OBJECTIVES: Endoscopic eradication therapy is used to treat mucosal neoplasms in Barrett's esophagus, but cannot cure cancers that have metastasized to lymph nodes. The risk of such metastases has been proposed as a reason to consider esophagectomy rather than endoscopic therapy for esophageal mucosal neoplasia. The objective of our study was to determine the frequency of lymph-node metastases in patients with high-grade dysplasia (HGD) and intramucosal carcinoma in Barrett's esophagus. METHODS: We performed a systematic review using the PRISMA guidelines to identify studies that included patients who had esophagectomy for HGD or intramucosal carcinoma in Barrett's esophagus, and that reported final pathology results after examination of esophagectomy specimens. RESULTS: We identified 70 relevant reports that included 1,874 patients who had esophagectomy performed for HGD or intramucosal carcinoma in Barrett's esophagus. Lymph-node metastases were found in 26 patients (1.39%, 95% CI 0.86-1.92). No metastases were found in the 524 patients who had a final pathology diagnosis of HGD, whereas 26 (1.93%, 95% CI 1.19-2.66%) of the 1,350 patients with a final pathology diagnosis of intramucosal carcinoma had positive lymph nodes. CONCLUSIONS: The risk of unexpected lymph-node metastases for patients with mucosal neoplasms in Barrett's esophagus is in the range of 1-2%. Esophagectomy has a mortality rate that often exceeds 2%, with substantial morbidity and no guarantee of curing metastatic disease. Therefore, the risk of lymph-node metastases alone does not warrant the choice of esophagectomy over endoscopic therapy for HGD and intramucosal carcinoma in Barrett's esophagus.
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