RFA ablation and resection avoids esophagectomy in dysplastic Barrett’s and intramucosal adenocarcinoma

TORONTO – Radiofrequency ablation with or without endoscopic mucosal resection resulted in complete remission of high-grade dysplasia in 79% of patients and Barrett’s esophagus in 49%, and none of the patients required esophagectomy, according to Dr. Michal J. Lada.

"Endoscopic treatment of early neoplasia is a safe and effective modality," said Dr. Lada. "The use of esophagectomy for high-grade dysplasia has been eliminated since 2008 in our center and has been significantly decreased for intramucosal disease as primary therapy."

Early neoplasia is increasingly being identified because of better surveillance of known Barrett’s esophagus. Once Barrett’s is identified, it carries a 0.4% risk of progression to adenocarcinoma. For the year 2014, it is estimated that 18,100 people will be diagnosed with esophageal cancer, and 15,450 will die of the disease.

While esophagectomy was once advocated as the optimal treatment for high-grade dysplasia or intramucosal adenocarcinoma, it is associated with significant morbidity and impaired long-term alimentary outcomes. Radiofrequency ablation coupled with endoscopic mucosal resection (EMR) has emerged as the standard of care in the management of these patients, said Dr. Lada of the University of Rochester (N.Y.) Medical Center.

The 57 patients in this retrospective study (45 with high-grade dysplasia and 12 with intramucosal adenocarcinoma) underwent a total of 181 ablation procedures (mean of 3.2 per patient) between 2007 and 2012. EMR prior to ablation was applied liberally for any mucosal irregularities or nodules, being used in 61% of patients overall, and as a first procedure in 49%, for a total of 58 EMR procedures. With surveillance endoscopies every 2 months throughout treatment included, patients underwent a total of 753 procedures, averaging 13.2 procedures per patient.

"When we proposed this therapy to patients for high-grade dysplasia or intramucosal disease, we offered the option of esophagectomy, with the full disclosure that endoscopic treatment is a lifelong commitment rather than a single event," said Dr. Lada. "Esophagectomy can really be viewed as kind of a radical prophylaxis."

The mean age of treated patients was 66.2 years and 88% were male. Most patients had gastroesophageal reflux disease (89%) and were taking proton pump inhibitors (89%) on a long-term basis, Dr. Lada reported at the annual meeting of the American Association for Thoracic Surgery.

Complete remission of dysplasia was achieved in 79% of patients (45 of 57), with a median time of remission of 11.5 months. Complete remission of Barrett’s esophagus was achieved in 49% (28 of 57 patients), within a median of 18.4 months. All patients without complete remission continued endoscopic treatment.

The recurrence of dysplasia was observed in 21% of patients, with a time to recurrence of 29.1 months, and a return of Barrett’s esophagus was seen in only 7%, during a median of 14.8 months. Seven percent of patients progressed from high-grade dysplasia to intramucosal adenocarcinoma over a median of 12.6 months, but all of them were treated endoscopically. No patients required esophagectomy or developed metastatic disease.

There were six deaths during follow-up, none from esophageal cancer. There were also no major complications of treatment and only two minor complications.

"The use of endoscopic therapies appears justified as the new standard of care in the majority of patients with Barrett’s and early esophageal neoplasia," said Dr. Lada.

"Endoscopic therapy, using combinations of endoscopic resection and ablation, has revolutionized the treatment of patients with high-grade dysplasia and superficial adenocarcinomas. This strategy represents a major paradigm shift in the management of this disease, and I applaud the authors for being early adopters of this approach," commented Dr. Steven R. Demeester, a professor in the department of cardiothoracic surgery at the University of Southern California, Los Angeles, and an invited discussant on the paper.

"It’s an interesting paradox that while we now have endoscopic, organ-preserving techniques to treat these patients, at the same time there seems to be an increasing nihilism among our gastroenterology colleagues about the benefits of surveillance for Barrett’s esophagus," Dr. Demeester said.

Dr. Lada countered that, as an established referral center for reflux disease, the center’s referral numbers continue to increase.

Dr. Lada reported no financial disclosures. Dr. Demeester is a consultant for C2 Therapeutics, Bard/Davol, and Novadaq.

TORONTO – Radiofrequency ablation with or without endoscopic mucosal resection resulted in complete remission of high-grade dysplasia in 79% of patients and Barrett’s esophagus in 49%, and none of the patients required esophagectomy, according to Dr. Michal J. Lada.

"Endoscopic treatment of early neoplasia is a safe and effective modality," said Dr. Lada. "The use of esophagectomy for high-grade dysplasia has been eliminated since 2008 in our center and has been significantly decreased for intramucosal disease as primary therapy."

Early neoplasia is increasingly being identified because of better surveillance of known Barrett’s esophagus. Once Barrett’s is identified, it carries a 0.4% risk of progression to adenocarcinoma. For the year 2014, it is estimated that 18,100 people will be diagnosed with esophageal cancer, and 15,450 will die of the disease.

While esophagectomy was once advocated as the optimal treatment for high-grade dysplasia or intramucosal adenocarcinoma, it is associated with significant morbidity and impaired long-term alimentary outcomes. Radiofrequency ablation coupled with endoscopic mucosal resection (EMR) has emerged as the standard of care in the management of these patients, said Dr. Lada of the University of Rochester (N.Y.) Medical Center.

The 57 patients in this retrospective study (45 with high-grade dysplasia and 12 with intramucosal adenocarcinoma) underwent a total of 181 ablation procedures (mean of 3.2 per patient) between 2007 and 2012. EMR prior to ablation was applied liberally for any mucosal irregularities or nodules, being used in 61% of patients overall, and as a first procedure in 49%, for a total of 58 EMR procedures. With surveillance endoscopies every 2 months throughout treatment included, patients underwent a total of 753 procedures, averaging 13.2 procedures per patient.

"When we proposed this therapy to patients for high-grade dysplasia or intramucosal disease, we offered the option of esophagectomy, with the full disclosure that endoscopic treatment is a lifelong commitment rather than a single event," said Dr. Lada. "Esophagectomy can really be viewed as kind of a radical prophylaxis."

The mean age of treated patients was 66.2 years and 88% were male. Most patients had gastroesophageal reflux disease (89%) and were taking proton pump inhibitors (89%) on a long-term basis, Dr. Lada reported at the annual meeting of the American Association for Thoracic Surgery.

Complete remission of dysplasia was achieved in 79% of patients (45 of 57), with a median time of remission of 11.5 months. Complete remission of Barrett’s esophagus was achieved in 49% (28 of 57 patients), within a median of 18.4 months. All patients without complete remission continued endoscopic treatment.

The recurrence of dysplasia was observed in 21% of patients, with a time to recurrence of 29.1 months, and a return of Barrett’s esophagus was seen in only 7%, during a median of 14.8 months. Seven percent of patients progressed from high-grade dysplasia to intramucosal adenocarcinoma over a median of 12.6 months, but all of them were treated endoscopically. No patients required esophagectomy or developed metastatic disease.

There were six deaths during follow-up, none from esophageal cancer. There were also no major complications of treatment and only two minor complications.

"The use of endoscopic therapies appears justified as the new standard of care in the majority of patients with Barrett’s and early esophageal neoplasia," said Dr. Lada.

"Endoscopic therapy, using combinations of endoscopic resection and ablation, has revolutionized the treatment of patients with high-grade dysplasia and superficial adenocarcinomas. This strategy represents a major paradigm shift in the management of this disease, and I applaud the authors for being early adopters of this approach," commented Dr. Steven R. Demeester, a professor in the department of cardiothoracic surgery at the University of Southern California, Los Angeles, and an invited discussant on the paper.

"It’s an interesting paradox that while we now have endoscopic, organ-preserving techniques to treat these patients, at the same time there seems to be an increasing nihilism among our gastroenterology colleagues about the benefits of surveillance for Barrett’s esophagus," Dr. Demeester said.

Dr. Lada countered that, as an established referral center for reflux disease, the center’s referral numbers continue to increase.

Dr. Lada reported no financial disclosures. Dr. Demeester is a consultant for C2 Therapeutics, Bard/Davol, and Novadaq.

TORONTO – Radiofrequency ablation with or without endoscopic mucosal resection resulted in complete remission of high-grade dysplasia in 79% of patients and Barrett’s esophagus in 49%, and none of the patients required esophagectomy, according to Dr. Michal J. Lada.

"Endoscopic treatment of early neoplasia is a safe and effective modality," said Dr. Lada. "The use of esophagectomy for high-grade dysplasia has been eliminated since 2008 in our center and has been significantly decreased for intramucosal disease as primary therapy."

Early neoplasia is increasingly being identified because of better surveillance of known Barrett’s esophagus. Once Barrett’s is identified, it carries a 0.4% risk of progression to adenocarcinoma. For the year 2014, it is estimated that 18,100 people will be diagnosed with esophageal cancer, and 15,450 will die of the disease.

While esophagectomy was once advocated as the optimal treatment for high-grade dysplasia or intramucosal adenocarcinoma, it is associated with significant morbidity and impaired long-term alimentary outcomes. Radiofrequency ablation coupled with endoscopic mucosal resection (EMR) has emerged as the standard of care in the management of these patients, said Dr. Lada of the University of Rochester (N.Y.) Medical Center.

The 57 patients in this retrospective study (45 with high-grade dysplasia and 12 with intramucosal adenocarcinoma) underwent a total of 181 ablation procedures (mean of 3.2 per patient) between 2007 and 2012. EMR prior to ablation was applied liberally for any mucosal irregularities or nodules, being used in 61% of patients overall, and as a first procedure in 49%, for a total of 58 EMR procedures. With surveillance endoscopies every 2 months throughout treatment included, patients underwent a total of 753 procedures, averaging 13.2 procedures per patient.

"When we proposed this therapy to patients for high-grade dysplasia or intramucosal disease, we offered the option of esophagectomy, with the full disclosure that endoscopic treatment is a lifelong commitment rather than a single event," said Dr. Lada. "Esophagectomy can really be viewed as kind of a radical prophylaxis."

The mean age of treated patients was 66.2 years and 88% were male. Most patients had gastroesophageal reflux disease (89%) and were taking proton pump inhibitors (89%) on a long-term basis, Dr. Lada reported at the annual meeting of the American Association for Thoracic Surgery.

Complete remission of dysplasia was achieved in 79% of patients (45 of 57), with a median time of remission of 11.5 months. Complete remission of Barrett’s esophagus was achieved in 49% (28 of 57 patients), within a median of 18.4 months. All patients without complete remission continued endoscopic treatment.

The recurrence of dysplasia was observed in 21% of patients, with a time to recurrence of 29.1 months, and a return of Barrett’s esophagus was seen in only 7%, during a median of 14.8 months. Seven percent of patients progressed from high-grade dysplasia to intramucosal adenocarcinoma over a median of 12.6 months, but all of them were treated endoscopically. No patients required esophagectomy or developed metastatic disease.

There were six deaths during follow-up, none from esophageal cancer. There were also no major complications of treatment and only two minor complications.

"The use of endoscopic therapies appears justified as the new standard of care in the majority of patients with Barrett’s and early esophageal neoplasia," said Dr. Lada.

"Endoscopic therapy, using combinations of endoscopic resection and ablation, has revolutionized the treatment of patients with high-grade dysplasia and superficial adenocarcinomas. This strategy represents a major paradigm shift in the management of this disease, and I applaud the authors for being early adopters of this approach," commented Dr. Steven R. Demeester, a professor in the department of cardiothoracic surgery at the University of Southern California, Los Angeles, and an invited discussant on the paper.

"It’s an interesting paradox that while we now have endoscopic, organ-preserving techniques to treat these patients, at the same time there seems to be an increasing nihilism among our gastroenterology colleagues about the benefits of surveillance for Barrett’s esophagus," Dr. Demeester said.

Dr. Lada countered that, as an established referral center for reflux disease, the center’s referral numbers continue to increase.

Dr. Lada reported no financial disclosures. Dr. Demeester is a consultant for C2 Therapeutics, Bard/Davol, and Novadaq.