Case 2: click here for Powerpoint presentation (with voice-over).
Analysis case 2: click here for Powerpoint presentation (with voice-over)
do an early radical surgical approach treatment of this patient with multiple visible esophageal endoscopic cancer will avoid lymph node and liver metastasis, and improve the survival of the patient ?
Completely agree with Dr Rabago Torre, this young patient would have had a better opportunity of survival, and a more cost effective approach without all the acrobatics. Having multifocal abnormalities in this very long Barret’s was really a strong indication for radical surgery.
Even after embarking in the endoscopic treatment, giving precedence to the RFA treatment and leaving the second lesion with evidence of HGD and EAC was ill advised.
But anyway this patient had a very clear indication for surgical treatment from the index endoscopy
Thank you for looking at this case and sharing your thoughts. As a member of the training program committee, I would like to respond to your comments.
This particular case was an old case originating from 2007/2008, when knowledge of endoscopic therapy was less extensive as it is currently. In 2008, the care for patients with Barrett’s Esophagus in the Netherlands was just centralized in Barrett Expert Centers with a joint protocol to improve our clinical outcomes and patient management.
To Luis and Carlos:
Looking back on this case, we understand your opinion to advice immediate referral for surgery for this patient with multiple neoplastic lesions throughout the Barrett segment. Nevertheless, his stepwise treatment, although complicated, was within the confines of guidelines for endoscopic treatment. In the PowerPoint presentation you can see how we have critically reflected on every step of this patient’s treatment.
The key feature here was the endoscopic resection of a pop-up lesion at the end of the treatment phase that showed a mucosal cancer with high-risk features. At that time decision making was guided by the diagnosis of “mucosal” cancer. A recent study however has shown that high-risk mucosal cancers (such as in this case with a partially poorly differentiated mucosal cancer) the risk for lymph node and/or distant metastasis is comparable to that of submucosal cancers with high-risk features. For this patient an earlier restaging with EUS might had identified the local lymph node metastasis that were now detected at a later stage.
Our thoughts and take home messages on this case are further explained in the analysis-presentation (see above).
The next case from this series of challenging cases will be available soon!
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