title: Eliminating a need for esophagectomy: endoscopic treatment of Barrett esophagus with early esophageal neoplasia.
abstract: Over the past several years, endoscopic ablation and resection have become a new standard of care in the management of Barrett esophagus (BE) with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC). Risk factors for failure of endoscopic therapy and the need for subsequent esophagectomy have not been well elucidated. The aims of this study were to determine the efficacy of radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) in the management of BE with HGD or IMC, to discern factors predictive of endoscopic treatment failure, and to assess the effect of endoscopic therapies on esophagectomy volume at our institution. Data were obtained retrospectively for all patients who underwent endoscopic therapies or esophagectomy for a diagnosis of BE with HGD or IMC in our department between January 1, 2004, and December 31, 2012. Complete remission (CR) of BE or HGD or IMC was defined as 2 consecutive biopsy sessions without BE or HGD or IMC and no subsequent recurrence. Recurrence was defined by the return of BE or HGD or IMC after initial remission. Progression was defined as worsening of HGD to IMC or worsening of IMC to submucosal neoplasia or beyond. Overall, 57 patients underwent RFA with or without EMR for BE with HGD (n = 45) or IMC (n = 12) between 2007 and 2012, with a median follow-up duration of 35.4 months (range: 18.5-52.0 months). The 57 patients underwent 181 ablation sessions and more than half (61%) of patients underwent EMR as a component of treatment. There were no major procedural complications or deaths, with only 2 minor complications including 1 symptomatic stricture requiring dilation. Multifocal HGD or IMC was present in 43% (25/57) of patients. CR of IMC was achieved in 100% (12/12) at a median of 6.1 months, CR of dysplasia was achieved in 79% (45/57) at a median of 11.5 months, and CR of BE was achieved in 49% (28/57) at a median of 18.4 months. Following initial remission, 28% of patients (16/57) had recurrence of dysplasia (n = 12) or BE (n = 4). Progression to IMC occurred in 7% (4/57). All patients without CR continue endoscopic treatment. No patient required esophagectomy or developed metastatic disease. Overall, 6 patients died during the follow-up interval, none from esophageal cancer. Factors associated with failure to achieve CR of BE included increasing length of BE (6.0 ± 0.6 vs 4.0 ± 0.6cm, P = 0.03) and shorter duration of follow-up (28.5 ± 3.8 months vs 49.0 ± 5.8 months, P = 0.004). Shorter surveillance duration (17.8 ± 7.6 months vs 63.9 ± 14.4 months, P = 0.009) and shorter follow-up (21.1 ± 6.1 months vs 43.2 ± 4.1 months) were the only significant factors associated with failure to eradicate dysplasia. Our use of esophagectomy as primary therapy for BE with HGD or IMC has diminished since we began using endoscopic therapies in 2007. From a maximum of 16 esophagectomies per year for early Barrett neoplasia in 2006, we performed only 3 esophageal resections for such early disease in 2012, all for IMC, and we have not performed an esophagectomy for HGD since 2008. Although recurrence of BE or dysplasia/IMC was not uncommon, RFA with or without EMR ultimately resulted in CR of IMC in all patients, CR of HGD in the majority (79%), and CR of BE in nearly half (49%). No patient treated endoscopically for HGD or IMC subsequently required esophagectomy. In patients with BE with HGD or IMC, RFA and EMR are safe and highly effective. The use of endoscopic therapies appears justified as the new standard of care in most cases of BE with early esophageal neoplasia.
authors.affiliation: Department of Surgery, University of Rochester Medical Center, Rochester, New York.
authors.forename: Michal J
authors.initials: MJ
authors.lastname: Lada
authors.affiliation: Department of Surgery, University of Rochester Medical Center, Rochester, New York.. Electronic address: Thomas_watson@urmc.rochester.edu.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Watson
authors.affiliation: Department of Surgery, University of Rochester Medical Center, Rochester, New York.
authors.forename: Aqsa
authors.initials: A
authors.lastname: Shakoor
authors.affiliation: Department of Surgery, University of Rochester Medical Center, Rochester, New York.
authors.forename: Dylan R
authors.initials: DR
authors.lastname: Nieman
authors.affiliation: Department of Surgery, University of Rochester Medical Center, Rochester, New York.
authors.forename: Michelle
authors.initials: M
authors.lastname: Han
authors.affiliation: Department of Surgery, University of Rochester Medical Center, Rochester, New York.
authors.forename: Andreas
authors.initials: A
authors.lastname: Tschoner
authors.affiliation: Department of Surgery, University of Rochester Medical Center, Rochester, New York.
authors.forename: Christian G
authors.initials: CG
authors.lastname: Peyre
authors.affiliation: Department of Surgery, University of Rochester Medical Center, Rochester, New York.
authors.forename: Carolyn E
authors.initials: CE
authors.lastname: Jones
authors.affiliation: Chief Operating Officer, University Hospitals, Cleveland, Case Western Reserve University.
authors.forename: Jeffrey H
authors.initials: JH
authors.lastname: Peters
mesh_terms: D000230:Adenocarcinoma / Q000175:diagnosis / Q000601:surgery*; D000368:Aged; D001471:Barrett Esophagus / Q000175:diagnosis / Q000601:surgery*; D001706:Biopsy; D017115:Catheter Ablation / Q000009:adverse effects; D018450:Disease Progression; D004210:Dissection / Q000009:adverse effects / Q000379:methods*; D004938:Esophageal Neoplasms / Q000175:diagnosis / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects; D004945:Esophagoscopy / Q000009:adverse effects; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D011230:Precancerous Conditions / Q000175:diagnosis / Q000601:surgery*; D012074:Remission Induction; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Barrett Esophagus; ablation; adenocarcinoma; dysplasia; esophagectomy