Is Endoscopic Mucosal Resection (EMR) sufficient for the management of Barrett's esophagus-related neoplasia?

Aims Endoscopic mucosal resection (EMR) allows the evaluation of early neoplasia in Barrett's esophagus (BE) and can be curative. However, it has limitations that may compromise histological evaluation and curative resection. The aims were to evaluate the curative yield of EMR in visible lesions on BE and potential prognostic factors. Additionally, to assess the outcomes of EMR performed according to the ESGE guidelines (lesions of 20 mm or smaller with a flat-elevated morphology) [1] [2] [3] [4] [5].

Methods Retrospective cross-sectional study of patients with BE followed at the Hospital Clínic of Barcelona. All patients who underwent EMR for visible lesions were included. All EMRs were performed by a single expert endoscopist. Demographic, clinical, endoscopic, and pathological variables were recorded. A sufficient EMR was defined as a resection containing adenocarcinoma (ADK) and favorable histopathological criteria with R0 margins (even en bloc or piecemeal in one of the fragments) and cases with final diagnosis of intestinal metaplasia or dysplasia. Quantitative variables are expressed as median with interquartile range (IQR)

Results A total of 35 patients were included, the majority being men (82.9%), with a median age of 65 years (58.2-74). The extension of BE was 30 mm (20-60). The size of the lesions was 10.5 mm (8-15 mm) and 17 were 20 mm or smaller with a flat-elevated morphology. The rates of en bloc resection and sufficient resection were 62.9% (22/35) and 54.3% (19/35), respectively. Among the piecemeal resections, 10/13 (76.9%) were considered insufficient: 6/10 presented non evaluable margins (1 high-grade dysplasia, 3 ADK pT1a and 2 ADK pT1b) and 4/10 were ADK with positive margins. Regardind en bloc resections, 6/22 (27.3%) were considered insufficient, as they were ADK with positive margins (3 ADK pT1a and 3 ADK pT1b). The prognostic factors for an insufficient EMR were a size bigger than 10.5 mm (12/18 vs 3/16; p=0.005) and a previous biopsy showing ADK (8/8 vs 8/27; p<0.001). Among the cases that met ESGE criteria for EMR, EMR was insufficient in 35.3% (5/17 vs 11/18; p=0.060).

Conclusions EMR appears to be insufficient for the management of BE-related neoplasia, even in cases that meet current guideline criteria. EMR indications might be restricted to visible lesions with a prior diagnosis of dysplasia, with more advanced techniques considered for cases with prior biopsies showing adenocarcinoma. Further studies with larger sample sizes are needed to confirm these results.

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025

• References

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