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Clinical and pathological predictors of failure of endoscopic therapy for Barrett’s related high-grade dysplasia and early esophageal adenocarcinoma

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Abstract

Background and aims

Multimodal endoscopic treatment for Barrett’s esophagus (BE) related high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) is safe and effective. However, there is a paucity of data to predict the response to endoscopic treatment. This study aimed to identify predictors of failure to achieve complete eradication of neoplasia (CE-N) and complete eradication of intestinal metaplasia (CE-IM).

Methods

We performed a retrospective analysis of prospectively collected data of all HGD/EAC cases treated endoscopically at a tertiary referral center. Only patients with confirmed HGD/EAC from initial endoscopic mucosal resection (EMR) were included. Potential predictive variables including clinical characteristics, endoscopic features, and index histologic parameters of the EMR specimens were evaluated using multivariate Cox regression.

Results

A total of 457 patients were diagnosed with HGD/EAC by initial EMR from January 2008 to January 2019. Of these, 366 patients who underwent subsequent endoscopic treatment with or without RFA were included. Cumulative incidence rates at 3 years for CE-N and CE-IM were 91.4% (95% CI 87.8–94.2%) and 66.8% (95% CI 61.2–72.3%), respectively during a median follow-up period of 35 months. BE segment of 3–10 cm (HR 0.45; 95% CI 0.36–0.57) and > 10 cm (HR 0.25; 95% CI 0.15–0.40) were independent clinical predictors associated with failure to achieve CE-N. With respect to CE-IM, increasing age (HR 0.88; 95% CI 0.78–1.00) was another predictor along with BE segment of 3–10 cm (HR 0.37; 95% CI 0.28–0.49) and > 10 cm (HR 0.15; 95% CI 0.07–0.30). Lymphovascular invasion increased the risk of CE-N and CE-IM failure in EAC cases.

Conclusion

Failure to achieve CE-N and CE-IM is associated with long-segment BE and other clinical variables. Patients with these predictors should be considered for a more intensive endoscopic treatment approach at expert centers.

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Abbreviations

BE:

Barrett’s esophagus

BMI:

Body mass index

CE-N:

Complete eradication of neoplasia

CE-IM:

Complete eradication of intestinal metaplasia

CI:

Confidence intervals

EMR:

Endoscopic mucosal resection

ESD:

Endoscopic submucosal dissection

EAC:

Esophageal adenocarcinoma

GERD:

Gastroesophageal reflux disease

GEJ:

Gastroesophageal junction

HGD:

High-grade dysplasia

IM:

Intestinal metaplasia

IQR:

Interquartile range

IMC:

Intramucosal cancer

LVI:

Lymphovascular invasion

PDT:

Photodynamic therapy

PPI:

Proton pump inhibitor

RFA:

Radiofrequency ablation

SD:

Standard deviation

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Authors and Affiliations

  1. Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, Canada

    Yuto Shimamura, Yugo Iwaya, Ryosuke Kobayashi, Jeffrey D. Mosko, Gary R. May, Gabor Kandel, Paul Kortan, Norman Marcon & Christopher W. Teshima

  2. Department of Gastroenterology and Hepatology, Hospital Universitario Ramon Y Cajal, IRYCIS, Universidad de Alcala, Madrid, Spain

    Enrique Rodriguez de Santiago

  3. Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia

    Niroshan Muwanwella

  4. Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia

    Spiro Raftopoulos

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  1. Yuto Shimamura
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Contributions

Study conception and design: YS, YI, RK, CT; data acquisition: YS, YI, RK, NM, SR; analysis and interpretation of data: ERS, YS, YI, RK; drafting of the manuscript: YS, YI, RK, ERS, CT; critical revision of the manuscript for important intellectual content: JDM, GRM, GK, PK, NM, CWT; final manuscript approval: all authors approved the final manuscript.

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Correspondence to Yuto Shimamura.

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Yuto Shimamura, Yugo Iwaya, Ryosuke Kobayashi, Enrique Rodriguez de Santiago, Niroshan Muwanwella, Spiro Raftopoulos, Jeffrey D. Mosko, Gary R May, Gabor Kandel, Paul Kortan, Norman Marcon, and Christopher W. Teshima have no conflicts of interest or financial ties to disclose.

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Shimamura, Y., Iwaya, Y., Kobayashi, R. et al. Clinical and pathological predictors of failure of endoscopic therapy for Barrett’s related high-grade dysplasia and early esophageal adenocarcinoma. Surg Endosc 35, 5468–5479 (2021). https://doi.org/10.1007/s00464-020-08037-x

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