Keywords
Barrett's esophagus - adenocarcinoma - esophageal varices - endoscopic procedures
Case Report
A 67-year-old male with a recent diagnosis of a biopsy proven moderately differentiated
early adenocarcinoma arising from a short Barrett's segment (Prague classification
C0M1) was referred to our unit for endoscopic resection. He had history of stroke
and compensated nonalcoholic steatohepatitis cirrhosis, Child-Pugh A (5 points), and
Model for End-Stage Liver Disease score of 12 points. A computed tomography scan and
endoscopic ultrasound was previously performed to exclude loco-regional and distant
metastasis. Endoscopy revealed esophageal varices and a 5 mm flat lesion (Paris Classification
0-IIb) located close to the gastroesophageal junction at 35 cm from incisors, 5 o'clock
position over a variceal column ([Fig. 1]). The case was discussed with the hepatology team and in the upper gastrointestinal
cancer multidisciplinary meeting. Options including transinternal jugular portosystemic
shunt stent to reduce portal pressure and perform endoscopic resection were considered.
However, in view of the urgency to treat the cancer and the lesion being small, it
was decided to adopt the “band and leave” strategy. The lesion was marked using an
Argon Plasma Coagulation catheter and a single band (6 Shooter Saeed Multi-Band Ligator,
Cook Medical, Ireland) was applied to the target lesion. The remaining esophageal
varices were also treated in the same session with a total of five bands. After 6
months, endoscopy surveillance showed small varices and a scar with biopsies free
of malignancy ([Fig. 1]). At the time of this report 2 years after the treatment, the patient is still alive
and recurrence free.
Fig. 1 (A) Esophagus varices. (B) Short Barret's tongue 5 o'clock position with an area suspicious of malignancy (white
arrow). (C) Narrow band imaging magnification view of target lesion. (D) Histology of suspicious lesion showing highly atypical glandular structures compatible
with adenocarcinoma (hematoxylin eosin stain) (black circle). Therapeutic approach:
(E) Marked lesion with argon plasma catheter; (F) band applied. Surveillance endoscopy: (G) Scar area with no evidence of malignancy and squamous regeneration of the Barrett's
tongue; (H) small varices collapsed (7 o'clock position) with CO2 insufflation.
Endoscopic band ligation is the preferred endoscopic technique for endoscopic treatment
of acute esophageal variceal bleeding and secondary prophylaxis. “Band and leave”
strategy has been described for endoscopic treatment of small submucosal tumors, avoiding
resection and thus the risks of perforation and bleeding associated with the conventional
endoscopic resection techniques.[1]
[2]
[3] Salord et al also described a case report using this technique for the removal of
a T1 esophageal squamous tumor.[4] The tight rubber band causes ischemic necrosis followed by spontaneous sloughing
and re-epithelization. Size of the tumor and esophageal fibrosis from previous banding
can represent a limitation for this technique since it may not achieve complete ischemia
of the target lesion and subsequent relapse or difficulty in including the entire
lesion within the band. To our knowledge, this is the first case report of a successful
treatment of an early esophageal adenocarcinoma in a patient with underlying esophageal
varices. We propose this technique as an alternative therapeutic option for the management
of early Barrett's neoplasia in such high-risk patients with portal hypertension.
