Recurrent intestinal metaplasia at the gastroesophageal junction following endoscopic eradication of dysplastic Barrett’s esophagus may not be benign

 

 Permissions and Reprints

Background and study aims: Radiofrequency ablation (RFA) combined with endoscopic mucosal resection (EMR) is effective for eradicating dysplastic Barrett’s esophagus. The durability of response is reported to be variable. We aimed to determine the effectiveness and durability of RFA with or without EMR for patients with dysplastic Barrett’s esophagus.

Patients and methods: Patients with dysplastic Barrett’s esophagus referred to two academic hospitals were assessed with high definition white-light endoscopy, narrow-band imaging, and Seattle protocol biopsies. EMR was performed in visible lesions. RFA was performed at 3-month intervals until complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM) was achieved.

Results: In total, 137 patients received RFA (78 with EMR); 75 with over 12 months follow-up since commencing RFA. Pretreatment histology was intramucosal cancer (IMC) 21 %, high grade dysplasia (HGD) 54 %, low grade dysplasia (LGD) 25 %. CR-D rates were 88 %, 92 %, and 100 % at 1, 2, and 3 years; CR-IM rates were 69 %, 74 %, and 81 %. Kaplan–Meier analysis showed increasing probability of achieving CR-D/CR-IM over time. Of 26 patients maintaining CR-IM for > 12 months, five relapsed with intestinal metaplasia (19 %), and three with dysplasia (12 %). Recurrences occurred in patients with prior HGD/IMC, predominantly at the gastroesophageal junction (GEJ). None relapsed with cancer. Adverse events occurred in 4 % of RFA and 6.5 % of EMR procedures.

Conclusions: RFA combined with EMR is effective in achieving CR-D/CR-IM in the majority of patients with dysplastic Barrett’s esophagus, with an incremental response over time. While durable in the majority, recurrent intestinal metaplasia and dysplasia, frequently occurring at the GEJ, suggest long-term surveillance is warranted in high risk groups.

• References

• 1 Shaheen NJ, Sharma P, Overholt BF et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. NEJM 2009; 360: 2277-8888
  CrossrefPubMedGoogle Scholar
• 2 Bulsiewicz WJ, Kim HP, Dellon ES et al. Safety and efficacy of endoscopic mucosal therapy with radiofrequency ablation for patients with neoplastic Barrett’s esophagus. Clin Gastroenterol Hepatol 2013; 11: 636-642
  CrossrefPubMedGoogle Scholar
• 3 Okoro NI, Tomizawa Y, Dunagan KT et al. Safety of prior endoscopic mucosal resection in patients receiving radiofrequency ablation of Barrett’s esophagus. Clin Gastroenterol Hepatol 2012; 10: 150-154
  CrossrefPubMedGoogle Scholar
• 4 Pouw RE, Wirths K, Eisendrath P et al. Efficacy of radiofrequency ablation combined with endoscopic resection for Barrett’s esophagus with early neoplasia. Clin Gastroenterol Hepatol 2010; 8: 23-29
  CrossrefPubMedGoogle Scholar
• 5 van Vilsteren FG, Pouw RE, Seewald S et al. Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett’s oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial. Gut 2011; 60: 765-773
  CrossrefPubMedGoogle Scholar
• 6 Holscher AH, Bollschweiler E, Schroder W et al. Prognostic impact of upper, middle, and lower third mucosal or submucosal infiltration in early esophageal cancer. Ann Surg 2011; 254: 802-807 discussion 7 – 8
  CrossrefPubMedGoogle Scholar
• 7 Luna RA, Gilbert E, Hunter JG. High-grade dysplasia and intramucosal adenocarcinoma in Barrett’s esophagus: the role of esophagectomy in the era of endoscopic eradication therapy. Curr Opin Gastroenterol 2012; 28: 362-369
  CrossrefPubMedGoogle Scholar
• 8 Alvarez Herrero L, Pouw RE, van Vilsteren FG et al. Risk of lymph node metastasis associated with deeper invasion by early adenocarcinoma of the esophagus and cardia: study based on endoscopic resection specimens. Endoscopy 2010; 42: 1030-1036
  Article in Thieme ConnectPubMedGoogle Scholar
• 9 Shaheen NJ, Overholt BF, Sampliner RE et al. Durability of radiofrequency ablation in Barrett’s esophagus with dysplasia. Gastroenterology 2011; 141: 460-468
  CrossrefPubMedGoogle Scholar
• 10 Orman ES, Li N, Shaheen NJ. Efficacy and durability of radiofrequency ablation for Barrett’s esophagus: Systematic review and meta-analysis. Clin Gastroenterol Hepatol 2013; 11: 1245-1255
  CrossrefPubMedGoogle Scholar
• 11 Phoa KN, Pouw RE, van Vilsteren FG et al. 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
  CrossrefPubMedGoogle Scholar
• 12 Korst RJ, Santana-Joseph S, Rutledge JR et al. Patterns of recurrent and persistent intestinal metaplasia after successful radiofrequency ablation of Barrett’s esophagus. J Thorac Cardiovasc Surg 2013; 145: 1529-1534
  CrossrefPubMedGoogle Scholar
• 13 Vaccaro BJ, Gonzalez S, Poneros JM et al. Detection of intestinal metaplasia after successful eradication of Barrett’s Esophagus with radiofrequency ablation. Dig Dis Sci 2011; 56: 1996-2000
  CrossrefPubMedGoogle Scholar
• 14 Fleischer DE, Overholt BF, Sharma VK et al. Endoscopic radiofrequency ablation for Barrett’s esophagus: 5-year outcomes from a prospective multicenter trial. Endoscopy 2010; 42: 781-789
  Article in Thieme ConnectPubMedGoogle Scholar
• 15 Jayasekera C, Taylor AC, Desmond PV et al. Added value of narrow band imaging and confocal laser endomicroscopy in detecting Barrett’s esophagus neoplasia. Endoscopy 2012; 44: 1089-1095
  Article in Thieme ConnectPubMedGoogle Scholar
• 16 Sharma P, Dent J, Armstrong D et al. The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C & M criteria. Gastroenterology 2006; 131: 1392-1399
  CrossrefPubMedGoogle Scholar
• 17 Endoscopic Classification Review G. Update on the Paris classification of superficial neoplastic lesions in the digestive tract. Endoscopy 2005; 37: 570-578
  Article in Thieme ConnectPubMedGoogle Scholar
• 18 Sharma P, Weston AP, Topalovski M et al. Magnification chromoendoscopy for the detection of intestinal metaplasia and dysplasia in Barrett’s oesophagus. Gut 2003; 52: 24-27
  CrossrefPubMedGoogle Scholar
• 19 Schlemper RJ, Riddell RH, Kato Y et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut 2000; 47: 251-255
  CrossrefPubMedGoogle Scholar
• 20 Schlemper RJ, Kato Y, Stolte M. Diagnostic criteria for gastrointestinal carcinomas in Japan and Western countries: proposal for a new classification system of gastrointestinal epithelial neoplasia. J Gastroenterol Hepatol 2000; 15 (Suppl 3): G49-G57
  CrossrefPubMedGoogle Scholar
• 21 Pouw RE, Sharma VK, Bergman JJ et al. Radiofrequency ablation for total Barrett’s eradication: a description of the endoscopic technique, its clinical results and future prospects. Endoscopy 2008; 40: 1033-1040
  Article in Thieme ConnectPubMedGoogle Scholar
• 22 Cameron GR, Jayasekera CS, Williams R et al. Detection and staging of esophageal cancers within Barrett’s esophagus is improved by assessment in specialized Barrett’s units. Gastrointest Endosc 2014; 80: 971-983.e1
  CrossrefPubMedGoogle Scholar
• 23 Gupta M, Iyer PG, Lutzke L et al. Recurrence of esophageal intestinal metaplasia after endoscopic mucosal resection and radiofrequency ablation of Barrett’s esophagus: results from a US Multicenter Consortium. Gastroenterology 2013; 145: 79-86 e1
  CrossrefPubMedGoogle Scholar
• 24 Haidry RJ, Dunn JM, Butt MA et al. Radiofrequency ablation and endoscopic mucosal resection for dysplastic Barrett’s esophagus and early esophageal adenocarcinoma: outcomes of the UK National Halo RFA Registry. Gastroenterology 2013; 145: 87-95
  CrossrefPubMedGoogle Scholar
• 25 Inadomi JM, Somsouk M, Madanick RD et al. A cost-utility analysis of ablative therapy for Barrett’s esophagus. Gastroenterology 2009; 136: 2101-2114 e1 – 6
  CrossrefPubMedGoogle Scholar
• 26 Hur C, Choi SE, Rubenstein JH et al. The cost effectiveness of radiofrequency ablation for Barrett’s esophagus. Gastroenterology 2012; 143: 567-575
  CrossrefPubMedGoogle Scholar
• 27 Spechler SJ, Sharma P, Souza RF et al. American Gastroenterological Association. American Gastroenterological Association technical review on the management of Barrett’s esophagus. Gastroenterology 2011; 140: e18-52 quiz e13
  PubMedGoogle Scholar