Clinical Outcomes After Endoscopic Management of Low-Risk and High-Risk T1b Esophageal Adenocarcinoma: A Patient-Level Pooled Analysis of International Studies

Background & Aims Endoscopic eradication therapy is standard of care for T1a esophageal adenocarcinoma. There are limited data regarding long-term outcomes of endoscopic eradication therapy for T1b esophageal adenocarcinoma. The aim of this study was to assess clinical outcomes after endoscopic management of low-risk and high-risk T1b esophageal adenocarcinoma via a pooled analysis of individual patient-level data. Methods A pooled analysis of studies reporting endoscopic management of T1b esophageal adenocarcinoma was conducted. Inclusion required endoscopic resection revealing T1b esophageal adenocarcinoma with negative deep margins. High-risk T1b esophageal adenocarcinoma was defined by presence of: submucosal 2/3 or deep (>500 μm) submucosal invasion, lymphovascular invasion, or poor grade of differentiation. Clinical outcomes included all-cause and esophageal adenocarcinoma–related mortality, intraluminal recurrence, and extraluminal metastases. Results Of 418 studies identified, 7 with 216 patients were included (84% men; 94% White). The median follow-up was 48.1 months (interquartile range, 25.5–68.1 months). High-risk T1b esophageal adenocarcinoma was observed in 114 patients (53%). Baseline clinical characteristics were mostly similar between groups. Although the rates of intraluminal recurrence in the low-risk and high-risk groups were comparable (15% vs 22%; P = .30), the high-risk group had a 5-fold significantly higher risk of extraluminal metastases (11% vs 2%; P = .01). Both all-cause and esophageal adenocarcinoma–related mortality were significantly higher in the high-risk group (log rank P = .04). Conclusions In this international pooled analysis, rates of extraluminal metastases and esophageal adenocarcinoma–related mortality were very low in patients with low-risk T1b esophageal adenocarcinoma, supporting the role of endoscopic eradication therapy in this group. However, outcomes were significantly worse for the high-risk T1b group, suggesting careful patient selection and shared decision-making in this population.