Endoscopic resection and ablation versus esophagectomy for high-grade dysplasia and intramucosal adenocarcinoma.
BACKGROUND
Esophagectomy has been the traditional therapy for high-grade dysplasia and intramucosal adenocarcinoma. New endoscopic approaches allow treatment of these lesions with esophageal preservation. The aim of this study was to compare the outcome of endoscopic therapy with esophagectomy for high-grade dysplasia and intramucosal cancer.


METHODS
A retrospective review was performed of all patients treated for high-grade dysplasia or intramucosal adenocarcinoma from 2001 to April 2010.


RESULTS
Endoscopic therapy was performed in 40 patients (high-grade dysplasia = 22, intramucosal cancer = 18) and esophagectomy in 61 patients (high-grade dysplasia = 13, intramucosal cancer = 48). Endotherapy consisted of 102 endoscopic resections and 79 mucosal ablations (median 3 interventions per patient). In the endotherapy group, intramucosal cancer was completely resected in all patients. At last assessment, 10 patients have been converted to intestinal metaplasia without dysplasia and 21 to no residual intestinal metaplasia. Five patients have follow-up biopsy procedures pending after recent ablation, and esophagectomy was performed in 3 patients for failed endotherapy. A laparoscopic Nissen fundoplication has been performed in 8 patients after eradication of intestinal metaplasia. Esophagectomy resected the mucosal disease with negative margins in all patients. Compared with esophagectomy, endotherapy was associated with significantly lower morbidity (39% vs 0; P < .0001) and similar survival (94% at 3 years in both groups; median follow-up 34 months after esophagectomy vs 17 months after endotherapy; P = .0026).


CONCLUSIONS
Endoscopic therapy for high-grade dysplasia or intramucosal cancer has lower morbidity than an esophagectomy and similar survival during short-term follow-up, but required multiple procedures in most patients. Both therapies are appropriate options, but preservation of the esophagus allows the option of a fundoplication for reflux control, perhaps further improving long-term quality of life.
Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif 90033, USA.
Jörg
J
Zehetner
Steven R
SR
DeMeester
Jeffrey A
JA
Hagen
Shahin
S
Ayazi
Florian
F
Augustin
John C
JC
Lipham
Tom R
TR
DeMeester
D055011:Ablation Techniques / Q000009:adverse effects / Q000401:mortality; D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D000368:Aged; D001471:Barrett Esophagus / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects / Q000401:mortality; D004945:Esophagoscopy / Q000009:adverse effects / Q000401:mortality; D005260:Female; D018662:Fundoplication; D006801:Humans; D053208:Kaplan-Meier Estimate; D015141:Los Angeles; D008297:Male; D008875:Middle Aged; D009092:Mucous Membrane / Q000473:pathology / Q000601:surgery; D011788:Quality of Life; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome