Current Management of High-Risk Barrett's Adenocarcinoma: How Deep Can We Dive Endoscopically?

Abstract The proliferation of advanced endoscopic resection techniques has provided a minimally invasive alternative to esophagectomy and revolutionized outcomes for patients with early-stage esophageal adenocarcinoma (EAC). This paradigm shift and the resulting research data on clinical and histologic determinants of treatment outcome have highlighted the heterogeneity of outcomes within EAC staged as T1 by invasion depth. Multidisciplinary cancer care teams are now routinely facing difficult decisions regarding the management of high-risk T1 EAC to balance the risk of long-term lymph node (LNM) or distant metastasis against the risks of surgical resection. In this review, we summarize the current state of knowledge regarding the staging and risk stratification of T1 EAC, with particular attention to features that contribute to a higher risk of LNM and cancer mortality. We review recent clinical trial data on positioning the use of endoscopic resection (cap-assisted or submucosal dissection) versus surgical resection in high-risk T1 EAC patients and describe adjunctive techniques to further improve risk stratification and treatment. Finally, we explore emerging and future directions, such as artificial intelligence and advanced biomarker analysis to further aid decision-making and enhance patient outcomes.