Gastroenterology

Gastroenterology

Volume 145, Issue 1, July 2013, Pages 96-104
Gastroenterology

Original Research
Full Report: Clinical—Alimentary Tract
Remission of Barrett's Esophagus With Early Neoplasia 5 Years After Radiofrequency Ablation With Endoscopic Resection: A Netherlands Cohort Study

https://doi.org/10.1053/j.gastro.2013.03.046Get rights and content

Background & Aims

Radiofrequency ablation (RFA), with or without endoscopic resection effectively eradicates Barrett’s esophagus (BE) containing high-grade intraepithelial neoplasia and/or early-stage cancer. We followed patients who received RFA for BE containing high-grade intraepithelial neoplasia and/or early-stage cancer for 5 years to determine the durability of treatment response.

Methods

We followed 54 patients with BE (2−12 cm), previously enrolled in 4 consecutive cohort studies in which they underwent focal endoscopic resection in case of visible lesions (n = 40 [72%]), followed by serial RFA every 3 months. Patients underwent high-resolution endoscopy with narrow-band imaging at 6 and 12 months after treatment and then annually for 5 years (median, 61 months; interquartile range, 53−65 months); random biopsy samples were collected from neosquamous epithelium and gastric cardia. After 5 years, endoscopic ultrasound and endoscopic resection of neosquamous epithelium were performed. Outcomes included sustained complete remission of neoplasia or intestinal metaplasia (IM), IM in gastric cardia, or buried glands in neosquamous epithelium.

Results

After 5 years, Kaplan-Meier analysis showed sustained complete remission of neoplasia and intestinal metaplasia in 90% of patients; neoplasia recurred in 3 patients and was managed endoscopically. Focal IM in the cardia was found in 19 of 54 patients (35%), in 53 of 1143 gastric cardia biopsies (4.6%). The incidence of IM of the cardia did not increase over time; and IM was diagnosed based on only a single biopsy in 89% of patients. Buried glands were detected in 3 of 3543 neosquamous epithelium biopsies (0.08%, from 3 patients). No endoscopic resection samples had buried glands.

Conclusions

Among patients who have undergone RFA with or without endoscopic resection for neoplastic BE, 90% remain in remission at 5-year follow-up, with all recurrences managed endoscopically. This treatment approach is therefore an effective and durable alternative to esophagectomy; www.trialregister.nl number, NTR2938.

Section snippets

Patient Selection

Patients were initially included if they had endoscopically visible BE with histology proven HGIN and/or early-stage cancer demonstrated on at least 2 separate endoscopies. Patients were treated per one of the following study protocols (Table 1):

  • 1.

    The first pilot study (AMC-I) on circumferential RFA using the HALO360 ablation device, with earlier en-bloc endoscopic resection allowed, of HGIN and/or early-stage cancer in patients with BE segment between 2 and 10 cm.11

  • 2.

    The second prospective study

Patient Characteristics and Initial Treatment

Fifty-five patients (45 men) with a mean age of 65 years (±9.6 years) were included, with a median BE length of C4M5 cm (IQR, C1−7 to M4−8 cm). Forty patients (72%) underwent endoscopic resection of visible abnormalities before the first RFA treatment. After RFA treatment, CR-neoplasia/CR-IM was achieved in 54 of 55 (98%) patients. One patient underwent surgery for persisting HGIN, as scarring after previous endoscopic resection treatment made it impossible to perform escape endoscopic

Discussion

In this prospective cohort of patients who reached CR-neoplasia and CR-IM after endoscopic resection/RFA, sustained remission was observed in 93% of 46 patients (95% CI: 82.5−97.8) who were followed for at least 5 years. Overall, sustained remission was demonstrated in 94% of 54 patients (95% CI: 84.9−98.1) during a median follow-up of 5 years. All recurrences of neoplasia observed during this trial were detected at an early stage during endoscopic follow-up and could be managed endoscopically;

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    Conflicts of interest This author discloses the following: Jacques J. G. H. M. Bergman has received grant support and medical supplies from BÂRRX Medical/Covidien, Cook Medical, Olympus Endoscopy, and AstraZeneca. The remaining authors disclose no conflicts.

    Funding This work was supported, in part, by BÂRRX Medical, Sunnyvale, CA.

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