Stepwise circumferential and focal ablation of Barrett’s esophagus with high-grade dysplasia: results of the first prospective series of 11 patients

Background and study aims: Stepwise circumferential and focal ablation of nondysplastic Barrett’s esophagus has proven safe and effective. This study assessed the efficacy and safety of ablation for Barrett’s esophagus with high-grade dysplasia (HGD), and residual Barrett’s esophagus with dysplasia after prior endoscopic resection for visible lesions.

Patients and methods: This was a prospective cohort study. All visible abnormalities were resected prior to ablation. Persistence of dysplasia and absence of invasive cancer was confirmed with biopsies after endoscopic resection. A balloon-based electrode was used for primary circumferential ablation and an endoscope-mounted electrode was used for secondary focal ablation. Eradication of dysplasia and Barrett’s esophagus was the main outcome measure.

Results: Eleven patients (eight men; median age 60 years) were treated (median Barrett’s length 5 cm). Visible abnormalities were removed with endoscopic resection in six patients. The worst pathological grade of residual Barrett’s esophagus after endoscopic resection and prior to ablation was LGD (n = 2) and HGD (n = 9). Patients underwent a median of two circumferential and two focal ablation sessions. Complete remission of dysplasia and complete endoscopic and histological removal of Barrett’s esophagus was achieved in 11/11 patients (100 %). There were no adverse events or strictures, and in none of the 473 biopsies of neo-squamous mucosa was subsquamous Barrett’s esophagus (“buried Barrett’s”) observed. During a median follow-up period of 14 months after the last treatment session and a median number of two follow-up endoscopies, none of the patients showed recurrence of dysplasia or endoscopic signs of recurrent Barrett’s mucosa.

Conclusions: Stepwise circumferential and focal ablation appears to be a safe and effective treatment for complete removal of Barrett’s esophagus containing HGD, and can be safely performed after prior endoscopic resection for endoscopically visible abnormalities.

References

• 1 Peters F P, Kara M A, Rosmolen W D. et al . Endoscopic treatment of high-grade dysplasia and early stage cancer in Barrett's esophagus.  Gastrointest Endosc. 2005;  61 506-514
• 2 Peters F P, Kara M A, Rosmolen W D. et al . Stepwise radical endoscopic resection is effective for complete removal of Barrett's esophagus with early neoplasia: a prospective study.  Am J Gastroenterol. 2006;  101 1449-1457
• 3 Pech O, Gossner L, May A. et al . Long-term results of photodynamic therapy with 5-aminolevulinic acid for superficial Barrett's cancer and high-grade intraepithelial neoplasia.  Gastrointest Endosc. 2005;  62 24-30
• 4 Overholt B F, Lightdale C J, Wang K K. et al . Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett's esophagus: international, partially blinded, randomized phase III trial.  Gastrointest Endosc. 2005;  62 488-498
• 5 Ell C, May A, Pech O. et al . Curative endoscopic resection of early esophageal adenocarcinomas (Barrett's cancer).  Gastrointest Endosc. 2007;  65 3-10
• 6 Prasad G A, Wang K K, Buttar N S. et al . Long-term survival following endoscopic and surgical treatment of high-grade dysplasia in Barrett's esophagus.  Gastroenterology. 2007;  132 1226-1233
• 7 May A, Gossner L, Pech O. et al . Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett's oesophagus: acute-phase and intermediate results of a new treatment approach.  Eur J Gastroenterol Hepatol. 2002;  14 1085-1091
• 8 Bergman J J. Endoscopic treatment of high-grade intraepithelial neoplasia and early cancer in Barrett's oesophagus.  Best Pract Res Clin Gastroenterol. 2005;  19 889-907
• 9 Bergman J J. Endoscopic resection for treatment of mucosal Barrett's cancer: time to swing the pendulum.  Gastrointest Endosc. 2007;  65 11-13
• 10 Seewald S, Akaraviputh T, Seitz U. et al . Circumferential EMR and complete removal of Barrett's epithelium: a new approach to management of Barrett's esophagus containing high-grade intraepithelial neoplasia and intramucosal carcinoma.  Gastrointest Endosc. 2003;  57 854-859
• 11 Peters F P, Krishnadath K K, Rygiel A M. et al . Stepwise radical endoscopic resection of the complete Barrett's esophagus with early neoplasia successfully eradicates pre-existing genetic abnormalities.  Am J Gastroenterol. 2007;  102 1853-1861
• 12 Ackroyd R, Brown N J, Davis M F. et al . Photodynamic therapy for dysplastic Barrett's oesophagus: a prospective, double blind, randomised, placebo controlled trial.  Gut. 2000;  47 612-617
• 13 Peters F, Kara M, Rosmolen W. et al . Poor results of 5-aminolevulinic acid-photodynamic therapy for residual high-grade dysplasia and early cancer in barrett esophagus after endoscopic resection.  Endoscopy. 2005;  37 418-424
• 14 Ackroyd R, Tam W, Schoeman M. et al . Prospective randomized controlled trial of argon plasma coagulation ablation vs. endoscopic surveillance of patients with Barrett's esophagus after antireflux surgery.  Gastrointest Endosc. 2004;  59 1-7
• 15 Dulai G S, Jensen D M, Cortina G. et al . Randomized trial of argon plasma coagulation vs. multipolar electrocoagulation for ablation of Barrett's esophagus.  Gastrointest Endosc. 2005;  61 232-240
• 16 Overholt B F, Panjehpour M, Halberg D L. Photodynamic therapy for Barrett's esophagus with dysplasia and/or early stage carcinoma: long-term results.  Gastrointest Endosc. 2003;  58 183-188
• 17 Hornick J L, Blount P L, Sanchez C A. et al . Biologic properties of columnar epithelium underneath reepithelialized squamous mucosa in Barrett's esophagus.  Am J Surg Pathol. 2005;  29 372-380
• 18 Van Laethem J L, Peny M O, Salmon I. et al . Intramucosal adenocarcinoma arising under squamous re-epithelialisation of Barrett's oesophagus.  Gut. 2000;  46 574-577
• 19 Hage M, Siersema P D, Vissers K J. et al . Genomic analysis of Barrett's esophagus after ablative therapy: persistence of genetic alterations at tumor suppressor loci.  Int J Cancer. 2006;  118 155-160
• 20 Krishnadath K K, Wang K K, Taniguchi K. et al . Persistent genetic abnormalities in Barrett's esophagus after photodynamic therapy.  Gastroenterology. 2000;  119 624-630
• 21 Ragunath K, Krasner N, Raman V S. et al . Endoscopic ablation of dysplastic Barrett's oesophagus comparing argon plasma coagulation and photodynamic therapy: a randomized prospective trial assessing efficacy and cost-effectiveness.  Scand J Gastroenterol. 2005;  40 750-758
• 22 Sharma V K, Wang K K, Overholt B F. et al . Balloon-based, circumferential, endoscopic radiofrequency ablation of Barrett's esophagus: 1-year follow-up of 100 patients.  Gastrointest Endosc. 2007;  65 185-195
• 23 Bergman J J, Fockens P. Ablating Barrett's metaplastic epithelium: are the techniques ready for clinical use?.  Gut. 2006;  55 1222-1223
• 24 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
• 25 Aiko T, Sasako M. The new Japanese Classification of Gastric Carcinoma: Points to be revised.  Gastric Cancer. 1998;  1 25-30
• 26 Peters F P, Kara M A, Curvers W L. et al . Multiband mucosectomy for endoscopic resection of Barrett's esophagus: feasibility study with matched historical controls.  Eur J Gastroenterol Hepatol. 2007;  19 311-315
• 27 Dunkin B J, Martinez J, Bejarano P A. et al . Thin-layer ablation of human esophageal epithelium using a bipolar radiofrequency balloon device.  Surg Endosc. 2006;  20 125-130
• 28 Ganz R A, Utley D S, Stern R A. et al . Complete ablation of esophageal epithelium with a balloon-based bipolar electrode: a phased evaluation in the porcine and in the human esophagus.  Gastrointest Endosc. 2004;  60 1002-1010
• 29 Morales T G, Camargo E, Bhattacharyya A. et al . Long-term follow-up of intestinal metaplasia of the gastric cardia.  Am J Gastroenterol. 2000;  95 1677-1680