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Endoscopic Mucosal Resection (EMR) for High Grade Dysplasia (HGD) and Early Esophageal Cancer

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Rahmani, Emad Y., M.D.; Arney, Kathy L., R.N.; Turpin, Carolyn, R.N.

American Journal of Gastroenterology: September 2005 - Volume 100 - Issue - p S49–S50
Supplement Abstracts Submitted for the 70th Annual Scientific Meeting of the American College of Gastroenterology: ESOPHAGUS
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Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN.

Purpose: Endoscopic mucosal resection (EMR) is considered a major advance in minimally invasive surgery in the gastrointestinal tract. EMR is particularly appealing in the management of high-grade dysplasia in Barrett's esophagus which has been a difficult area in clinical decision-making. This utility of endoscopic therapy is based on the notion that there is no lymph node metastasis in high-grade dysplasia and very low rate of metastasis in invasive cancer confined to the mucosa. Endoscopic ablative therapies like photodynamic therapy have been successful for high-grade dysplasia in Barrett's esophagus. However, important limitation of such therapy is the lack of pathology specimen confirming that disease is confined to the mucosa and uncertainty of complete ablation especially where the disease might be deeper than superficial mucosa.

Methods: Patients: During the period of January 2002 to May 2005, 52 patients had 183 EMR for the treatment of esophageal lesions. There were 39 males and 13 females, mean age was 70 (34–86). The indications were endoscopic resection of HGD (n = 24), early cancer (n = 27), endoscopic resection of a lesion which pathology biopsy was not conclusive (n = 1).

Methods: EMR was performed using submucosal injection of either normal saline or dextrose 50% along with methylene blue. EMR kit (Olympus) was used to excise the specimen. Mean size of resected specimen was 1.2 cm (0.5–2.0). Different specimen bottles were used for the lesion versus the surroundings. Mean number of specimen per patient was 4 (range 1–6). All patients underwent meticulous staging including EUS, CT and PET scan.

Results: Complete endoscopic excision was achieved in fifty patients. Cancer extending to the lateral margin of the specimen was seen in (n = 8). HGD extending to the margin of the surrounding tissue was seen in (n = 14). Tumor was upgraded from T1 to T2 was seen in 2 patients, while it was downgraded from T1 to HGD in 5, and to LGD in one patient. Photodynamic therapy was used in 21 patients to ablate residual HGD/T1 cancer. Follow up for up to 3 years revealed HGD± T1 cancer-free in all but three patients. Two patients died from progressive disease and one from unrelated cancer.

Conclusions: EMR with or without other modality should be considered as a treatment option in all esophageal HGD or superficial adenocarcinoma

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