%) patients were men, and 97% were white. Table 2 summarizes the pathologic findings in the esophagectomy specimens stratified by pre-esophagectomy diagnosis. At esophagectomy, 4 of 60 patients (6.7%; 95% CI, 1.8%-16.2%)

Discussion

This study describes one of the largest series of patients undergoing esophagectomy for BE with HGD or IMC. The low rate (6.7%) of submucosal invasion at esophagectomy in patients with BE with HGD or IMC on biopsy sharply contrasts with the frequently quoted 40% risk of occult cancer. Submucosal invasion is an important end point in studies of such patients because HGD and IMC can potentially be treated by local therapies such as PDT, RFA, or EMR. Importantly, submucosal invasion confers a risk

References (29)

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DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. This study was funded by the Ken and Louise Goldberg Award.

Presented in part at Digestive Disease Week, May 17-22, 2008, San Diego, California (Gastroenterology 2008;134:M1598).

See CME section; p. 914.

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