A 48-year-old man with known Barrett's oesophagus (long-segment, 6 cm) undergoes surveillance endoscopy. Biopsies from a nodular area confirm intramucosal adenocarcinoma (T1a, no submucosal invasion, no lymphovascular invasion). The most appropriate management is:
- A Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) with subsequent radiofrequency ablation (RFA) of residual Barrett's mucosa ✓
- B Oesophagectomy (Ivor Lewis procedure)
- C Surveillance endoscopy in 3 months without intervention
- D Chemoradiation followed by re-endoscopy in 8 weeks
Explanation
T1a (intramucosal) oesophageal adenocarcinoma has extremely low risk of lymph node metastasis (<2%) when confined to the mucosa without lymphovascular invasion. Endoscopic resection (EMR for lesions <2 cm, ESD for larger/poorly defined lesions) achieves R0 resection with cure rates >95% — comparable to surgery but with far less morbidity. Following complete resection of the dysplastic/cancerous nodule, radiofrequency ablation of the remaining Barrett's segment reduces the risk of metachronous neoplasia. Oesophagectomy is reserved for T1b (submucosal) or higher T-stage disease where LN risk exceeds 20%. BSG/ESGE guidelines endorse endoscopic therapy as the gold standard for early (T1a) Barrett's neoplasia.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.