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TERAPIA CHIRURGICA DELLA DISPLASIA GRAVE IN ESOFAGO DI BARRETT

TERAPIA CHIRURGICA DELLA DISPLASIA GRAVE IN ESOFAGO DI BARRETT. Luigi Bonavina,MD Cattedra e U.O. Chirurgia Generale, Policlinico San Donato Università degli Studi di Milano. XXIV Congresso Nazionale A.C.O.I. Montecatini Terme, 27 Maggio 2005. Esophageal adenocarcinoma Melanoma

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TERAPIA CHIRURGICA DELLA DISPLASIA GRAVE IN ESOFAGO DI BARRETT

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  1. TERAPIA CHIRURGICA DELLA DISPLASIA GRAVE IN ESOFAGO DI BARRETT Luigi Bonavina,MD Cattedra e U.O. Chirurgia Generale, Policlinico San Donato Università degli Studi di Milano XXIV Congresso Nazionale A.C.O.I. Montecatini Terme, 27 Maggio 2005

  2. Esophageal adenocarcinoma Melanoma Prostate Cancer Breast Cancer Lung Cancer Colorectal Cancer Rate ratio (relative to 1975) Pohl H, J Natl Cancer Inst 2005

  3. 5-YR SURVIVAL RATES ACC. TO WALL INFILTRATION 90% 80% 1 cm 70% 30%

  4. PREVALENCE OF NODE+ ACC. TO WALL INFILTRATION % Bonavina et al, WJS 2003

  5. GASTROESOPHAGEAL REFLUX DISEASE Barrett’s metaplasia Low grade dysplasia High grade dysplasia (in situ carcinoma) Invasive carcinoma

  6. MOLECULAR EVENTS IN THE SEQUENCE BARRETT’S ESOPHAGUS-ADENOCARCINOMA Diploid cell p53/p16 mutation Clonal expansion and multicentricity Unpredictable molecular alterations (5q,18q,13q) Adenocarcinoma Barrett M, Nature Genetics 1999

  7. HIGH-GRADE DYSPLASIA Dysplasia is the histological expression of genetic alterations that favor cell growth and neoplasia. Glands show severe cytologic atypia, gland complexity with cribriform change and complete loss of nuclear polarity

  8. CUMULATIVE CANCER INCIDENCE 1.0 0.8 HGD # Ca / n = 33/76 p < .001 Negative, Indefinite, LGD # Ca / n = 9/251 0.6 Probability 0.4 0.2 0.0 0 6 12 2 4 8 10 14 Years Reid et al, AJG 2000

  9. HISTOLOGIC CHANGES AFTER TREATMENT OF BE(median F/U > 5 yrs) Parrilla et al, 2003

  10. OUTCOME OF RESECTION ACC. TO SURVEILLANCE Cumulative survival % p< 0.01 months Incarbone et al, Surg Endosc 2002

  11. DIFFICULTIES WITH THE DIAGNOSIS OF HGD • Interobserver agreement is 85% for distinguishing HGD from lesser lesions • There can be substantial disagreement when distinguishing HGD from intramucosal cancer • Dysplastic areas and foci of invasive cancer can be missed by 4-quadrant biopsy technique

  12. EXTENT OF HGD • FOCAL (histologic abnormalities confined to single focus involving up to 5 crypts) • DIFFUSE (abnormalities present in more than 5 crypts or in multiple biopsy specimen) Buttar, 2001

  13. EXTENT OF HGD AND CANCER RISK n=100 4-quadrant biopses every 2 cm Focal4/33 (14%) Diffuse28/67 (56%) p<0.001 Buttar et al., Gastroenterology 2001

  14. RECCOMENDATION OF PRACTICE PARAMETERS COMMITTEE OF A.C.G. “…patients with focal HGD may be followed with intensive endoscopic surveillance (every 3 months), whereas intervention (e.g. endoscopic ablation or esophagectomy) should be considered for patients with diffuse HGD” Sampliner et al, 2002

  15. Can extent of high grade dysplasia in Barrett’s oesophagus predict the presence of adenocarcinoma at oesophagectomy? • Revision of preop biopsy specimen in 42 patients who had esophagectomy for HGD • Acc. to Cleveland Clinic criteria, 48% with focal and 67% with diffuse HGD had cancer (pNS) • Acc. to Mayo Clinic criteria, 72% with focal and 54% with diffuse HGD had cancer (pNS) Dar et al, Gut 2003

  16. RATE OF “OCCULT” INVASIVE CARCINOMA IN HGD

  17. HIGH RATE OF OCCULT CARCINOMA • Erroneous definition of HGD (missed intramucosal ADC) • Inclusion of patients with warning signs (presence of nodules/ulcers) • Failure to f/u closely during the first year (cancer missed at 1st endoscopy because of sampling error)

  18. TREATMENT OF HIGH-GRADE DYSPLASIA • Intensive surveillance • Endoscopic ablation • Endoscopic mucosectomy • Esophagectomy

  19. ENDOSCOPIC MUCOSAL RESECTION FOR HGD/IM-Ca 1.Area of Barrett’s < 20 mm in diameter 2. Cancers confined to the lamina propria 3. Involved peripheral or deep margins or extension through muscularis mucosa require esophagectomy

  20. S.B., male, 62 yr old: S/P endoscopic mucosectomy: invasive adenocarcinoma on the resected specimen

  21. TIMING OF SURGERY AND SURVIVAL Prompt Attitude (n=20) 100 100% 80 Expectant Attitude (n=13) 60 Cancer-related survival (%) 52.5% 40 30 p = 0.0094 0 0 24 48 72 96 120 144 168 192 Romagnoli, JACS 2003

  22. FREQUENCY OF ESOPHAGECTOMY AND HOSPITAL MORTALITY Mortality rate (%) Case load/year Metzger,Dis Esoph 2004

  23. PARTIAL ESOPHAGECTOMY AND JEJUNAL INTERPOSITION • Theoretical drawbacks • High mediastinal anastomosis • Incomplete Barrett’s ablation • Limited clinical experience (Siewert)

  24. NERVE SPARING ESOPHAGECTOMY

  25. LAPAROSCOPIC + TRANS-CERVICAL VIDEOASSISTED MEDIASTINAL DISSECTION Bonavina et al, J Lap Adv Surg Tech, 2004

  26. ADENOCARCINOMA OF EGJ 506 consecutive patients (1992-2004) University of Milano, Department of Surgery (31%)

  27. PATIENTS REFERRED FOR HGDn=30

  28. STAGING PROTOCOL • Operative risk assessment • Repeat endoscopy + Lugol staining • Brushing cytology • 4-quadrant biopsies every cm • Look for nodules/ulcers • EUS/CT scan if doubtful • High-dose PPI if less than HGD • Repeat endoscopy (at 1-3 months)

  29. RESULTS OF STAGING AND THERAPY (n=30) 1st endoscopy: 7 invasive carcinoma (>surgery) 1 LGD 22 HGD (73%) 2nd endoscopy: 5 invasive carcinoma (>surgery) 1 LGD 17 HGD (57%) 15 surgery (9 TME, 6 TTE) 1 PDT 1 PPI therapy

  30. RESULTS OF ESOPHAGECTOMY FOR HGD n=15 • No operative mortality • Morbidity • 2 atelectasis • 1 chylothorax • Pathology • 1 LGD • 4 invasive carcinoma (27%) • 10 confirmed HGD

  31. ESOPHAGECTOMY FOR HGD Actuarial survival (n=15)

  32. ONGOING RESEARCH PROTOCOLS Endoscopic peritumoral ink injection Laparoscopic nodal removal Histopathological assessment Tailored lymphadenectomy based on the sentinal node concept

  33. CONCLUSIONS Prevalence of adenocarcinoma detected at endoscopy was 40% in patients referred with diagnosis of HGD 27% of patients with confirmed endoscopic diagnosis of HGD had cancer in the resected specimen E.M.R. should be recommended only in patients with low likelihood of lymphatic spread Videoassisted transmediastinal esophagectomy is the approach of choice in intramucosal tumors

  34. “Surgery remains radical prophylaxis.…offering a massive macroscopic morbid solution for a microscopic mucosal problem” Barr, Gut 2003; 52:14-5

  35. FUTURE SCENARIO • Improved reflux control by fundoplication • Barrett’s ablation and chemoprevention of genomic instability (Aspirin?) • Tailored surgical approach (vagal sparing procedures, sentinel node technology)

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