Optimal Endoluminal Treatment of Barrett's Esophagus: Integrating Novel Strategies into Clinical Practice

Raf Bisschops

Disclosures

Expert Rev Gastroenterol Hepatol. 2010;4(3):319-333. 

In This Article

Expert Commentary

Over the last 5 years the treatment paradigm for early Barrett's neoplasia has changed considerably. Owing to the high risk of subtotal esophagectomy, endoscopists have searched for endoluminal therapy options because of the low risk of metastasis in Barrett's neoplasia that is limited to the mucosa. It has now become clear that HGIN or mucosal cancer under specified conditions is no longer an indication for surgery but that endoluminal treatment has become the first choice for treatment (Figure 4). However, the risk of metachronous disease is considerably high and this necessitates a very meticulous follow-up or additional ablation.[7] With the introduction of RFA, a new ablation method has become available that is safer than PDT and APC, and more efficacious than APC. Nevertheless, intestinal metaplasia is not eradicated in 100% of patients and recurrence of intestinal metaplasia appears to occur.[94] Therefore, it is still too early to omit the follow-up that is necessary after treatment for neoplasia. It is also particularly important to emphasize that no single study demonstrated efficacy of RFA for ablating adenocarcinoma and that patients with residual adenocarcinoma on random four-quadrant biopsies were excluded from the studies.[82,89–101] Therefore, it is currently advised to resect all visible abnormalities prior to ablation as was undertaken in 31 out of 44 patients in the Academic Medical Center Amsterdam studies.[93] It has indeed been shown that pre-ER biopsies have a rather poor predictive value for the final pathological diagnosis of the ER specimen. This is only accurate in 61% of cases with more severe pathology found in 21% of the ER specimens. Of these upgraded lesions the majority are small visible lesions.[102] It is, therefore, very important to perform a thorough endoscopic inspection using advanced imaging techniques before any endoscopic treatment option, in particular RFA, is chosen for HGIN Barrett's esophagus. Since RFA is easy to perform, the endoscopic work-up of patients with early neoplasia will probably be the most challenging and difficult part in training gastroenterologists to define the exact endoluminal therapy for each patient. In particular, in patients with very long segment Barrett's it is important to realize that small lesions can be missed and these may harbor cancer.[66]

Figure 4.

Integrated endoluminal therapy with endoscopic resection, circumferential and focal radiofrequency ablation. This is an example of a 60-year-old patient with a long segment Barrett's (C8M10). (A) One type IIa lesion was present as is seen in panel (B) at the 4 o'clock position with a narrow-band imaging image. (C) First, an endoscopic resection as a staging procedure was performed showing a well differentiated mucosal lesion without lymphovascular infiltration. After two follow-up endoscopies with multiple biopsies showed no residual cancer, the patient was treated with circumferential radiofrequency ablation twice (D & E). Subsequently, she was additionally treated three times with focal radiofrequency ablation (F) resulting in complete eradication of dysplasia and intestinal metaplasia (G).

Until recently, HGIN and early Barrett's cancer were the formal indications to treat patients. However, with the introduction of a new and safer ablation technique one might argue whether patients at an earlier disease stage of LGIN are eligible for therapy. In a US sham-controlled trial, progression in the LGIN cohort to HGIN occurred in 14% of the patients after 12 months.[80] Risks of complications that are associated with previous ER will probably be more limited.[93] One of the problems with LGIN is the poor interobserver agreement on this diagnosis among pathologists. However, once LGIN is confirmed by two or more expert pathologists, the reported risk for progression to cancer is 16–28%.[103,104] In addition, the presence of LGIN is also a risk factor for the presence of more advanced lesions elsewhere in the Barrett's segment that may have been missed during a previous endoscopy, especially in a long segment Barrett. This again makes endoscopic detection of early lesions essential in the training of endoscopists. There are even data suggesting that cost–benefit balance is in favor of ablating nondysplastic Barrett's.[105] However, since not all patients can be cleared of intestinal metaplasia and long-term follow-up data are still lacking, this is currently not a good indication. What we do need, however, are better validated prognostic markers to select patients with LGIN or nondysplastic Barrett's for RFA therapy.

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