Today's Mistakes and Tomorrow's Wisdom… in the Management of T1b Barrett's Adenocarcinoma

Abstract

Background: Given the limitation that endoscopic resection only enables local intraluminal treatment without lymphadenectomy, the standard treatment of esophageal adenocarcinoma (EAC) with invasion of the submucosa (T1b) has long been surgical esophageal resection. However, in recent literature, the risk of lymph node metastases (LNM) associated with T1b EAC appears to be lower than previously assumed, and endoscopic management is increasingly being considered a valid and less invasive alternative to surgery.

Summary: Surgical esophageal resection performed after radical endoscopic resection of T1b EAC often does not show any residual tumor or LNM in the resected specimen. Given the morbidity and mortality associated with surgical esophageal resection, endoscopic management with strict surveillance protocols has been more widely applied provided that the initial tumor was radically removed by endoscopic resection, reserving surgery for those cases where the additional risk of surgical esophageal resection is justified. These are the cases where intraluminal recurrent neoplasia is found that cannot be retreated endoscopically or cases with locoregional LNM detected during follow-up. In the future, selection of patients who can safely be managed endoscopically and those who may benefit from additional surgery after endoscopic resection of T1b EAC may become more tailored, using risk prediction calculators or sentinel node navigated surgery.

Key messages: Management of patients with T1b EAC is shifting from surgical treatment to less invasive endoscopic treatment strategies, including watchful waiting approaches. The risk of LNM of T1b EAC appears to be lower than long assumed. In the future, management of T1b EAC may become more individualized based on tools to predict LNM risk per patient case.

Keywords: Barrett's esophagus; Endoscopic resection; Esophageal adenocarcinoma; Submucosal cancer.

Fig. 1

Watchful waiting strategy in a T1b EAC case. a–c Paris type 0-Is lesion in a Barrett's esophagus. After endoscopic submucosal dissection (T1sm1 LVI- G2 R0), the patient was surveyed according to the PREFER follow-up regimen (Table 1). d, e After 2 years of endoscopic follow-up, 1 suspicious mediastinal lymph node was found during radial EUS. Sampling with EUS-fine needle aspiration using a linear EUS-scope demonstrated a lymph node metastasis (LNM). No other LNM or distant metastases were found on the performed PET-scan, and the patient could be treated with a curative intent.