Esophagectomy for failed endoscopic therapy in patients with high-grade dysplasia or intramucosal carcinoma

• Published in: Diseases of the esophagus Vol. 27; no. 4; pp. 362 - 367
• Main Authors: Hunt, B. M., Louie, B. E., Dunst, C. M., Lipham, J. C., Farivar, A. S., Sharata, A., Aye, R. W.
• Format: Journal Article
• Language: English
• Published: United States Blackwell Publishing Ltd 01.05.2014
• Subjects: Aged; Barrett Esophagus - pathology; Barrett Esophagus - surgery; Barrett's esophagus; Carcinoma - pathology; Carcinoma - surgery; Catheter Ablation; Cohort Studies; endoscopic mucosal resection; esophageal neoplasm; Esophageal Neoplasms - pathology; Esophageal Neoplasms - surgery; Esophagectomy; Esophagoscopy; Female; Humans; Male; Mucous Membrane - pathology; Mucous Membrane - surgery; Neoplasm Invasiveness; Neoplasms, Multiple Primary - pathology; Neoplasms, Multiple Primary - surgery; radiofrequency ablation; Retrospective Studies; Salvage Therapy; Treatment Failure; Treatment Outcome; endoscopic mucosal resection; esophagectomy; esophageal neoplasm; radiofrequency ablation; Barrett's esophagus
• ISSN: 1120-8694; 1442-2050
• DOI: 10.1111/dote.12096

Summary Endoscopic therapy (ablation +/− endoscopic resection) for high‐grade dysplasia and/or intramucosal carcinoma (IMC) of the esophagus has demonstrated promising results. However, there is a concern that a curable, local disease may progress to systemic disease with repeated endotherapy. We performed a retrospective review of patients who underwent esophagectomy after endotherapy at three tertiary care esophageal centers from 2006 to 2012. Our objective was to document the clinical and pathologic outcomes of patients who undergo esophagectomy after failed endotherapy. Fifteen patients underwent esophagectomy after a mean of 13 months and 4.1 sessions of endotherapy for progression of disease (53%), failure to clear disease (33%), or recurrence (13%). Initially, all had Barrett's, 73% had ≥3‐cm segments, 93% had a nodule or ulcer, and 91% had multifocal disease upon presentation. High‐grade dysplasia was present at index endoscopy in 80% and IMC in 33%, and some patients had both. Final pathology at esophagectomy was T0 (13%), T1a (60%), T1b (20%), and T2 (7%). Positive lymph nodes were found in 20%: one patient was T2N1 and two were T1bN1. Patients with T1b, T2, or N1 disease had more IMC on index endoscopy (75% vs. 18%) and more endotherapy sessions (median 6.5 vs. 3). There have been no recurrences a mean of 20 months after esophagectomy. Clinical outcomes were comparable to other series, but submucosal invasion (27%) and node‐positive disease (20%) were encountered in some patients who initially presented with a locally curable disease and eventually required esophagectomy after failed endotherapy. An initial pathology of IMC or failure to clear disease after three treatments should raise concern for loco‐regional progression and prompt earlier consideration of esophagectomy.