Optimizing and personalizing Barrett’s neoplasia management Facilitating future transition

In recent years, the incidence of esophageal cancer, particularly adenocarcinoma, has risen significantly in Western countries. Barrett’s Esophagus (BE) is a recognized precursor to this malignancy. Patients with BE are regularly monitored through endoscopy to detect abnormal cells or cancer at an early, treatable stage. A combined therapeutic approach comprising of endoscopic resection of abnormalities and ablation of Barrett’s mucosa has been demonstrated to be both effective and safe for patients with low-grade dysplasia, high-grade dysplasia, or early esophageal cancer. Part 1 of this dissertation introduces endoscopic eradication therapy (EET), addresses common procedural errors in managing Barrett’s-related neoplasia and provides practical recommendations for endoscopists to mitigate these errors.
Part 2 examines the expansion of endoscopic treatment criteria for esophageal cancer. It evaluates the outcomes of endoscopic submucosal dissections (ESD) in the Netherlands and evaluates the risk of residual neoplasia in patients with non-radical (R1) resections, i.e. presence of tumor cells in the deep resection margin following endoscopic therapy. ESD has proven safe and effective for the removal of (deep) invasive submucosal tumors. Furthermore, the studies indicated that only half of the patients with R1 resections were diagnosed with residual tumor tissue, suggesting that current recommendations for additional surgery after R1 resection may lead to overtreatment of some patients. Furthermore, the importance of expert centers for managing patients with ultra-long Barrett segments, given their higher risk of neoplastic progression, is also discussed.
Part 3 focuses on personalized care following successful endoscopic treatment for Barrett’s-related neoplasia. The natural progression course of untreated dysplasia to a symptomatic cancer stage was evaluated. Additionally, the risk of mortality from non-esophageal cancer causes was evaluated in the population of patients after successful EET, which was nearly 40 times greater than mortality from esophageal cancer recurrence. The Charlson Comorbidity Index proved useful in predicting this mortality risk. These studies may offer valuable insights for future treatment strategies.