Neoplasia in Barrett’s oesophagus: the earlier the intervention, the better the long-term outcome

Treatment types for the eradication of early Barrett’s oesophagus-associated neoplasia vary according to the severity of the lesions. When comparing long-term results of those with pre-neoplastic or very early forms of neoplasia with more advanced lesions, the more extensive intervention of endoscopic submucosal dissection (ESD) may not balance the risk of greater oncologic severity.

“Early Barrett’s oesophagus-associated neoplasia can be curatively treated by endoscopic resection with high success rates, especially if followed by ablation therapy; however, the choice of the resection method is still a matter of debate,” Dr Fadi Younis (University Hospital Hamburg-Eppendorf, Germany) explained [1]. The presented retrospective study investigated the long-term outcomes in patients with Barrett’s oesophagus-associated neoplasia when the choice of treatment with endoscopic mucosal resection (EMR) or ESD was lesion-based. The current guideline of the European Society of Gastrointestinal Endoscopy recommends EMR for visible lesions ≤2 cm with low probability of submucosal invasion and for larger or multifocal benign dysplastic lesions [2]. ESD is suggested in case of suspected submucosal invasion, lesion size >2 cm, and lesions in scarred or fibrotic areas.

The main study outcomes were defined as complete remission or eradication of the neoplasia (CE-N) and intestinal metaplasia (CE-IM) after ESD or EMR. The baseline characteristics showed a total of 364 participants of whom 268 had EMR and 96 ESD. Participants undergoing ESD had a greater extent of disease, more visible lesions, and more difficult interventions. “In the pre-resection and post-resection, we can see that they had 90% of adenocarcinoma in the final histology and they had more difficult interventions,” Dr Younis further specified the post-interventional histology outcomes of the ESD participants. The rate of adenocarcinomas in histology after EMR was 65.3%. Looking at lesion morphology, however, no difference was detected between the groups.

The primary resection treatment of all cancers and high-grade dysplasia’s showed success rates of over 96% for initial CE-N in both groups and initial biopsy proven CE-IM in 85.5% (EMR) and 82% (ESD) of cases in the per-protocol analysis. In the intention-to-treat cohort, these percentages were lower with initial CE-N in 78.5% (EMR) and 72.2% (ESD) and CE-IM in 66.7% and 58.6%, respectively. The long-term follow-up revealed CE-N status 2 years after EMR in 92% (per-protocol) and 62% (intention-to-treat) compared with 89% (per-protocol) and 48% (intention-to-treat) in those who received ESD. After 5 years, complete eradication in the per-protocol and intention-to-treat analyses was still present in the EMR group with 85% and 43% versus 75% and 20% after ESD. Looking at the differences by Kaplan-Meier estimates for risk of recurrence, the curves showed a significant difference between the groups: at the point of longest follow-up, 11% of the EMR and 23% of the ESD participants had recurrent neoplasia (P=0.02).

As for adverse events, Dr Younis stated that the overall safety in the 2 groups was similar but participants with ESD had more refractory strictures which required stent insertions and operations.

“Allocation of EMR versus ESD works, but the biology also counts,” Dr Younis expressed in his conclusion.

1. Younis F, et al. Clinical stratification for endoscopic submucosal dissection versus endoscopic mucosal resection for Barrett’s associated neoplasia: long-term follow-up. OP211, UEG Week 2022, 8–11 October, Vienna, Austria.
2. Pimentel-Nunes P, et al. 2022;54(6):591–622.

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Posted on 2 December, 2022