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The impact of endoscopic ultrasound findings on clinical decision making in Barrett's esophagus with high-grade dysplasia or early esophageal adenocarcinoma

Authors

  • W. J. Bulsiewicz,

    Corresponding author
    1. Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
    • Address correspondence to: Dr William J. Bulsiewicz, MD, MSc, Center for Esophageal Diseases and Swallowing University of North Carolina School of Medicine, CB 7080, Chapel Hill, NC 27599-7080, USA. Email: wbulsiew@med.unc.edu

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  • E. S. Dellon,

    1. Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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  • A. J. Rogers,

    1. Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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  • S. Pasricha,

    1. Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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  • R. D. Madanick,

    1. Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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  • I. S. Grimm,

    1. Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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  • N. J. Shaheen

    1. Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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  • Grant Support: This research was supported, in part, by award number T32 DK07634 from the National Institutes of Health and award number KL2RR025746 from the National Center for Research Resources.
  • Authors Contributions

    Conception and design: William J. Bulsiewicz, Evan S. Dellon, Ryan M. Madanick, Ian S. Grimm, Nicholas J. Shaheen.

  • Analysis and interpretation of the data: Willian J. Bulsiewicz, Evan S. Dellon, Albert J. Rogers, Sarina Pasricha, Nicholas J. Shaheen
  • Drafting of the article: William J. Bulsiewicz, Evan S. Dellon, Albert J. Rogers, Nicholas J. Shaheen.
  • Conflict of Interest Disclosure: Dr. Shaheen reports research grants from BARRX Medical, Oncoscope, CSA Medical, Takeda, and AstraZeneca. He is a consultant for CSA Medical, AstraZeneca, Takeda, Oncoscope, and NeoGenomics. Dr. Dellon reports a research grant from AstraZeneca and is a consultant for Oncoscope. No conflicts of interest exist for William Bulsiewicz, Albert Rogers, Sarina Pasricha, Ryan Madanick, and Ian Grimm.

Summary

The clinical utility of endoscopic ultrasound (EUS) for staging patients with Barrett's esophagus and high-grade dysplasia (HGD) or intramucosal carcinoma (IMC) prior to endoscopic therapy is unclear. We performed a retrospective analysis of patients with HGD or IMC referred to an American medical center for endoscopic treatment between 2004 and 2010. All patients had pretreatment staging by EUS. We examined the frequency that EUS findings consistent with advanced disease (tumor invasion into the submucosa, lymph node involvement, or regional metastasis) led to a change in management. The analysis was stratified by nodularity and pre-EUS histology. We identified one hundred thirty-five patients with HGD (n = 106, 79%) or IMC (n = 29, 21%) had staging by EUS (79 non-nodular, 56 nodular). Pathologic lymph nodes or metastases were not found by EUS. There were no endosonographic abnormalities noted in any patient with non-nodular mucosa (0/79). Abnormal EUS findings were present in 8/56 patients (14%) with nodular neoplasia (five IMC, three HGD). Endoscopic mucosal resection was performed in 44 patients with a nodule, with 13% (6/44) having invasive cancer. In nodular neoplasia, the EUS and endoscopic mucosal resection were abnormal in 24% (5/21) and 40% (6/15) of those with IMC and 9% (3/35) and 0% (0/29) of those with HGD, respectively. In this study we found that EUS did not alter management in patients with non-nodular HGD or IMC. Because the diagnostic utility of EUS in subjects with non-nodular Barrett's esophagus is low, the value of performing endoscopic mucosal resection in this setting is questionable. For patients with nodular neoplasia, resection of the nodule with histological examination had greater utility than staging by EUS.

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