Treatment for Barrett’s crucial in preventing esophageal adenocarcinoma

(Conclusion)

After a mean follow-up of 45 months, 42 patients (40 percent) had no histological evidence of BE, 43 patients (41 percent) had no dysplasia, 14 patients (13 percent) had low-grade dysplasia, two patients (2 percent) had high-grade dysplasia and four patients (4 percent) developed cancer. Based on current estimates of cancer incidence in high-grade and low-grade dysplasia, 20 cancers would have been anticipated in this group versus the four that did occur (P<0.001).

In addition, the length of residual BE was significantly reduced from 7 cm to 2 cm. Esophageal strictures developed in 22 percent of patients. Based on their results, the researchers concluded that PDT was an effective treatment for helping to eliminate existing cancer and reducing the incidence of anticipated cancer in BE.

• Endoscopic Mucosal resection. The advantage of endoscopic mucosal resection (EMR is that practitioners retrieve large pathological specimens that can be used to assess the completeness and success of the resection. In one study be Lee et al., 26 patients with nodular/villiform lesions within BE underwent EMR (Gastrointest Endosc 2002;55:AB204). The researchers used a cap with a rim that allows placement of a snare around the specimen. This enables the procedure to be carried out with a single endoscope pass.

Of the 26 patients in the study, four had histological evidence of submucosal invasion of cancer, and three had subsequent esophagectomy with the finding of stage 1 lesions. One patient with intramucosal cancer and negative margins had esophagectom with no evidence of residual cancer. There were no complications from EMR. The investigators concluded that EMR or nodules within (BE) provides useful diagnostic information as well as a means of therapy.

It can serve as an alternative therapy in those patients who are poor surgical candidates. Another study by Bergman et al. Used a prototype flexible large-caliber EMR cap in 22 patients with high-grade dysplasia and early cancer in BE. The flexible cap was easily introduced in all but one patient. The mean maximum and minimum diameter of the MER specimens were 22mm and 18mm, respectively, compared to the 12mm and 10mm diameters of the specimens removed with the standard cap. Six patients developed mild postprocedure bleeding, and one had mild retrosternal pain.

• Combined EMR and ablation techniques. Researchers are also investigating using a combination of MER and ablation therapy – primarily PDT and argon plasma coagulation. In one multicenter study comprising 114 patients, those with early adenocarcinoma (95 patients) in BE were treated. EMR was used in 69 patients, PDT was used in 32, both procedures were combined to treat 10 patients, and three patients underwent primary treatment with argon plasma coagulation. Complete local remission was achieved in 98 percent of patients.

During an average follow-up of 34 months, 30 percent of patients developed metachronous lesions that were successfully treated endoscopically in all but one case. The calculated five-year survival rate (80 percent) was equal to the standard population at age 65. The authors concluded that endoscopic management can replace esophageal resection in patients with high-grade dysplasia and intramucosal cancer in BE.

More research needed. Further research will help determined which of the aforementioned therapies for BE are the most beneficial for patients. We don’t really know if any of these treatments work. The concept is, if we eradicate (BE), the risk of esophageal cancer would decrease. Researchers need to study whether or not this concept is true and which techniques work. The bottom line entails a good discussion between the physician and patients, and education about the risks and benefits of conventional and new techniques.