Endoscopy Could Spare More Barrett's Patients From Surgery

Damian McNamara

November 17, 2017

ORLANDO — Endoscopic therapy is as effective for people with Barrett's esophagus who present with intramucosal carcinoma as it is for those who present with high-grade dysplasia, new research shows.

The noninvasive alternative to surgery is the current treatment of choice for Barrett's esophagus with high-grade dysplasia, said Rajesh Krishnamoorthi, MD, from the Virginia Mason Medical Center in Seattle. But for people with Barrett's esophagus with intramucosal cancer, data on the effectiveness of the procedure are limited, he pointed out.

That stepwise progression of Barrett's esophagus — from no dysplasia to low-grade dysplasia to high-grade dysplasia to intramucosal cancer to adenocarcinoma — "gives us multiple opportunities to intervene," he explained.

Dr Krishnamoorthi presented results from an international, multicenter, consortium study comparing endoscopy with surgery in this population here at the World Congress of Gastroenterology 2017, where the research won the 2017 Category Award for esophagus research.

He and his colleagues assessed 276 people with Barrett's esophagus: 70 with intramucosal carcinoma and 206 patients with high-grade dysplasia. All patients underwent endoscopy at one of 10 centers in Australia, Europe, and the United States. Median age was 66 years, 84% of the cohort was male, and median length of the Barrett's esophagus segment was 6 cm.

Rates of complete eradication of intestinal metaplasia — a primary outcome — were not significantly different in the carcinoma and dysplasia groups (81% vs 89%; P = .62).

Rates of complete eradication of dysplasia — another primary outcome — were also not significantly different in the carcinoma and dysplasia groups (84% vs 90%; P = .77).

On multivariate analysis, after adjustment for age, sex, and length of Barrett's esophagus, differences between the carcinoma and dysplasia groups were still not significant for the complete eradication of intestinal metaplasia (hazard ratio [HR], 1.15; P = .81) or the complete eradication of dysplasia (HR, 1.21; P = .79).

"In this large, well-defined cohort of Barrett's esophagus patients, the effectiveness of endoscopic therapy for intramucosal cancer is comparable to that for high-grade dysplasia," Dr Krishnamoorthi said.

After the complete eradication of intestinal metaplasia, there was no significant difference in the rate of Barrett's esophagus recurrence between the carcinoma and dysplasia groups (44% vs 35%; P = .21).

The observational nature of the study and the exclusion of patients lost to follow-up are potential limitations, Dr Krishnamoorthi acknowledged.

This is a good first step. It's promising. This may be something we can develop and then train everybody to be good.

"Esophagectomy is an extraordinarily morbid surgery. So evidence that the treatment of intramucosal carcinoma is as successful as the treatment of high-grade dysplasia — so people don't have to go to surgery — is a big step forward," said session comoderator David Bjorkman, MD, from the University of Utah in Salt Lake City, who is president of the World Gastroenterology Organisation.

He asked about the generalizability of the results, given that all the participating endoscopists were highly experienced.

"I agree that it takes expert endoscopists with extensive experience to do this," Dr Krishnamoorthi said.

"There are a lot of nuances to this therapy," Dr Bjorkman told Medscape Medical News. However, he added, a lot of techniques in gastroenterology are perfected at expert centers before they get propagated to general practice.

"This is a good first step. It's promising. This may be something we can develop and then train everybody to be good," he said.

Dr Krishnamoorthi and Dr Bjorkman have disclosed no relevant financial relationships.

World Congress of Gastroenterology 2017: Abstract 5. Presented October 16, 2017.

Follow Medscape Gastroenterology on Twitter @MedscapeGastro and Damian McNamara @MedReporter

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....