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Tu1596 Female Gender in Esophageal Intramucosal Adenocarcinoma Treated With Endoscopic Mucosal Resection: a Case Series
Abstracts
Tu1596 Female Gender in Esophageal Intramucosal Adenocarcinoma Treated With Endoscopic Mucosal Resection: a Case Series Patrick T. Hickey*, Shashin Shah, Hiral Shah Lehigh Valley Health Network, Allentown, PA Background: Barrett’s esophagus (BE) is a premalignant esophageal condition which may lead to dysplasia and esophageal adenocarcinoma (EAC). The incidence of BE has increased in the last two decades. High-grade dysplasia (HGD) carries significant risk of progression to EAC. Patients with HGD and intramucosal adenocarcinoma (IMA) are increasingly treated with endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA). Women have a lower risk of progression from BE to HGD or EAC. Females diagnosed with HGD are presumed to have an equal risk of progression to IMA or EAC. Herein we describe a case series of female patients with varying presentations of IMA treated with EMR and RFA.Cases:Patient 1: A 66 year old female with a history of pancreatic cancer and Whipple procedure had an esophagogastroduodenoscopy (EGD) showing gastroesophageal junction (GEJ) nodularity with HGD on biopsy. Subsequent EMR showed IMA with HGD at the margins. There was no nodularity on repeat EGD with negative biopsies. Follow up EGDs were done every 3 months with multiple EMR for GEJ nodularity, with negative pathology.Patient 2: A 75 year old female with a history of BE was found to have HGD and IMA on biopsy during surveillance EGD. EGD/EUS showed a para-aortic lymph node (!1 cm) and esophageal nodularity treated with EMR. She had BE with HGD, low-grade dysplasia (LGD), possible IMA, and negative lymph node FNA. Repeat EGD had no nodularity and the patient underwent RFA for BE. Repeat EGD showed GEJ irregularity and BE without dysplasia. She was treated with RFA on 3 separate occasions for short segment BE. Subsequent EGD with GEJ biopsy was free of pathology.Patient 3: A 75 year old female with a history of reflux and gastritis was found to have an irregular Z-line and esophagitis on EGD. Barrett’s mucosa with HGD (unable to exclude IMA) was found. An EGD showed GEJ nodularity treated with EMR at two sites. Pathology showed IMA with invasion into the muscularis mucosae with negative deep margins. Repeat EGD showed no residual BE. Discussion: BE is common, and found in 4% of patients undergoing EGD. It is estimated BE has a 20-fold increased risk of developing EAC. Visible nodules with HGD suggest a more advanced lesion; EMR upstages the diagnosis to cancer in up to 40% of cases. Currently endoscopic treatment with EMR/RFA is the standard of care for BE with HGD or IMA leading to a low recurrence rate. Female patients with esophageal HGD and/or IMA undergo EMR/RFA, but no data suggests their response is the same as male patients. Further investigation of gender differences may reveal distinct incidence and response to EMR/RFA. Such differences would affect prognostication, timing of surveillance, and treatment. Our case opens a discussion to examine gender differences in esophageal HGD and IMA which should studied in the future.
Tu1597 Current Practice Patterns for Esophageal Stenting in Malignancy: a Web-Based Survey of Endoscopists Who Place Self-Expanding Metal Stents Jessica L. Mckee*1, David L. Diehl1, Harshit S. Khara1, Kimberly J. Fairley1, Amitpal S. Johal1, Amir Rezk2 1 Gastroenterology, Geisinger Medical Center, Selinsgrove, PA; 2Internal Medicine, Geisinger Medical Center, Danville, PA The introduction in 1992 of esophageal self-expanding metallic stents (E-SEMS) for palliation of the dysphagia of esophageal cancer (EC) quickly replaced competing palliative approaches. E-SEMS offered the advantage of immediate relief of dysphagia, and risks of placement were lower than existing palliative technologies. More than 20 years on, however, there is a better understanding of the advantages and disadvantages of E-SEMS. We designed a web-based survey to better understand the practice patterns of physicians who place E-SEMS and to poll their opinions about unmet needs. Methods: An 18-item survey was designed to evaluate current practices and preferences for E-SEMS, and to try to reach a consensus of unmet needs of the current technology. Results: 25 respondents (24 gastroenterologists and 1 surgeon, all in academic practice) completed the survey. The decision to proceed with E-SEMS placement for EC is most commonly arrived at after discussion with a multidisciplinary EC management team (63%). Most, but not all practitioners place E-SEMS prior to neoadjuvant treatment, but only about half routinely remove them; 29% routinely remove the E-SEMS at the end of RT. Use of surgical gastric or jejunal feeding tubes instead of stents was observed by 83% of respondents. Fluoroscopic placement is most common, with only 16% relying exclusively on endoscopic placement; however endoscopic confirmation is usually done (76%). Endoscopic tumor palliation is uncommonly done (17%). Larger stent diameters (22 or 23mm) are used most commonly (64%) while 36% prefer the 18mm stent. 52% of respondents have used E-SEMS smaller than 18mm; these are for very tight obstructions or when a larger stent caused pain. Pain after E-SEMS placement was seen as a problem with current technology, described by 54% of respondents, but stent removal was done “rarely” or “never” by 88%. Other problems with current E-SEMS include issues related to placement across the GE junction (poor stent positioning or reflux, described in 42%). Unmet needs for E-SEMS use in the United States include biodegradable stents (58%), the need for stents with less radial force (50%), antireflux valve incorporated into stent (46%), and stents that conform better to the angle of the GE junction (29%). Conclusions: Currently marketed E-SEMS are widely used for palliation of dysphagia in esophageal malignancy, but respondents have
AB524 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
identified some problems with current stent design and function. Pain after placement is often seen but rarely results in stent removal. E-SEMS are typically placed after discussion with a multidisciplinary EC panel. Surgically placed feeding tubes continue to be used in some cases instead of E-SEMS. Unmet needs include E-SEMS that cause less pain, and are more suited to placement across the GE junction. Biodegradable stents are of interest to 58% of respondents.
Tu1598 Placement of Fully-Covered Self-Expanding Metal Esophageal Stents for Relief of Dysphagia Is Safe and Effective in Patients Receiving Neoadjuvant Cheomoradiation Joshua Hartman*1, Susana Gonzalez1, Petros C. Benias2, Lionel S. D’Souza2, David L. Carr-Locke2, Ashish R. Shah3, Amrita Sethi3, Tamas A. Gonda3, John M. Poneros3, Frank G. Gress3, Ryan Wong4, Satish Nagula4, Juan Carlos Bucobo4, Jonathan Buscaglia4, Natasha Chhabra5, Adam J. Goodman5, Douglas G. Adler6, Christopher J. Dimaio1 1 Icahn School of Medicine at Mount Sinai, New York, NY; 2Mount Sinai Beth Israel, New York, NY; 3Columbia University, New York, NY; 4Stony Brook University, Stony Brook, NY; 5New York University, New York, NY; 6 University of Utah School of Medicine, Salt Lake City, NY Introduction: For patients with locally advanced esophageal cancer undergoing neoadjuvant therapy, the traditional management of malignant dysphagia has been the use of enteral feeding tubes or parenteral nutrition. The use of fully-covered selfexpanding metal stents (FCSEMS) has become an acceptable alternative option in this population. However, it is unknown what the safety and efficacy is in the use of FCSEMS in patients undergoing neoadjuvant chemoradiation. AIMS: To assess the safety and efficacy of FCSEMS in patients with locally advanced esophageal cancer undergoing neoadjuvant chemoradiation. Methods: Multi-center retrospective analysis of cases performed at six tertiary centers between January 2008 and November 2014. Patient demographics, lesion characteristics, technical success, clinical outcomes, and adverse events (AE) were collected and analyzed. Technical success was defined as successful placement of stent. Clinical outcomes include dysphagia score and nutritional parameters. Results: A total of 75 patients were identified (median age 64; 75% male). Primary tumor pathological diagnosis and location within esophagus were as follows: adenocarcinoma 33 (45.2%), squamous cell carcinoma 40 (54.8%); proximal 7 (9.3%), mid 24 (32%), distal 44 (58.67%). Tumor stage:!T3 9 (14.3%), T3 any N 41 (65.1%), T4N1/N2 13 (20.6%). Neoadjuvant therapy included chemotherapy alone 23 (30.7%), radiation therapy alone 1 (1.3%), and combined chemotherapy and radiation 39 (52%). Stent placement was successful in 100% cases. Dysphagia scores improved significantly after stent placement (2.77 vs 0.66, p!0.001). At the conclusion of neoadjuvant therapy, weight, BMI, and albumin all significantly worsened despite stent placement (Table 1). Pain was the most common immediate AE (28%); pain (21.3%) and recurrent dysphagia (16%) were the most common AE within 30 days (Table 2). Only 2 (2.7%) patients required stent removal for pain. Stent migration (22.7%) was the most common long-term AE. Stent migration was diagnosed due to symptoms 75.9% of the time, with 54.5% reporting dysphagia. Median time to stent migration was 44.5 (0-180) days, indicating stent migration prior to completion of neoadjuvant therapy. Stent revision or replacement was performed in 89.7% of patients with migrated stents. A total of 10 (13.2%) patients proceeded to surgery. Conclusion: The use of FCSEMS in patients undergoing neoadjuvant therapy for esophageal cancer is effective at relieving dysphagia. However, nutritional parameters appear to worsen during treatment despite stent placement. Pain is the most common short-term AE, though rarely requires stent removal. Stent migration remains the most common long-term AE and typically requires endoscopic reintervention. Major complications such as perforation, bleeding, or fistula formation are uncommon.
Table 1. Nutritional parameters at baseline and at conclusion of
neoadjuvant therapy. Parameter Weight BMI Albumin
Baseline
Conclusion
P-value
88.0 (49.6-210) 23.80 (16.6-34) 3.5 (1.5-4.5)
79.02 (33.5-195) 21.96 (14.5-30.39) 3.0 (1.2-4.1)
!0.001 !0.001 !0.001
Table 2. Adverse events. Adverse event
Immediate
Post-procedure (!30 days)
Bleeding Perforation Migration Aspiration Pain Food impaction Recurrent dysphagia GERD Fistula
1 (1.3%) 0 2 (2.6%) 0 21 (28.0%) -
2 (2.6%) 0 11 (14.7%) 2 (2.6%) 16 (21.3%) 1 (1.3%) 12 (16.0%) 11 (14.7%) 2 (2.6%)
Long-term (O30 days) 5 1 17 5 12 3 16 10 6
(6.7%) (1.3%) (22.7%) (6.7%) (16.0%) (4.0%) (21.3%) (13.3%) (8.0%)
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Tu1596 Female Gender in Esophageal Intramucosal Adenocarcinoma Treated With Endoscopic Mucosal Resection: a Case Series Patrick T. Hickey*, Shashin Shah, Hiral Shah Lehigh Valley Health Network, Allentown, PA Background: Barrett’s esophagus (BE) is a premalignant esophageal condition which may lead to dysplasia and esophageal adenocarcinoma (EAC). The incidence of BE has increased in the last two decades. High-grade dysplasia (HGD) carries significant risk of progression to EAC. Patients with HGD and intramucosal adenocarcinoma (IMA) are increasingly treated with endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA). Women have a lower risk of progression from BE to HGD or EAC. Females diagnosed with HGD are presumed to have an equal risk of progression to IMA or EAC. Herein we describe a case series of female patients with varying presentations of IMA treated with EMR and RFA.Cases:Patient 1: A 66 year old female with a history of pancreatic cancer and Whipple procedure had an esophagogastroduodenoscopy (EGD) showing gastroesophageal junction (GEJ) nodularity with HGD on biopsy. Subsequent EMR showed IMA with HGD at the margins. There was no nodularity on repeat EGD with negative biopsies. Follow up EGDs were done every 3 months with multiple EMR for GEJ nodularity, with negative pathology.Patient 2: A 75 year old female with a history of BE was found to have HGD and IMA on biopsy during surveillance EGD. EGD/EUS showed a para-aortic lymph node (!1 cm) and esophageal nodularity treated with EMR. She had BE with HGD, low-grade dysplasia (LGD), possible IMA, and negative lymph node FNA. Repeat EGD had no nodularity and the patient underwent RFA for BE. Repeat EGD showed GEJ irregularity and BE without dysplasia. She was treated with RFA on 3 separate occasions for short segment BE. Subsequent EGD with GEJ biopsy was free of pathology.Patient 3: A 75 year old female with a history of reflux and gastritis was found to have an irregular Z-line and esophagitis on EGD. Barrett’s mucosa with HGD (unable to exclude IMA) was found. An EGD showed GEJ nodularity treated with EMR at two sites. Pathology showed IMA with invasion into the muscularis mucosae with negative deep margins. Repeat EGD showed no residual BE. Discussion: BE is common, and found in 4% of patients undergoing EGD. It is estimated BE has a 20-fold increased risk of developing EAC. Visible nodules with HGD suggest a more advanced lesion; EMR upstages the diagnosis to cancer in up to 40% of cases. Currently endoscopic treatment with EMR/RFA is the standard of care for BE with HGD or IMA leading to a low recurrence rate. Female patients with esophageal HGD and/or IMA undergo EMR/RFA, but no data suggests their response is the same as male patients. Further investigation of gender differences may reveal distinct incidence and response to EMR/RFA. Such differences would affect prognostication, timing of surveillance, and treatment. Our case opens a discussion to examine gender differences in esophageal HGD and IMA which should studied in the future.
Tu1597 Current Practice Patterns for Esophageal Stenting in Malignancy: a Web-Based Survey of Endoscopists Who Place Self-Expanding Metal Stents Jessica L. Mckee*1, David L. Diehl1, Harshit S. Khara1, Kimberly J. Fairley1, Amitpal S. Johal1, Amir Rezk2 1 Gastroenterology, Geisinger Medical Center, Selinsgrove, PA; 2Internal Medicine, Geisinger Medical Center, Danville, PA The introduction in 1992 of esophageal self-expanding metallic stents (E-SEMS) for palliation of the dysphagia of esophageal cancer (EC) quickly replaced competing palliative approaches. E-SEMS offered the advantage of immediate relief of dysphagia, and risks of placement were lower than existing palliative technologies. More than 20 years on, however, there is a better understanding of the advantages and disadvantages of E-SEMS. We designed a web-based survey to better understand the practice patterns of physicians who place E-SEMS and to poll their opinions about unmet needs. Methods: An 18-item survey was designed to evaluate current practices and preferences for E-SEMS, and to try to reach a consensus of unmet needs of the current technology. Results: 25 respondents (24 gastroenterologists and 1 surgeon, all in academic practice) completed the survey. The decision to proceed with E-SEMS placement for EC is most commonly arrived at after discussion with a multidisciplinary EC management team (63%). Most, but not all practitioners place E-SEMS prior to neoadjuvant treatment, but only about half routinely remove them; 29% routinely remove the E-SEMS at the end of RT. Use of surgical gastric or jejunal feeding tubes instead of stents was observed by 83% of respondents. Fluoroscopic placement is most common, with only 16% relying exclusively on endoscopic placement; however endoscopic confirmation is usually done (76%). Endoscopic tumor palliation is uncommonly done (17%). Larger stent diameters (22 or 23mm) are used most commonly (64%) while 36% prefer the 18mm stent. 52% of respondents have used E-SEMS smaller than 18mm; these are for very tight obstructions or when a larger stent caused pain. Pain after E-SEMS placement was seen as a problem with current technology, described by 54% of respondents, but stent removal was done “rarely” or “never” by 88%. Other problems with current E-SEMS include issues related to placement across the GE junction (poor stent positioning or reflux, described in 42%). Unmet needs for E-SEMS use in the United States include biodegradable stents (58%), the need for stents with less radial force (50%), antireflux valve incorporated into stent (46%), and stents that conform better to the angle of the GE junction (29%). Conclusions: Currently marketed E-SEMS are widely used for palliation of dysphagia in esophageal malignancy, but respondents have
AB524 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
identified some problems with current stent design and function. Pain after placement is often seen but rarely results in stent removal. E-SEMS are typically placed after discussion with a multidisciplinary EC panel. Surgically placed feeding tubes continue to be used in some cases instead of E-SEMS. Unmet needs include E-SEMS that cause less pain, and are more suited to placement across the GE junction. Biodegradable stents are of interest to 58% of respondents.
Tu1598 Placement of Fully-Covered Self-Expanding Metal Esophageal Stents for Relief of Dysphagia Is Safe and Effective in Patients Receiving Neoadjuvant Cheomoradiation Joshua Hartman*1, Susana Gonzalez1, Petros C. Benias2, Lionel S. D’Souza2, David L. Carr-Locke2, Ashish R. Shah3, Amrita Sethi3, Tamas A. Gonda3, John M. Poneros3, Frank G. Gress3, Ryan Wong4, Satish Nagula4, Juan Carlos Bucobo4, Jonathan Buscaglia4, Natasha Chhabra5, Adam J. Goodman5, Douglas G. Adler6, Christopher J. Dimaio1 1 Icahn School of Medicine at Mount Sinai, New York, NY; 2Mount Sinai Beth Israel, New York, NY; 3Columbia University, New York, NY; 4Stony Brook University, Stony Brook, NY; 5New York University, New York, NY; 6 University of Utah School of Medicine, Salt Lake City, NY Introduction: For patients with locally advanced esophageal cancer undergoing neoadjuvant therapy, the traditional management of malignant dysphagia has been the use of enteral feeding tubes or parenteral nutrition. The use of fully-covered selfexpanding metal stents (FCSEMS) has become an acceptable alternative option in this population. However, it is unknown what the safety and efficacy is in the use of FCSEMS in patients undergoing neoadjuvant chemoradiation. AIMS: To assess the safety and efficacy of FCSEMS in patients with locally advanced esophageal cancer undergoing neoadjuvant chemoradiation. Methods: Multi-center retrospective analysis of cases performed at six tertiary centers between January 2008 and November 2014. Patient demographics, lesion characteristics, technical success, clinical outcomes, and adverse events (AE) were collected and analyzed. Technical success was defined as successful placement of stent. Clinical outcomes include dysphagia score and nutritional parameters. Results: A total of 75 patients were identified (median age 64; 75% male). Primary tumor pathological diagnosis and location within esophagus were as follows: adenocarcinoma 33 (45.2%), squamous cell carcinoma 40 (54.8%); proximal 7 (9.3%), mid 24 (32%), distal 44 (58.67%). Tumor stage:!T3 9 (14.3%), T3 any N 41 (65.1%), T4N1/N2 13 (20.6%). Neoadjuvant therapy included chemotherapy alone 23 (30.7%), radiation therapy alone 1 (1.3%), and combined chemotherapy and radiation 39 (52%). Stent placement was successful in 100% cases. Dysphagia scores improved significantly after stent placement (2.77 vs 0.66, p!0.001). At the conclusion of neoadjuvant therapy, weight, BMI, and albumin all significantly worsened despite stent placement (Table 1). Pain was the most common immediate AE (28%); pain (21.3%) and recurrent dysphagia (16%) were the most common AE within 30 days (Table 2). Only 2 (2.7%) patients required stent removal for pain. Stent migration (22.7%) was the most common long-term AE. Stent migration was diagnosed due to symptoms 75.9% of the time, with 54.5% reporting dysphagia. Median time to stent migration was 44.5 (0-180) days, indicating stent migration prior to completion of neoadjuvant therapy. Stent revision or replacement was performed in 89.7% of patients with migrated stents. A total of 10 (13.2%) patients proceeded to surgery. Conclusion: The use of FCSEMS in patients undergoing neoadjuvant therapy for esophageal cancer is effective at relieving dysphagia. However, nutritional parameters appear to worsen during treatment despite stent placement. Pain is the most common short-term AE, though rarely requires stent removal. Stent migration remains the most common long-term AE and typically requires endoscopic reintervention. Major complications such as perforation, bleeding, or fistula formation are uncommon.
Table 1. Nutritional parameters at baseline and at conclusion of
neoadjuvant therapy. Parameter Weight BMI Albumin
Baseline
Conclusion
P-value
88.0 (49.6-210) 23.80 (16.6-34) 3.5 (1.5-4.5)
79.02 (33.5-195) 21.96 (14.5-30.39) 3.0 (1.2-4.1)
!0.001 !0.001 !0.001
Table 2. Adverse events. Adverse event
Immediate
Post-procedure (!30 days)
Bleeding Perforation Migration Aspiration Pain Food impaction Recurrent dysphagia GERD Fistula
1 (1.3%) 0 2 (2.6%) 0 21 (28.0%) -
2 (2.6%) 0 11 (14.7%) 2 (2.6%) 16 (21.3%) 1 (1.3%) 12 (16.0%) 11 (14.7%) 2 (2.6%)
Long-term (O30 days) 5 1 17 5 12 3 16 10 6
(6.7%) (1.3%) (22.7%) (6.7%) (16.0%) (4.0%) (21.3%) (13.3%) (8.0%)
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