Manner Hendrik, May Andrea, Pech Oliver, Gossner Liebwin, Rabenstein Thomas, Günter Erwin, Vieth Michael, Stolte Manfred, Ell Christian
Department of Internal Medicine II, HSK Wiesbaden, Wiesbaden, Germany.
Am J Gastroenterol. 2008 Oct;103(10):2589-97. doi: 10.1111/j.1572-0241.2008.02083.x. Epub 2008 Sep 10.
Endoscopic therapy (ET) has become a less risky alternative to open surgery in mucosal Barrett's cancer (BC) because of the very low risk of lymph node (LN) metastasis. Recently published surgical series demonstrated that even in case of minimal submucosal invasion of BC, the risk for LN metastasis is very low. In consequence, also these patients might be eligible for curative ET. The aim of this study was to prospectively evaluate the efficacy and safety of endoscopic resection (ER) in these patients.
From September 1996 to September 2003, the suspicion or definite diagnosis of submucosal BC was made in 80 patients referred to our department. Of those, 21 patients (20 male [95.2%], mean age 62 +/- 9 yr, range 47-78) fulfilled the definition of "low-risk" submucosal cancer: invasion of the upper submucosal third (sm1), absence of infiltration into lymph vessels/veins, histological grade G1/2, and macroscopic type I/II. ET was carried out using ER with the suck-and-cut technique with or without an additive ablation of non-neoplastic remnants of Barrett's esophagus.
One of the 21 patients was referred to surgery directly after the detection of sm1 invasion at the beginning of the study. One patient died (not tumor-related) before completion of ET. Using definitive ET, complete remission (CR) was achieved in 18 of 19 patients (95%) after a mean of 5.3 months (range 1-18) and a mean of 2.9 resections (range 1-9). Only one minor complication (bleeding without drop in hemoglobin level >2 g/dL) occurred (5% of patients). During a mean follow-up (FU) of 62 months (range 45-89), recurrent or metachronous carcinomas were found in 5 patients (28%). Repeat ET was carried out successfully using ER (4 patients) and argon plasma coagulation (1 patient). In one of the 19 patients (5%), tumor freedom had not been achieved after a total of 2 ER. This patient died of a heart attack before surgery could be performed. The calculated 5-yr survival rate of all 21 patients was 66%. No tumor-related death occurred.
As in mucosal BC, ER is associated with favorable outcomes even in case of "low-risk" submucosal BC. Further and larger clinical trials are required before a general recommendation for ER as the treatment of choice in "low-risk" submucosal BC can be given.
由于淋巴结转移风险极低，内镜治疗（ET）已成为黏膜型巴雷特癌（BC）开放性手术的一种风险较低的替代方案。最近发表的手术系列研究表明，即使是BC黏膜下侵犯程度极小的病例，淋巴结转移风险也非常低。因此，这些患者也可能适合接受根治性ET。本研究的目的是前瞻性评估内镜切除术（ER）在这些患者中的疗效和安全性。
1996年9月至2003年9月，80例转诊至我科的患者被怀疑或确诊为黏膜下BC。其中，21例患者（20例男性[95.2%]，平均年龄62±9岁，范围47 - 78岁）符合“低风险”黏膜下癌的定义：侵犯黏膜下层上三分之一（sm1），无淋巴管/静脉浸润，组织学分级G1/2，以及大体类型I/II。ET采用吸切技术进行ER，可加用或不加用对巴雷特食管非肿瘤性残余组织的消融。
在研究开始时，21例患者中有1例在检测到sm1侵犯后直接转诊至外科手术。1例患者在ET完成前死亡（与肿瘤无关）。采用确定性ET，19例患者中有18例（95%）在平均5.3个月（范围1 - 18个月）和平均2.9次切除（范围1 - 9次）后实现完全缓解（CR）。仅发生1例轻微并发症（出血但血红蛋白水平下降未超过2 g/dL）（占患者的5%）。在平均62个月（范围45 - 89个月）的随访（FU）期间，5例患者（28%）发现复发或异时性癌。采用ER（4例患者）和氩等离子体凝固术（1例患者）成功进行了重复ET。19例患者中有1例（5%）在总共2次ER后仍未实现无瘤状态。该患者在手术前死于心脏病发作。计算得出的21例患者的5年生存率为66%。未发生与肿瘤相关的死亡。
与黏膜型BC一样，即使是“低风险”黏膜下BC，ER也具有良好的治疗效果。在能够普遍推荐ER作为“低风险”黏膜下BC的首选治疗方法之前，还需要进一步开展更大规模的临床试验。
