title: Endoluminal resection for sessile neoplasia in the GI tract is associated with a low recurrence rate and a high 5-year survival rate.
abstract: BACKGROUND
  Endoluminal resection (ELR) is an alternative to surgery for the removal of superficial neoplastic lesions of the GI tract. We previously reported a complete resection (CR) rate of 89% when using ELR techniques. However, the long-term efficacy of ELR for the eradication of sessile lesions, as well as patient survival after ELR, is not known.
  
  
  OBJECTIVE
  To assess the long-term recurrence rate of GI lesions that were completely resected by ELR and to determine the long-term (5-year) survival rate of patients who had ELR for GI lesions that contained high-grade dysplasia (HGD) or adenocarcinoma (AdCa).
  
  
  METHODS
  From a larger cohort of 92 consecutive patients who had undergone ELR of sessile lesions from 1997 to 2000, long-term follow-up was obtained. Patient survival rates were considered in terms of disease-specific mortality.
  
  
  RESULTS
  Endoscopic follow-up was possible in 44 patients (48%) and 46 lesions (46%). At the time of the initial ELR, the median age was 68.5 years. The median duration of follow-up was 3.8 years after ELR (range 7 months to 8.1 years). Resected lesions were located in the esophagus (25%), stomach (11%), duodenum (25%), colon (27%), and rectum (11%). Post-ELR histopathology consisted of adenomas (46%), HGD (16%), AdCa (11%), lymphoma (2%), leiomyoma (2%), carcinoid (2%), lesions indeterminate for dysplasia (2%), and nondysplastic lesions (18%). CR was achieved in 42 patients and 44 lesions (96%) after initial ELR procedures (range 1-3). Thirty-seven of 39 neoplastic lesions (95%) in this cohort achieved initial CR. Two lesions (found in 2 patients) that did not achieve initial CR were excluded from analysis. Four of 37 neoplastic lesions (10.8%) that underwent successful ELR had local recurrence of neoplasia (median time to recurrence was 1.9 years). Two of the 4 neoplastic recurrences were successfully eradicated by subsequent endoscopic techniques (95% overall eradication rate). Long-term endoscopic follow-up was possible in 12 of 20 patients (60%) with HGD or AdCa who achieved initial CR. These 12 patients had HGD (n = 7) or AdCa (n = 5) and were observed for an average of 4.9 years (range 1.4-7.9 years) after an ELR. Two of these patients died during follow-up, but only 1 death (8%) was lesion related. When comparing post-ELR pathology, HGD and AdCa trended toward an increased risk of recurrence compared with other neoplastic lesions (hazard ratio 4.75 [95% CI, 0.49-46.35], P = .18).
  
  
  CONCLUSIONS
  A retrospective study with 52% of patients lost to long-term endoscopic follow-up, which limited the sample size and the number of events.
  
  
  CONCLUSIONS
  ELR effectively eradicates sessile neoplastic lesions from the GI tract, with a low recurrence rate (10.8%) at long-term follow-up. Post-ELR surveillance is important, because local recurrences may be amenable to endoscopic eradication. HGD and cancers may carry an increased risk for a local recurrence, with a 5-year disease-specific survival of 92%. This study suggests that ELR is associated with a low recurrence rate for neoplastic lesions and appreciable long-term survival in patients with highly dysplastic lesions. Additional, long-term follow-up studies are necessary to investigate the role of ELR in the treatment of highly dysplastic lesions of the GI tract.
authors.affiliation: Gastroenterology Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
authors.forename: Andrew Y
authors.initials: AY
authors.lastname: Wang
authors.forename: Nuzhat A
authors.initials: NA
authors.lastname: Ahmad
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Zaidman
authors.forename: Colleen M
authors.initials: CM
authors.lastname: Brensinger
authors.forename: James D
authors.initials: JD
authors.lastname: Lewis
authors.forename: William B
authors.initials: WB
authors.lastname: Long
authors.forename: Michael L
authors.initials: ML
authors.lastname: Kochman
authors.forename: Gregory G
authors.initials: GG
authors.lastname: Ginsberg
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D016001:Confidence Intervals; D018572:Disease-Free Survival; D004724:Endoscopy / Q000379:methods* / Q000401:mortality; D016099:Endoscopy, Gastrointestinal / Q000379:methods* / Q000401:mortality; D005260:Female; D005770:Gastrointestinal Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods / Q000401:mortality; D009364:Neoplasm Recurrence, Local / Q000401:mortality* / Q000473:pathology; D009367:Neoplasm Staging; D011336:Probability; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome