Outcomes after Endoscopic Mucosal Resection for T1a Esophageal Adenocarcinoma with Suggested Algorithm for Management

BACKGROUND: Esophageal adenocarcinoma (EAC) is a well-known complication of Barrett’s esophagus (BE). The ASGE, AGA, and ACG have established guidelines regarding the diagnosis, management and surveillance of patients diagnosed with BE.  Endoscopic mucosal resection (EMR) is an acceptable therapeutic option for T1a EAC versus esophagectomy. However, no clear guidelines exist regarding the management and follow up of patients with early EAC after EMR. The purpose of this study is: (1) to better define the outcome of EMR for T1a EAC; (2) to analyze the characteristics of our BE patients that underwent EMR for EAC; 3) to evaluate repeat EMR for positive margins of EAC in initial resection specimens. METHODS: A retrospective cohort study was conducted of patients at a tertiary care center with BE patients with early EAC who underwent EMR. The electronic medical record was reviewed to collect the following data: age, sex, age at diagnosis of BE and EAC, length of BE segment, pathology results, and imaging. RESULTS: 31 patients with BE who underwent EMR for early EAC were assessed. 29 (93.55%) were male. The median age was 67 ± 9.7 years. The median ages at BE and EAC diagnoses were 63 ± 10.5 years and 63 ± 10.3 years, respectively. The length of BE segments ranged from u003c 1 cm to 14cm and 17 (54.84%) patients had short segment BE. 19 (61.29%) patients had EAC diagnosed on their first EGD at our institution. On pathology, 8 (25.81%) EMR specimens had margins positive for EAC. 7 (87.5%) of these patients underwent repeat EMR; 5 were successful and 1 required esophagectomy for persistently positive margins. 26 (83.86%) patients had PET/CT after EMR, 4 (15.38%) of which were positive. Overall, 2 (6.45%) patients had EAC recurrence, occurring at 70 and 71 months; both had successful repeat EMR. Mean length of follow up at our institution was 29.1 ± 21.9 months (range 2-87 months). CONCLUSIONS: BE is a known risk factor for EAC. Our study suggests BE patients with early EAC who undergo EMR have a low rate of EAC recurrence. In our population, short segment BE also carried a risk for EAC and should not be de-emphasized. EMR specimens with margins positive for EAC can be successfully managed with repeat EMR.