Barrett’s: Does radiofrequency ablation reduce the need for a follow-up?

Barrettʼs esophagus (BE) is a well-known premalignant condition.
The diagnosis of BE is made if the distal esophagus is lined with columnar epithelium with a minimum length of 1 cm (tongues or circular) containing specialized intestinal metaplasia (IM) at histopathological examination [1]. BE is associated with a 30- to 50-fold increased risk of developing esophageal adenocarcinoma, which has an annual incidence of 0.12 % to 0.2 % in patients without intraepithelial neoplasia (IEN) [2] [3]. For this reason, endoscopic surveillance with biopsies of metaplastic epithelium has been recommended to detect dysplasia or cancer at an early stage, when it is still curable, preferably endoscopically.

At present, the approach to a patient with BE depends mainly on presence of IEN, which increases risk of development of esophageal adenocarcinoma (patients with confirmed low-grade IEN have a risk of progression to high-grade IEN or adenocarcinoma 13.4 % per year and in patients with high-grade IEN, risk of developing adenocarcinoma increases to approximately 10 % to 20 % per year).

Patients without IEN should be provided with antireflux therapy and undergo endoscopic surveillance. European Society of Gastrointestinal Endoscopy guidelines from 2017 recommend varying surveillance intervals for different BE lengths. For BE ≥1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies [1]. It is important to note that before entering these intervals, a patient should undergo two high-quality endoscopies performed 6 months apart to reliably exclude presence of IEN. In our center, we usually follow patients with “short” segment BE every 3 to 5 years (individual adjustment based on other risk factors such as obesity, family history, presence/absence of esophagitis etc.) and patients with “long” segment BE every 2 to 3 years.

If IEN (or early cancer) is detected and confirmed by a specialized “esophageal” pathologist, patients are candidates for endoscopic treatment – endoscopic resection (ER) or endoscopic submucosal dissection (ESD) of all visible lesions and/or ablation therapy for flat Barrettʼs mucosa. ER/ESD is indicated in all patients with histologically proven cancer and RFA is indicated after ER/ESD to ablate residual Barrettʼs mucosa.

Thus, radiofrequency ablation (RFA) is the first-line treatment for patients with flat BE with confirmed low- or high-grade IEN and for patients after curative ER/ESD of early adenocarcinoma (EAC) or any other visible abnormalities to eradicate the remnant metaplastic epithelium and prevent recurrence of neoplasia and/or of BE [1] [3].

RFA uses thermal energy generated by a radiofrequency current to destroy the diseased tissue and is currently the most effective and standard method of ablation used in patients with BE-related neoplasia. Aims of RFA (and of other endoscopic treatment in general) are to achieve complete eradication and remission of both IEN and IM, meaning complete disappearance of BE macroscopically and also microscopically.

• References

• 1 Weusten B, Bisschops R, Coron E. et al. Endoscopic management of Barrett’s esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2017; 49: 191-198
• 2 Martinek J, Benes M, Brandtl P. et al. Low incidence of adenocarcinoma and high-grade intraepithelial neoplasia in patients with Barrettʼs esophagus: a prospective cohort study. Endoscopy 2008; 40: 711-716
• 3 Shaheen NJ, Sharma P, Overholt BF. et al. Radiofrequency ablation in barrettʼs esophagus with dysplasia. N Engl J Med 2009; 360: 2277-2288
• 4 Orman ES, Nan LI, Shaheen NJ. Efficacy and durability of radiofrequency ablation for barrettʼs esophagus: systematic review and meta-analysis. Clin Gastroenterol Hepatol 2013; 11: 1245-1255
• 5 Krajciova J, Janicko M, Falt P. et al. Radiofrequency ablation in patients with Barrett’s esophagus-related neoplasia – long-term outcomes in the Czech National Database. J Gastrointest Liver Dis 2019; 28: 149-155
• 6 Shaheen NJ, Falk GW, Iyer PG. et al. ACG Clinical Guideline: Diagnosis and Management of Barrettʼs esophagus. Am J Gastroenterol 2016; 11: 30-50
• 7 Cotton CC, Haidry R, Thrift AP. et al. Development of evidence-based surveillance intervals after radiofrequency ablation of Barrett’s esophagus. Gastroenterology 2018; 155: 316-326.e6