|International Session (Panel Discussion)1 (JGES・JSGE・JSGS)|
|Sat. October 14th 9:00 - 11:20 Room 11: Fukuoka International Congress Center 502+503|
|DIAGNOSIS AND TREATMENT OF SUPERFICIAL BARRETT'S ESOPHAGEAL CANCER: QUESTIONS TO CLARIFY|
|E. D. Fedorov|
|Moscow University Hospital N31|
|The incidence of esophageal adenocarcinoma (EAC) has been increasing 6-fold and accounts for 60-70% of esophageal cancers in the West. The presence of Barrett's esophagus (BE) conferred a relative risk of EAC of 11.3 over that of the general population. In Japan SCC accounts for >90% of esophageal cancers, while the proportion of EAC remains around 1-2%; however the incidence of GERD has been increasing rapidly, with a similar trend in the incidence of EAC. According to the West studies SSBE has an extremely low oncogenic risk. In Japan the clinical situation is contrary: EAC is associated with SSBE in 44.9% and many of them are not accompanied by intestinal metaplasia, indicating unique "East-genomic" EAC, or just definition's differences? Intriguing, recent trials have indicated a lower incidence rate of EAC in classical "West" BE. Moreover, up to 97% of EAC are arising in undiagnosed Barrett's!
BE-associated neoplasia can be scattered, flat and could be easily missed. The sensitivity of detecting may be improved by HD-magnification endoscopy with acetic acid. Optical electronic high-resolution "chromoendoscopy" has been used to obtain more detailed imaging of the vasculature and mucosa and thus to improve the efficiency of sampling. A metaanalysis demonstrated an increased diagnostic yield of 34%. Computer-aided detection provides an even higher level of accuracy. Probe-based confocal laser endomicroscopy enhance detection of BE-associated dysplasia compared with HD-WLE (sensitivity: 96% vs. 40%). Pilot studies demonstrate increased yield of high-resolution microendoscopy. Volumetric laser endomicroscopy with laser marking allows for comprehensive assessment of a significant length of esophagus and can effectively distinguish abnormal epithelium with the accuracy 87%. Wide area transepithelial sampling increase dysplasia detection rate by 39.8% in addition to random biopsy protocol.
Endoscopic resection should be used for the treatment and staging of all visible superficial dysplastic lesions in BE. The role of ESD in EAC is evolving, demonstrating a high level (88-89%) of R0 resections and low rate of severe complications. ESD may be considered for lesions where EMR is unable to achieve en-bloc resection and for lesions at risk for submucosal invasion. Obviously as we mastering the technique of ESD, it will be increasingly used to remove EAC. Ablative techniques, such as radiofrequency ablation, APC or cryotherapy each have a limited role as monotherapy with curative intent, but they are applicable for ablation of residual metaplasia following resection.