title: Multidisciplinary treatment of T1a adenocarcinoma in Barrett's esophagus: contemporary comparison of endoscopic and surgical treatment in physiologically fit patients.
abstract: Previous reports comparing endoscopic therapy (ET) and surgical therapy (ST) have predominantly assessed patients with high-grade dysplasia. The study aim was to compare ET to ST in physiologically fit patients with cT1a adenocarcinoma (EAC).
  
  
  
  Review of two prospective databases yielded 100 patients presenting with clinical cT1a EAC between 2000 and 2013. Only physiologically fit patients who were candidates for either treatment were analyzed.
  
  
  
  Presenting patient characteristics were similar between ET (n = 36) and ST groups (n = 49). Surgical patients were less likely to be staged with EMR (43 vs 100 %) and were associated with mass lesions >1 cm at EGD (p = 0.01), multifocal EAC (p = 0.03), and positive margins for EAC on EMR (p < 0.05). On multivariate analysis, only multifocal HGD was an independent factor for surgery. Following esophagectomy, R0 resection rates for Barrett's esophagus and cancer were 100 %. Incidence of surgery decreased over the study period from 85 to 25 %. All ET patients had EMR, and 28 patients underwent additional ablative therapies for Barrett's esophagus. Following ET, eradication rates of EAC, dysplasia, and BE were 92, 81, and 53 %, respectively. Morbidity rates were comparable between groups (ST 51 % vs ET 39 %, p = 0.31). In-hospital mortality rate was zero in each group. Recurrence rates in ST and ET group were 2 and 11 % (p = 0.08). In the ET group, two patients with endoluminal cancer recurrence after complete eradication underwent esophagectomy. Age-adjusted overall survival was comparable.
  
  
  
  In high-volume esophageal centers, ST and ET provide equally safe and effective treatment for cT1a EAC in medically fit patients. While the results of this study provide a historical perspective and clearly demonstrate an evolution toward ET over time, the appropriate treatment modality is best selected in a multidisciplinary fashion with EMR providing the most accurate staging. In endoscopically treated patients, indefinite endoscopic follow-up required, however, standardized long-term follow-up protocols are needed.
authors.affiliation: Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA.
authors.forename: Henner M
authors.initials: HM
authors.lastname: Schmidt
authors.affiliation: Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA.
authors.forename: Kamran
authors.initials: K
authors.lastname: Mohiuddin
authors.affiliation: Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA.
authors.forename: Artur M
authors.initials: AM
authors.lastname: Bodnar
authors.affiliation: Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA.
authors.forename: Mustapha
authors.initials: M
authors.lastname: El Lakis
authors.affiliation: Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA.
authors.forename: Stephen
authors.initials: S
authors.lastname: Kaplan
authors.affiliation: Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA.
authors.forename: Shayan
authors.initials: S
authors.lastname: Irani
authors.affiliation: Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA.
authors.forename: Ian
authors.initials: I
authors.lastname: Gan
authors.affiliation: Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Ross
authors.affiliation: Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA. donald.low@virginiamason.org.
authors.forename: Donald E
authors.initials: DE
authors.lastname: Low
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001471:Barrett Esophagus / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000473:pathology / Q000601:surgery*; D016629:Esophagectomy; D004945:Esophagoscopy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D010348:Patient Care Team
keywords: Barrett’s esophagus; EMR; Endoscopy; Esophageal cancer; Esophagectomy; Multidisciplinary