Approach to patients with positive vertical margins after endoscopic resection of Barrett’s neoplasia

Endoscopic eradication therapy (EET) has revolutionized the management of Barrett's esophagus (BE)-related neoplasia (patients with early esophageal adenocarcinoma [EAC], high grade dysplasia [HGD], and select cases with low grade dysplasia), reducing the morbidity and mortality related to esophagectomy and preventing EAC-related mortality [1] [2] [3]. The basic principles of EET include endoscopic resection (ER) using endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for any visible lesion (technique of ER ideally based on lesion characteristics), followed by ablation of the remaining BE epithelium to reduce the risk of metachronous neoplasia. The goal of EET should be complete eradication of intestinal metaplasia and complete eradication of neoplasia, followed by enrollment in endoscopic surveillance programs for early detection of BE-related neoplasia recurrence. ER plays a pivotal role in both the management of patients with BE-related neoplasia and the overall success of any EET program. ER specimens routinely undergo histopathological assessment for overall highest grade of neoplasia, depth of neoplastic invasion, tumor differentiation, lymphovascular invasion, and tumor/dysplasia involvement of lateral and vertical margins. It is expected that the number of patients with a tumor-positive vertical margin (R1v) will increase given the expanding indications of EET and increased overall uptake of this management strategy for this patient population. While current guidelines recommend consideration of adjunct surgery in patients with R1v, this recommendation is based on minimal data describing outcomes and risk of residual neoplasia after R1v. Should all patients with R1v undergo esophagectomy? What is the risk of residual neoplasia in patients with R1v on follow-up endoscopy or surgical specimens after esophagectomy?