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• W2061018002 abstract "Endoscopic therapy is appropriate and may replace esophagectomy as the treatment of choice in Barrett's esophagus with high-grade dysplasia and early adenocarcinoma in appropriately selected patients.Barrett's esophagus (BE) is a well-established premalignant condition that entails a 30- to 50-fold greater risk for development of esophageal adenocarcinoma (EAC) with an estimated annual incidence of EAC of approximately 0.5%.1Sharma P. McQuaid K. Dent J. et al.A critical review of the diagnosis and management of Barrett's esophagus: the AGA Chicago workshop.Gastroenterology. 2004; 127: 310-330Google Scholar, 2Sharma P. Falk G.W. Weston A.P. et al.Dysplasia and cancer in a large multicenter cohort of patients with Barrett's esophagus.Clin Gastroenterol Hepatol. 2006; 4: 566-572Google Scholar There has been a dramatic increase in incidence of EAC (incremental increase of 4%-10%/year), which has a dismal overall 5-year survival rate of 10%.3Eloubeidi M.A. Mason A.C. Desmond R.A. et al.Temporal trends (1973-1997) in survival of patients with esophageal adenocarcinoma in the United States: a glimmer of hope?.Am J Gastroenterol. 2003; 98: 1627-1633Google Scholar Esophageal carcinogenesis is a multistep process with progression through increasing grades of dysplasia to invasive cancer, a progression that occurs in a probabilistic rather than deterministic manner.4Haggitt R.C. Barrett's esophagus, dysplasia, and adenocarcinoma.Hum Pathol. 1994; 25: 982-993Google Scholar Despite its several imperfections (sampling errors, observer variability), histologic classification of dysplasia on endoscopic biopsy specimens is the single most predictive variable for progression to cancer in patients with BE. The degree of dysplasia has been shown to correlate with the risk for development cancer, and high-grade dysplasia (HGD) is associated with the greatest risk.5Buttar N.S. Wang K.K. Sebo T.J. et al.Extent of high-grade dysplasia in Barrett's esophagus correlates with risk of adenocarcinoma.Gastroenterology. 2001; 120: 1630-1639Google Scholar Although the precise estimate of EAC development in HGD is uncertain, approximately 30% to 35% progress to invasive cancer within 5 years.6Puli S. Rastogi A. Mathur S. et al.Development of esophageal adenocarcinoma in patients with Barrett's esophagus and high grade dysplasia undergoing surveillance: a meta-analysis and systematic review.Gastrointest Endosc. 2006; 63 ([abstract]) (AB83)Google Scholar Endoscopic therapy is appropriate and may replace esophagectomy as the treatment of choice in Barrett's esophagus with high-grade dysplasia and early adenocarcinoma in appropriately selected patients. Several management strategies have been proposed for the management of HGD in BE, each with its proponents and critics. Although options of surgery and intensive surveillance have been suggested, the main focus of this editorial is to evaluate the role of endoscopic therapies for HGD and early EAC in patients with BE. Esophagectomy has traditionally been the standard treatment for patients with HGD. This approach has been advocated primarily as the result of studies demonstrating cancer in approximately 40% of esophagectomy specimens in patients with HGD.7Heitmiller R.F. Redmond M. Hamilton S.R. Barrett's esophagus with high-grade dysplasia: an indication for prophylactic esophagectomy.Ann Surg. 1996; 224: 66-71Google Scholar However, the prevalence of a missed cancer in these patients is probably low in patients who undergo aggressive endoscopic biopsy protocols. Esophagectomy has mortality rates in the range of 3% to 5% and morbidity rates of 20% to 50% even when performed in high-volume and expert centers, making it a less than attractive option for these patients.8Hulscher J.B. van Sandick J.W. de Boer A.G. et al.Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.N Engl J Med. 2002; 347: 1662-1669Google Scholar BE and associated neoplasia have also been reported after subtotal esophagectomy, which suggests that endoscopic surveillance may still be required in these patients after surgery.9O'Riordan J.M. Tucker O.N. Byrne P.J. et al.Factors influencing the development of Barrett's epithelium in the esophageal remnant postesophagectomy.Am J Gastroenterol. 2004; 99: 205-211Google Scholar Intensive endoscopic surveillance is based on the premise that most patients who progress to cancer can be detected at a curative stage with rigorous endoscopic biopsy protocols.10Schnell T.G. Sontag S.J. Chejfec G. et al.Long-term nonsurgical management of Barrett's esophagus with high-grade dysplasia.Gastroenterology. 2001; 120: 1607-1619Google Scholar However, the practicality and effectiveness of this protocol is debatable. The uncertainties regarding the natural history of HGD could cause significant anxiety to these patients and negatively affect their quality of life. Although the validity of this approach is questionable, it may be a reasonable alternative in older patients who are not candidates for endoscopic or surgical therapy. With improved endoscopic imaging techniques (such as high-resolution endoscopy, narrow band imaging [NBI], autofluorescence imaging [AFI], etc),11Sharma P. Bansal A. Mathur S. et al.The utility of a narrow band imaging endoscopy system in patients with Barrett's esophagus.Gastrointest Endosc. 2006; 64: 167-175Google Scholar, 12Kara M.A. Bergman J.J. Autofluorescence imaging and narrow-band imaging for the detection of early neoplasia in patients with Barrett's esophagus.Endoscopy. 2006; 38: 627-631Google Scholar and the availability of better staging and therapeutic tools, endoscopic therapies have become attractive alternatives for the treatment of HGD or early EAC in patients with BE. Because of the low likelihood of lymph node metastases or hematogenous dissemination in patients with HGD and early EAC13Stein H.J. Feith M. Mueller J. et al.Limited resection for early adenocarcinoma in Barrett's esophagus.Ann Surg. 2000; 232: 733-742Google Scholar along with the drawbacks of esophagectomy, endoscopic therapies have become attractive viable alternatives for these patients. Stein et al13Stein H.J. Feith M. Mueller J. et al.Limited resection for early adenocarcinoma in Barrett's esophagus.Ann Surg. 2000; 232: 733-742Google Scholar in a large series of patients who underwent esophagectomy for mucosal EAC, reported that lymph node metastasis was not observed in a single lymph node from among 350 resected. Endoscopic mucosal resection (EMR) involves local snare excision of the lesion with HGD and has been increasingly used in recent years. It is safe and allows an accurate histolopathologic grading of all resected specimens and thus confirmation of the diagnosis with complete resection of the lesion. Conceptually, the role of EMR can be categorized into 2 groups: (1) diagnostic/staging tool and (2) therapeutic/curative treatment option for HGD or mucosal EAC. Diagnostic EMR. With the increasing armamentarium for endoscopic therapies in BE patients with HGD or early cancer, accurate staging is critical because the success of endoscopic therapies is clearly dependent on this. Although EUS has been used to estimate cancer depth, its accuracy has varied in different studies. Standard EUS at 7.5 or 12 MHz accurately predicts the depth of invasion in only 50% to 60% cases and high-frequency catheter probes tend to overstage early lesions, leading to overall disappointing and variable results.14Waxman I. Raju G.S. Critchlow J. et al.High-frequency probe ultrasonography has limited accuracy for detecting invasive adenocarcinoma in patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma: a case series.Am J Gastroenterol. 2006; 101: 1773-1779Google Scholar In a recent large study that compared high-resolution endoscopy with high-frequency ultrasound catheter probes in 100 patients with early esophageal cancer, the latter was accurate in diagnosing only 2 of 14 patients with submucosal tumor invasion. Overall, there was no significant difference between the 2 techniques in assessing tumor penetration.15May A. Gunter E. Roth F. et al.Accuracy of staging in early oesophageal cancer using high resolution endoscopy and high resolution endosonography: a comparative, prospective, and blinded trial.Gut. 2004; 53: 634-640Google Scholar Because EMR specimens are significantly larger than biopsy samples, they allow for more precise assessment of depth of tumor invasion into the mucosa and submucosa. This allows gastroenterologists to treat HGD and early cancers with endoscopic therapies with greater confidence regarding rates of metastatic disease. Nijhawan and Wang16Nijhawan P.K. Wang K.K. Endoscopic mucosal resection for lesions with endoscopic features suggestive of malignancy and high-grade dysplasia within Barrett's esophagus.Gastrointest Endosc. 2000; 52: 328-332Google Scholar assessed whether EMR can be used in the diagnosis of lesions within the BE segment in 25 patients whose endoscopic appearances were suspicious for carcinoma or HGD. EMR diagnosed superficial EAC in 52% and HGD in 16% of the patients. More importantly, it resulted in a change in diagnosis in 11 (44%) patients (3 downgraded to benign disease and 8 upgraded to a higher degree). The staging power of EMR specimens was demonstrated by Vieth et al17Vieth M. Ell C. Gossner L. et al.Histological analysis of endoscopic resection specimens from 326 patients with Barrett's esophagus and early neoplasia.Endoscopy. 2004; 36: 776-781Google Scholar in a multicenter study that involved an analysis of 742 EMR specimens in 326 patients with Barrett's neoplasia. Of the 326 patients, 31 (9.5%) patients did not show any neoplastic changes, although previous biopsy specimens had suggested dysplasia. Lightdale et al,18Lightdale C.J. Larghi A. Rotterdam H. et al.Endoscopic ultrasonography (EUS) and endoscopic mucosal resection (EMR) for staging and treatment of high-grade dysplasia (HGD) and early adenocarcinoma (EAC) in Barrett's esophagus (BE).Gastrointest Endosc. 2004; 59 ([abstract]) (AB90)Google Scholar in a series of 42 patients undergoing EMR, reported that 5 of 27 patients (18.5%) diagnosed with HGD initially were upgraded to mucosal EAC and 6 of 15 (40%) patients with mucosal EAC were upgraded to invasive EAC. Inaccurate staging can result in substantial deleterious consequences for the patient. A patient with nondysplastic BE could be subjected to esophagectomy or patients with submucosal invasion in whom surgery is recommended may undergo multiple EMRs. These findings also underscore the importance of good communication and teamwork between the endoscopist and pathologist. Pathologists will need to be trained in processing and interpretation of EMR specimens, including artifacts associated with EMR techniques such as submucosal fluid injection and cauterization. Thus, EMR provides a more accurate diagnosis than conventional biopsies and is useful in the staging of HGD and mucosal EAC. Therapeutic EMR. Therapeutic EMR is recommended for lesions limited to the mucosa and, although it is controversial, some experts recommend this procedure even if the lesion is limited to the upper third of the submucosa. EMR can be considered therapeutic if the tumor is confined to the mucosa and clear margins of resection (lateral and basal) are obtained. A recent nonblinded and nonrandomized study evaluated the efficacy and safety of EMR in 100 patients with low-risk EAC (defined as macroscopic type I, IIa, IIb, and IIc; lesion diameter up to 20 mm, mucosal lesion without invasion into lymph vessels, and histologic grades G1 and G2).19Ell C. May A. Pech O. et al.Curative endoscopic resection of early esophageal adenocarcinomas (Barrett's cancer).Gastrointest Endosc. 2007; 65: 3-10Google Scholar There were no major complications, and complete remission was achieved in 99% of patients after 1.9 months. During a follow-up period of 36.7 months, recurrent or metachronous cancer was found in 11% of patients, all of whom were successfully treated with endoscopic resection. The overall calculated 5-year survival rate was 98%. Recently, the role of circumferential EMR and complete removal of Barrett's epithelium in patients with HGD or early EAC has been explored to reduce recurrence rates. This technique involves the endoscopic resection of the entire BE segment, including the neoplastic lesion. It also allows complete histologic correlation and may provide a more sustained treatment response during follow-up. It may reduce the risk of buried Barrett's glands, and the neosquamous mucosa that regenerates after this treatment does not appear to have the genetic abnormalities that were present in the BE segment before treatment. In a recent study, Peters et al20Peters F.P. Kara M.A. Rosmolen W.D. et al.Stepwise radical endoscopic resection is effective for complete removal of Barrett's esophagus with early neoplasia: a prospective study.Am J Gastroenterol. 2006; 101: 1449-1457Google Scholar evaluated the efficacy of this technique in 37 BE patients with early neoplasia. Complete eradication of early neoplasia was achieved in all patients in a median number of 3 sessions and complete removal of BE was achieved in 89% of patients. During a follow-up of 11 months, no recurrence of neoplasia or BE was reported. However, this treatment protocol using circumferential EMRs is associated with a 30% to 40% rate of esophageal stenosis that requires endoscopic dilatations, may make subsequent resections difficult because of scarring, and requires a high level of endoscopic expertise. The data on the long-term effects of this approach, especially on recurrence of BE and associated neoplasia and its impact on the surveillance protocols, are lacking. EMR-related major complications include bleeding and perforation. Usually bleeding can be controlled endoscopically with epinephrine injections, cauterization, or endoscopic clipping and small perforations can be closed with endoscopic clipping. Currently, this technique allows en bloc resection only of relatively small lesions. Piecemeal resection is often required for larger lesions that preclude a conclusive assessment of completeness of the resection. EMR is associated with the risk of recurrent neoplasia (either metachronous or synchronous) during follow-up in up to 20% of cases,21Peters F.P. Kara M.A. Rosmolen W.D. et al.Endoscopic treatment of high-grade dysplasia and early stage cancer in Barrett's esophagus.Gastrointest Endosc. 2005; 61: 506-514Google Scholar underscoring the importance of complete removal or ablation of all BE. As the techniques for EMR continue to evolve, Japanese endoscopists have developed methods for en bloc resections of large neoplastic lesions using a technique called endoscopic submucosal dissection. This technique could eliminate the problem of positive tumor margins associated with piecemeal EMR. This technique has primarily been reported in gastric and colonic carcinomas and recently in patients with esophagogastric junction tumors (4 Barrett's-associated cancers).22Kakushima N. Yahagi N. Fujishiro M. et al.Efficacy and safety of endoscopic submucosal dissection for tumors of the esophagogastric junction.Endoscopy. 2006; 38: 170-174Google Scholar Although this technique appears to be promising, data on this technique in BE patients are sparse. Also, these procedures require a high degree of expertise and tend to be lengthy, require prolonged sedation, and can be associated with a high complication rate. Ablative techniques are based on the hypothesis that injury to the metaplastic and dysplastic epithelium would reverse the pathophysiologic sequence that leads to the development of BE and subsequently to the restoration of the normal squamous lining. Of all the ablative techniques developed to reverse BE and to treat HGD and early EAC, photodynamic therapy (PDT) clearly has been used most extensively and reported in a randomized controlled trial. PDT involves the administration of a photosensitizing drug (porfimer sodium in the United States) that is activated by a nonthermal light directed at the esophageal tissue during endoscopy, resulting in mucosal damage from formation of highly reactive, unstable singlet oxygen species. Several studies have shown its effectiveness in eliminating HGD. Overholt et al23Overholt B.F. Panjehpour M. Halberg D.L. Photodynamic therapy for Barrett's esophagus with dysplasia and/or early stage carcinoma: long term results.Gastrointest Endosc. 2003; 58: 183-188Google Scholar in their long-term follow-up report (mean follow-up 58.5 months) on 103 BE patients with neoplasia showed that HGD was eliminated in 94% of the patients. Ablation therapy with PDT has been used as an adjunct to EMR to eradicate the remaining BE segment, thus potentially reducing the risk of recurrent neoplastic lesions. A recent prospective study (EMR with PDT) in 33 patients with BE reported that endoscopic treatment was successful in 93% of the cases and, although 5 patients had recurrence of HGD, all were successfully resected with EMR. At a median follow-up of 19 months, 93% of the endoscopically treated patients were in remission.21Peters F.P. Kara M.A. Rosmolen W.D. et al.Endoscopic treatment of high-grade dysplasia and early stage cancer in Barrett's esophagus.Gastrointest Endosc. 2005; 61: 506-514Google Scholar Complications of PDT include photosensitivity, fever, chest pain, odynophagia, pleural effusion, and most important, esophageal strictures that have been reported in up to 20% to 36% of treated patients. In a retrospective analysis of 131 patients who underwent PDT, 27% had strictures; further, a history of esophageal stricture, performance of EMR before PDT, and more than 1 PDT application were identified as risk factors for stricture formation in these patients.24Prasad G.A. Wang K.K. Buttar N.S. et al.Predictors of stricture formation after photodynamic therapy for high-grade dysplasia in Barrett's esophagus.Gastrointest Endosc. 2007; 65: 60-66Google Scholar Subsquamous residual Barrett's mucosa and persisting genetic abnormalities after PDT are other drawbacks that merit mention.23Overholt B.F. Panjehpour M. Halberg D.L. Photodynamic therapy for Barrett's esophagus with dysplasia and/or early stage carcinoma: long term results.Gastrointest Endosc. 2003; 58: 183-188Google Scholar, 25Krishnadath K.K. Wang K.K. Taniguchi K. et al.Persistent genetic abnormalities in Barrett's esophagus after photodynamic therapy.Gastroenterology. 2000; 119: 624-630Abstract Full Text Full Text PDF Scopus (124) Google Scholar Although the use of other ablative techniques in nondysplastic BE has been described extensively in the literature, studies evaluating their efficacy in HGD and early cancer patients are limited with small number of patients, lack of randomized trials, and absence of long-term follow-up data. Ablation with argon plasma coagulation in 29 patients with HGD showed that HGD responded to treatment in 86% of the patients, with complete regression of the BE segment in 22 patients.26Attwood S.A. Lewis C.J. Caplin S. et al.Argon beam plasma coagulation as therapy for high-grade dysplasia in Barrett's esophagus.Clin Gastroenterol Hepatol. 2003; 1: 258-263Google Scholar Sharma et al27Sharma P. Jaffe P.E. Bhattacharyya A. et al.Laser and multipolar electrocoagulation ablation of early Barrett's adenocarcinoma: long-term follow-up.Gastrointest Endosc. 1999; 49: 442-446Google Scholar reported favorable outcomes for 6 patients with mucosal EAC treated with neodymium:yttrium-aluminium-garnet laser and multipolar electrocoagulation. Potassium titanyl phosphate laser ablation in 6 patients with HGD or early EAC resulted in a complete response in all patients.28Gossner L. May A. Stolte M. et al.KTP laser destruction of dysplasia and early cancer in columnar-lined Barrett's esophagus.Gastrointest Endosc. 1999; 49: 8-12Google Scholar These techniques, although easier to use because treatment can be delivered through the channel of the endoscope, are essentially “point-and-shoot” techniques that require more time and provide nonuniform ablation. Preliminary results on the use of new ablative therapies such as radiofrequency ablation and cryoablation in BE patients with and without HGD or early cancers appear promising. Nine patients with HGD were treated with radiofrequency ablation, of which 5 achieved complete ablation with no endoscopic evidence of BE, 2 had persistent HGD, 1 had nondysplastic BE, and another had indeterminate dysplasia.29Wells C.D. Jae Kim H. Moirano M.M. et al.Successful ablation of Barrett's esophagus (BE) with dysplasia using the Halo360 ablation system: a single-center experience.Am J Gastroenterol. 2006; 101 ([abstract]) (AB1400)Google Scholar Similarly, Johnston et al30Johnston M.H. Cash B.D. Dykes C.A. et al.Cryoablation of dysplasia in Barrett's esophagus (BE) and early stage esophageal cancer.Gastrointest Endosc. 2006; 63 ([abstract]) (AB223)Google Scholar studied the efficacy and safety of endoscopic spray cryoablation in 4 patients with HGD or early EAC. After a mean follow-up of 16 months, dysplasia was eliminated in all patients and the dysplasia in the patient with early EAC was downgraded to low-grade dysplasia. Long-term results in larger cohorts of patients treated with these ablative modalities are eagerly awaited. Given the uncertainties in the management of HGD, it is important that randomized controlled trials are conducted to help guide therapy for patients. Unfortunately, head-to-head comparisons of the various treatment options are limited or fraught by their retrospective design. Herein lies the importance of the 5-year follow-up of the randomized phase III trial of efficacy of PDT with porfimer sodium in BE patients with HGD, reported in this issue of Gastrointestinal Endoscopy. In their previous report, the authors presented 2-year data from their international, multicenter phase III randomized trial that examined the efficacy of treating HGD by PDT with porfimer sodium. The results showed a significant difference in favor of the group that was treated with PDT along with omeprazole compared to omeprazole only in the ablation of HGD (77% vs 39%, P < .0001) and occurrence of cancer (13% vs 20%, P < .006).31Overholt B.F. Lightdale C.J. Wang K.K. et al.Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett's esophagus: international, partially blinded, randomized phase III trial.Gastrointest Endosc. 2005; 62: 488-498Google Scholar In this study, they report the results of the long-term phase of the study that compared PDT with observation (omeprazole-only group).32Overholt B.F. Wang K.K. Burdick S. et al.Five-year efficacy and safety of photodynamic therapy with Photofrin in Barrett's high-grade dysplasia.Gastrointest Endosc. 2007; 66: 460-468Abstract Full Text Full Text PDF Scopus (301) Google Scholar There were 208 patients initially enrolled in the trial and all patients who completed the first 2 years of the trial as per protocol were eligible for follow-up. Patients in the PDT arm received a maximum of 3 courses over 5 years with courses of PDT separated by at least 3 months. All patients were followed up with an intensive endoscopic surveillance biopsy protocol, and pathologists at one center assessed biopsies in a blinded manner. Patients who required intervening therapy or those who progressed to cancer were considered as treatment failures. Of the 102 patients eligible for long-term follow-up, only 61 patients (PDT 48, omeprazole 13) were enrolled in the long-term follow-up phase. Intention-to-treat analysis showed that, at 5 years, PDT was significantly more effective than omeprazole alone in eliminating HGD (77% [106/138] vs 39% [27/70], P < .0001) with a significant difference between survival curves favoring PDT (P = .004). Patients in the PDT group were less likely to progress to cancer compared with the omeprazole group (15% vs 29%, P = .027), although the trial was not designed to test this outcome. Overholt et al32Overholt B.F. Wang K.K. Burdick S. et al.Five-year efficacy and safety of photodynamic therapy with Photofrin in Barrett's high-grade dysplasia.Gastrointest Endosc. 2007; 66: 460-468Abstract Full Text Full Text PDF Scopus (301) Google Scholar are the first to provide long-term results of a randomized controlled trial that has compared 2 competing treatment alternatives in patients with HGD. However, there are limitations to the interpretation of this study, and several elements of this study deserve attention. A large number of patients were lost to follow-up. Patients and physicians were not blinded to the treatment, which could have potentially biased the results, although bias in the primary outcomes was unlikely because the pathologists were blinded to treatment and patient identifiers. No details of the chromoendoscopic staining of the Barrett's mucosa are provided. It is worth noting that PDT did not eliminate HGD in approximately 25% of patients, and the probability of maintaining complete ablation at the end of 5 years was only 48%. The progression of cancer in 15% of patients treated with PDT is concerning. All these data highlight the importance of continued surveillance after PDT. In this study, PDT was the only treatment modality and no more than 3 courses of PDT were allowed as per the study protocol. It is unclear whether addition of EMR or additional courses of PDT could improve treatment outcomes. No information on the quality of life in patients undergoing PDT was documented, which may have provided useful information to conduct cost-utility analysis in the management of HGD. Ultimately, conclusive evidence of the superiority of endoscopic therapy could only be provided by a randomized prospective study that compares endoscopic therapy with radical esophagectomy. Although this, in principle, would be ideal, justifying a study such as this would be very difficult in view of the promising results of endoscopic therapies, the high number of patients required to show noninferiority of endoscopic therapy, patients not wishing to be confronted with such widely differing strategies, and the risk of unplanned cross-overs that make interpretation of results very complex. Treatment of BE patients with HGD should be individualized. PDT is one of the several pieces of the HGD management puzzle. Local availability of equipment for enhanced imaging and endoscopic therapies, expertise of the endoscopists, experience of the pathologist in the evaluation of the resected specimens, and the expertise of the surgeon are all important variables in determining how a patient with HGD should be managed. Patient factors include age, presence of comorbidities, life expectancy and quality of life, ability to tolerate multiple procedures, extent of the disease (length of BE, unifocal vs multifocal HGD), and presence of hiatal hernia (Fig. 1). In our opinion, endoscopic therapy is safe and effective in selected BE patients with HGD or early EAC. All patients with suspected neoplasia within the Barrett's segment should undergo enhanced endoscopic imaging (NBI, AFI, confocal microscopy, etc) along with high-resolution endoscopy to detect the various foci of dysplastic areas. Grading of the extent of BE should be done by using the Prague C&M criteria, which includes assessment of the circumferential (C) and maximum (M) extent of the visualized BE segment.33Sharma P. Dent J. Armstrong D. et al.The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria.Gastroenterology. 2006; 131: 1392-1399Abstract Full Text Full Text PDF Scopus (785) Google Scholar Referring the patient to an expert center should be considered. EUS should be performed to detect metastatic lymph nodes, detection of which would preclude the use of endoscopic therapies. We recommend diagnostic EMR in patients with HGD or early EAC followed by histopathologic evaluation of the specimens because EMR has been shown to alter staging in HGD patients, which could lead to a significant change in treatment plans (endoscopic therapy vs surgery). In patients with positive deep margins or extensive submucosal invasion, surgical resection is advised, whereas patients with mucosal lesions should be treated endoscopically (Fig. 2). Patients with shorter BE segments should be treated with continued EMR with an effort to resect the entire Barrett's mucosa or a combination of EMR with mucosal ablation in those with longer BE segments. Although the cutoff length for continued EMR versus combination of EMR with PDT is not defined, we recommend continued EMR for Prague grade C ≤3 and M ≤5 cm and a combination of EMR with mucosal ablation (PDT, radiofrequency ablation, etc) for longer lengths. The therapeutic objective of endoscopic therapies should be complete removal of the Barrett's epithelium in the management of BE with HGD and early EAC. At this time, close surveillance of these patients after endoscopic therapy is mandatory to identify recurrent lesions.Figure 2Management algorithm for dysplasia in BE.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The accumulated evidence suggests that endoscopic therapy is appropriate and may replace esophagectomy as the treatment of choice in BE with HGD and early EAC in appropriately selected patients. Future research should focus on long-term follow-up data on patients treated with endoscopic therapies. Improved patient selection may be possible in the future by defining high-risk groups with identification of biomarkers and optical markers through enhanced endoscopic imaging tools such as NBI, AFI, and confocal microscopy. The development of stapling devices, endoscopic suturing, and endoscopic platforms to manage and reduce complications associated with endoscopic therapies is highly desirable." @default.
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• W2061018002 title "Endoscopic therapy for high-grade dysplasia in Barrett's esophagus: ablate, resect, or both?" @default.
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