Occult esophageal adenocarcinoma - Extent of disease and implications for effective therapy

Objective The need for esophagectomy in patients with Barrett's esophagus, with no en doscopically Visible lesion, and a biopsy showing high-grade dysplasia or a denocarcinoma has been questioned. Recently, endoscopic techniques to ablat e the neoplastic mucosa have been encouraged. The aim of this study was to determine the extent of disease present in patients with clinically occult esophageal adenocarcinoma to define the magnitude of therapy required to ac hieve cure. Methods Thirty-three patients with high-grade dysplasia (23 patients) or adenocarci noma (10 patients) and no endoscopically visible lesion underwent repeat en doscopy and systematic biopsy followed by esophagectomy. The surgical speci mens were analyzed to determine the biopsy error rate in detecting occult a denocarcinoma. In those with cancer, the depth of wall penetration and the presence of lymph node metastases on conventional histology and immunohisto chemistry staining was determined. The findings were compared with those in 12 patients (1 with high-grade dysplasia, 11 with adenocarcinoma) who had visible lesions on endoscopy. Results The biopsy error rate for detecting occult adenocarcinoma was 43%. Of 25 pa tients with cancer and no visible lesion, the cancer was limited to the muc osa in 22 (88%) and to the submucosa in 3 (12%). After en bloc esophagectom y, one patient without a visible lesion had a single node metastasis on con ventional histology. No additional node metastases were identified on immun ohistochemistry. The 5-year survival rate after esophagectomy was 90%. Pati ents with endoscopically visible lesions were significantly more likely to have invasion beyond the mucosa (9/12 vs. 3/25, p = 0.01) and involvement o f lymph nodes (5/9 vs. 1/10, p = 0.057). Conclusions Endoscopy with systematic biopsy cannot reliably exclude the presence of oc cult adenocarcinoma in Barrett's esophagus. The lack of an endoscopically v isible lesion does not preclude cancer invasion beyond the muscularis mucos ae, cautioning against the use of mucosal ablative procedures. The rarity o f lymph node metastases in these patients encourages a more limited resecti on with greater emphasis on improved alimentary function (esophageal stripp ing with vagal nerve preservation) to provide a quality of life compatible with the excellent 5-year survival rate of 90%.