Endoscopy 2020; 52(09): 812-813
DOI: 10.1055/a-1119-1030
E-Videos

Successful treatment of refractory Barrett’s neoplasia with hybrid argon plasma coagulation: a case series

Arvind J. Trindade
Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, United States
,
Diana Wee
Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, United States
,
Praneet Wander
Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, United States
,
Molly Stewart
Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, United States
,
Calvin Lee
Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, United States
,
Petros C. Benias
Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, United States
,
Matthew J. McKinley
Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, United States
› Author Affiliations
 

    A 60-year-old woman with Barrett’s esophagus (Prague class C8M10) with flat high grade dysplasia underwent radiofrequency ablation (RFA) therapy. She underwent four sessions with the circumferential balloon and one treatment with the focal 90 ablation catheter for a total of five sessions. Sessions were performed every 3 months and the patient adhered to maximal acid suppression therapy.

    The patient returned for a sixth session (15 months from the start of therapy). Endoscopy showed a 5-cm area of salmon-colored mucosa remaining. There was also a slightly raised 2-cm island that was suspicious for residual neoplasia ([Fig. 1], arrow). The decision was made to perform extensive biopsies to rule out progression of disease. Results showed intramucosal cancer in the raised area while the remaining distal Barrett’s segment was nondysplastic.

    Zoom Image
    Fig. 1 Endoscopy with narrow band imaging showing a Barrett’s segment after five sessions of radiofrequency ablation. There was a raised area (yellow arrow) of intramucosal cancer.

    Given the presence of refractory Barrett’s mucosa, the decision was made to switch therapy to hybrid argon plasma coagulation (hAPC). The neoplastic island was removed using band ligation endoscopic mucosal resection technique; histology showed intramucosal cancer with negative margins. The EMR defect was treated with hAPC. The mucosa was raised using a submucosal injection (Erbejet, Effect 50; Erbe Elektromedizin GmbH, Tübingen, Germany) and ablated at 40 W ([Video 1]). The remaining distal nondysplastic Barrett’s mucosa was also treated with hAPC at 60 W ([Fig. 2]).

    Video 1 Endoscopic mucosal resection (EMR) of a raised Barrett’s area, hybrid argon plasma coagulation (hAPC) of the EMR defect, and hAPC of the remaining flat Barrett’s mucosa.


    Quality:
    Zoom Image
    Fig. 2 Treatment of the Barrett’s segment that was refractory to radiofrequency ablation. a Endoscopic mucosal resection (EMR) of the raised area, and hybrid argon plasma coagulation (hAPC) of the EMR defect. b The remaining flat, nondysplastic Barrett’s mucosa also underwent hAPC.

    Follow-up endoscopy 3 months later showed minimal islands, which were re-treated with hAPC ([Fig. 3]). Follow-up endoscopy 6 months from the start of hAPC therapy showed complete eradication of intestinal metaplasia ([Fig. 4]), as confirmed by histology from biopsies. The patient tolerated all procedures well and had no post-procedural pain.

    Zoom Image
    Fig. 3 Follow-up endoscopy 3 months after one session of hybrid argon plasma coagulation (hAPC) showing minimal islands remaining.
    Zoom Image
    Fig. 4 Endoscopy after two sessions of hybrid argon plasma coagulation showed complete eradication of intestinal metaplasia and dysplasia.

    This case shows that hAPC is an option when RFA has failed. In our institution we have used hAPC to successfully treat five consecutive cases of disease that was refractory to RFA with or without cryotherapy ([Table 1]).

    Table 1

    Information for five patient who were refractory to radiofrequency ablation with our without cryotherapy and who were successfully treated with hybrid argon plasma coagulation.

    Patient

    Patient age, years/sex

    Initial Prague class and grade of dysplasia

    Treatment prior to hAPC (no. of sessions)

    Prague class prior to hAPC

    CE-D achieved prior to hAPC

    Sessions of hAPC, n

    CE-IM achieved after hAPC

    1

    60/F

    C8M10
    HGD

    RFA (5)

    C1M5

    No

    2

    Yes

    2

    51/M

    C7M8
    LGD

    RFA (4)
    Cryo (3)

    C2M4

    Yes

    2

    Yes

    3

    72/F

    C8M10

    RFA (4)
    Cryo (2)

    C6M7

    No

    3

    Yes

    4

    76/M

    C7M7

    RFA (4)
    Cryo (2)

    C2M3

    No

    2

    Yes

    5

    75/M

    C4M5

    RFA (3)

    C2M3

    No

    2

    Yes

    hAPC, hybrid argon plasma coagulation; CE-D, complete eradication of dysplasia; CE-IM, complete eradication of intestinal metaplasia; F, female; HGD, high grade dysplasia; FRA, radiofrequency ablation; M, male; LGD, low grade dysplasia; Cryo, cryotherapy.

    Endoscopy_UCTN_Code_CPL_1AH_2AK

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    #

    Competing interests

    Dr. Benias is a consultant for Medtronic.
    Dr. Trindade is a consultant for Olympus America and Pentax America, and has received research support from Ninepoint Medical.


    Corresponding author

    Arvind J. Trindade, MD
    Division of Gastroenterology
    Long Island Jewish Medical Center
    Zucker School of Medicine at Hofstra/Northwell
    Northwell Health System
    270-05 76th Avenue
    New Hyde Park, NY 11040
    United States   
    Fax: +1-718-470-5509   

    Publication History

    Publication Date:
    27 February 2020 (online)

    © Georg Thieme Verlag KG
    Stuttgart · New York


    Zoom Image
    Fig. 1 Endoscopy with narrow band imaging showing a Barrett’s segment after five sessions of radiofrequency ablation. There was a raised area (yellow arrow) of intramucosal cancer.
    Zoom Image
    Fig. 2 Treatment of the Barrett’s segment that was refractory to radiofrequency ablation. a Endoscopic mucosal resection (EMR) of the raised area, and hybrid argon plasma coagulation (hAPC) of the EMR defect. b The remaining flat, nondysplastic Barrett’s mucosa also underwent hAPC.
    Zoom Image
    Fig. 3 Follow-up endoscopy 3 months after one session of hybrid argon plasma coagulation (hAPC) showing minimal islands remaining.
    Zoom Image
    Fig. 4 Endoscopy after two sessions of hybrid argon plasma coagulation showed complete eradication of intestinal metaplasia and dysplasia.