ENDOSCOPIC FOLLOW-UP OF HIGH-RISK ADENOCARCINOMA ARISING FROM BARRETT’S ESOPHAGUS (BE), RESULTS OF 120 PATIENTS FROM THE DUTCH BARRETT EXPERT CENTER COHORT

Aims After radical endoscopic resection(ER) of esophageal adenocarcinoma(EAC) in BE with high-risk(HR) features, optimal management is unclear. This concerns three groups: HR-T1a-EAC (poorly(G3)/undifferentiated(G4) cancer a/o lymphovascular invasion(LV+)); low-risk(LR) T1b-EAC (submucosal invasion< 500um, no G3/G4, no LV); HR-T1b EAC (invasion>500um, G3/G4, a/o LV+). Endoscopic follow-up(FU) to detect lymph node metastases(N+) at a curable stage is considered in selected cases, however, optimal FU strategy is unclear. Aim was to evaluate outcomes of endoscopic FU in all patients treated by radical ER for HR-T1a or T1b-EAC.

Methods Endoscopic therapy for BE-neoplasia in the Netherlands is centralized in 9 expert centers with specifically trained endoscopists and pathologists. In an ongoing registry, treatment/FU data of all patients treated endoscopically for BE-neoplasia in the Netherlands, is collected in a dedicated database. We identified all patients who underwent radical ER for HR-T1a or T1b-EAC, followed by endoscopic FU with gastroduodenoscopy(GDS) ± endoscopic ultrasound(EUS). Outcome parameters were N+, distant metastases(M+) and tumor-related-death(TRD).

Results From Jan-2008 to Oct-2019, 120 patients (median 74years) underwent radical ER of HR-T1a(n=27), LR-T1b (n=55) or HR-T1b EAC(n=38) and endoscopic FU (median 29months(IQR 15-48), with 5/2 GDS/EUS). Nine patients were diagnosed with N+ (n=4;3%) and/or M+ (n=5;4%) after median 27mo FU(23-38), diagnosed by EUS-FNA (n=5), or CT performed for symptoms (n=4). N+/M+ was found in 22% of HR-T1a, 2% LR-T1b and 5% HR-T1b patients. The 4 patients with N+-disease were treated with curative intent; 1 was cured, 1 is still treated, 2 died of complications. Overall, TRD was 6%(n=7) (2/7 from treatment complications). Non-EAC related mortality was 8,3%.

Conclusions We found an unexpected high risk of N+ associated with HR-T1a EAC. Treatment with curative intent was still an option in almost half of patients with N+, and TRD was lower than non-TRD. Thus, in selected patients, endoscopic FU may be justified. The optimal strategy is yet to be established.