Liebwin Gossner

KTP laser destruction of dysplasia and early cancer in columnar-lined Barrett's esophagus

BACKGROUNDnThe rising incidence of esophageal adenocarcinoma in western countries requires a new strategy in the management of dysplasia in Barretts esophagus. Esophagectomy, which has high morbidity and mortality rates, has been recommended to treat patients with severe dysplasia. Strictly superficial laser coagulation with tissue ablation therefore is a desirable option for the management of dysplasia in Barretts esophagus because the tissue to be ablated is only about 2 mm thick. Potassium-titanyl-phosphate (KTP) laser light with a wavelength of 532 nm is preferentially absorbed by hemoglobin and therefore combines excellent coagulation with limited tissue penetration. We report first clinical results with KTP laser superficial vaporization of dysplasia and early cancer in Barretts esophagus.nnnMETHODSnEight men and 2 women 43 to 84 years of age with short segments of Barretts esophagus or traditional Barretts esophagus and histologically proved low-grade (n = 4) and high-grade (n = 4) dysplasia or early adenocarcinoma (n = 2) were selected for this pilot study. For all patients thermal endoscopic destruction was conducted with a frequency-doubled neodymium:yttrium-aluminum-garnet (Nd:YAG) KTP laser system. Laser therapy was performed by means of the free-beam method with coaxial insufflation of gas. An average of 2.4 sessions per patient were required for ablation of the Barretts mucosa.nnnRESULTSnTwo to three days after laser treatment the response of the ablated mucosa was assessed with endoscopy and biopsy. Samples taken showed fibrinoid necrosis of the mucosal layer. A complete response was obtained for all 10 patients. Replacement by normal squamous cell epithelium was induced in combination with acid suppression therapy of up to 80 mg omeprazole daily. No complications occurred. In two patients biopsy showed specialized mucosa beneath the restored squamous cell epithelial layer. Follow-up times were as long as 15 months (mean value 10.6 months).nnnCONCLUSIONSnKTP laser destruction of Barretts esophagus induced mucosal regeneration with normal squamous cell epithelium in combination with acid suppression. Limitation of the depth of thermal destruction in Barretts esophagus minimizes risk for perforation or stricture formation. KTP laser ablation of Barretts esophagus seems to be feasible and safe in short segments of Barretts esophagus with dysplasia or early cancer.

Endoscopic Resection of Superficial Esophageal Squamous-Cell Carcinomas: Western Experience

OBJECTIVES:Endoscopic resection of esophageal squamous-cell neoplasia with curative intent appears to be an alternative treatment to radical surgery when the malignant neoplasia is intraepithelial or limited to the mucosal layer, since the risk for lymph-node metastases is very low. In contrast to Japan, there has so far been only limited experience in Europe and the United States with endoscopic resection in such cases. In the present observational study, we report on the largest prospective series so far in Western countries of patients with early squamous-cell cancer or carcinoma in situ, who were treated using endoscopic resection therapy.METHODS:Between December 1997 and November 2001, 115 patients with a suspicion of early squamous cancer were referred for local endoscopic therapy. A total of 39 patients (mean age 61.4 ± 10.2 yr) with early esophageal carcinoma (n = 29) and carcinoma in situ (Cis) (n = 10) fulfilled the criteria for local endoscopic therapy and were treated using endoscopic resection. Ten patients had Cis (group A), 19 had mucosal cancer (group B), and 10 had submucosal cancer (group C). All patients in group C were inoperable or had refused surgery.RESULTS:A total of 94 resections were performed. Nine of the 10 patients in group A (90%), 19 of the 19 in group B (100%), and 8 of the 10 in group C (80%) achieved a complete response during a mean follow-up period of 29.7 ± 14.3 months. Tumor-related deaths occurred in three patients (one in group B, who was inoperable; two in group C, who refused surgery). No major complications such as perforation or bleeding requiring blood transfusion occurred. Minor complications were seen in six patients (15%)—three with minor bleeding after endoscopic resection and three with esophageal stenoses, who were successfully treated using injection therapy or dilatation. Calculated 5-yr survival was 90% in group A, 89% in group B, and 0% in group C.CONCLUSIONS:Endoscopic resection appears to be an effective and safe method of curative treatment in patients with Cis and mucosal squamous-cell carcinomas of the esophagus. The preferred method in patients with submucosal cancer should be esophagectomy or chemoradiotherapy, whenever possible.

Early Neoplasia in Barrett’s Esophagus

Over the last 10–20 years, the incidence of adenocarcinomas in Barrett’s esophagus has increased enormously in many Western countries [1]–[5]. The increase in these countries is greater than that of all other malignant epithelial tumors, so that the term “new epidemic” has even been applied [6].