How effective is endoscopic management compared with surgical management for high grade dysplasia in patients with BO?

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How effective is endoscopic management compared with surgical management for high grade dysplasia in patients with BO?

Introduction

The diagnosis of high grade dysplasia (HGD) in a patient with Barrett’s Oesophagus increases the risk of either harbouring or developing oesophageal adenocarcinoma. Treatment options for HGD can range from surgical resection through to endoscopic treatments. Data from surgical resections performed in patients with HGD have noted the presence of adenocarcinoma varies, with reported rates between 7%[1] and 36%.[2][3] A systematic review reported the presence of T1b / submucosal adenocarcinoma in 12.7% cases.[4] The majority of this data is from a period prior to the routine use of EMR around 2005 which enables improved staging and detection of both T1a and T1b lesions. Surgical resection is effective in removing the dysplastic area but is associated with potentially significant perioperative morbidity and mortality as well as an impact on quality of life. Recent developments in endoscopic techniques have led to improved methods for resecting and ablating the dysplastic epithelium. The understanding of lymph node risk associated with lesions as they progress from HGD to T1b lesions allows us to use this information to tailor treatment options for our patients.[4][5]

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Surgery

Oesophagectomy is major surgery with associated perioperative morbidity and mortality. There is data to support that oesophageal surgery should be performed in specialised units and in these centres the perioperative mortality is reduced to 2-4% or less.[6][7] Perioperative morbidity remains an issue after oesophageal surgery, with major morbidity reported in 25-40% of patients.[8][7] The benefit of surgical resection is the ability to remove all dysplastic epithelium and any undiagnosed adenocarcinoma and the locoregional nodal basins. This allows for a long term disease free survival greater than 90% without the need for ongoing surveillance.[8]

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Endoscopic therapies

Endoscopic therapies (photodynamic therapy, argon plasma coagulation, radiofrequency ablation, endoscopic mucosal resection) for HGD have evolved significantly recently. They can be broadly divided into resection or ablation techniques. Endoscopic mucosal resection can be used as both a diagnostic and therapeutic tool and has the benefit of providing a histopathological specimen. It can be combined with ablative techniques such as radiofrequency ablation to treat larger areas of mucosa. A systematic review of endoscopic treatments has found that they are generally safe with only one death reported in the pooled data of 2831 cases.[9] The morbidity associated with endoscopic treatments in less than that associated with surgery. The short term efficacy in eradication of HGD varies from 66-100% and long term data is lacking.[9]

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Surgery versus endoscopic therapies

There are no randomised controlled trials comparing surgery with endoscopic treatments for HGD. A Cochrane review updated in 2012 excluded 13 non-randomised retrospective studies comparing outcomes between surgery and endoscopic treatments.[8] A meta-analysis of seven non-randomised studies comparing endoscopic and surgical management has also been performed.[10] These studies demonstrate similar overall survival and cancer related mortality between the two groups with the endoscopic group having a higher neoplasia recurrence rate, however, 78-100% patients were able to undergo repeat endoscopic treatment successfully. There was no statistical difference in procedure related mortality and the endoscopic group have less procedure related morbidity.[10] The studies utilised in these reviews come from world leading centres with excellent results, but all highlight, that to achieve these results multiple endoscopic sessions are needed. Intensive endoscopic follow protocols are also paramount to detect and manage any local recurrences[11][12][13] (see also After successful endoscopic treatment for BO neoplasia, how frequently should patients undergo endoscopy?).

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Evidence summary and recommendations

Evidence summary Level References
In specialist centres, endoscopic treatment of patients with high grade dysplasia provides similar outcomes to surgery with regard to overall survival and cancer related mortality. III-2 [8], [9], [10], [11], [12], [13]
In specialist centres, patients with high grade dysplasia undergoing endoscopic treatments compared to surgery have less morbidity, but a higher incidence of local recurrence. III-2 [8], [9], [10], [11], [12], [13]
Evidence-based recommendationQuestion mark transparent.png Grade
It is recommended that patients with high grade dysplasia in Barrett’s Oesophagus be managed in centres with high volume experience of the condition. The treatment and follow-up should occur in those specialist centres.
C


Practice pointQuestion mark transparent.png

Patients with high grade dysplasia in Barrett's Oesophagus can be discussed at a multidisciplinary team meeting at a specialist centre.

Endoscopic treatment will be the first line treatment option for the majority of patients with high grade dysplasia in Barrett's Oesophagus. There will be a group of patients for whom endoscopic treatment is not appropriate or successful and will be best treated with surgery in a specialist centre.

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References

  1. Levine DS, Haggitt RC, Blount PL, Rabinovitch PS, Rusch VW, Reid BJ. An endoscopic biopsy protocol can differentiate high-grade dysplasia from early adenocarcinoma in Barrett's esophagus. Gastroenterology 1993 Jul;105(1):40-50 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8514061.
  2. Falk GW, Rice TW, Goldblum JR, Richter JE. Jumbo biopsy forceps protocol still misses unsuspected cancer in Barrett's esophagus with high-grade dysplasia. Gastrointest Endosc 1999 Feb;49(2):170-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9925694.
  3. Kariv R, Plesec TP, Goldblum JR, Bronner M, Oldenburgh M, Rice TW, et al. The Seattle protocol does not more reliably predict the detection of cancer at the time of esophagectomy than a less intensive surveillance protocol. Clin Gastroenterol Hepatol 2009 Jun;7(6):653-8; quiz 606 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19264576.
  4. 4.0 4.1 Konda VJ, Ross AS, Ferguson MK, Hart JA, Lin S, Naylor K, et al. Is the risk of concomitant invasive esophageal cancer in high-grade dysplasia in Barrett's esophagus overestimated? Clin Gastroenterol Hepatol 2008 Feb;6(2):159-64 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18096439.
  5. Dunbar KB, Spechler SJ. The risk of lymph-node metastases in patients with high-grade dysplasia or intramucosal carcinoma in Barrett's esophagus: a systematic review. Am J Gastroenterol 2012 Jun;107(6):850-62; quiz 863 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22488081.
  6. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002 Apr 11;346(15):1128-37 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11948273.
  7. 7.0 7.1 Markar SR, Karthikesalingam A, Thrumurthy S, Low DE. Volume-outcome relationship in surgery for esophageal malignancy: systematic review and meta-analysis 2000-2011. J Gastrointest Surg 2012 May;16(5):1055-63 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22089950.
  8. 8.0 8.1 8.2 8.3 8.4 Bennett C, Green S, Decaestecker J, Almond M, Barr H, Bhandari P, et al. Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus. Cochrane Database Syst Rev 2012 Nov 14;11:CD007334 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23152243.
  9. 9.0 9.1 9.2 9.3 Menon D, Stafinski T, Wu H, Lau D, Wong C. Endoscopic treatments for Barrett's esophagus: a systematic review of safety and effectiveness compared to esophagectomy. BMC Gastroenterol 2010 Sep 27;10:111 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20875123.
  10. 10.0 10.1 10.2 10.3 Wu J, Pan YM, Wang TT, Gao DJ, Hu B. Endotherapy versus surgery for early neoplasia in Barrett's esophagus: a meta-analysis. Gastrointest Endosc 2013 Sep 27 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24079410.
  11. 11.0 11.1 11.2 Pech O, Bollschweiler E, Manner H, Leers J, Ell C, Hölscher AH. Comparison between endoscopic and surgical resection of mucosal esophageal adenocarcinoma in Barrett's esophagus at two high-volume centers. Ann Surg 2011 Jul;254(1):67-72 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21532466.
  12. 12.0 12.1 12.2 Prasad GA, Wang KK, Buttar NS, Wongkeesong LM, Krishnadath KK, Nichols FC 3rd, et al. Long-term survival following endoscopic and surgical treatment of high-grade dysplasia in Barrett's esophagus. Gastroenterology 2007 Apr;132(4):1226-33 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17408660.
  13. 13.0 13.1 13.2 Schembre DB, Huang JL, Lin OS, Cantone N, Low DE. Treatment of Barrett's esophagus with early neoplasia: a comparison of endoscopic therapy and esophagectomy. Gastrointest Endosc 2008 Apr;67(4):595-601 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18279860.

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Appendices


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