Long-term outcomes of patients with Barrett's esophagus and high-grade dysplasia or early cancer treated with endoluminal therapies with intention to complete eradication

      Background

      Endoluminal therapy is an option for selected patients with Barrett's esophagus and high-grade dysplasia or early cancer.

      Objective

      To assess long-term outcomes of patients treated with endoluminal therapy with the goal of complete eradication of all dysplasia and intestinal metaplasia.

      Design

      Retrospective cohort study.

      Patients

      Selected patients referred with dysplastic Barrett's esophagus.

      Intervention

      Endoluminal therapy combining resection and photodynamic therapy, radiofrequency ablation, and/or argon plasma coagulation treatment was individualized based on patient and lesion characteristics, technique evolution, and interval response.

      Main Outcome Measurements

      We assessed complete eradication of dysplasia, all intestinal metaplasia, and recurrences.

      Results

      A total of 166 patients were treated and had at least 1 year of follow-up. Complete elimination of neoplasia was achieved in 157 patients (95%) and complete elimination of intestinal metaplasia in 137 patients (83%). After therapy, patients were followed for 33 (range 18-58) months. Among patients who achieved complete elimination of intestinal metaplasia, subsequent recurrent intestinal metaplasia was detected in 48 (35%) and dysplasia in 12 (9%). Among those who achieved only complete elimination of dysplasia, recurrent dysplasia was detected in 6 of 19 patients (32%). Multifocal dysplasia and patient's age were dysplasia and/or carcinoma recurrence risk factors in the multivariable and univariable analyses. Complete elimination of intestinal metaplasia was a protective factor in the univariable analysis. Retreatment achieved remission in 90% of cases. Forty-two patients (23.9%) had complications, including 21 with stricture (11.9%) and 1 treatment-related death.

      Limitations

      Retrospective study and evolution of endoscopic modalities.

      Conclusion

      Multiple-mode endoluminal therapy for Barrett's esophagus with high-grade dysplasia or early cancer with intention to complete eradication of all intestinal metaplasia was successful, with low observed recurrence of dysplasia or cancer. However, recurrence of intestinal metaplasia occurs in one-third of cases and supports continued endoscopic surveillance even after complete eradication.

      Abbreviations:

      APC (argon plasma beam coagulation), BE (Barrett's esophagus), HGD (high-grade dysplasia), LGD (low-grade dysplasia), PDT (photodynamic therapy), RFA (radiofrequency ablation)
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      References

        • Sharma P.
        • Falk G.W.
        • Weston A.P.
        • et al.
        Dysplasia and cancer in a large multicenter cohort of patients with Barrett's esophagus.
        Clin Gastroenterol Hepatol. 2006; 4: 566-572
        • Spechler S.J.
        Dysplasia in Barrett's esophagus: limitations of current management strategies.
        Am J Gastroenterol. 2005; 100: 927-935
        • Holscher A.H.
        • Bollschweiler E.
        • Schneider P.M.
        • et al.
        Early adenocarcinoma in Barrett's oesophagus.
        Br J Surg. 1997; 84: 1470-1473
        • Rice T.W.
        Pro: esophagectomy is the treatment of choice for high-grade dysplasia in Barrett's esophagus.
        Am J Gastroenterol. 2006; 101: 2177-2179
        • Prasad G.A.
        • Buttar N.S.
        • Wongkeesong L.M.
        • et al.
        Significance of neoplastic involvement of margins obtained by endoscopic mucosal resection in Barrett's esophagus.
        Am J Gastroenterol. 2007; 102: 2380-2386
        • Prasad G.A.
        • Wang K.K.
        • Buttar N.S.
        • et al.
        Long-term survival following endoscopic and surgical treatment of high-grade dysplasia in Barrett's esophagus.
        Gastroenterology. 2007; 132: 1226-1233
        • Das A.
        • Singh V.
        • Fleischer D.E.
        • et al.
        A comparison of endoscopic treatment and surgery in early esophageal cancer: an analysis of surveillance epidemiology and end results data.
        Am J Gastroenterol. 2008; 103: 1340-1345
        • National Institute for Health and Clinical Excellence
        National Institute for Health and Clinical Excellence Web site.
        Barrett's oesophagus: ablative therapy for the treatment of Barrett's oesophagus. National Institute for Health and Clinical Excellence, LondonIssued August 2010
        • Peters F.P.
        • Kara M.A.
        • Rosmolen W.D.
        • et al.
        Endoscopic treatment of high-grade dysplasia and early stage cancer in Barrett's esophagus.
        Gastrointest Endosc. 2005; 61: 506-514
        • Ell C.
        • May A.
        • Pech O.
        • et al.
        Curative endoscopic resection of early esophageal adenocarcinomas (Barrett's cancer).
        Gastrointest Endosc. 2007; 65: 3-10
        • Prasad G.A.
        • Wu T.T.
        • Wigle D.A.
        • et al.
        Endoscopic and surgical treatment of mucosal (T1a) esophageal adenocarcinoma in Barrett's esophagus.
        Gastroenterology. 2009; 137: 815-823
        • Pech O.
        • Behrens A.
        • May A.
        • et al.
        Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus.
        Gut. 2008; 57: 1200-1206
        • Pouw R.E.
        • Seewald S.
        • Gondrie J.J.
        • et al.
        Stepwise radical endoscopic resection for eradication of Barrett's oesophagus with early neoplasia in a cohort of 169 patients.
        Gut. 2010; 59: 1169-1177
        • Badreddine R.J.
        • Prasad G.A.
        • Wang K.K.
        • et al.
        Prevalence and predictors of recurrent neoplasia after ablation of Barrett's esophagus.
        Gastrointest Endosc. 2010; 71: 697-703
        • 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
        • Overholt B.F.
        • Lightdale C.J.
        • Wang K.K.
        • et al.
        Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett's esophagus: international, partially blinded, randomized phase III trial.
        Gastrointest Endosc. 2005; 62: 488-498
        • Shaheen N.J.
        • Sharma P.
        • Overholt B.F.
        • et al.
        Radiofrequency ablation in Barrett's esophagus with dysplasia.
        N Engl J Med. 2009; 360: 2277-2288
        • Chennat J.
        • Konda V.J.
        • Ross A.S.
        • et al.
        Complete Barrett's eradication endoscopic mucosal resection: an effective treatment modality for high-grade dysplasia and intramucosal carcinoma—an American single-center experience.
        Am J Gastroenterol. 2009; 104: 2684-2692
        • Moss A.
        • Bourke M.J.
        • Hourigan L.F.
        • et al.
        Endoscopic resection for Barrett's high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit.
        Am J Gastroenterol. 2010; 105: 1276-1283
        • Seewald S.
        • Akaraviputh T.
        • Seitz U.
        • et al.
        Circumferential EMR and complete removal of Barrett's epithelium: a new approach to management of Barrett's esophagus containing high-grade intraepithelial neoplasia and intramucosal carcinoma.
        Gastrointest Endosc. 2003; 57: 854-859
        • Peters F.P.
        • Kara M.A.
        • Rosmolen W.D.
        • et al.
        Stepwise radical endoscopic resection is effective for complete removal of Barrett's esophagus with early neoplasia: a prospective study.
        Am J Gastroenterol. 2006; 101: 1449-1457
        • van Vilsteren F.G.
        • Pouw R.E.
        • 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
        • Overholt B.F.
        Acid suppression and reepithelialization after ablation of Barrett's esophagus.
        Dig Dis. 2000; 18: 232-239
        • Vaccaro B.J.
        • Gonzalez S.
        • Poneros J.M.
        • et al.
        Detection of intestinal metaplasia after successful eradication of Barrett's esophagus with radiofrequency ablation.
        Dig Dis Sci. 2011; 56: 1996-2000