Josephus Huijsmans

Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus.

Objective: Endoscopic therapy is increasingly being used in the treatment of high-grade intraepithelial neoplasia (HGIN) and mucosal adenocarcinoma (BC) in patients with Barrett’s oesophagus. This report provides 5 year follow-up data from a large prospective study investigating the efficacy and safety of endoscopic treatment in these patients and analysing risk factors for recurrence. Design: Prospective case series. Setting: Academic tertiary care centre. Patients: Between October 1996 and September 2002, 61 patients with HGIN and 288 with BC were included (173 with short-segment and 176 with long-segment Barrett’s oesophagus) from a total of 486 patients presenting with Barrett’s neoplasia. Patients with submucosal or more advanced cancer were excluded. Interventions: Endoscopic therapy. Main outcome measures: Rate of complete remission and recurrence rate, tumour-associated death. Results: Endoscopic resection was performed in 279 patients, photodynamic therapy in 55, and both procedures in 13; two patients received argon plasma coagulation. The mean follow-up period was 63.6 (SD 23.1) months. Complete response (CR) was achieved in 337 patients (96.6%); surgery was necessary in 13 (3.7%) after endoscopic therapy failed. Metachronous lesions developed during the follow-up in 74 patients (21.5%); 56 died of concomitant disease, but none died of BC. The calculated 5 year survival rate was 84%. The risk factors most frequently associated with recurrence were piecemeal resection, long-segment Barrett’s oesophagus, no ablative therapy of Barrett’s oesophagus after CR, time until CR achieved >10 months and multifocal neoplasia. Conclusions: This study showed that endoscopic therapy was highly effective and safe, with an excellent long-term survival rate. The risk factors identified may help stratify patients who are at risk for recurrence and those requiring more intensified follow-up.

Long-term Efficacy and Safety of Endoscopic Resection for Patients With Mucosal Adenocarcinoma of the Esophagus

BACKGROUND & AIMSnBarretts esophagus-associated high-grade dysplasia is commonly treated by endoscopy. However, most guidelines offer no recommendations for endoscopic treatment of mucosal adenocarcinoma of the esophagus (mAC). We investigated the efficacy and safety of endoscopic resection in a large series of patients with mAC.nnnMETHODSnWe collected data from 1000 consecutive patients (mean age, 69.1 ± 10.7 years; 861 men) with mAC (481 with short-segment and 519 with long-segment Barretts esophagus) who presented at a tertiary care center from October 1996 to September 2010. Patients with low-grade and high-grade dysplasia and submucosal or more advanced cancer were excluded. All patients underwent endoscopic resection of mACs. Patients found to have submucosal cancer at their first endoscopy examination were excluded from the analysis.nnnRESULTSnAfter a mean follow-up period of 56.6 ± 33.4 months, 963 patients (96.3%) had achieved a complete response; surgery was necessary in 12 patients (3.7%) after endoscopic therapy failed. Metachronous lesions or recurrence of cancer developed during the follow-up period in 140 patients (14.5%) but endoscopic re-treatment was successful in 115, resulting in a long-term complete remission rate of 93.8%; 111 died of concomitant disease and 2 of Barretts esophagus-associated cancer. The calculated 10-year survival rate of patients who underwent endoscopic resection of mACs was 75%. Major complications developed in 15 patients (1.5%) but could be managed conservatively.nnnCONCLUSIONSnEndoscopic therapy is highly effective and safe for patients with mAC, with excellent long-term results. In an almost 5-year follow-up of 1000 patients treated with endoscopic resection, there was no mortality and less than 2% had major complications. Endoscopic therapy should become the standard of care for patients with mAC.

Macroscopic Classification of Early Barrett's Neoplasia in 416 Lesions: Prospective Data From the Wiesbaden Barrett's Cancer Register

Macroscopic Classification of Early Barrett’s Neoplasia in 416 Lesions: Prospective Data From the Wiesbaden Barrett’s Cancer Register Oliver Pech, Liebwin Gossner, Josephus Huijsmans, Andrea May, Christian Ell Background: The macroscopic appearance of early gastric cancer according to the Japanese criteria is an important prognostic factor for local endoscopic therapy in these patients. Sofar, there is no standardised classification of neoplasia in Barrett’s esophagus and no prospective data about distribution of the different macroscopic types are available. Patients & Methods: All patients refered to our hospital for endoscopic therapy of early Barrett’s cancer underwent an extensive staging programme including upper high resolution video endoscopy with biopsies of all visible lesions and four-quadrant biopsies and endoscopic ultrasound (EUS) (12.5 or 20 MHz miniprobes). The macroscopic type according to the Japanese classification for early stomach cancer (polypoid tumor (type I), flat and slightly elevated (IIa), flat and level (IIb), flat depressed (IIc), and ulcerated (III)) was defined by an experienced endoscopist. The local tumor stage was confirmed by EUS or endoscopic resection. These data were documented prospectively in an electronic database. Results: 380 patients (323 male, 57 female; mean age 66.6G10.9 years) with Barrett’s neoplasia (416 lesions: high grade dysplasia (HGD) (nZ32), mucosal (nZ343) or submucosal (nZ 41)) were included and documented. The distribution of the macroscopic type was as follows: Type I nZ54 (13%); IIa nZ152 (36.5%); IIb nZ117 (28%); IIc nZ17 (4%); IIa+c nZ69 (16.5%); III nZ7 (2%). 89% of all type IIb lesions were HGD or well differentiated and only 2% had submucosal invasion. Conclusion: This is the first analysis of the macroscopic type of early Barrett’s neoplasia in a large number of patients and demonstrates the distribution in these patients. Harder to detect flat lesions are by far the most frequent neoplasias in Barrett’s esophagus (85%). Type IIb seems to be the most favourable macroscopic type regarding differentiation and local tumor stage.