ESOFAGO DI BARRETT TERAPIA MEDICA & ENDOSCOPICA Massimo Conio Sanremo Massimo Conio Sanremo.

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ESOFAGO DI BARRETT TERAPIA MEDICA & ENDOSCOPICA Massimo Conio Sanremo

Transcript of ESOFAGO DI BARRETT TERAPIA MEDICA & ENDOSCOPICA Massimo Conio Sanremo Massimo Conio Sanremo.

ESOFAGO DI BARRETTTERAPIA MEDICA & ENDOSCOPICA

Massimo Conio

Sanremo

Barrett's Esophagus & HGDBarrett's Esophagus & HGDStrategiesStrategies

Barrett's Esophagus & HGDBarrett's Esophagus & HGDStrategiesStrategies

Passive: surveillance

Active: endotherapysurgerychemoprevention

Passive: surveillance

Active: endotherapysurgerychemoprevention

Barrett's Esophagus & HGDBarrett's Esophagus & HGDBarrett's Esophagus & HGDBarrett's Esophagus & HGD

58 patients follow-up: 10 years

26% invasive cancer 27% “regression”

58 patients follow-up: 10 years

26% invasive cancer 27% “regression”

Gastroenterology 1996

ChemopreventionChemopreventionChemopreventionChemoprevention

COX-2 inhibition

Prostaglandins enhance: Proliferation Angiogenesis Invasiveness Apoptosis inhibition

COX-2 inhibition

Prostaglandins enhance: Proliferation Angiogenesis Invasiveness Apoptosis inhibition

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Years of follow-up

Dys

plas

ia r

ate

%

El-Serag et al., Am J Gastroenterol 2004

0

10

20

30

40

50

60

70

80No PPI Therapy

PPI Therapy

Esophagectomy (40% simultaneous foci of intramucosal cancer) Morbidity 48% Mortality 2-3%

Barrett’s Esophagus with High-Grade Dysplasia

CP1109264-26

Barrett’s with High-Grade Dysplasia On Biopsy. No Visible Lesion.

SCJSCJ

SCJSCJ

SCJSCJ

Barrett's Esophagus;Histologic Maps of Surgical Resections

Barrett's Esophagus;Histologic Maps of Surgical Resections

Barrett's, no dysplasiaLow-grade dysplasiaHigh-grade dysplasiaAdenocarcinoma

CP1109264-27

Photodynamic therapy (PDT)sodium porfimer (Photofrin®)5-aminolevulinic acid

ThermalLaser (Nd:YAG, KTP)Argon Plasma Coagulator (APC)MPEC

MechanicalUltrasonicMicrowave

Cryotherapy

Endoscopic Ablative Therapies For Barrett’s Esophagus With HGD

Esophagus: Japanese dataEsophagus: Japanese data

About 1000 patients

• “En-bloc” (< 3 cm) CR 100%• Piecemeal ( 3 cm) CR 86% (N1:

23%)

About 1000 patients

• “En-bloc” (< 3 cm) CR 100%• Piecemeal ( 3 cm) CR 86% (N1:

23%)

5-year survival 97.9% (surgery: 98%)

Visible nodular abnormalities

Comorbidities/Advanced age

Efficacy to be determined

Endoscopic Mucosal Resection (EMR)Barrett’s Esophagus

When not to do EMRWhen not to do EMR

20 Mhz probe EUS at 7.5 MHz

Superficial cancers

m

sm

pm1

pm2

Oblique aspiration mucosectomy device

Attached to tip of conventional endoscope.

Tanabe et al. Gastrointest Endosc, 2004

Tanabe et al. Gastrointest Endosc, 2004

GROUP A GROUP B

N. Sessions (mean)* 1.3 0.6 2.8 2.0

Complete remission* 97% 59%

Complications 1 spurting 1 oozing*statistically significant

EMR in Barrett’s esophagus with HGD

Ell et al., Gastroenterology 2000

EMR in Barrett’s esophagusEMR in Barrett’s esophagus

Change in the diagnosis: 44%

32% up-staging

Change in the diagnosis: 44%

32% up-staging

Nijhawan et al., Gastrointest Endosc 2000

May 2000 – December 2003:

39 pts (mean age 62.8±11.4 yrs)

Mucosal abnormalities: 36

EUS 20-MHz

May 2000 – December 2003:

39 pts (mean age 62.8±11.4 yrs)

Mucosal abnormalities: 36

EUS 20-MHz

EMR for High-Grade Dysplasia and Intramucosal Cancer

Conio, Repici, Cestari, World J Gastroenterol 2005

Histology of lesionsHistology of lesions

Histology Pre-EMR Post-EMR

LGD - 5 (12.8%)HGD 35 (89.7%) 27 (69.2%)IM. AC 4 (10.3%) 2 (5.1%)Invasive AC - 5 (12.8%)

Change of the original diagnosis 25.6%

EMR for HGD and/or Intramucosal CancerEMR for HGD and/or Intramucosal Cancer

AC sm 3 AC >> Surgery (no residual disease) 2 AC >> Follow-up (cancer free)

ComplicationsBleeding 4 patients (endoscopic treatment) Follow-up (median 20 months)1 recurrence (HGD) >> EMR

AC sm 3 AC >> Surgery (no residual disease) 2 AC >> Follow-up (cancer free)

ComplicationsBleeding 4 patients (endoscopic treatment) Follow-up (median 20 months)1 recurrence (HGD) >> EMR

EMR and PDT in Barrett’s esophagusEMR and PDT in Barrett’s esophagus

Downstaging: 8 (47%)Follow-up 13 months: CR 16 (94%)

Complications: stricture 30%bleeding 6%

Downstaging: 8 (47%)Follow-up 13 months: CR 16 (94%)

Complications: stricture 30%bleeding 6%

Buttar, Gastrointest Endosc 2001

17 patients (EMR 1 cm) (PDT 200J/cm2)

Circumferential EMRCircumferential EMR

Multifocal HGD & IM cancer

5 “visible” and 7 “no visible” lesions Circumferential BE: median length 5 cmComplications: 4/31 EMR sessions (bleeding) Follow-up: no recurrences (median 9 mo)

Multifocal HGD & IM cancer

5 “visible” and 7 “no visible” lesions Circumferential BE: median length 5 cmComplications: 4/31 EMR sessions (bleeding) Follow-up: no recurrences (median 9 mo)

Seewald et al., Gastrointest Endosc 2003

Circumferential EMR in Barrett’s EsophagusCircumferential EMR

in Barrett’s Esophagus

21 pts (19 T1N0; 2 T0N0) EUS 20-MHz Polypectomy snare & saline Circumferential BE: median length 5 cm Complications: 4/21 (bleeding) Follow-up: 2/21 (mean 18 months)

21 pts (19 T1N0; 2 T0N0) EUS 20-MHz Polypectomy snare & saline Circumferential BE: median length 5 cm Complications: 4/21 (bleeding) Follow-up: 2/21 (mean 18 months)

Giovannini et al., Endoscopy 2004

1st endoscope: lifting

2nd endoscope: cutting

Kuwano et al., Ann Surg 2004

Double Endoscopic Intraluminal Operation

(DEILO)

CP1109264-1

Adenocarcinoma of Cardia with Short Barrett’s

SummarySummary

Surveillance finds dysplasia or early cancer New endoscopic diagnostic method EMR: long term results awaited EMR for non-dysplastic Barrett’s

Surveillance finds dysplasia or early cancer New endoscopic diagnostic method EMR: long term results awaited EMR for non-dysplastic Barrett’s