Endoscopic therapy (ET) has become a less risky alternative to open surgery in mucosal Barrett's cancer (BC) because of the very low risk of lymph node (LN) metastasis. Recently published surgical series demonstrated that even in case of minimal submucosal invasion of BC, the risk for LN metastasis is very low. In consequence, also these patients might be eligible for curative ET. The aim of this study was to prospectively evaluate the efficacy and safety of endoscopic resection (ER) in these patients.
From September 1996 to September 2003, the suspicion or definite diagnosis of submucosal BC was made in 80 patients referred to our department. Of those, 21 patients (20 male [95.2%], mean age 62 ± 9 yr, range 47–78) fulfilled the definition of “low-risk” submucosal cancer: invasion of the upper submucosal third (sm1), absence of infiltration into lymph vessels/veins, histological grade G1/2, and macroscopic type I/II. ET was carried out using ER with the suck-and-cut technique with or without an additive ablation of non-neoplastic remnants of Barrett's esophagus.
One of the 21 patients was referred to surgery directly after the detection of sm1 invasion at the beginning of the study. One patient died (not tumor-related) before completion of ET. Using definitive ET, complete remission (CR) was achieved in 18 of 19 patients (95%) after a mean of 5.3 months (range 1–18) and a mean of 2.9 resections (range 1–9). Only one minor complication (bleeding without drop in hemoglobin level >2 g/dL) occurred (5% of patients). During a mean follow-up (FU) of 62 months (range 45–89), recurrent or metachronous carcinomas were found in 5 patients (28%). Repeat ET was carried out successfully using ER (4 patients) and argon plasma coagulation (1 patient). In one of the 19 patients (5%), tumor freedom had not been achieved after a total of 2 ER. This patient died of a heart attack before surgery could be performed. The calculated 5-yr survival rate of all 21 patients was 66%. No tumor-related death occurred.
As in mucosal BC, ER is associated with favorable outcomes even in case of “low-risk” submucosal BC. Further and larger clinical trials are required before a general recommendation for ER as the treatment of choice in “low-risk” submucosal BC can be given.
1Department of Internal Medicine II, HSK Wiesbaden, Wiesbaden, Germany; 2Department of Medicine I, Klinikum Karlsruhe, Karlsruhe, Germany; 3Institute of Pathology, Bayreuth Hospital, Bayreuth, Germany
Reprint requests and correspondence: Hendrik Manner, M.D., Klinik Innere Medizin II, HSK Wiesbaden, Ludwig-Erhard-Strasse 100, 65199 Wiesbaden, Germany.
CONFLICT OF INTEREST
Guarantor of the article: Christian Ell.
Specific author contributions: Hendrik Manner has planned and conducted the study and drafted the manuscript. Andrea May, Oliver Pech, Liebwin Gossner, Thomas Rabenstein, Erwin Guenter, Michael Vieth, Manfred Stolte, and Christian Ell have planned and conducted the study. All authors have approved the final draft submitted.
Financial support: None.
Potential competing interests: None.
Received July 27, 2007; accepted April 30, 2008.