Long-Segment Barrett’s Esophagus With High-Grade Dysplasia, Early Adenocarcinoma and Recurrence

23 Jun 2021 03:00 05:00
São Paulo
Bruno Zilberstein Host

Patient Profile & Clinical History

  • Patient: 65-year-old white male

  • Smoking History: Non-smoker.

  • Symptoms: Heartburn and regurgitation for 20 years.

  • Dysphagia: No dysphagia and no respiratory symptoms initially.

  • PPI Therapy: Regular use of PPI; 60 mg Dexlansoprazole for the last 3 years.

  • Weight: No weight loss (BMI = 25 kg/m2).

Initial Diagnosis Process

Endoscopy

  • Hiatal Hernia: 2 cm hiatal hernia.

  • Barrett’s Esophagus: C4M6 Barrett’s esophagus (Prague classification).

  • Nodular Area: Nodular area with microvascular pattern alterations.

  • Biopsies: High-grade dysplasia in Barrett’s epithelium.

Imaging

  • CT Scan and Echo-endoscopy: No remarkable findings.

Initial Therapeutic Process

  • Endoscopic Treatment: ESD / resection of the lesion and 60% of the columnar epithelium.

  • Histology: Moderately differentiated adenocarcinoma (T1a).

  • Invasion: Invasion limited to the mucosa.

  • Margins: Lateral and deep margins free of adenocarcinoma.

Follow-up Endoscopy 3 Months After ESD

  • Hiatal Hernia: 3 cm hiatal hernia (Type I).

  • Ulcer: Ulcer in distal esophagus at the previous site of ESD.

  • Recurrent Columnar Epithelium: Recurrent columnar epithelium in distal esophagus.

  • Biopsies: Barrett’s epithelium with intestinal metaplasia without dysplasia.

  • Planned Management: Surveillance endoscopy planned for 2 months, with biopsies/Seattle protocol, and RFA ablation of the Barrett epithelium.

Delayed Follow-up Due to COVID-19 Pandemic

Due to the COVID-19 pandemic, the patient returned to our department only after 14 months, complaining of mild dysphagia.

Endoscopy

  • No stenosis.

  • Lesion A: Elevated lesion on the anterior wall of the distal esophagus. Biopsies (A).

  • Lesion B: Ulcer-infiltrative lesion at the right posterolateral wall of the distal esophagus. Biopsies (B).

  • Hiatal Hernia: 3 cm hiatal hernia (Type I).

Biopsy Results

  • A: Invasive, moderately differentiated adenocarcinoma at the squamous-columnar junction.

  • B: Poorly differentiated carcinoma at the squamous-columnar junction with intestinal metaplasia and high-grade dysplasia in the adjacent columnar mucosa.

PET-CT Scan

  • Finding: 2-3 cm lesion at the GEJ (SUV max 11.2).

  • Lymph Nodes: No suspicious lymph nodal invasion.

Definitive Surgical Treatment

  • Procedure: Subtotal esophagectomy with lymphadenectomy and gastric pull-up.

  • Histology: Poorly differentiated adenocarcinoma at the squamo-columnar junction with intestinal metaplasia and high-grade dysplasia in the adjacent columnar mucosa (pT3pN2M0).

Postoperative Follow-up

  • Postoperative Treatment: Postoperative chemotherapy.

  • Outcome: Six months after surgery, the patient was disease-free without any complication.

Presentation of the Case

Prof. Bruno Zilberstein (FMUSP – Brazil) | Dr Sergio Szachnowicz (FMUSP – Brazil)

Discussion Points

  1. Diagnosis and management of long Barrett’s esophagus with HGD

  2. Endoscopic treatment of early adenocarcinoma

  3. Surveillance after endoscopic treatment of Barrett’s adenocarcinoma

  4. Siewert type I adenocarcinoma: Staging, treatment options, and best practices.

Discussion Leader

Bruno Zilberstein with a top level panel currently being assembled.

Panel for Discussion

Italo Braghetto, Santiago de Chile | Ivan Cecconello, São Paulo | John Clarke, Stanford | Yeong Yeh (Justin) Lee, Kuala Lumpur | Eduardo GH Moura, São Paulo | Matthew Read, Melbourne | Rubens AA Sallum, São Paulo | Andrew Taylor, Melbourne | David Wang, Dallas | Yinglian Xiao, Guangzhou