Prospective Endoscopic Follow-up of Patients With Submucosal and High Risk Mucosal Esophageal Adenocarcinoma

Barrett Esophagus Clinical Trial

— PREFER  

Official title:

Endoscopic Management of Patients With High Risk T1a and T1b N0M0 Esophageal Adenocarcinoma: a Prospective Multicenter Registry.

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT03222635
• Other study ID #: NL6116501817
• Status: Recruiting
• Phase: N/A
• Start date: July 25, 2017
• Est. completion date: July 25, 2028

Study information

• Verified date: April 2024
• Source: Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)
• Contact: Vincent Bos, MD
• Phone: +31204445500
• Email: v.bos[@]amsterdamumc.nl
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Aim of this prospective multicenter study is to evaluate the safety of an endoscopic follow-up strategy in patients treated with endoscopic resection (ER) for submucosal or high-risk mucosal esophageal adenocarcinoma (T1bN0M0 or HR T1aN0M0 EAC).

Description:

Traditionally, the risk of lymph node metastasis associated with submucosal EAC was considered too high to offer patients endoscopic follow-up. Only in elderly patients with comorbidity, more often an endoscopic protocol is selected. However, the risk of lymph node metastasis associated with submucosal EAC is mainly based on surgical series. Recently a number of studies, which included patients treated endoscopically, were published indicating that the risk of lymph node metastasis may be much lower than generally assumed (1-5). Therefore, a less invasive and organ preserving approach may not only be an option in the frail and elderly, but for all patients with submucosal EAC's.

Yet, no data exists on the risk of lymph node metastasis in high risk T1a EAC. The risk is assumed to be lower than for EACs invading into the submucosal layer. However, a recent retrospective analysis from our own research group shows that this risk may be higher than previously assumed (6). In this nationwide retrospective study, we analyzed lymph node metastasis rates and EAC related mortality rates concerning patients with high risk T1a, low risk T1b or high risk T1b EAC who received endoscopic treatment. The study was performed in 9 Barrett Expert Centers in the Netherlands (2008-2019). 120 patients were included in the analysis, and results showed the highest lymph node metastasis risk in the high risk T1a patient group.

Aim of this multicenter study is to prospectively evaluate the safety of endoscopic follow-up in patients treated by endoscopic resection for submucosal (T1bN0M0) and high risk mucosal (T1aN0M0) EAC.

High-resolution upper endoscopy with white-light endoscopy and narrow-band imaging supplemented with an EUS are performed every three months during the first two years after ER. After 1 year, a CT-thorax/abdomen will be performed to check for distant metastasis. During the third and fourth year of follow-up, EUS and upper endoscopy are performed every six months. From the fifth year on, EUS and upper endoscopy are performed annually.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 225
• Est. completion date: July 25, 2028
• Est. primary completion date: July 25, 2028
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Patients with submucosal or high-risk mucosal EAC diagnosed in an ER specimen, by an expert gastrointestinal (GI) pathologists.

• Signed informed consent.

Exclusion Criteria:

• Prior history of high-risk mucosal or =T1sm.

• Synchronous esophageal squamous cell carcinoma.

• Suspicion on lymph node metastasis or distant metastasis on EUS, ultrasound of the neck or CT-thorax-abdomen performed six weeks after ER during baseline measurement.

• Tumor-positive deep resection margin (R1) in ER specimen.

• Patients unable to give signed informed consent.

Related Conditions & MeSH terms

• Adenocarcinoma
• Barrett Esophagus
• Esophageal Neoplasms
• High-risk Mucosal Esophageal Adenocarcinoma
• Submucosal Esophageal Adenocarcinoma

Intervention

Procedure:
• Endoscopic follow-up
Endoscopic follow-up by means of regular upper endoscopies and endoscopic ultrasounds

Locations

Country	Name	City	State
Australia	Westmead hospital	Sydney
Belgium	AZ Maria Middelares Ghent	Gent
Belgium	UZ Leuven	Leuven
Belgium	AZ Delta Roeselare	Roeselare
Germany	Universitätsklinikum Augsburg	Augsburg
Germany	EVK Duesseldorf	Duesseldorf
Germany	MRI TUM	Münich
Germany	Barmherzige Brüder Regensburg	Regensburg
Netherlands	Amsterdam UMC	Amsterdam
Netherlands	Catharina Hospital	Eindhoven
Netherlands	University Medical Center Groningen	Groningen
Netherlands	St. Antonius Hospital	Nieuwegein
Netherlands	Radboudumc	Nijmegen
Netherlands	Erasmus MC - University Medical Center	Rotterdam
Netherlands	Haga Medical Center	The Hague
Netherlands	Isala Clinics	Zwolle
Switzerland	Hirslanden private hospital group	Zürich
United Kingdom	University College London Hospital	London
United Kingdom	Nottingham University Hospitals NHS Trust	Nottingham

Sponsors (1)

Lead Sponsor	Collaborator
Amsterdam UMC

Countries where clinical trial is conducted

Australia,  Belgium,  Germany,  Netherlands,  Switzerland,  United Kingdom, 

References & Publications (6)

Alvarez Herrero L, Pouw RE, van Vilsteren FG, ten Kate FJ, Visser M, van Berge Henegouwen MI, Weusten BL, Bergman JJ. Risk of lymph node metastasis associated with deeper invasion by early adenocarcinoma of the esophagus and cardia: study based on endoscopic resection specimens. Endoscopy. 2010 Dec;42(12):1030-6. doi: 10.1055/s-0030-1255858. Epub 2010 Oct 19. — View Citation

Manner H, May A, Pech O, Gossner L, Rabenstein T, Gunter E, Vieth M, Stolte M, Ell C. Early Barrett's carcinoma with "low-risk" submucosal invasion: long-term results of endoscopic resection with a curative intent. Am J Gastroenterol. 2008 Oct;103(10):2589-97. doi: 10.1111/j.1572-0241.2008.02083.x. Epub 2008 Sep 10. — View Citation

Manner H, Pech O, Heldmann Y, May A, Pauthner M, Lorenz D, Fisseler-Eckhoff A, Stolte M, Vieth M, Ell C. The frequency of lymph node metastasis in early-stage adenocarcinoma of the esophagus with incipient submucosal invasion (pT1b sm1) depending on histological risk patterns. Surg Endosc. 2015 Jul;29(7):1888-96. doi: 10.1007/s00464-014-3881-3. Epub 2014 Oct 8. — View Citation

Manner H, Pech O, Heldmann Y, May A, Pohl J, Behrens A, Gossner L, Stolte M, Vieth M, Ell C. Efficacy, safety, and long-term results of endoscopic treatment for early stage adenocarcinoma of the esophagus with low-risk sm1 invasion. Clin Gastroenterol Hepatol. 2013 Jun;11(6):630-5; quiz e45. doi: 10.1016/j.cgh.2012.12.040. Epub 2013 Jan 26. — View Citation

Nieuwenhuis EA, van Munster SN, Meijer SL, Brosens LAA, Jansen M, Weusten BLAM, Alvarez Herrero L, Alkhalaf A, Schenk E, Schoon EJ, Curvers WL, Koch AD, van de Ven SEM, Verheij EPD, Nagengast WB, Westerhof J, Houben MHMG, Tang T, Bergman JJGHM, Pouw RE; Dutch Barrett Expert Centers. Analysis of metastases rates during follow-up after endoscopic resection of early "high-risk" esophageal adenocarcinoma. Gastrointest Endosc. 2022 Aug;96(2):237-247.e3. doi: 10.1016/j.gie.2022.03.005. Epub 2022 Mar 12. — View Citation

Scholvinck D, Kunzli H, Meijer S, Seldenrijk K, van Berge Henegouwen M, Bergman J, Weusten B. Management of patients with T1b esophageal adenocarcinoma: a retrospective cohort study on patient management and risk of metastatic disease. Surg Endosc. 2016 Sep;30(9):4102-13. doi: 10.1007/s00464-016-5071-y. Epub 2016 Jun 29. Erratum In: Surg Endosc. 2016 Sep;30(9):4114. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	5-year disease-specific mortality/survival (descriptive statistics in SPSS, percentages, survival analysis)	Disease specific mortality is decribed as mortality directly linked to the esophageal adenocarcinoma (i.e., metastasized EAC, metastasized disease with a simultaneously primary cancer present and it cannot be ruled out (based on histology) that the metastases are related to the other primary cancer, death due to complications of the endoscopic procedure, death due to complications after surgery or CRT, no clear cause of death in patients who have metastases or untreated local recurrence). If patients are diagnosed with distant metastases, and subsequently die of a non-tumor related cause, patients will still be documented as tumor-related death. Will be measured in number of patients and percentages. Survival analysis using Kaplan Meier will be performed.	5 years
Primary	Overall survival (descriptive statistics in SPSS, percentages, survival analysis)	Overall survival of study population (tumor-related + non-tumor-related deaths). Measured in numbers and percentages, survival analysis (KM).	5 years
Secondary	Lymph node metastasis, confirmed by cytology and/or histology (descriptive statistics in SPSS, number of patients (%))	Confirmed by cytology and/or histology by performing FNA during EUS or biopsies.	5 years
Secondary	Local recurrence eligible for endoscopic therapy (descriptive statistics in SPSS, number of patients (%))	In case a local recurrence is found during FU endoscopy, histopathology have to show if it is recurrent cancer.	5 years
Secondary	Local recurrence requiring surgical therapy (descriptive statistics in SPSS, number of patients (%))	In case a local cancer recurrence is not amendable for endoscopic re-treatment, for example due to extensive disease or fibrosis, a patient will be referred for surgery if possible.	5 years
Secondary	Distant metastasis, histologically proven (descriptive statistics in SPSS, number of patients (%))	Primary tumor of distant metastasis should be histopathologically evalueted by taking biopsies.	5 years
Secondary	Quality of life during follow-up endoscopies (questionnaires)	Quality of life is assessed by using questionnaires on set time points during the whole study.	5 years