Introduction Endoscopic resection (ER) of Barrett’s cancer with curative intent is extremely effective for lesions limited to the mucosal layer of the oesophagus. Lesions extending beyond the muscularis mucosae into the submucosa are considered for radical therapy due to risk of lymph node metastases. Radical treatment is not without risk, reported mortality of oesophagectomy is 2–5%.
Methods All patients referred for ER of Barrett’s cancer had data collected prospectively between 2006 and 2015. The database was interrogated by independent researchers blinded to the endoscopic procedures for patients with SM invasive cancers.
Results 261 endoscopic resections were performed in 182 patients during the study period. 26 (14%) patients had SM invasion following ER. 12 had undergone endoscopic submucosal dissection (ESD) and 14 endoscopic mucosal resection (EMR). 22 (85%) lesions were superficially submucosally invasive (SM1), 4 were >SM1 (15%). Table 1 shows outcomes after ER. Mean disease free survival was 4.31 years (Range 0.7 to 10.8) in this cohort. 3 patients died of recurrent cancer, 3 patients died of co-morbid conditions.
All 9 patients in the endoscopy group were clear of cancer at follow up. There was 1 recurrence treated with further ER. Of the 6 patients undergoing surgery 5 had no residual neoplasia in the oesophagectomy specimen (pTxN0M0). 1 patient had a pT1N0M0 cancer with LVI and signet ring cells and died 2 years after surgery. 1 patient was considered for surgery but was turned down due to comorbidities and subsequently died of cancer 6 years following ER. 3 patients have been discharged to their referring centres for consideration of surgery.
7 patients underwent chemoradiotherapy. 6 of 7 patients treated with chemoradiotherapy were clear of recurrence on follow up. 1 patient developed recurrence of cancer and died 2 years after ER.
Conclusion This data challenges the current paradigm of radical therapy following ER of SM1 Barrett’s cancers. Outcomes for patients managed endoscopically are excellent. 5 patients undergoing surgery in our cohort had no residual disease in the oesophagectomy specimen and potentially could have undergone endoscopic follow up alone. Patients found to have SM1 lesions without poor prognostic features can effectively be managed without radical intervention. SM invasive cancers require an individualised management plan tailored to histology and co-morbidities. There does not appear to be a demonstrable difference between chemoradiotherapy and surgery.
Disclosure of Interest None Declared