1
|
Prevalence and Incidence of Intestinal Metaplasia and Dysplasia of Gastric Cardia in Patients With Barrett's Esophagus After Endoscopic Therapy. Clin Gastroenterol Hepatol 2020; 18:82-88.e1. [PMID: 31077822 PMCID: PMC6842071 DOI: 10.1016/j.cgh.2019.04.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/03/2019] [Accepted: 04/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic eradication therapy (EET) for Barrett's esophagus (BE) has unclear effects on the gastric cardia. We investigated the prevalence of intestinal metaplasia (IM) and dysplasia in the cardia after complete eradication of IM (CEIM) and the incidence of newly diagnosed cardia IM or dysplasia after EET. METHODS We performed a prospective study, from 2013 through 2016, of patients with previously successful EET undergoing surveillance after CEIM (cross-sectional group) and treatment-naïve patients with BE undergoing EET (longitudinal group). Standard biopsies were collected from multiple levels in the cardia and analyzed histologically. We calculated the prevalence (cross-sectional group) and the incidence (longitudinal group) of cardia IM or dysplasia after EET. RESULTS Of the 116 patients in the cross-sectional group, 17 (15%) had cardia IM or dysplasia after CEIM: 12 patients had IM, 2 patients were indefinite for dysplasia, and 3 patients had low-grade dysplasia. Cardia IM or dysplasia were most commonly found at the tops of gastric folds. Among 42 subjects in the longitudinal group, the pre-treatment prevalence of cardia IM or dysplasia was 28.5% (3 with non-dysplastic IM, 9 with dysplastic IM, 1 indefinite for dysplasia, 2 with low-grade dysplasia, 3 with high-grade dysplasia, and 3 with intramucosal cancer). All achieved CEIM. The incidence of cardia IM or dysplasia was 11.9% after 18 months of follow up. IM or dysplasia was more higher in the cardia after CEIM than in the tubular esophagus (P < .01). CONCLUSIONS In a prospective study, we found that cardia dysplasia becomes less, not more, common, after successful EET; recurrence of IM or dysplasia was more frequent in the cardia than the esophagus. Patients with BE undergoing EET should have careful examination of the cardia, with a single set of surveillance biopsies at the top of the gastric folds.
Collapse
|
2
|
Siddiki HA, Lam-Himlin DM, Kahn A, Bandres MV, Burdick GE, Crowell MD, Pannala R, Ramirez FC, Vela MF, Fleischer DE. Intestinal metaplasia of the gastric cardia: findings in patients with versus without Barrett's esophagus. Gastrointest Endosc 2019; 89:759-768. [PMID: 30447215 DOI: 10.1016/j.gie.2018.10.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 10/31/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS There is controversy about finding intestinal metaplasia (IM) of the gastric cardia on biopsy. The most recent American College of Gastroenterology guideline comments that IM cardia is not more common in patients with Barrett's esophagus (BE). It provides limited guidance on whether the cardia should be treated when patients with BE undergo endoscopic eradication therapy (EET) and whether the cardia should undergo biopsy after ablation. The aims of our study were to determine the frequency in the proximal stomach of (1) histologic gastric cardia mucosa and (2) IM cardia. A third aim was to explore the frequency of advanced pathology (dysplasia and adenocarcinoma) in the cardia after patients with BE have undergone EET. METHODS Consecutive patients undergoing esophagogastroduodenoscopy between January 2008 and December 2014 who had proximal stomach biopsies were included. Patients who had histologically confirmed BE were compared with those without BE. RESULTS Four hundred sixty-two patients, 289 with BE and 173 without BE, were included. Histologically confirmed cardiac mucosa was found in 81.6% of all patients. This was more frequent in those with versus without BE (86% vs 75%; odds ratio [OR], 2.06; 95% confidence interval [CI], 1.28-3.32; P = .003). IM cardia was more common in the BE group (17% vs 7%; OR, 2.67; 95% CI, 1.38-5.19; P = .004). Advanced pathology was more likely in the patients with BE who had undergone EET. CONCLUSIONS Cardiac mucosa is present in most patients who undergo endoscopy for upper GI symptoms. IM cardia is more common in patients with BE than those without. Advanced histologic changes in the cardia were seen only in the subgroup of patients with BE who had undergone EET.
Collapse
Affiliation(s)
- Hassan A Siddiki
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Dora M Lam-Himlin
- Department of Pathology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Allon Kahn
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - M Veronica Bandres
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - George E Burdick
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Michael D Crowell
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Rahul Pannala
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | | | - Marcelo F Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - David E Fleischer
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| |
Collapse
|
3
|
Neoplastic Barrett’s oesophagus and long-term follow-up after endoscopic therapy: complete histological eradication of Barrett associated with high-grade dysplasia significantly decreases neoplasia relapse. Surg Endosc 2016; 30:5410-5418. [DOI: 10.1007/s00464-016-4898-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/26/2016] [Indexed: 01/28/2023]
|
4
|
Phoa KN, Pouw RE, Bisschops R, Pech O, Ragunath K, Weusten BLAM, Schumacher B, Rembacken B, Meining A, Messmann H, Schoon EJ, Gossner L, Mannath J, Seldenrijk CA, Visser M, Lerut T, Seewald S, ten Kate FJ, Ell C, Neuhaus H, Bergman JJGHM. Multimodality endoscopic eradication for neoplastic Barrett oesophagus: results of an European multicentre study (EURO-II). Gut 2016; 65:555-62. [PMID: 25731874 DOI: 10.1136/gutjnl-2015-309298] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 02/07/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Focal endoscopic resection (ER) followed by radiofrequency ablation (RFA) safely and effectively eradicates Barrett's oesophagus (BO) containing high-grade dysplasia (HGD) and/or early cancer (EC) in smaller studies with limited follow-up. Herein, we report long-term outcomes of combined ER and RFA for BO (HGD and/or EC) from a single-arm multicentre interventional study. DESIGN In 13 European centres, patients with BO ≤ 12 cm with HGD and/or EC on 2 separate endoscopies were eligible for inclusion. Visible lesions (<2 cm length; <50% circumference) were removed with ER, followed by serial RFA every 3 months (max 5 sessions). Follow-up endoscopy was scheduled at 6 months after the first negative post-treatment endoscopic control and annually thereafter. OUTCOMES complete eradication of neoplasia (CE-neo) and intestinal metaplasia (CE-IM); durability of CE-neo and CE-IM (once achieved) during follow-up. Biopsy and resection specimens underwent centralised pathology review. RESULTS 132 patients with median BO length C3M6 were included. After entry-ER in 119 patients (90%) and a median of 3 RFA (IQR 3-4) treatments, CE-neo was achieved in 121/132 (92%) and CE-IM in 115/132 patients (87%), per intention-to-treat analysis. Per-protocol analysis, CE-neo and CE-IM were achieved in 98% and 93%, respectively. After a median of 27 months following the first negative post-treatment endoscopic control, neoplasia and IM recurred in 4% and 8%, respectively. Mild-to-moderate adverse events occurred in 25 patients (19%); all managed conservatively or endoscopically. CONCLUSIONS In patients with early Barrett's neoplasia, intensive multimodality endotherapy consisting of ER combined with RFA is safe and highly effective, and the treatment effect appears to be durable during mid-term follow-up. TRIAL REGISTRATION NUMBER NTR 1211, http://www.trialregister.nl.
Collapse
Affiliation(s)
- K Nadine Phoa
- Department of Gastroenterology and Hepatology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Raf Bisschops
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Vlaams Brabant, Belgium
| | - Oliver Pech
- Department of Internal Medicine II, Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Krish Ragunath
- Department of Gastroenterology, Queens Medical Centre, Nottingham, UK
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Brigitte Schumacher
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Bjorn Rembacken
- Department of Gastroenterology, The General Infirmary at Leeds, Leeds, UK
| | - Alexander Meining
- Department of Gastroenterology, Klinikum rechts der Isar, Munich, Germany
| | - Helmut Messmann
- Department of Gastroenterology, Augsburg Hospital, Augsburg, Germany
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Liebwin Gossner
- Department of Internal Medicine II, Karlsruhe Hospital, Karlsruhe, Germany
| | - Jayan Mannath
- Department of Gastroenterology, Queens Medical Centre, Nottingham, UK
| | - C A Seldenrijk
- Department of Pathology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Mike Visser
- Department of Pathology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Toni Lerut
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Vlaams Brabant, Belgium
| | - Stefan Seewald
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Fiebo J ten Kate
- Department of Pathology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Christian Ell
- Department of Internal Medicine II, Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Horst Neuhaus
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
5
|
Belghazi K, Cipollone I, Bergman JJGHM, Pouw RE. Current Controversies in Radiofrequency Ablation Therapy for Barrett's Esophagus. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2016; 14:1-18. [PMID: 26891725 PMCID: PMC4783441 DOI: 10.1007/s11938-016-0080-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT Barrett's esophagus (BE) is the most important risk factor for esophageal adenocarcinoma. Through the sequence of no dysplasia to low-grade dysplasia (LGD) and high-grade dysplasia (HGD), eventually early cancer (EC) may develop. The risk of neoplastic progression is relatively low, 0.5-0.9 % per patient per year. However, once diagnosed, esophageal adenocarcinoma is often irresectable, and 5-year survival is only 15 %. Therefore, non-dysplastic BE patients are kept under endoscopic surveillance to detect early neoplasia in a curable stage. In case of LGD confirmed by an expert pathologist, risk of neoplastic progression is high. In these confirmed LGD patients, prophylactic ablation using radiofrequency ablation (RFA) of the Barrett's segment has proven to significantly reduce risk of neoplastic progression. Once patients are diagnosed with HGD or EC, they have a clear indication for endoscopic treatment. The cornerstone for endoscopic management of early Barrett's neoplasia is endoscopic resection of mucosal abnormalities. Endoscopic resection (ER) provides a large tissue specimen for accurate histological evaluation to select those patients for further endoscopic management, who have neoplasia limited to the mucosa, well to moderately differentiated and without lymph-vascular invasion. After ER, the remainder of the Barrett's mucosa can be eradicated with RFA, to prevent occurrence of metachronous lesions.
Collapse
Affiliation(s)
- Kamar Belghazi
- Academic Medical Center, Department of Gastroenterology and Hepatology, Room C2-329, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ilaria Cipollone
- Academic Medical Center, Department of Gastroenterology and Hepatology, Room C2-329, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jacques J G H M Bergman
- Academic Medical Center, Department of Gastroenterology and Hepatology, Room C2-329, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Roos E Pouw
- Academic Medical Center, Department of Gastroenterology and Hepatology, Room C2-329, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| |
Collapse
|
6
|
Conio M, Fisher DA, Blanchi S, Ruggeri C, Filiberti R, Siersema PD. One-step circumferential endoscopic mucosal cap resection of Barrett's esophagus with early neoplasia. Clin Res Hepatol Gastroenterol 2014; 38:81-91. [PMID: 23856637 DOI: 10.1016/j.clinre.2013.05.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/24/2013] [Accepted: 05/29/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Focal endoscopic mucosal resection (EMR) of visible intraepithelial lesions arising within Barrett's esophagus (BE) may miss synchronous lesions that are not endoscopically apparent. Stepwise radical endoscopic resection would obviate this concern by removing all BE; however, it requires repeated endoscopy which may increase the risk of complications, particularly for patients with circumferential BE. The aim of the study was to evaluate the safety and efficacy of one-step complete circumferential resection of BE by cap-assisted EMR (EMR-C) among patients with circumferential BE and high-grade dysplasia or intramucosal carcinoma. PATIENTS AND METHODS Between January 2003 and March 2010, 47 patients with circumferential BE and biopsy-proven high-grade dysplasia or intramucosal cancer underwent EMR-C. We evaluated: (1) complete eradication of neoplasia, (2) complete eradication of metaplasia, and (3) complications including bleeding and esophageal stricture. RESULTS Complete eradication of neoplasia and complete eradication of metaplasia were achieved after a median follow-up of 18.4 months in 91% (43/47) of patients. After EMR-C, two patients (one IMC, one invasive cancer) underwent esophagectomy. Histology of the resected specimens showed no residual disease and a T1bN0 lesion, respectively. Two patients had progression of neoplasia. A stenosis occurred in 18 out of 45 patients (40%). All stenoses were treated with dilations and two required temporary placement of a covered stent. CONCLUSION One-step complete EMR-C is a safe and effective technique which can be considered in patients with early neoplastic lesions. Although 40% of patients developed dysphagia, this could well be managed endoscopically.
Collapse
Affiliation(s)
- Massimo Conio
- Department of Gastroenterology, General Hospital, Sanremo, Italy.
| | - Deborah A Fisher
- Department of Gastroenterology, Durham Veterans Affairs Medical Center and Duke Medical Center, NC, USA
| | - Sabrina Blanchi
- Department of Gastroenterology, General Hospital, Sanremo, Italy
| | | | - Rosa Filiberti
- Epidemiology, Biostatistics and Clinical Trials, IRCCS, San Martino - IST National Institute for Cancer Research, Genova, Italy
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| |
Collapse
|
7
|
Phoa KN, Pouw RE, van Vilsteren FGI, Sondermeijer CMT, Ten Kate FJW, Visser M, Meijer SL, van Berge Henegouwen MI, Weusten BLAM, Schoon EJ, Mallant-Hent RC, Bergman JJGHM. Remission of Barrett's esophagus with early neoplasia 5 years after radiofrequency ablation with endoscopic resection: a Netherlands cohort study. Gastroenterology 2013; 145:96-104. [PMID: 23542068 DOI: 10.1053/j.gastro.2013.03.046] [Citation(s) in RCA: 183] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 03/20/2013] [Accepted: 03/21/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND & AIMS Radiofrequency ablation (RFA), with or without endoscopic resection effectively eradicates Barrett's esophagus (BE) containing high-grade intraepithelial neoplasia and/or early-stage cancer. We followed patients who received RFA for BE containing high-grade intraepithelial neoplasia and/or early-stage cancer for 5 years to determine the durability of treatment response. METHODS We followed 54 patients with BE (2-12 cm), previously enrolled in 4 consecutive cohort studies in which they underwent focal endoscopic resection in case of visible lesions (n = 40 [72%]), followed by serial RFA every 3 months. Patients underwent high-resolution endoscopy with narrow-band imaging at 6 and 12 months after treatment and then annually for 5 years (median, 61 months; interquartile range, 53-65 months); random biopsy samples were collected from neosquamous epithelium and gastric cardia. After 5 years, endoscopic ultrasound and endoscopic resection of neosquamous epithelium were performed. Outcomes included sustained complete remission of neoplasia or intestinal metaplasia (IM), IM in gastric cardia, or buried glands in neosquamous epithelium. RESULTS After 5 years, Kaplan-Meier analysis showed sustained complete remission of neoplasia and intestinal metaplasia in 90% of patients; neoplasia recurred in 3 patients and was managed endoscopically. Focal IM in the cardia was found in 19 of 54 patients (35%), in 53 of 1143 gastric cardia biopsies (4.6%). The incidence of IM of the cardia did not increase over time; and IM was diagnosed based on only a single biopsy in 89% of patients. Buried glands were detected in 3 of 3543 neosquamous epithelium biopsies (0.08%, from 3 patients). No endoscopic resection samples had buried glands. CONCLUSIONS Among patients who have undergone RFA with or without endoscopic resection for neoplastic BE, 90% remain in remission at 5-year follow-up, with all recurrences managed endoscopically. This treatment approach is therefore an effective and durable alternative to esophagectomy; www.trialregister.nl number, NTR2938.
Collapse
Affiliation(s)
- K Nadine Phoa
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | - Fiebo J W Ten Kate
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Mike Visser
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Sybren L Meijer
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Bas L A M Weusten
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology, Catharina Hospital, Eindhoven, The Netherlands
| | | | | |
Collapse
|
8
|
Abstract
Barrett's esophagus (BE) is an acquired condition characterized by replacement of stratified squamous epithelium by a cancer predisposing metaplastic columnar epithelium. Endoscopy with systemic biopsy protocols plays a vital role in diagnosis. Technological advancements in dysplasia detection improves outcomes in surveillance and treatment of patients with BE and dysplasia. These advances in endoscopic technology radically changed the treatment for dysplastic BE and early cancer from being surgical to organ-sparing endoscopic therapy. A multimodal treatment approach combining endoscopic resection of visible and/or raised lesions with ablation techniques for flat BE mucosa, followed by long-term surveillance improves the outcomes of BE. Safe and effective endoscopic treatment can be either tissue acquiring as in endoscopic mucosal resection and endoscopic submucosal dissection or tissue ablative as with photodynamic therapy, radiofrequency ablation and cryotherapy. Debatable issues such as durability of response, recognition and management of sub-squamous BE and optimal management strategy in patients with low-grade dysplasia and non-dysplastic BE need to be studied further. Development of safer wide field resection techniques, which would effectively remove all BE and obviate the need for long-term surveillance, is another research goal. Shared decision making between the patient and physician is important while considering treatment for dysplasia in BE.
Collapse
|
9
|
Allende D, Dumot J, Yerian L. Esophageal squamous cell carcinoma arising after endoscopic ablation therapy of Barrett's esophagus with high-grade dysplasia. Report of a case. Dis Esophagus 2013; 26:314-8. [PMID: 23009180 DOI: 10.1111/j.1442-2050.2012.01411.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with Barrett's esophagus are at risk for dysplasia and esophageal adenocarcinoma. Although surgery was the mainstay treatment for Barrett's dysplasia and cancer, patients with high-grade dysplasia and early cancers now have several nonsurgical treatment options. Most of the endoscopic therapies are relatively safe but do carry a risk for complications. Treatment failure with progression of the disease is the most severe complication, especially among patients with low surgical risk. Cryoablation has been used with promising results in both high-grade dysplasia and early esophageal cancer. A patient with a well-documented history of Barrett's esophagus with high-grade dysplasia that underwent multiple sessions of photodynamic therapy and salvage cryoablation for residual high-grade dysplasia was presented. The patient was diagnosed with squamous cell carcinoma of the distal esophagus approximately 1 year after cryoablation. This is the first complete report of squamous cell carcinoma occurring after endoscopic ablation for Barrett's neoplasia. Careful follow up is necessary in any endoscopic ablation program due to the risk of recurrent neoplasia.
Collapse
Affiliation(s)
- D Allende
- Pathology and Laboratory Medicine Department, Cleveland Clinic Florida, Weston, FL 33331, USA.
| | | | | |
Collapse
|
10
|
Abstract
Endoscopy has a vital role in the diagnosis, screening, surveillance and treatment of Barrett esophagus. Over the past few decades, tremendous advances have been made in endoscopic technology, and the management of dysplasia and early cancer in Barrett esophagus has changed radically from being surgical to organ-sparing endoscopic therapy. Proper endoscopic techniques and systematic biopsy protocols improve dysplasia detection, and endoscopic surveillance improves outcomes in patients with Barrett esophagus and dysplasia. Endoscopic treatment can be tissue acquiring (as in endoscopic mucosal resection and endoscopic submucosal dissection) or ablative (as with photodynamic therapy, radiofrequency ablation and cryotherapy). Treatment is usually multimodal, combining endoscopic resection of visible lesions with one or more mucosal ablation techniques, followed by long-term surveillance. Such treatment is safe and effective. Shared decision-making between the patient and physician is important while considering treatment for dysplasia in Barrett esophagus. Issues such as durability of response, importance of subsquamous Barrett epithelium and the optimal management strategy in patients with low-grade dysplasia and nondysplastic Barrett esophagus need to be studied further. Development of safer wide-field resection techniques, which would effectively remove all Barrett esophagus and obviate the need for long-term surveillance, is needed.
Collapse
Affiliation(s)
- Aparna Repaka
- Division of Gastroenterology, University Hospitals Case Medical Center, Case Western Reserve University, Wearn 247, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | | |
Collapse
|
11
|
Bulsiewicz WJ, Shaheen NJ. The role of radiofrequency ablation in the management of Barrett's esophagus. Gastrointest Endosc Clin N Am 2011; 21:95-109. [PMID: 21112500 DOI: 10.1016/j.giec.2010.09.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Studies in the last several years have consistently shown radiofrequency ablation (RFA) to be effective, safe, and well tolerated in the treatment of nondysplastic and dysplastic Barrett's esophagus (BE). The results found at academic medical centers have been reproduced in the community setting. RFA provides a safe and cost-effective alternative to surgery or surveillance in the management of high-grade dysplasia (HGD). RFA should be given serious consideration as first-line therapy for HGD. This article reviews the evidence behind RFA to differentiate it from other management strategies in terms of efficacy, durability, safety, tolerability, and cost-effectiveness. The role of RFA in the management of BE is described, including endoscopic resection. Future directions are identified for research that will help to better define the role of RFA in the management of BE.
Collapse
Affiliation(s)
- William J Bulsiewicz
- GI Outcomes Training Program, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | |
Collapse
|
12
|
|
13
|
Triadafilopoulos G. Blitzkrieg for barrett's esophagus containing early neoplasia. Clin Gastroenterol Hepatol 2010; 8:7-9. [PMID: 19788932 DOI: 10.1016/j.cgh.2009.09.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Accepted: 09/14/2009] [Indexed: 02/07/2023]
|
14
|
Dumot JA, Vargo JJ, Falk GW, Frey L, Lopez R, Rice TW. An open-label, prospective trial of cryospray ablation for Barrett's esophagus high-grade dysplasia and early esophageal cancer in high-risk patients. Gastrointest Endosc 2009; 70:635-44. [PMID: 19559428 DOI: 10.1016/j.gie.2009.02.006] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Accepted: 02/01/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic ablation of Barrett's esophagus (BE) is a treatment option for patients with high-grade dysplasia (HGD) and intramucosal carcinoma (IMCA). OBJECTIVE To assess the safety and efficacy of a unique noncontact method of liquid nitrogen cryoablation as measured by histologic response rate and cancer-free survival. DESIGN Single-center, nonrandomized cohort study. SETTING Referral center, conducted between September 2005 and September 2008. PATIENTS Patients with BE and HGD or IMCA who were deemed inoperable or who refused esophagectomy. Age, length of BE, and previous ablation were not exclusion criteria. INTERVENTION Cryoablation every 6 weeks until endoscopic resolution. EMR was used for pathologic staging of nodular areas before cryoablation and focal residual areas during the follow-up period. MAIN OUTCOME MEASUREMENTS Histologic response was defined by the worst pathology obtained at any level of the esophagus or gastric cardia in 1 of 3 categories: (1) incremental = absence of HGD and IMCA in all biopsy specimens, (2) partial = residual IMCA with absence of any dysplasia, and (3) complete = absence of any intestinal metaplasia or dysplasia. RESULTS Thirty patients underwent ablation; 9 had undergone previous ablation or mucosectomy. Twenty-seven of 30 patients (90%) had downgrading of pathology stage after treatment. Elimination of cancer or downgrading of HGD at last follow-up was 68% for HGD and 80.0% for IMCA, with a median follow-up period of 12 months (25th percentile, 6; 75th percentile, 24). Minor adverse events included mild pain (n = 7), a low incidence of mild strictures (n = 3), and lip ulcer (n = 1). One major adverse event (perforation) in a patient with Marfan syndrome occurred with the prototype system. During follow-up, 3 of 6 patients with complete response had recurrence of dysplasia or cancer in the gastric cardia. LIMITATIONS A nonrandomized, single-center study with a heterogeneous cohort of patients. CONCLUSIONS Patients with BE and HGD or IMCA have a positive response to endoscopic cryotherapy at 1-year follow-up.
Collapse
Affiliation(s)
- John A Dumot
- Departments of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA.
| | | | | | | | | | | |
Collapse
|
15
|
Randomized trial of argon plasma coagulation versus endoscopic surveillance for barrett esophagus after antireflux surgery: late results. Ann Surg 2008; 246:1016-20. [PMID: 18043104 DOI: 10.1097/sla.0b013e318133fa85] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine the efficacy of endoscopic argon plasma coagulation (APC) for ablation of Barrett esophagus. SUMMARY BACKGROUND DATA APC has been used to ablate Barrett esophagus. However, the long-term outcome of this treatment is unknown. This study reports 5-year results from a randomized trial of APC versus surveillance for Barrett esophagus in patients who had undergone a fundoplication for the treatment of gastroesophageal reflux. METHODS Fifty-eight patients with Barrett esophagus were randomized to undergo either ablation using APC or ongoing surveillance. At a mean 68 months after treatment, 40 patients underwent endoscopy follow-up. The efficacy of treatment, durability of the neosquamous re-epithelialization, and safety of the procedure were determined. RESULTS Initially, at least 95% ablation of the metaplastic mucosa was achieved in all treated patients. At the 5-year follow-up, 14 of 20 APC patients continued to have at least 95% of their previous Barrett esophagus replaced by neosquamous mucosa, and 8 of these had complete microscopic regression of the Barrett esophagus. Five of the 20 surveillance patients had more than 95% regression of their Barrett esophagus, and 4 of these had complete microscopic regression (1 after subsequent APC treatment). The length of Barrett esophagus shortened significantly in both study groups, although the extent of regression was greater after APC treatment (mean 5.9-0.8 cm vs. 4.6-2.2 cm). Two patients who had undergone APC treatment developed a late esophageal stricture, which required endoscopic dilation, and 2 patients in the surveillance group developed high-grade dysplasia during follow-up. CONCLUSIONS Regression of Barrett esophagus after fundoplication is more likely, and greater in extent, in patients who undergo ablation with APC. In most patients treated with APC the neosquamous mucosa remains stable at up to 5-year follow-up. The development of high-grade dysplasia only occurred in patients who were not treated with APC.
Collapse
|
16
|
Weston AP. Automated circumferential Barrett's ablation by using radiofrequency energy: a welcome step in the right direction. Gastrointest Endosc 2007; 65:196-9. [PMID: 17258974 DOI: 10.1016/j.gie.2006.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Accepted: 11/01/2006] [Indexed: 12/10/2022]
|
17
|
|
18
|
Ganz RA. Photodynamic therapy is nonthermal injury. Gastrointest Endosc 2005; 62:820; author reply 820. [PMID: 16246712 DOI: 10.1016/j.gie.2005.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Accepted: 06/03/2005] [Indexed: 12/10/2022]
|