Management of superficial Barrett's epithelium-related neoplasms by endoscopic mucosal resection: clinicopathologic analysis of 27 cases

Abstract

Endoscopic mucosal resection (EMR), a relatively new endoluminal therapeutic technique with low morbidity and no mortality reported to date, is advocated for the treatment of Barrett's esophagus (BE)-related superficial neoplasms. However, recent studies revise its success downward, particularly regarding the ability to achieve complete excision. To evaluate what remains an evolving technique, we analyzed our experience with a series of 27 esophageal EMRs (20 lesions in 18 patients). Our goal was to evaluate the diagnostic, staging, and therapeutic advantages of EMR separately by correlating the initial biopsies and pre-EMR endoscopic ultrasound (EUS) staging with the final histologic diagnoses and stage. Persistence/recurrence of neoplastic tissue was also correlated with the margin status of the resections. The mean size of the neoplasms, which included low-grade dysplasias (n=2), high-grade dysplasias (n=8), intramucosal carcinomas (n=14), and submucosal invasive carcinomas (n=3), was 11 mm. EUS correctly reported an intramucosal or submucosal lesion in 70% of the cases while it overstaged 18% and understaged 12% of the cases. The biopsy diagnosis corresponded to the EMR diagnosis in 63% of the cases. The biopsy underestimated the grade of the lesion in 21% of the cases. EMR revealed a lower histologic grade compared with the biopsy in 16% of the cases. The resection was microscopically complete in only 4% of the cases. No residual/recurrent disease was observed in 10 lesions (9 patients) at 4 to 63 months (mean, 23 months) post-EMR. However, 9 lesions (8 patients) persisted/recurred 28 days to 25 months (mean, 6 months) after treatment; 56% of the cases with positive lateral margin(s) and negative deep margin persisted/recurred. However, 86% of the EMRs with positive deep margin showed residual tumor/recurrence on follow-up biopsies. In conclusion, we observed that EMR offers improved diagnosis and staging as compared with biopsy and EUS. This is a significant advantage since it can modify patients' management. However, frequent incompleteness of resection and high persistence/recurrence are significant pitfalls that dictate continued endoscopic surveillance.