Case 1: click here for Powerpoint-presentation (with voice-over).
Analysis Case 1: click here for Powerpoint-presentation (with voice-over).
Dear staff of of BEST Academia,
Thank you for this very interesting case. In this case, in my opinion, at the T-9 mo, when irregular area was observed in the retroflexed position, in the area of the prior ER, and biopsy have shown the G3 (poorly diff. adeno Ca), it was the indication for proceeding directly to surgery (esophagus-cardia-resection), not for endoscopic resection. I think the G3 tumor is contraindication for endoscopic resection (like in cases of sessile malignant colonic polyp or early adeno Ca of stomach).
Dear staff of BEST Academia
thank you for this interesting case. I agree with dr Spoznikov, possibly it would have been better to go straight for surgery at 9 mo.
Nevertheless, the whole therapy-process can be seen as a success!
I did not see Barrett’s esophagus, the native photo of the lesion is not informative, I see only a thickening of the mucosa, there are no images of EUS and CT, multiple fragmentary resections …
Many thanks for a very interesting and really challenging case.
Several questions if you please:
1. Do you think that the patient initially had two lesions, G1 and G3, and one of them was overlooked?
2. How you can explain the wrong EUS staging (EUS usually can differentiate T0 and T3 tumors) – difficult location or something else?
3. Taking into consideration the final result, do you now recommend to take a biopsy from a scar after endoscopic resection for cancer in Barret’s esophagus?
Dear BEST-Academia Team, sorry for sharing my concerns for this patient management. From the beginning it looked like a lesion not resectable with standard EMR techniques and probably not amenable at all for endoscopic resection. This approach has significantly delayed surgical treatment and exposed the patient to risk of local/distant cancer diffusion. It’s really strange you show this as a training case.
Thankyou, interesting real life case which demonstrates the importance of close endoscopic follow up in these patients. The initial cardia lesion looked bulky and suspicious for submucosal invasion. I am surprised by subsequent initial histology but would have had a very low threshold for performing biopsies at the first post EMR FU (at 3 months) rather than rush into RFA. The photos at 3 months showed once again suspicion of a bulky submucosal lesion and it was an error to rush into performing RFA. Lessons: histology may be misleading, close endoscopic FU after resection essential, don’t rush to perform RFA after ER. The cardia can be a tricky area for both assessment and treatment. The ongoing endoscopic FU ensured a successful outcome in the end but curative surgery delayed by at least 6 months.
The 1st endoscopic image on retroversion looks ominous to me. It is a large lesion with some distortion of GEJ and I think it is more of a sessile lesion rather than IIa/b. I am not surprised that the histology was upstaged from HGD to Ca. This was reseted in 2 pieces with R0 vertical margin, unclear of lateral margins. 1st FU EGD in 3 months there was mucosal irregularity assumed incomplete healing not biopsied but went on for RFA. There could have been a residual ca here that was treated with RFA. Subsequently invasive poor differentiated ca diagnosed.
In my current practice in such a high risk lesion I would have opted for wide margin Enbloc resection with ESD that would have given accurate staging and excision.
Great case and thank you all. I hope you are all well. I was not convince that this was a Barretts cancer, but more of an OGJ adenocarcinoma in a sessile nodule which was partly under the squamous epithelium. The rest is history and an ESD would be have been great. Can you please show the before and after photos, after the 1st ER at T-0 to reveal how much ER was done?
Thank you very much for looking at the case and sharing your thoughts. As members of the training program committee we would like to respond to you all.
We believe that sharing endoscopic cases is one of the most valuable ways to share knowledge. Next to sharing text-book cases of endoscopic procedures, we believe that it is also equally important to share the difficult and complicated cases. These complicated ‘real-life’ cases contain important lessons for gastroenterologists during their care for patients with Barrett’s related neoplasia, and also stimulate viewers to reflect on difficult cases.
We aim for this platform to be a safe place, where cases can be shared and openly discussed, without criticism or judgement. We think it is valuable to evaluate these challenging cases to learn from each other. To start off on this platform, we will be sharing cases from a registry, which included patients treated for BE-neoplasia from 2008 in the Netherlands. This registry includes 1348 patients of which 94% achieved complete eradication of Barrett’s Esophagus at the end of the treatment period. 1% of the patients showed progression of disease that exceeded the boundaries for curative endoscopic treatment. The presented cases originate mainly from this 1%.
Our thoughts and take home messages on this case are explained in the Analysis-presentation (see above). In summary, we advise not to proceed with RFA-treatment if incomplete healing of the esophagus is seen, to prevent neoplasia from being missed by the endoscopist and delay in the treatment.
To Boris and Jos:
We do not consider G3 in biopsies to be a definite indication for surgery. The definition of differentiation grade is based upon how much of the specimen shows glandular formation, 5th edition GE WHO blue book p41: G1 >95% gland formation; G2 50-95% gland formation; G3<50% gland formation. So this definition is very dependent on the size of the tissue specimen. A biopsy that hit the ugliest part of the lesion may be G3, however, this may be only a small fraction of the whole lesion. Therefore, we always assess if endoscopic resection is still possible technically, to obtain a proper tissue specimen for accurate histological diagnosis.
This indeed a very short Barrett segment, but given the presence of a small tongue of Barrett’s mucosa in the distal oesophagus and intestinal metaplasia in biopsies, we did diagnose it as such. In such a case, we never perform EUS or CT before diagnostic endoscopic resection. For this, I refer you to the powerpoint presentations on work-up and endoscopic resection on this website.
1. Good hypothesis, however, adequate inspection was performed prior to the endoscopic resection and all visible lesions were resected. Also, the recurrence was in the scar of the prior resection.
2. EUS staging was only performed to assess lymph nodes, and not to assess T-stage. This would have been difficult also, since the lesion was very small and at a difficult location to assess with EUS.
3. The short answer is no, only take biopsies in case of endoscopic abnormalities as in this case. So if you are in doubt, take biopsies, but if it looks normal, biopsies have a low yield. But you are right that in this particular case, biopsies may have identified the cancer earlier.
Thank you for your critical comment. As mentioned above, we choose to share and discuss these challenging cases to reflect and learn from each other. Furthermore, the lesion was more extensively imaged than the picture that is demonstrated. Indeed the lesion may appear a bit bulky, however, the endoscopists performing the procedure, with ample experience in assessing such lesions, did judge the lesion as endoscopically resectable. Also, based on the first histological outcome, there was no suspicion on deep submucosal invasion.
To Sean and Krish:
Thank you for the lessons and recommendations. One of our main lessons from this case is indeed not to rush into RFA after ER, in case of incomplete healing or doubtful areas in the esophagus. Also, a thorough check after ER is of the utmost importance. Nowadays, if suspicion on submucosal invasion is present and/or the lesion is too large for ER-cap, performing or referring for ESD is indicated and could be a good alternative in this case.
The second case from this series of challenging cases will be available soon.
We hope to see you at the next case discussion!
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