Safety and efficacy of endoscopic spray cryotherapy for esophageal cancer

Although surgery is traditionally the standard of care for esophageal cancer, esophagectomy carries significant morbidity. Alternative endoscopic therapies are needed for patients who are not candidates for conventional treatment. The objective of this study is to assess the safety, efficacy, and tolerability of spray cryotherapy of esophageal adenocarcinoma. This study includes patients with esophageal adenocarcinoma who had failed or were not candidates for conventional therapy enrolled retrospectively and prospectively in an open-label registry and patients in a retrospective cohort from 11 academic and community practices. Endoscopic spray cryotherapy was performed until biopsy proven local tumor eradication or until treatment was halted due to progression of disease, patient withdrawal or comorbidities. Eighty-eight patients with esophageal adenocarcinoma (median age 76, 80.7% male, mean length 5.1 cm) underwent 359 treatments (mean 4.4 per patient). Tumor stages included 39 with T1a, 25 with T1b, 9 with unspecified T1, and 15 with T2. Eighty-six patients completed treatment with complete response of intraluminal disease in 55.8%, including complete response in 76.3% for T1a, 45.8% for T1b, 66.2% for all T1, and 6.7% for T2. Mean follow-up was 18.4 months. There were no deaths or perforations related to spray cryotherapy. Strictures developed in 12 of 88 patients (13.6%) but were present before spray cryotherapy in 3 of 12. This study suggests that endoscopic spray cryotherapy is a safe, well-tolerated, and effective treatment option for early esophageal adenocarcinoma.

Safety and efficacy of endoscopic spray cryotherapy for esophageal cancer

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Background: Although surgery is traditionally the standard of care for esophageal cancer, esophagectomy carries significant morbidity and mortality. Alternative endoscopic therapies are needed for patients who are not candidates for conventional treatment. The objective of this study was to assess the safety, efficacy, and tolerability of spray cryotherapy of esophageal cancer. Methods: This study includes patients enrolled retrospectively and prospectively in an open-label registry and patients in a retrospective cohort from twelve academic and community practices. Endoscopic spray cryotherapy was performed until local tumor eradication was confirmed by biopsy or until treatment was halted due to progression of disease, patient withdrawal or co-morbidities. Results: One-hundred and eight patients (median age 75.5, 79.6% male, 93.5% adenocarcinoma, mean length 5.2 cm) underwent 442 treatments (mean 4.2 per patient). Tumor stages included 40 with T1a, 27 with T1b, 10 with unspecified T1, 15 with T2, and 16 with no T stage reported. One-hundred and six patients completed treatment with complete response of intraluminal disease in 54.7%, including complete response in 74.4% for T1a, 50% for T1b, 65.3% for all T1, 6.7% for T2, and 50% for those with no T stage reported. Mean follow-up was 17.3 months. There were no deaths or perforations related to spray cryotherapy. Strictures developed in 11 of 108 patients (10.2%) but were present before spray cryotherapy in 3 of 11. Conclusions: This study suggests that endoscopic spray cryotherapy is safe, well tolerated and effective for early esophageal cancer in patients who are not candidates for conventional therapy.

Endoscopic spray cryotherapy for esophageal cancer: safety and efficacy

BACKGROUND

Few options exist for patients with localized esophageal cancer ineligible for conventional therapies. Endoscopic spray cryotherapy with low-pressure liquid nitrogen has demonstrated efficacy in this setting in early studies.

OBJECTIVE

To assess the safety and efficacy of cryotherapy in esophageal carcinoma.

DESIGN

Multicenter, retrospective cohort study.

SETTING

Ten academic and community medical centers between 2006 and 2009.

PATIENTS

Subjects with esophageal carcinoma in whom conventional therapy failed and those who refused or were ineligible for conventional therapy.

INTERVENTIONS

Cryotherapy with follow-up biopsies. Treatment was complete when tumor eradication was confirmed by biopsy or when treatment was halted because of tumor progression, patient preference, or comorbid condition.

MAIN OUTCOME MEASUREMENTS

Complete eradication of luminal cancer and adverse events.

RESULTS

Seventy-nine subjects (median age 76 years, 81% male, 94% with adenocarcinoma) were treated. Tumor stage included T1-60, T2-16, and T3/4-3. Mean tumor length was 4.0 cm (range 1-15 cm). Previous treatment including endoscopic resection, photodynamic therapy, esophagectomy, chemotherapy, and radiation therapy failed in 53 subjects (67%). Forty-nine completed treatment. Complete response of intraluminal disease was seen in 31 of 49 subjects (61.2%), including 18 of 24 (75%) with mucosal cancer. Mean (standard deviation) length of follow-up after treatment was 10.6 (8.4) months overall and 11.5 (2.8) months for T1 disease. No serious adverse events were reported. Benign stricture developed in 10 (13%), with esophageal narrowing from previous endoscopic resection, radiotherapy, or photodynamic therapy noted in 9 of 10 subjects.

LIMITATIONS

Retrospective study design, short follow-up.

CONCLUSIONS

Spray cryotherapy is safe and well tolerated for esophageal cancer. Short-term results suggest that it is effective in those who could not receive conventional treatment, especially for those with mucosal cancer.

Safety and efficacy of endoscopic spray cryotherapy for Barrett's esophagus with high-grade dysplasia

BACKGROUND

Endoscopic ablation to treat Barrett's esophagus (BE) with high-grade dysplasia (HGD) is associated with a decreased incidence of esophageal adenocarcinoma. Endoscopic spray cryotherapy (CRYO) demonstrates promising preliminary data.

OBJECTIVE

To assess the safety and efficacy of CRYO in BE with HGD.

DESIGN

Multicenter, retrospective cohort study.

SETTING

Nine academic and community centers; treatment period, 2007 to 2009.

PATIENTS

Subjects with HGD confirmed by 2 pathologists. Previous EMR was allowed if residual HGD remained.

INTERVENTIONS

CRYO with follow-up biopsies.

MAIN OUTCOME MEASUREMENTS

Complete eradication of HGD with persistent low-grade dysplasia, complete eradication of all dysplasia with persistent nondysplastic intestinal metaplasia, and complete eradication of all intestinal metaplasia.

RESULTS

Ninety-eight subjects (mean age 65.4 years, 83% male) with BE and HGD (mean length 5.3 cm) underwent 333 treatments (mean 3.4 treatments per subject). There were no esophageal perforations. Strictures developed in 3 subjects. Two subjects reported severe chest pain managed with oral narcotics. One subject was hospitalized for bright red blood per rectum. Sixty subjects had completed all planned CRYO treatments and were included in the efficacy analysis. Fifty-eight subjects (97%) had complete eradication of HGD, 52 (87%) had complete eradication of all dysplasia with persistent nondysplastic intestinal metaplasia, and 34 (57%) had complete eradication of all intestinal metaplasia. Subsquamous BE was found in 2 subjects (3%).

LIMITATIONS

Nonrandomized, retrospective study with no control group, short follow-up (10.5 months), lack of centralized pathology, and use of surrogate outcome for decreased cancer risk.

CONCLUSIONS

CRYO is a safe and well-tolerated therapy for BE and HGD. Short-term results suggest that CRYO is highly effective in eradicating HGD.

Cryospray ablation (CSA) in the palliative treatment of squamous cell carcinoma of the esophagus

Background

Esophageal carcinoma is the ninth most prevalent cancer worldwide with squamous cell carcinoma (SCCA) and adenocarcinoma accounting for the vast majority of new cases (13,900 in 2003). Cure rates in the U.S. are less than 10%, similar to lung cancer. More than 50% of patients with esophageal carcinoma present with unresectable or metastatic disease, are not surgical candidates, or display disease progression despite the addition of neoadjuvant chemoradiotherapy to surgery. Need for improved palliation exits.

Case presentation

This case describes a 73-year-old African American male who presented with recurrent squamous cell carcinoma (SCCA) of the esophagus who has a achieved complete remission for 24 months via endoscopic cryospray ablation.

Conclusion

Endoscopic cryo spray ablation warrants further investigation as a palliative treatment modality for esophageal cancer. This is the first reported case in the medical literature.

Cryoablation of Barrett's esophagus: a pilot study

BACKGROUND

Numerous ablative modalities have demonstrated varying degrees of efficacy in the eradication of Barrett's esophagus (BE). However, they are associated with either high cost, patient discomfort, complications, tedious application, residual underlying BE, or some combination of the above. The aim of this study was to evaluate the safety and the efficacy of a new cryogenic device by using liquid nitrogen sprayed through an open tipped cryogenic catheter placed through the accessory channel of an upper endoscope.

METHODS

A prospective, single center study was performed on patients with a long-standing history of BE followed in a Barrett's registry. Patients with degrees of dysplasia ranging from none to multifocal high-grade dysplasia were treated. All patients were treated with 40 mg rabeprazole 3 times per day during the treatment period. Elimination of acid reflux was confirmed via 24-hour esophageal pH studies. Cryoablation was applied hemicircumferentially to 4-cm-long segments at monthly intervals, until the entire segment of BE was eliminated.

RESULTS

Eleven patients were treated. There was reversal of BE in all patients. In 9 of 11 (78%) patients who completed the protocol, there was complete endoscopic and histologic reversal of BE. There was no subsquamous specialized intestinal metaplasia at the 6-month follow-up. No complications occurred.

CONCLUSIONS

Based on preliminary results, low-pressure spray cryoablation of BE under direct endoscopic visualization is safe and easy to perform. Its relative lack of patient discomfort and its simplicity and demonstrated efficacy make it a modality that should be further explored in the ablation of GI mucosal lesions such as BE and perhaps early esophageal cancer.

Technology insight: ablative techniques for Barrett's esophagus--current and emerging trends

New mucosal ablative techniques that can be used in the esophagus have emerged over the past two decades. These techniques have been develop primarily to treat the precursors of esophageal adenocarcinoma: dyspla, in Barrett's esophagus and early esophageal cancer. Although high-grade dysplasia and early stage cancer can be treated with esophagectomy, the inherent morbidity and mortality of esophageal adenocarcinoma and the morbidities, difficulties, costs and limitations of the current technology mean that there has been a significant increase in interest and research regarding alternative treatments such as ablative techniques. At this stage it is not clear which of the numerous endoscopic ablative techniques available---photodynamic therapy, laser therapy, multipolar electrocoagulation, argon plasma coagulation, endoscopic mucosal resection, radiofrequency ablation or cryotherapy--will emerge as superior. In addition, it has yet to be determined whether the risks associated with ablation therapy are less than the risk of Barrett's esophagus progressing to cancer. Whether ablation therapy eliminates o significantly reduces the risk of cancer, eliminates the need for surveillance endoscopy, or is cost-effective, also remains to be seen. Comparative triads that are now underway should help to answer these questions.

Technology Insight: ablative techniques for Barrett's esophagus—current and emerging trends

New mucosal ablative techniques that can be used in the esophagus have emerged over the past two decades. These techniques have been developed primarily to treat the precursors of esophageal adenocarcinoma: dysplasia in Barrett's esophagus and early esophageal cancer. Although high-grade dysplasia and early stage cancer can be treated with esophagectomy, the inherent morbidity and mortality of esophageal adenocarcinoma and the morbidities, difficulties, costs and limitations of the current technology mean that there has been a significant increase in interest and research regarding alternative treatments such as ablative techniques. At this stage it is not clear which of the numerous endoscopic ablative techniques available-photodynamic therapy, laser therapy, multipolar electrocoagulation, argon plasma coagulation, endoscopic mucosal resection, radiofrequency ablation or cryotherapy-will emerge as superior. In addition, it has yet to be determined whether the risks associated with ablation therapy are less than the risk of Barrett's esophagus progressing to cancer. Whether ablation therapy eliminates or significantly reduces the risk of cancer, eliminates the need for surveillance endoscopy, or is cost-effective, also remains to be seen. Comparative trials that are now underway should help to answer these questions.

Cryotherapy and other newer techniques

Potential modalities for the ablation of Barrett's mucosa are increasing with new technologies. Three of the newest are high- and low-pressure spray cryotherapy and ultrasonic epithelial ablation. Data regarding low-pressure spray cryotherapy are particularly promising. It has a depth of ablation approximating 2 mm, is technically easy to perform, and involves unique cellular mechanisms of injury relative to other thermal techniques that may prove ideally suited for the treatment of GI neoplasms and premalignant lesions such as Barrett's esophagus. A Barrett's ablation trial with cryotherapy is ongoing at the National Naval Medical Center.

The prevalence and clinical characteristics of short segments of specialized intestinal metaplasia in the distal esophagus on routine endoscopy

OBJECTIVE

To prospectively determine the prevalence and clinical characteristics of short segments of specialized intestinal metaplasia in the distal esophagus. Short segment is defined as extending less than 2 cm proximal to the esophagogastric junction. This has been referred to by some investigators as "short segment Barrett's esophagus."

METHODS

One hundred and seventy two patients undergoing elective esophagogastroduodenoscopy were consecutively enrolled. Patients with known Barrett's esophagus were excluded. All study patients completed a symptom questionnaire. At endoscopy, the presence of esophagitis and locations of the diaphragmatic hiatus, esophagogastric junction, and the squamocolumnar junction were recorded. Biopsy specimens were obtained at the squamocolumnar junction to identify specialized intestinal metaplasia and 2 cm above the squamocolumnar junction to evaluate for histological esophagitis.

RESULTS

Two patients (1.2%) had at least 2 cm of columnar-lined esophagus. Of the 170 patients without 2 cm of columnar-lined esophagus, 16 (9.4%) patients had short segments of specialized intestinal metaplasia. Twelve (7.0%) of these patients had specialized intestinal metaplasia limited to the esophagogastric junction. All patients with specialized intestinal metaplasia were Caucasian, and there was a slight male predominance. Patients without specialized intestinal metaplasia (n = 154, 90.6%) did not differ statistically with respect to age, gender, use of acid-suppressing drugs, alcohol, or smoking history. Pyrosis and regurgitation were significantly more common in patients with specialized intestinal metaplasia involving the distal 2 cm of the esophagus or the esophagogastric junction. Cough was more common in the group with specialized intestinal metaplasia limited to the esophagogastric junction. The groups were similar in frequency of dysphagia, globus sensation, nocturnal pyrosis, eructation, early satiety, nausea, and abdominal pain.

CONCLUSIONS

Specialized intestinal metaplasia less than 2 cm proximal to the esophagogastric junction is common in Caucasian patients undergoing routine esophagogastroduodenoscopy. Pyrosis and regurgitation are significantly more common in patients with short segments of specialized intestinal metaplasia, whether involving the distal 2 cm of the esophagus or the esophagogastric junction alone. Alcohol and tobacco use are no more common in patients with specialized intestinal metaplasia than in those without metaplasia. The presence of specialized intestinal metaplasia did not correlate with either endoscopic or histological esophagitis.

Impacts of logging and wildfire on an upland black spruce community in northwestern Ontario

Plant species composition and community structure were compared among four sites in an upland black spruce community in northwestern Ontario. One site had remained undisturbed since the 1930s and three had been disturbed by either logging, fire, or both logging and fire. Canonical correspondence ordination analyses indicated that herbaceous species composition and abundance differed among the disturbance types while differences in the shrub and tree strata were less pronounced. In the herb stratum Pleurozium schreberi, Ptilium crista-castrensis and Dicranum polysetum were in greatest abundance on the undisturbed forest site, while the wildfire and burned cutover sites were dominated by Epilobium angustifolium and Polytrichum juniperinum. The unburned harvested site was dominated by Epilobium angustifolium, Cornus canadensis and Pleurozium schreberi. Species richness was lower on the undisturbed site than on any of the disturbed sites while species diversity (H') and evenness (Hill's E5) were higher on the unburned harvested site than on the other sites. Results suggest that herb re-establishment is different among harvested and burned sites in upland black spruce communities and we hypothesize that differences in the characteristics of the disturbance were responsible, in particular, the impact of burning on nutrient availability. These differences need to be taken into account in determining the effects of these disturbances on biodiversity and long-term ecosystem management.

Expansion of the Ki-67 proliferative compartment correlates with degree of dysplasia in Barrett's esophagus

BACKGROUND

Barrett's esophagus is a histologically defined premalignant lesion of the esophagus in which normal squamous epithelium is replaced by intestinalized columnar epithelium. In a multistep progression from Barrett's esophagus to fully developed carcinoma, accelerated proliferation may indicate or precede genomic instability and, therefore, may be an important factor in the pathogenesis and/or prediction of malignant transformation. Ki-67 is a nuclear antigen expressed in proliferating cells, (G1, S, G2, and M phases) but not in resting cells (G0 phase). This study was undertaken to determine if Ki-67 expression correlates with the degree of dysplasia and if Ki-67 expression can help to differentiate those patients with or without dysplasia.

METHODS

The Ki-67 proliferation fraction in 87 paraffin embedded esophageal biopsies from 43 patients with the Ki-67 antibody (MIB-1) was analyzed using immunohistochemistry. Using a computerized proliferation index program (QNA v2.54, Becton Dickinson Cellular Imaging Systems, Inc., Elmhurst, IL), a Ki-67 score was derived for the luminal surface, upper esophageal crypt, lower crypt, and underlying glandular zone of the columnar-lined esophagus.

RESULTS

Significant differences in Ki-67 scores were noted in each zone among different histologic categories: normal gastric ([NG] n = 17); Barrett's without dysplasia ([ND] n = 17); low grade dysplasia ([LG] n = 21); high grade dysplasia ([HG] n = 14); and adenocarcinoma ([CA] n = 5). The pattern of Ki-67 expression was associated strongly with each histologic category. The percentage of Ki-67 positive nuclei in each mucosal zone statistically separated high grade from low grade dysplasia (P < 0.001). In high grade dysplastic tissues, the Ki-67 positive nuclei were found predominantly on the surface epithelium and upper crypt zones, whereas in low grade dysplasia, the majority of Ki-67 positive nuclei were found in the lower crypt zone. The number of Ki-67 positive nuclei in each mucosal component also was significantly different in Barrett's esophagus without dysplasia when compared with Barrett's esophagus with low grade dysplastic tissues. (P < 0.001) Staining patterns of indefinite for dysplasia by H & E staining separated into several distinct patterns (five LG, seven ND, one NG) whereas six biopsies with low grade dysplasia had a Ki-67 expression pattern more consistent with that of high grade dysplasia.

CONCLUSION

The Ki-67 staining pattern correlated with histologic findings in Barrett's esophagus and may represent an additional parameter for differentiating patients with or without dysplasia.

Dietary management of obesity: evaluation of the time-energy displacement diet in terms of its efficacy and nutritional adequacy for long-term weight control

1. An unsupplemented 4200 kJ (1000 kcal) diet emphasizing large quantities of relatively unrefined complex carbohydrates was evaluated among sixty obese adults for its effectiveness and nutritional adequacy in a long-term weight-control programme. Patients were followed individually as outpatients by a physician and dietician-an average of thirteen visits over 26 weeks. Assessment of health indices included anthropometric measurements, blood pressure, lipid levels and assays for seven vitamins, beta-carotene and iron. 2. Weight loss averaged 8.2 kg or 24% of excess weight during the 6 months of active treatment. Over an average of 17 months of post-treatment follow-up, 44% of patients continued to lose weight and 92% remained below pretreatment levels. 3. Average skinfold thickness fell 7 mm (P less than 0.001) whereas muscle mass was maintained (arm muscle circumference + 10 mm, not significant; creatinine-height index + 3% of standard (Bistrian et al. 1975; not significant). Systolic and diastolic blood pressure fell 7 and 5 mmHg respectively (P less than 0.01). Total serum cholesterol and triglycerides fell 200 and 660 mg/1 respectively (P less than 0.01), while high-density-lipoprotein-cholesterol remained statistically unchanged. Mean serum levels of retinol, beta-carotene, folate, vitamin B12, ascorbic acid, Fe and transferrin saturation, and activity coefficients for thiamin, riboflavin and pyridoxine were within normal limits after periods of treatment ranging from 5 to 84 weeks. 4. An earlier age of onset of obesity tended to be associated with greater weight loss during treatment and lesser weight rebound during follow-up. 5. The results indicate that the experimental diet, without supplementation, was nutritionally adequate as well as effective for long-term weight control.

Acclimation, temperature selection, and heat exchange in the turtle, Chrysemys scripta

Turtles acclimated to temperatures between 3 and 19 degrees C were placed in a thermal gradient. The animals usually selected temperatures above 28 degrees C within 1 h after placement in the gradient, attaining a final thermal preferendum between 31 and 33 degrees C. Turtles placed in the gradient for extended periods of time were more active during the day; the temperature selected was not related to activity or time of day. Turtles were transferred from a constant temperature bath at 10 or 30 degrees C to a calorimeter at 30 or 10 degrees C. Mean body temperature (Tb) and temperatures of the heart (The), brain (Tbr), and cloaca (Tcl) as well as heart rate were continuously monitored. In a 0.76-kg turtle, temperatures increased to two-thirds of the final difference between the initial temperature and the final temperature in the following times (min): Tb, 5.5; The, 6.0; Tcl, 9.0. The increase in Tbr varied depending on whether the head was extended or retracted. Rapid changes in ambient water temperature had relatively little effect on the heart rate of a submerged turtle. Heart rates were closely related to The and were practically independent of brain temperature.

Word associations of schizophrenic children

A study of word associations in 84 normal and 16 disturbed 10- and 11-yr.-old children was made through an integration of two prior methods of word-association research: the study of pathological features of adult schizophrenic language and the study of psycholinguistic features of developmental changes in children's associations. The associations of 8 schizophrenic children and 8 non-schizophrenic children in residential treatment were compared with those of 84 normal children. The associative differences were most consistent and definitive among the schizophrenic children: they gave fewer common responses and more idiosyncratic, unrelated responses. All the children made responses termed “playing with the word,” which is a sign of association disturbance in adults but appears to be normal in children. The associative differences observed between normal and disturbed children were interpreted as not so much reflecting a “developmental lag” in associative structure as a difficulty in selection of an association from what is believed to be a normal associative repertoire. The variability in occurrence of common responses plus the appearance of the expected “paradigmatic shift” in all the children supported this interpretation.