Endoscopic Mucosal Resection Provides Less Invasive Treatment Alternative for Patients With Mucosal Esophageal Adenocarcinoma

Points to remember

• The incidence of esophageal adenocarcinoma (EAC) is increasing more rapidly than the incidence of any other form of malignancy in the United States. Current survival following diagnosis of EAC remains poor, with less than 20% of patients surviving more than 5 years.
• Esophagectomy, often combined with preoperative chemoradiotherapy, is the mainstay of treatment for EAC. But this surgery is associated with considerable mortality and morbidity, including a lengthy hospital stay and lifelong dietary restrictions.
• Endoscopic mucosal resection (EMR) is emerging as a less invasive alternative to surgical therapy in selected patients with mucosal EAC. It can be performed as an outpatient procedure and allows the patient to resume eating full meals.
• Recent Mayo Clinic study data show that survival outcomes associated with EMR are comparable to those associated with esophagectomy.

The challenge

Esophagectomy has been the standard of care for patients with esophageal adenocarcinoma (EAC). This approach, however, has:

• Mortality rates of 2% to 10% (depending on hospital volume and patient comorbidities)
• Substantial morbidity (from 30% to 40%)
• Lengthy postoperative hospital stays (an average of 20 days, on the basis of data from more than 800 patients in the Surveillance Epidemiology and End Results database)

The surgery itself involves alteration of normal anatomy—the loss of the gastroesophageal sphincter. The stomach may no longer empty well, and there is risk of developing gastroesophageal reflux or Barrett esophagus after surgery. Complications such as anastomotic leak in the chest as well as cardiac and pulmonary problems also are possible. In addition, it typically takes weeks for the multiple incisions to heal fully and for patients to begin eating well.

A new approach

Mayo Clinic is among a handful of medical centers that now offer minimally invasive endoscopic mucosal resection (EMR), alone or in combination with other mucosal ablation techniques such as photodynamic therapy (PDT), to patients with mucosal (T1a) EAC.

Lesions suctioned into the cap during mucosal resection

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Cautery current applied to remove tissue during mucosal resection

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During EMR, a liquid is injected under the lesion and then an endoscope is used to shave off the lesions. EMR is typically performed on an outpatient basis. Once the tumor invades the second layer of tissue or when patients present with symptoms such as dysphagia, traditional surgery is typically recommended. For this reason, regular endoscopic surveillance is critical for patients with Barrett's esophagus who have been treated endoscopically.

The major benefits associated with EMR are elimination of hospital stay and reduced mortality and morbidity. Patients typically recover more quickly from EMR than those treated surgically and can resume eating full meals a few days after the procedure.

Possible complications from EMR include esophageal perforation and a slightly increased risk of bleeding (about 5% of patients treated at Mayo). Delayed possible complications include esophageal stricture (scarring), which typically occurs a few weeks after the procedure and sometimes after multiple procedures.

Follow-up endoscopic surveillance, with biopsies and EMR as indicated, should be performed every 3 months during the first year of follow-up, every 6 months during the second year, and yearly thereafter.

Research

Because the endoscopic approach is new and performed only at select referral centers, outcome data are just emerging.

In a retrospective study of 178 Mayo Clinic patients who received a diagnosis of mucosal EAC between 1998 and 2007, 132 (74%) were treated with EMR and 46 (26%) were treated surgically. Endoscopic therapy consisted of EMR alone or in combination with PDT.

Mayo researchers found that overall survival and cumulative mortality in the 2 treatment approaches were comparable at 5 years. Further analysis of the study data suggests that treatment modality was not a significant predictor of survival. In addition, recurrent carcinoma was detected in 12% of the patients treated endoscopically, all of whom were successfully re-treated endoscopically with no impact on overall survival.

In summary, endoscopic therapy with EMR in conjunction with ablative therapy appears to be a reasonable alternative to esophagectomy in patients with mucosal EAC. Overall survival appears to be comparable with low recurrence rates.

The Mayo Clinic Barrett's esophagus unit offers a multidisciplinary approach to:

• Evaluate early symptoms
• Devise a surveillance schedule
• Perform all tests and medical and surgical treatments