Ablation of residual Barrett’s epithelium after endoscopic resection: a randomized long-term follow-up study of argon plasma coagulation vs. surveillance (APE study)
submitted 30 October 2012
accepted after revision 24 September 2013
18 December 2013 (online)
Background and study aim: It is commonly assumed that ablation of any remaining Barrett’s epithelium after endoscopic resection of early Barrett’s neoplasia improves outcome by reducing the rate of metachronous lesions, but this has not yet been evaluated in a randomized trial. The aim of this study was to compare argon plasma coagulation (APC) with surveillance only for the management of residual Barrett’s epithelium following endoscopic resection.
Patients and methods: Patients in whom focal early Barrett’s neoplasia (high grade intraepithelial neoplasia [HGIN] or mucosal cancer) had been curatively resected by endoscopy were randomly assigned to undergo ablation of the residual Barrett’s segment by APC or surveillance only; pH-metry-adjusted proton pump inhibitor therapy was administered in both groups. The main outcome parameter was recurrence-free survival. Follow-up endoscopies with biopsies in cases of further residual Barrett’s epithelium were carried out at 6-monthly intervals in both groups.
Results: A total of 63 patients (57 male [90.5 %]) were included in the study (ablation group n = 33; surveillance group n = 30). For complete Barrett’s ablation, a mean number of 4 ± 1.6 APC sessions were required (range 2 – 7). The mean follow-up duration did not differ significantly between ablation (28.2 ± 13.7 months, range 0 – 44) and surveillance patients (24.7 ± 14.8 months, range 0 – 45; P = 0.159). The number of secondary lesions was 1 in the ablation group (3 %), and 11 in the surveillance group (36.7 %), leading to significantly higher recurrence-free survival for the patients undergoing ablation (P = 0.005).
Conclusions: Thermal ablation of residual Barrett’s epithelium leads to a significant reduction in neoplasia recurrence rate compared with a surveillance strategy during a limited follow-up of 2 years. A longer follow-up duration may have led to a relatively higher rate of secondary neoplasia in both groups of patients.
- 1 Ell C, May A, Gossner L et al. Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett’s esophagus. Gastroenterology 2000; 118: 670-677
- 2 Pech O, Behrens A, May A et al. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett’s oesophagus. Gut 2008; 57: 1200-1206
- 3 Ell C, May A, Pech O et al. Curative endoscopic resection of early esophageal adenocarcinomas (Barrett’s cancer). Gastrointest Endosc 2007; 65: 3-10
- 4 Chennat J, Konda VJA, Ross AS et al. Complete Barrett’s eradication endoscopic mucosal resection (CBE-EMR): an effective treatment modality for high grade dysplasia (HGD) and intramucosal carcinoma (IMC) – an American single center experience. Am J Gastroenterol 2009; 104: 2684-2692
- 5 Moss A, Bourke MJ, Hourigan LF et al. Endoscopic resection for Barrett’s high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit. Am J Gastroenterol 2010; 105: 1276-1283
- 6 Prasad GA, Wu TT, Wigle DA et al. Endoscopic and surgical treatment of mucosal (T1a) esophageal adenocarcinoma in Barrett’s esophagus. Gastroenterology 2009; 137: 815-823
- 7 Pech O, Bollschweiler E, Manner H et al. Comparison between endoscopic and surgical resection of mucosal esophageal adenocarcinoma in Barrett’s esophagus at two high-volume centers. Ann Surg 2011; 254: 67-72
- 8 Oh DS, Hagen JA, Chandrasoma PT et al. Clinical biology and surgical therapy of intramucosal adenocarcinoma of the esophagus. J Am Coll Surg 2006; 203: 152-161
- 9 Stein HJ, Feith M, Bruecher BL et al. Early esophageal cancer: pattern of lymphatic spread and prognostic factors for long-term survival after surgical resection. Ann Surg 2005; 242: 566-573
- 10 May A, Gossner L, Pech O et al. Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett’s esophagus: acute-phase and intermediate results of a new treatment approach. Eur J Gastroenterol Hepatol 2002; 14: 1085-1091
- 11 Sharma P, Dent J, Armstrong D et al. The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C&M Criteria. Gastroenterology 2006; 131: 1392-1399
- 12 Manner H, May A, Miehlke S et al. Ablation of nonneoplastic Barrett’s mucosa using argon plasma coagulation with concomitant esomeprazole therapy (APBANEX): a prospective multicenter evaluation. Am J Gastroenterol 2006; 101: 1762-1769
- 13 Schulz H, Miehlke S, Antos D et al. Ablation of Barrett’s epithelium by endoscopic argon plasma coagulation in combination with high-dose omeprazole. Gastrointest Endosc 2000; 51: 659-663
- 14 Pereira-Lima JC, Busnello JV, Saul C et al. Higher power setting argon plasma coagulation for the eradication of Barrett’s esophagus. Am J Gastroenterol 2000; 95: 1661-1668
- 15 Pouw RE, Wirths K, Eisendrath P et al. Efficacy of radiofrequency ablation combined with endoscopic resection for Barrett’s esophagus with early neoplasia. Clin Gastroenterol Hepatol 2010; 8: 23-29
- 16 Shaheen NJ, Sharma P, Overholt BF et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med 2009; 360: 2277-2288
- 17 Gondrie JJ, Pouw RE, Sondermeijer C et al. Effective treatment of early Barrett’s neoplasia with stepwise circumferential and focal ablation using the HALO system. Endoscopy 2008; 40: 370-379
- 18 Gondrie JJ, Pouw RE, Sondermeijer C et al. Stepwise circumferential and focal ablation of Barrett’s esophagus with high-grade dysplasia: results of the first prospective series in 11 patients. Endoscopy 2008; 40: 359-369
- 19 Fleischer DE, Overholt BE, Sharma VK et al. Endoscopic ablation of Barrett’s esophagus: a multicenter study with 2.5-year follow-up. Gastrointest Endosc 2008; 68: 867-876
- 20 Vaccaro BJ, Gonzalez S, Poneros JM et al. Detection of intestinal metaplasia after successful eradication of Barrett’s esophagus with radiofrequency ablation. Dig Dis Sci 2011; 56: 1996-2000
- 21 Shaheen NJ, Overholt BF, Sampliner RE et al. Durability of radiofrequency ablation in Barrett’s esophagus with dysplasia. Gastroenterology 2011; 141: 460-468
- 22 Konda VJ, Ross AS, Ferguson MK et al. Is the risk of concomitant invasive esophageal cancer in high-grade dysplasia in Barrett’s esophagus overestimated?. Clin Gastroenterol Hepatol 2008; 6: 159-164
- 23 Manner H, May A, Rabenstein T et al. Prospective evaluation of a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal endoscopy. Scand J Gastroenterol 2007; 42: 397-405
- 24 Manner H, Enderle MD, Pech O et al. Second-generation argon plasma coagulation: two-center experience with 600 patients. J Gastroenterol Hepatol 2008; 23: 872-878
- 25 Van Vilsteren FGI, Pouw R, Seewald S et al. Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett’s oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial. Gut 2011; 60: 765-773