Management of Barrett’s Esophagus and Associated Lesions

This week we discuss Barrett’s esophagus, and management of associated dysplastic and neoplastic lesions. We are excited to welcome on esteemed guest Dr. John Hunter, former chair of surgery at and now the CEO of OHSU Health Systems and also the Kenneth A.J. Mackenzie Professor of Surgery, who will help guide us through the conversation about treatment options for both Barrett’s esophagus and early esophageal cancer.

High Yield Reviews/ Practice Guidelines:

NCCN Clinical Practice Guidelines: Esophageal and Esophagogastric Junction Cancers

High yield resource to explore the management of esophageal cancers, including those early T stage lesions.

Advances in the Diagnosis and Treatment of Barrett’s Esophagus and Early Esophageal Cancer; Summary of the Kelly and Carlos Pellegrini SSAT/SAGES Luncheon Symposium.

Gould JC, Wendling MR, Oeschlager BK, Mittal SK, Komanduri S, Perry KA, Cleary S, Galandiuk S, Scott DJ, Fisichella PM, Shaheen NJ, Haisley KR11, Hunter JG.

Great updated 2017 review outlining the management of Barrett’s and early esophageal adenocarcinoma.

ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus

Nicholas J Shaheen MD, MPH, FACG, Gary W Falk MD, MS, FACG, Prasad G Iyer MD, MSc, FACG, Lauren B Gerson MD, MSc, FACG

Guidelines from the American College of Gastroenterology, outlining diagnosis and management strategy for Barrett’s–written in 2015.

Primary Literature Discussed in the Episode:

Durability of radiofrequency ablation in Barrett’s esophagus with dysplasia.

Shaheen NJ, Overholt BF, Sampliner RE, Wolfsen HC, Wang KK, Fleischer DE, Sharma VK, Eisen GM, Fennerty MB, Hunter JG, Bronner MP, Goldblum JR, Bennett AE, Mashimo H, Rothstein RI, Gordon SR, Edmundowicz SA, Madanick RD, Peery AF, Muthusamy VR, Chang KJ, Kimmey MB, Spechler SJ, Siddiqui AA, Souza RF, Infantolino A, Dumot JA, Falk GW, Galanko JA, Jobe BA, Hawes RH, Hoffman BJ, Sharma P, Chak A, Lightdale CJ.

The AIM Dysplasia Trial, published in Gastroenterology in 2011, which helped to validate the efficacy of ablation for barrett’s + dysplasia. 90%+ of patients in both the low grade dysplasia and high grade dysplasia group had complete eradication of dysplasia and metaplasia. Progression of disease, defined as low grade dysplasia turning into high grade dysplasia or invasive cancer or high grade dysplasia turning into invasive cancer occurred  in 1.37% chance per patient, per year in patients that had RFA. In the SHAM cohort (over the first year, prior to SHAM group cross over into the RFA group), annual progression rate was 16.3%. So a marked difference.

Late Recurrence of Barrett’s Esophagus After Complete Eradication of Intestinal Metaplasia is Rare: Final Report From Ablation in Intestinal Metaplasia Containing Dysplasia Trial.

Cotton CC, Wolf WA, Overholt BF, Li N, Lightdale CJ, Wolfsen HC, Pasricha S, Wang KK, Shaheen NJ; AIM Dysplasia Trial Group.

 

5 year follow up data from the AIM trial, published in Gastroenterology in 2017. They showed, that of the 92% of patients that had metaplasia completely eradicated, about a third had recurrence of barretts or dysplasia, with 17% having recurrence of dyplasia. Importantly, about 70% of these recurrences occured within 1 year follow up, and incidence of recurrence after 1 year went down during every subsequent follow up year, with no recurrences occuring in any patient during the 5th and final follow up year.

 

Radiofrequency ablation vs endoscopic surveillance for patients with Barrett esophagus and low-grade dysplasia: a randomized clinical trial.

Phoa KN, van Vilsteren FG, Weusten BL, Bisschops R, Schoon EJ, Ragunath K, Fullarton G, Di Pietro M, Ravi N, Visser M, Offerhaus GJ, Seldenrijk CA, Meijer SL, ten Kate FJ, Tijssen JG, Bergman JJ.

Published in JAMA 2013. They assigned patients with low grade dysplasia in the setting of Barretts to either ablation or surveillance. There was a reduced risked of progression to high grade dysplasia and cancer for RFA ablation of the barretts and dysplasia versus surveillance alone. Progression to high grade dysplasia or invasive cancer occured in 1.5% of patients in the ablation group vs 26.5% in the control group. Ablation reduced risk of progression to invasive cancer by 7.4% with a number needed to treat of 13.6. After ablation, 12% of patients suffered from a postop stricture, requiring a median of 1 dilation

Important Literature Not Directly Discussed:

Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett’s oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial.

van Vilsteren FG, Pouw RE, Seewald S, Alvarez Herrero L, Sondermeijer CM, Visser M, Ten Kate FJ, Yu Kim Teng KC, Soehendra N, Rösch T, Weusten BL, Bergman JJ.

 

2011 paper in Gut, out of the Netherlands. They assigned patients with high grade dysplasia, in situ cancer or T1a cancer to either endoscopic resection of the dyplastic lesion and then ablation of Barretts in 6-8 weeks, or endoscopic resection of the lesion with a portion of the Barretts, and then stepwise resection of the rest of the Barretts over a max 4 more EGD sessions. They found that for both groups >90% had complete response of neoplasia and metaplasia at a median follow up of 2 years. Importantly, in the local endoscopic resection and RFA group 14% of patients developed postop stenosis, versus nearly 90% of patients in the stepwise endoscopic resection group.