Sa1563 The Clinical Utility of Endoscopic Ultrasound Before Ablation in Patients With Barrett's Esophagus and High-Grade Dysplasia or Intramucosal Carcinoma

Sa1563 The Clinical Utility of Endoscopic Ultrasound Before Ablation in Patients With Barrett’s Esophagus and High-Grade Dysplasia or Intramucosal Carcinoma William J. Bulsiewicz, Albert J. Rogers, Evan S. Dellon, Sarina Pasricha, Ryan D. Madanick, Ian S. Grimm, Nicholas J. Shaheen Division of Digestive Diseases, Center for Esophageal Diseases & Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC; Internal Medicine Residency Program, University of North Carolina School of Medicine, Chapel Hill, NC; University of North Carolina School of Medicine, Chapel Hill, NC Background: Endoscopic ultrasound (EUS) is often used to stage patients with Barrett’s esophagus (BE) and high-grade dysplasia (HGD) or intramucosal carcinoma (IMC) prior to ablation, since tumor invasion or lymphadenopathy might preclude endoscopic therapy in favor of esophagectomy. The clinical utility of EUS in this role is unclear.AIM: To assess the utility of EUS prior to ablation in BE patients with HGD or IMC. Methods: We performed a retrospective analysis of endoscopy records to identify all BE patients with HGD or IMC, as confirmed by histology, who underwent upper EUS in anticipation of endoscopic ablative therapy at our institution between June 2006 and November 2010. Pertinent data were extracted, including demographics, disease-specific parameters (histology before EUS, time with BE/dysplasia prior to EUS), endoscopic findings (Prague C/M classification, presence of esophagitis or nodule), EUS findings (tumor invasion, submucosal nodule, wall thickening, lymph nodes) and fine needle aspiration results. Contraindications to ablation were defined as tumor invasion beyond the superficial submucosa on EUS, regional lymph node involvement, invasive adenocarcinoma on endoscopic mucosal resection specimen, or distant metastasis. Results: Among 273 patients identified by endoscopy records, 7 did not have BE, 37 did not have an EUS, and 94 had an EUS for an alternative indication. The remaining 135 patients with BE and an EUS for pre-ablation staging were analyzed. Forty four subjects underwent EMR. Ablation was contraindicated in 14 patients (8 with invasion beyond superficial submucosa on EUS, 6 with invasive adenocarcinoma detected by EMR). Ablation contraindications were more likely among those with IMC (78.6% vs. 14.9%, p 0.01), mucosal nodularity (100%vs. 34.7%, p 0.001), wall thickening on EUS (100% vs. 32.2%, p 0.001), and suspicious lymph nodes on EUS (35.7% and 3.3%, p 0.001). Stratified by histology and nodularity, ablation was contraindicated in 11/21 with nodular IMC (52%) and 3/35 with nodular HGD (9%). EUS identified invasion beyond the superficial submucosa in 5/21 with nodular IMC (24%) and 3/35 with nodular HGD (9%). EMR upstaged histology in 10/18 with nodular HGD (56%) and 6/10 with nodular IMC (60%), all 6 of which were invasive adenocarcinoma. All 79 patients with non-nodular disease (HGD or IMC) lacked contraindication to ablation. There were no complications attributed to EUS. Conclusions: EUS identified a contraindication to ablation in 9% with nodular HGD and 24% with nodular IMC but did not alter management in patients with non-nodular disease. The diagnostic utility of EUS in such subjects is low.