All right, let's move into the esophagus. Can I move this forward? These are my disclosures. So this is an 82-year-old gentleman, history of right lower lobectomy for lung cancer seven years ago, history of brain surgery for metastasis five years ago, had a cabbage and aortic valve replacement, he's on anticoagulation, has a long history of reflux, upper endoscopy, long segment Barrett's with paths showing high-grade dysplasia, and he's put on your schedule for mucosal resection in a half-hour time slot. And you see this, so I'll start out front. Where are you from? Mayo Clinic, Arizona. Mayo Clinic, Arizona. What's your name? Mary Jane. Okay. And who are you working with? Dr. Fukami, Norio, Anderson, Michelle. Perfect. So what would you and Nori do with this lesion? What would you and Nori do with this lesion? I guess it depends on who identified it the first time. They'll want to confirm that it's cancer because it obviously looks concerning. They've just seen high-grade dysplasia, but what worries you here? Oh, they only found high-grade dysplasia? On the biopsy, yeah. Oh, I don't think they went deep enough. I will do an EOS like, you know, we've done right now. Here's your EOS. Here's the lesion. Well, I can see that it's going deeper than — I think the layer right now is — Oh, you said EOS. Next person. Where are you from? Leahy Clinic. Leahy Clinic. Who are you working with? Annemarie Joyce. So have you done ultrasound? Some? Yes, some. So what do you see here? So I think it's not going through the MP. Okay, good. So the muscular looks okay? Yeah. Down here, maybe something in the semicosep, right? Sort of worries you. How good is the EOS for that? Where are you coming from? It's Brilliant Clinic. And who are you working? Vivek Kesar. Oh, okay. What would you do with — how good is this? In terms of diagnosis. In terms of staging it or diagnosing it or telling you what happened, we do EOS, but Is this worrisome? It is worrisome. It's asymmetric thickening involving the mucosa and submucosa, so you — So you think there's submucosal invasion and that concerns you and, you know, EOS we think is pretty good, but not infallible. What else? Next. Where are you coming from? Hi. I'm Erica. Hi. I'm coming from Ohio State. Oh, great. Peter Lee's there. Peter's there. You guys are taking all our people. George is there. Raj Shah's there. So what do you think about that? I don't think EOS is that — No. What do you think about the endoscopy picture? The endoscopy picture? It's not like an easy nodule that you can necessarily band-ligate, I wouldn't think. What else is worrisome about that? The look. I would say... I mean, I can't tell if it's any ulceration or anything like that, but... That's what you look at, but it's certainly depressed. There's a little bit of yellowish stuff on it. It looks nasty. What are you going to do? What are you going to do with this thing? On your schedule for mucosal resection. Where are you coming from? I'm coming from the University of Colorado. I'm working with Sachin Wani and Hazim Hammad. I don't think it's amenable to mucosal resection, but we could try ESD. There's a few cases that we've done that have looked like T1B cancers on EUS, but with ESD they have actually been T1A. So let's ask the faculty. Peter, would you do ESD on this? Yeah, definitely. You would? Pardon me? Okay, favor? Not that day with 30 minutes, but on a different day. Who else? We'll stage with EUS first, because that ulcerated look does not look T1 to me. EUS, you do it. It's hard to know what to do with it. I think if you do do it, it's significant, because typically for patients that are sent to us that have a nodule or whatever, we don't do EUS, right? We just take it out. But this thing that you're looking at, firstly, you're looking for an excuse not to take it out, because to my mind, I mean, that looks like an ulcerated cancer, no question. Ashley, you sound like VA doctor. You're looking for reasons not to do something. I showed this to Jacques Bergman, the father of this haptic tire. He said, cancer, leave it alone. Do we know what the biopsy was, Samitabh? The biopsy had been high-grade dysplasia. Okay. So I did more biopsies, and they still say high-grade dysplasia can't exclude cancer. You know, regular glands and luminal necrosis. So I referred him to a thoracic surgeon just to be sure. However, you know, he's had prior lung resection, has heart disease, aortic valve, has a mess of the brain, even though clearly a survivor wants everything done. A VA surgeon. Pardon me? Must have been a VA surgeon. A VA patient. What about cryo? How about cryo? I mean, can somebody tell me why they don't want to do years of this? Or a large-gap EMR. Or at least try to lift it. The basic question is, what is the pathology, and is the muscle layer preserved? Yeah, it is. If the muscle layer is preserved, he is good for me and Peter. So sometimes things can be ulcerated also because of PPI use, although this guy was on PPI, was doubled his PPI. And cryo has been reported with liquid nitrogen in depressed lesions and making them disappear. I've seen cases of that, and it's a great option to consider. Can I ask a question, just the opposite question, just for Peter to help us with? What morphology would make you say no? I think that's the opposite question here, right? It is obviously a concerning lesion for cancer. No one's going to argue that. So can you maybe for all of us start talking about the morphology features that you wouldn't have said 100% let's go forward? Right. So if you look at the predictors where ESD may be, I mean, I will have a hard time ablating any nodular or depressed lesion unless there is some really extraordinary circumstances as the first-line therapy. That's one. This lesion appears resectable. We can argue whether ESD or large-cap EMR is the way to go, but that provides you, first of all, a chance for cure, and secondly, if that is not a cure, you have staging. And we are very much attuned to staging EMR in Barrett's, but I believe ESD can be used in the same way. And then once you know the exact staging, rather at least high-grade dysplasia, maybe carcinoma, what you're getting on biopsy, then you can decide with higher degree of certainty do I do on top of this cryo, do I do radiation chemotherapy, and so forth and so on. It gives you to do some more informed decision. But suspected cancer is a prime indication for ESD. I mean, that's fair. When would you not do it? I mean, obviously you saw a lymph node on EUF. Correct. That will keep me away from doing it if you see a lymph node. Or in the muscle, into the muscle. I don't know if that's fair, Peter. There's some morphology where you say this is going to be advanced esophageal cancer, so I think a teaching point would be like morphologically. I mean, I can't see the pictures because it's a small quadrant, so maybe we can go into the picture. I'm not arguing what you would do or what should be done. I'm just trying to say what would be the teaching point to say morphologically. I don't care what the EUF says. I don't think this is right to perform ESD. Good point. So traditionally lesions that are ulcerated are not good target for ESD in broad terms. Barrett is a little bit different because acid comes into play, and it's hard to know sometimes how much of this is cancer-related ulceration versus acid-related ulceration. In this case, certainly I will make sure that the patient is on double-dose PPI. There is nothing wrong to bring them a month or two from now. That's the thing. Sometimes they can change. Yeah, Bill. To add to what Peter is saying is that you now have two biopsies that have not demonstrated cancer. You're not going to be able to convince an oncologist to give trimodality chemotherapy and radiation therapy or even immunotherapy or whatever without pathology. You're not going to be able to convince a surgeon to resect this person who's 82 years old with a history of brain medicine. And so I would also throw my hat into the ESD world for this as well because if anything, even if you failed the ESD, even if you got a positive vertical margin, you at least have pathologic diagnosis and confirmation of what this is. If you cannot do ESD, then large-cap EMR I think is absolutely valid here as well if you're not able to do ESD. The lesion is fairly small, but I think the key point is you need pathology. That's why I said the two most important things here are what is the pathology and is the muscle layer preserved or not. In terms of cryo, we've really only used it for palliation, not as a first-line therapy for a potentially resectable lesion, so I wouldn't do that. So we brought him back for a second look exactly for those reasons. And this is not my video, but it's a better video because Roycetekno makes better videos than I do. But it's a similar depressed lesion, and the technique that we used – I'll show you my pictures later. They're a lot worse. The technique is to do a – I don't have the patience that Phil and Peter do, but do a circumferential incision, do some degree of dissection, and then rather than being a purist, you can also use a snare, sort of do a hybrid technique and take it out, especially when there's a lot of fibrosis underneath it. If you can get just enough of a lift, it makes life a little bit easier. And he – is this his? Yeah, I think so. I thought he had a high-grade dysphagia, but he had a well-differentiated adenocarcinoma, slightly invasive, negative margins, no lymphobascular involvement. And I promised you I'd show you my picture, so not quite as good as what video that Roy would make, but I was more concerned with at least struggling with all the fibrosis and ugliness, but this is what it looked like at the end of it. How did it look like with the PPI? Any better or no? It did – It doesn't really look that much different. There was still that little depressed area, but when you started injecting and lifting it, it started actually lifting. A lot of that depression is not ulceration going in, exactly what Peter was saying. Until you try, sometimes you just don't know. You can't deal with these depressed lesions with ESD. EMR, you just won't get enough of lifting. I mean, you can get burned with these esophagus lesions in two ways. One is that the ulceration is acid-related. The other one, not here, but, I mean, prior biopsies can create the impression of a vascular area, and basically you're seeing a healing biopsy rather than a vascular area, so keep that in mind. And prior EMR, and prior RFA, and prior cryo, and all those malfeasances that come to a quaternary surgery. So pattern interpretation can get confusing. Yes, that one, yeah, I didn't think he had no parts in that one because that must have been Roy's pat. This gentleman had high-grade dysplasia, actually, of what we resected without cancer. So it can fool you sometimes. The things you can't rely on biopsies sometimes are the grade of the cancer. On a high grade, it'll sometimes be lower or higher, and sometimes what looks like a cancer is not cancer. You don't want to live your life doing that, but this is a case where it really didn't have cancer. And just so that no good deed goes unpunished, we kept him in the house for five days because he had aortic valve replacement, he was in heparin, we kept him in heparin, and then two days after discharge he came in with a bleed. But, you know, the bleed was just an ulceration. Two months later, kind of gratifying to see that it's gone. Just a few points. I have to step out, so I don't know. Did we mention anything regarding stricture rates in the esophagus with esophageal dysplasia? We did not, but if you could circle it. Right, so just kind of a point to make. Remember, in the esophagus, the wider you resect, whether it's EMR or ESD, there's going to be a higher risk for stricture formation. So that's something to keep in mind when deciding. Now, having said that, and then the last point is that in cases where there's a lot of submucosal fibrosis and these type of lesions, when you start doing ESD, the tendency is always to cut close to the lesion. But when it's very fibrotic, it's going to be extremely challenging because when you inject, it's not going to lift well. You're not going to be able to form a flap to get underneath the lesion. So when you have a fibrotic lesion, you actually want to come out. Don't be scared to start way out of the lesion in order to get into the submucose and then deal with the fibrosis. Dr. Chuck, one of the questions is the ulcerations are always worrisome. How do you manage them? Do you give them a few days of PPI, bring them back to manage the lesion, or would you tackle it in the same setting? Yeah, I'll wait a few weeks, actually, give them double-dose PPI, really preach that to them, and then look again because that can change. And in the esophagus, it can sometimes fool you. In general, if it's actively ulcerated, you don't want to be doing ASD anyway, but the appearance can change a little bit. We start double-dose in the clinic at the time of the consult and add carafate to older patients who appear to be noncompliant. We start that at the time of the consult because it takes a few weeks for them to get in for the procedure anyway. So that's another tip I use. Double-dose, carafate, spend a lot of time educating them about, you know, how we want them to look like, hysterosophagus to look like when they come on the table.

mucosal resection

esophageal lesion

endoscopic ultrasound

high-grade dysplasia

pathology confirmation