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Su1472 Endoscopic Submucosal Dissection for Patients With Esophageal Cancer Aged Over 75 Years
Abstracts
intramucosal carcinoma (IMC) & submucosal carcinoma (T1). Minimally-invasive therapies with endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are gaining momentum and acceptance as alternatives in the management of EM. Aims: Compare changes in treatment trends and evaluate disease eradication from 2000-2010. Methods: Treatment strategies for Barrett’s-associated EM lesions were collected from a prospectively maintained database. Decisions for treatment were based on standard histological Barrett’s sampling, staging EMRs of visible lesions and EUS in all patients, and/or CT or PET/CT. Barrett’s segment from surgical and endoscopic therapies were analyzed for: complete eradication of EM, residual dysplasia, treatment complications and disease status at follow-up. Results: Eighty one patients were included (median age of 65 yrs [29-83]; male ratio of 3.8). Forty eight patients had surgical resection; 6 patients were upgraded to surgery following staging EMRs for visible lesions (with no residual invasive component in 5 of these). Pre-surgical histological grades of EM were: HGD (n⫽4), IMC (n⫽25) and T1 mucosal carcinoma (n⫽19). The morbidity for esophagectomy was 29% with one in-hospital death (2%). Anastomotic stricture requiring dilatation occurred in 4 (8%) patients. The followup time for surgical patients ranged from 9 days to 8 yrs; all patients were cured of EM.Endoscopic treatment with curative intent was performed in 27 patients (80% requiring EMR followed by RFA). The pre-treatment EM grades for the endoscopy group included: HGD (n⫽13), IMC (n⫽11) and T1 mucosal carcinoma (n⫽3). Overall, follow-up for this cohort ranged from 11 days to 3 yrs. All patients were treated as day cases. A median of 2.4 RFA sessions were required. The rate of complete resolution for EM was 100% in the endoscopic group; 69% had complete eradication of Barrett’s. Six high risk surgical candidates, unsuitable for 1st-line endoscopy with curative intent, had endoscopic salvage treatment for EM lesions; followup available was from 0.2 to 1.8 yrs, with 4 patients still alive & undergoing treatment. Complications of endoscopy were a single arterial bleed (2%) following an EMR which was controlled by clipping; the patient required a blood transfusion. Conclusions: The addition of minimally-invasive endoscopic approaches to staging & therapy for Barrett’s-related EM has represented a safe & accurate means of triaging patients to appropriate therapies. Use of EMR & RFA is an effective & safe alternative to surgery in selected patients. However, close interdisciplinary collaboration of specialists in gastroenterology, surgery, & pathology is mandatory for optimum outcomes.
Su1470 Is There Additional Benefit in Using Confocal Laser Endomicroscopy (CLE) Over Narrow Band Imaging (NBI) in Neoplasia Detection for Barrett’s Esophagus (BE) Patients? Ngozi I. Okoro, Kenneth K. Wang, Ganapathy A. Prasad, Namasivayam Vikneswaran, Lori S. Lutzke, Kelly T. Dunagan Mayo Clinic Rochester, Rochester, MN Background: Confocal laser microscopy is an imaging technology that integrates a confocal laser microscope in the tip of a standard videoendoscope or as a probe that can be passed through the channel of any endoscope. The aim is to provide real-time histology, allowing high resolution in vivo histological assessment at subcellular resolution during endoscopy. NBI was developed primarily to emphasize the mucosal microvasculature and to identify vascular alterations indicative of dysplasia. The accuracy in reported studies for the detection of neoplasia for both modalities has been excellent. The aim of this study was to evaluate the sensitivity and specificity of CLE in NBI negative patients with BE associated dysplasia. Methods: We identified NBI negative patients with BE associated dysplasia seen in the BE unit at the Mayo Clinic Rochester between November 2008 and November 2009 using a prospectively maintained database. NBI negativity was the absence of visible and nodular lesions, as well as irregular mucosal or vascular patterns. These patients then underwent their next routine surveillance EGD. Those patients who had an NBI negative exam then had a circumferential CLE exam of the BE segment during the same procedure. Surveillance biopsies were then obtained and used as a reference standard. Estimates of sensitivity and specificity were calculated using binomial proportions. Results: A total of 166 patients were evaluated. Of these 6 refused to consent for the CLE exam, 4 patients were NBI positive, 22 had no discernible BE segment, 27 underwent RFA and 85 EMR, and 6 patients did not have CLE for technical reasons. 16 patients completed the study with surveillance biopsies positive for dysplasia (HGD) in 6 patients. The sensitivity for dysplasia detection using CLE was 100% (CI 61-100%) and the specificity was also 100% (CI 75-100%). Conclusion: We can infer that CLE can provide some incremental benefit for the diagnosis of dysplasia in patients who are NBI negative.
www.giejournal.org
Su1471 Endoscopic Follow Up of Post-Treatment Barrett’s Esophagus Role of New Imaging Techniques Helga Bertani1, Flavia Pigò1, Raffaele Manta1, Mauro Manno1, Luisa Losi2, Vincenzo G. Mirante1, Rita Conigliaro1 1 Endoscopy Unit-Nuovo Ospedale Civile S. Agostino Estense, Modena, Italy; 2Pathology Unit, University of Modena and Reggio Emilia, Modena, Italy Background: Treatment of dysplastic Barrett’s esophagus (BE) ranges from endoscopic management, to esophagectomy. Endoscopic follow up after ablation is critical to detect recurrent/residual metaplastic/dysplastic tissue and to guide next therapeutic steps. The sensitivity of white light endoscopy (WLE), after ablative therapy could be influenced by changes related to ablation technique or scar tissue. Virtual chromoendoscopy (Narrow Band Imaging, Olympus, Japan) could be useful to bypass misreading of healing process and/or scar tissue but also with NBI, scar tissue could be misread as residual/recurrence Barrett’s tissue. Probe based confocal laser endomicroscopy (pCLE) (Cellvizio, MaunaKea Tech, France), which enables us a real time in-vivo visualization of Barrett’s glands might improve accuracy of WLE to detect residual/recurrence BE bypassing architectural and mucosal changes related to ablative therapy. Methods: we evaluated 10 male patients (mean age 54.1, range 27-71) in followup for BE -1 short-Barrett and 9 long-Barrett, sec. Prague Class. (range of Mextension 1to13 cm). All of them underwent endoscopic or surgical ablation (7 radiofrequency ablation, 1 esophagectomy ⫹ radiofrequency ablation for residual BE, 2 EMR) for dysplastic Barrett (1 undetermined dysplasia, 6 lowgrade (LG) dysplasia, 2 high grade (HG) dysplasia, 1 adenocarcinoma (ADK). Endoscopic therapy (radiofrequency, EMR) was performed since normal mucosa was seen at WLE. The first follow-up endoscopy (median time 12 months, range 3-24) was performed three months later last ablative therapy and included one or more different techniques (WLE, NBI, pCLE). We performed target biopsies, if recurrence was suspected; otherwise random biopsies according to Seattle protocol were performed. Sensitivity of each technique was assessed. Results: a total of 22 procedures were evaluated; only 5/8 WLE procedures were positively associated with histology (62%; 95%CI 20-82%), whereas 4/4 NBI (100%; 95%CI 28-86 %) and 9/10 pCLE (100%, 95%CI 59-92%) identified residual of intestinal metaplasia (p⬍0.05 for WLE vs NBI and pCLE) respectively. 1 case of residual HG dysplasia was diagnosed by NBI. Presence of various degrees of microscopic flogosis and fibrosis (75% of total histological exams) did not influence significantly the correct endoscopic evaluation (p⫽0.2; Fisher exact’s test). Conclusions: WLE performance rate is poor for the evaluation of treated BE due to changes of architecture and vasculature of esophageal mucosa or scar tissue after ablative therapy. NBI is more accurate than WLE for diagnosis residual Barrett’s glands in mucosa treated with ablation and/or resection but pCLE has the highest accuracy in detection residual Barrett’s glands.
Su1472 Endoscopic Submucosal Dissection for Patients With Esophageal Cancer Aged Over 75 Years Osamu Kikuchi, Hirokazu Mouri, Kazuhiro Matsueda, Hiroshi Yamamoto Department of gastroenterology, Kurashiki Central Hospital, Okayama, Japan Introduction: Endoscopic submucosal dissection (ESD) is an effective treatment for early esophageal cancer. However, this procedure in elderly patients has not been studied in detail. We retrospectively reviewed our ESD cases to evaluate the effect and safety of ESD in patients aged ⱖ75 years with early esophageal cancer. Methods: From January 2005 to October 2010, 53 patients (45 males and 8 females) with esophageal cancer underwent ESD as the initial treatment. We reviewed their medical records to find demographic data, pathological findings, complications and length of hospital stay after ESD. Complete resection was defined as en-bloc resection with tumor-free margins. Results: Ten of the 53 patients were ⱖ75 years of age (older group) and 43 were ⬍75 years of age (younger group). The incidence of major comorbidities was significantly higher among the older (7 of 10; 70%) than the younger (13 of 43; 30%) patients (p ⫽ 0.03, Fisher’s exact test). The most frequent comorbidity was a history of pulmonary conditions (3 and 6 in the older and younger groups, respectively). Six, 4 and 0 patients in the older group, and 19, 18 and 6 in the younger group had pTis, pT1a and pT1b, respectively. The complete resection rates were 90% (9/10) and 91% (39/43) in the older and younger groups, respectively. The ESDassociated complication rates did not significantly differ between the older and younger groups (10% vs. 26%). The most frequent complication was mediastinal emphysema without obvious perforation and conservative therapy resolved all complications. The length of the hospital stay after ESD did not significantly differ between the older and younger groups (9.1 ⫾ 2.5 vs. 9.6 ⫾ 2.2 days). No deaths were attributable to ESD-associated complications. Conclusion: These findings indicate that the prevalence of ESD-associated complications is not significantly increased among elderly patients. Thus, ESD appears to be effective against early esophageal cancer and is well-tolerated by elderly patients.
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB275
intramucosal carcinoma (IMC) & submucosal carcinoma (T1). Minimally-invasive therapies with endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are gaining momentum and acceptance as alternatives in the management of EM. Aims: Compare changes in treatment trends and evaluate disease eradication from 2000-2010. Methods: Treatment strategies for Barrett’s-associated EM lesions were collected from a prospectively maintained database. Decisions for treatment were based on standard histological Barrett’s sampling, staging EMRs of visible lesions and EUS in all patients, and/or CT or PET/CT. Barrett’s segment from surgical and endoscopic therapies were analyzed for: complete eradication of EM, residual dysplasia, treatment complications and disease status at follow-up. Results: Eighty one patients were included (median age of 65 yrs [29-83]; male ratio of 3.8). Forty eight patients had surgical resection; 6 patients were upgraded to surgery following staging EMRs for visible lesions (with no residual invasive component in 5 of these). Pre-surgical histological grades of EM were: HGD (n⫽4), IMC (n⫽25) and T1 mucosal carcinoma (n⫽19). The morbidity for esophagectomy was 29% with one in-hospital death (2%). Anastomotic stricture requiring dilatation occurred in 4 (8%) patients. The followup time for surgical patients ranged from 9 days to 8 yrs; all patients were cured of EM.Endoscopic treatment with curative intent was performed in 27 patients (80% requiring EMR followed by RFA). The pre-treatment EM grades for the endoscopy group included: HGD (n⫽13), IMC (n⫽11) and T1 mucosal carcinoma (n⫽3). Overall, follow-up for this cohort ranged from 11 days to 3 yrs. All patients were treated as day cases. A median of 2.4 RFA sessions were required. The rate of complete resolution for EM was 100% in the endoscopic group; 69% had complete eradication of Barrett’s. Six high risk surgical candidates, unsuitable for 1st-line endoscopy with curative intent, had endoscopic salvage treatment for EM lesions; followup available was from 0.2 to 1.8 yrs, with 4 patients still alive & undergoing treatment. Complications of endoscopy were a single arterial bleed (2%) following an EMR which was controlled by clipping; the patient required a blood transfusion. Conclusions: The addition of minimally-invasive endoscopic approaches to staging & therapy for Barrett’s-related EM has represented a safe & accurate means of triaging patients to appropriate therapies. Use of EMR & RFA is an effective & safe alternative to surgery in selected patients. However, close interdisciplinary collaboration of specialists in gastroenterology, surgery, & pathology is mandatory for optimum outcomes.
Su1470 Is There Additional Benefit in Using Confocal Laser Endomicroscopy (CLE) Over Narrow Band Imaging (NBI) in Neoplasia Detection for Barrett’s Esophagus (BE) Patients? Ngozi I. Okoro, Kenneth K. Wang, Ganapathy A. Prasad, Namasivayam Vikneswaran, Lori S. Lutzke, Kelly T. Dunagan Mayo Clinic Rochester, Rochester, MN Background: Confocal laser microscopy is an imaging technology that integrates a confocal laser microscope in the tip of a standard videoendoscope or as a probe that can be passed through the channel of any endoscope. The aim is to provide real-time histology, allowing high resolution in vivo histological assessment at subcellular resolution during endoscopy. NBI was developed primarily to emphasize the mucosal microvasculature and to identify vascular alterations indicative of dysplasia. The accuracy in reported studies for the detection of neoplasia for both modalities has been excellent. The aim of this study was to evaluate the sensitivity and specificity of CLE in NBI negative patients with BE associated dysplasia. Methods: We identified NBI negative patients with BE associated dysplasia seen in the BE unit at the Mayo Clinic Rochester between November 2008 and November 2009 using a prospectively maintained database. NBI negativity was the absence of visible and nodular lesions, as well as irregular mucosal or vascular patterns. These patients then underwent their next routine surveillance EGD. Those patients who had an NBI negative exam then had a circumferential CLE exam of the BE segment during the same procedure. Surveillance biopsies were then obtained and used as a reference standard. Estimates of sensitivity and specificity were calculated using binomial proportions. Results: A total of 166 patients were evaluated. Of these 6 refused to consent for the CLE exam, 4 patients were NBI positive, 22 had no discernible BE segment, 27 underwent RFA and 85 EMR, and 6 patients did not have CLE for technical reasons. 16 patients completed the study with surveillance biopsies positive for dysplasia (HGD) in 6 patients. The sensitivity for dysplasia detection using CLE was 100% (CI 61-100%) and the specificity was also 100% (CI 75-100%). Conclusion: We can infer that CLE can provide some incremental benefit for the diagnosis of dysplasia in patients who are NBI negative.
www.giejournal.org
Su1471 Endoscopic Follow Up of Post-Treatment Barrett’s Esophagus Role of New Imaging Techniques Helga Bertani1, Flavia Pigò1, Raffaele Manta1, Mauro Manno1, Luisa Losi2, Vincenzo G. Mirante1, Rita Conigliaro1 1 Endoscopy Unit-Nuovo Ospedale Civile S. Agostino Estense, Modena, Italy; 2Pathology Unit, University of Modena and Reggio Emilia, Modena, Italy Background: Treatment of dysplastic Barrett’s esophagus (BE) ranges from endoscopic management, to esophagectomy. Endoscopic follow up after ablation is critical to detect recurrent/residual metaplastic/dysplastic tissue and to guide next therapeutic steps. The sensitivity of white light endoscopy (WLE), after ablative therapy could be influenced by changes related to ablation technique or scar tissue. Virtual chromoendoscopy (Narrow Band Imaging, Olympus, Japan) could be useful to bypass misreading of healing process and/or scar tissue but also with NBI, scar tissue could be misread as residual/recurrence Barrett’s tissue. Probe based confocal laser endomicroscopy (pCLE) (Cellvizio, MaunaKea Tech, France), which enables us a real time in-vivo visualization of Barrett’s glands might improve accuracy of WLE to detect residual/recurrence BE bypassing architectural and mucosal changes related to ablative therapy. Methods: we evaluated 10 male patients (mean age 54.1, range 27-71) in followup for BE -1 short-Barrett and 9 long-Barrett, sec. Prague Class. (range of Mextension 1to13 cm). All of them underwent endoscopic or surgical ablation (7 radiofrequency ablation, 1 esophagectomy ⫹ radiofrequency ablation for residual BE, 2 EMR) for dysplastic Barrett (1 undetermined dysplasia, 6 lowgrade (LG) dysplasia, 2 high grade (HG) dysplasia, 1 adenocarcinoma (ADK). Endoscopic therapy (radiofrequency, EMR) was performed since normal mucosa was seen at WLE. The first follow-up endoscopy (median time 12 months, range 3-24) was performed three months later last ablative therapy and included one or more different techniques (WLE, NBI, pCLE). We performed target biopsies, if recurrence was suspected; otherwise random biopsies according to Seattle protocol were performed. Sensitivity of each technique was assessed. Results: a total of 22 procedures were evaluated; only 5/8 WLE procedures were positively associated with histology (62%; 95%CI 20-82%), whereas 4/4 NBI (100%; 95%CI 28-86 %) and 9/10 pCLE (100%, 95%CI 59-92%) identified residual of intestinal metaplasia (p⬍0.05 for WLE vs NBI and pCLE) respectively. 1 case of residual HG dysplasia was diagnosed by NBI. Presence of various degrees of microscopic flogosis and fibrosis (75% of total histological exams) did not influence significantly the correct endoscopic evaluation (p⫽0.2; Fisher exact’s test). Conclusions: WLE performance rate is poor for the evaluation of treated BE due to changes of architecture and vasculature of esophageal mucosa or scar tissue after ablative therapy. NBI is more accurate than WLE for diagnosis residual Barrett’s glands in mucosa treated with ablation and/or resection but pCLE has the highest accuracy in detection residual Barrett’s glands.
Su1472 Endoscopic Submucosal Dissection for Patients With Esophageal Cancer Aged Over 75 Years Osamu Kikuchi, Hirokazu Mouri, Kazuhiro Matsueda, Hiroshi Yamamoto Department of gastroenterology, Kurashiki Central Hospital, Okayama, Japan Introduction: Endoscopic submucosal dissection (ESD) is an effective treatment for early esophageal cancer. However, this procedure in elderly patients has not been studied in detail. We retrospectively reviewed our ESD cases to evaluate the effect and safety of ESD in patients aged ⱖ75 years with early esophageal cancer. Methods: From January 2005 to October 2010, 53 patients (45 males and 8 females) with esophageal cancer underwent ESD as the initial treatment. We reviewed their medical records to find demographic data, pathological findings, complications and length of hospital stay after ESD. Complete resection was defined as en-bloc resection with tumor-free margins. Results: Ten of the 53 patients were ⱖ75 years of age (older group) and 43 were ⬍75 years of age (younger group). The incidence of major comorbidities was significantly higher among the older (7 of 10; 70%) than the younger (13 of 43; 30%) patients (p ⫽ 0.03, Fisher’s exact test). The most frequent comorbidity was a history of pulmonary conditions (3 and 6 in the older and younger groups, respectively). Six, 4 and 0 patients in the older group, and 19, 18 and 6 in the younger group had pTis, pT1a and pT1b, respectively. The complete resection rates were 90% (9/10) and 91% (39/43) in the older and younger groups, respectively. The ESDassociated complication rates did not significantly differ between the older and younger groups (10% vs. 26%). The most frequent complication was mediastinal emphysema without obvious perforation and conservative therapy resolved all complications. The length of the hospital stay after ESD did not significantly differ between the older and younger groups (9.1 ⫾ 2.5 vs. 9.6 ⫾ 2.2 days). No deaths were attributable to ESD-associated complications. Conclusion: These findings indicate that the prevalence of ESD-associated complications is not significantly increased among elderly patients. Thus, ESD appears to be effective against early esophageal cancer and is well-tolerated by elderly patients.
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB275