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Ameyaw PA, Parsons D, Mahmoud A, Marie R, Nagar A, Aslanian HR. Coexistent Eosinophilic Esophagitis and Dysplastic Barrett's Esophagus With Rapid Eosinophilic Infiltration of Neosquamous Mucosa After Radiofrequency Ablation. ACG Case Rep J 2024; 11:e01488. [PMID: 39221230 PMCID: PMC11361630 DOI: 10.14309/crj.0000000000001488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/22/2024] [Accepted: 07/26/2024] [Indexed: 09/04/2024] Open
Abstract
The coexistence of eosinophilic esophagitis (EoE) and Barrett's esophagus (BE) is rare despite the known association of gastroesophageal reflux disease with both conditions. Radiofrequency ablation is an effective endoscopic eradication therapy in patients with dysplastic BE. However, the efficacy and outcomes of radiofrequency ablation in patients with concomitant EoE and BE are not well known. We report a case of rapid eosinophilic infiltration of the neosquamous mucosa after the complete eradication of long-segment dysplastic BE in a patient with coexisting BE and EoE.
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Affiliation(s)
- Prince A. Ameyaw
- Department of Medicine, Bridgeport Hospital/Yale New Haven Health, Bridgeport, CT
| | - David Parsons
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT
| | - Ali Mahmoud
- Department of Pathology, Yale School of Medicine, New Haven, CT
| | - Robert Marie
- Department of Pathology, Yale School of Medicine, New Haven, CT
| | - Anil Nagar
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT
| | - Harry R. Aslanian
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT
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2
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Maan ADI, Sharma P, Koch AD. Curative criteria for endoscopic treatment of oesophageal adenocarcinoma. Best Pract Res Clin Gastroenterol 2024; 68:101886. [PMID: 38522884 DOI: 10.1016/j.bpg.2024.101886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/23/2024] [Indexed: 03/26/2024]
Abstract
The incidence of oesophageal adenocarcinoma has been increasing rapidly in the Western world. A well-known risk factor for developing this type of tumour is reflux disease, which can cause metaplasia from the squamous cell mucosa to columnar epithelium (Barrett's Oesophagus) which can progress to dysplasia and eventually adenocarcinoma. With the rise of the incidence of oesophageal adenocarcinoma, research on the best way to manage this disease is of great importance and has changed treatment modalities over the last decades. The gold standard for superficial adenocarcinoma has shifted from surgical to endoscopic management when certain criteria are met. This review will discuss the different curative criteria for endoscopic treatment of oesophageal adenocarcinoma.
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Affiliation(s)
- Annemijn D I Maan
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas and VA Medical Centre, 4801 E Linwood Blvd, Kansas City, USA.
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
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3
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Weusten BLAM, Bisschops R, Dinis-Ribeiro M, di Pietro M, Pech O, Spaander MCW, Baldaque-Silva F, Barret M, Coron E, Fernández-Esparrach G, Fitzgerald RC, Jansen M, Jovani M, Marques-de-Sa I, Rattan A, Tan WK, Verheij EPD, Zellenrath PA, Triantafyllou K, Pouw RE. Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2023; 55:1124-1146. [PMID: 37813356 DOI: 10.1055/a-2176-2440] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2: ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3: ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4: ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5: ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6: ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7: ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8: ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9: ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B: ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C: ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D: ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E: ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11: After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.
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Affiliation(s)
- Bas L A M Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto Portugal
| | - Massimiliano di Pietro
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Francisco Baldaque-Silva
- Advanced Endoscopy Center Carlos Moreira da Silva, Department of Gastroenterology, Pedro Hispano Hospital, Matosinhos, Portugal
- Division of Medicine, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital and University of Paris, Paris, France
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, IMAD, Centre hospitalier universitaire Hôtel-Dieu, Nantes, Nantes, France
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), Geneva, Switzerland
| | - Glòria Fernández-Esparrach
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Biomedical Research Network on Hepatic and Digestive Diseases (CIBEREHD), Barcelona, Spain
| | - Rebecca C Fitzgerald
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Marnix Jansen
- Department of Histopathology, University College London Hospital NHS Trust, London, UK
| | - Manol Jovani
- Division of Gastroenterology, Maimonides Medical Center, New York, New York, USA
| | - Ines Marques-de-Sa
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto Portugal
| | - Arti Rattan
- Department of Gastroenterology, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - W Keith Tan
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Eva P D Verheij
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Pauline A Zellenrath
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
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Vantanasiri K, Iyer PG. State-of-the-art management of dysplastic Barrett's esophagus. Gastroenterol Rep (Oxf) 2022; 10:goac068. [PMID: 36381221 PMCID: PMC9651477 DOI: 10.1093/gastro/goac068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 10/19/2022] [Accepted: 10/24/2022] [Indexed: 08/15/2023] Open
Abstract
Endoscopic eradication therapy (EET) has become a standard of care for treatment of dysplastic Barrett's esophagus (BE) and early Barrett's neoplasia. EET mainly consists of removal of any visible lesions via endoscopic resection and eradication of all remaining Barrett's mucosa using endoscopic ablation. Endoscopic mucosal resection and endoscopic submucosal dissection are the two available resection techniques. After complete resection of all visible lesions, it is crucial to perform endoscopic ablation to ensure complete eradication of the remaining Barrett's segment. Endoscopic ablation can be done either with thermal techniques, including radiofrequency ablation and argon plasma coagulation, or cryotherapy techniques. The primary end point of EET is achieving complete remission of intestinal metaplasia (CRIM) to decrease the risk of dysplastic recurrence after successful EET. After CRIM is achieved, a standardized endoscopic surveillance protocol needs to be implemented for early detection of BE recurrence.
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Affiliation(s)
- Kornpong Vantanasiri
- Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Prasad G Iyer
- Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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5
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Pimentel-Nunes P, Libânio D, Bastiaansen BAJ, Bhandari P, Bisschops R, Bourke MJ, Esposito G, Lemmers A, Maselli R, Messmann H, Pech O, Pioche M, Vieth M, Weusten BLAM, van Hooft JE, Deprez PH, Dinis-Ribeiro M. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy 2022; 54:591-622. [PMID: 35523224 DOI: 10.1055/a-1811-7025] [Citation(s) in RCA: 334] [Impact Index Per Article: 111.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
ESGE recommends that the evaluation of superficial gastrointestinal (GI) lesions should be made by an experienced endoscopist, using high definition white-light and chromoendoscopy (virtual or dye-based).ESGE does not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection.ESGE recommends endoscopic submucosal dissection (ESD) as the treatment of choice for most superficial esophageal squamous cell and superficial gastric lesions.For Barrett's esophagus (BE)-associated lesions, ESGE suggests the use of ESD for lesions suspicious of submucosal invasion (Paris type 0-Is, 0-IIc), for malignant lesions > 20 mm, and for lesions in scarred/fibrotic areas.ESGE does not recommend routine use of ESD for duodenal or small-bowel lesions.ESGE suggests that ESD should be considered for en bloc resection of colorectal (but particularly rectal) lesions with suspicion of limited submucosal invasion (demarcated depressed area with irregular surface pattern or a large protruding or bulky component, particularly if the lesions are larger than 20 mm) or for lesions that otherwise cannot be completely removed by snare-based techniques.ESGE recommends that an en bloc R0 resection of a superficial GI lesion with histology no more advanced than intramucosal cancer (no more than m2 in esophageal squamous cell carcinoma), well to moderately differentiated, with no lymphovascular invasion or ulceration, should be considered a very low risk (curative) resection, and no further staging procedure or treatment is generally recommended.ESGE recommends that the following should be considered to be a low risk (curative) resection and no further treatment is generally recommended: an en bloc R0 resection of a superficial GI lesion with superficial submucosal invasion (sm1), that is well to moderately differentiated, with no lymphovascular invasion, of size ≤ 20 mm for an esophageal squamous cell carcinoma or ≤ 30 mm for a stomach lesion or of any size for a BE-related or colorectal lesion, and with no lymphovascular invasion, and no budding grade 2 or 3 for colorectal lesions.ESGE recommends that, after an endoscopically complete resection, if there is a positive horizontal margin or if resection is piecemeal, but there is no submucosal invasion and no other high risk criteria are met, this should be considered a local-risk resection and endoscopic surveillance or re-treatment is recommended rather than surgery or other additional treatment.ESGE recommends that when there is a diagnosis of lymphovascular invasion, or deeper infiltration than sm1, or positive vertical margins, or undifferentiated tumor, or, for colorectal lesions, budding grade 2 or 3, this should be considered a high risk (noncurative) resection, and complete staging and strong consideration for additional treatments should be considered on an individual basis in a multidisciplinary discussion.ESGE recommends scheduled endoscopic surveillance with high definition white-light and chromoendoscopy (virtual or dye-based) with biopsies of only the suspicious areas after a curative ESD.
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Affiliation(s)
- Pedro Pimentel-Nunes
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- Department of Surgery and Physiology, Porto Faculty of Medicine, Portugal
| | - Diogo Libânio
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Center, The Netherlands
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia and Western Clinical School, University of Sydney, Sydney, Australia
| | - Gianluca Esposito
- Department of Medical-Surgical Sciences and Translational Medicine, Sant' Andrea Hospital, Sapienza University of Rome, Italy
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Helmut Messmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Bayern, Germany
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pierre H Deprez
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
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Choi KKH, Sanagapalli S. Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies. World J Gastrointest Oncol 2022; 14:568-586. [PMID: 35321279 PMCID: PMC8919017 DOI: 10.4251/wjgo.v14.i3.568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 11/12/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.
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Affiliation(s)
- Kevin Kyung Ho Choi
- AW Morrow Gastroenterology Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, NSW, Australia
| | - Santosh Sanagapalli
- Department of Gastroenterology, St Vincent’s Hospital, Darlinghurst 2010, NSW, Australia
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7
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van Munster S, Nieuwenhuis E, Weusten BLAM, Alvarez Herrero L, Bogte A, Alkhalaf A, Schenk BE, Schoon EJ, Curvers W, Koch AD, van de Ven SEM, de Jonge PJF, Tang TJ, Nagengast WB, Peters FTM, Westerhof J, Houben MHMG, Bergman JJ, Pouw RE. Long-term outcomes after endoscopic treatment for Barrett's neoplasia with radiofrequency ablation ± endoscopic resection: results from the national Dutch database in a 10-year period. Gut 2022; 71:265-276. [PMID: 33753417 PMCID: PMC8762001 DOI: 10.1136/gutjnl-2020-322615] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Radiofrequency ablation (RFA)±endoscopic resection (ER) is the preferred treatment for early neoplasia in Barrett's oesophagus (BE). We aimed to report short-term and long-term outcomes for all 1384 patients treated in the Netherlands (NL) from 2008 to 2018, with uniform treatment and follow-up (FU) in a centralised setting. DESIGN Endoscopic therapy for early BE neoplasia in NL is centralised in nine expert centres with specifically trained endoscopists and pathologists that adhere to a joint protocol. Prospectively collected data are registered in a uniform database. Patients with low/high-grade dysplasia or low-risk cancer, were treated by ER of visible lesions followed by trimonthly RFA sessions of any residual BE until complete eradication of BE (CE-BE). Patients with ER alone were not included. RESULTS After ER (62% of cases; 43% low-risk cancers) and median 1 circumferential and 2 focal RFA (p25-p75 0-1; 1-2) per patient, CE-BE was achieved in 94% (1270/1348). Adverse events occurred in 21% (268/1386), most commonly oesophageal stenosis (15%), all were managed endoscopically. A total of 1154 patients with CE-BE were analysed for long-term outcomes. During median 43 months (22-69) and 4 endoscopies (1-5), 38 patients developed dysplastic recurrence (3%, annual recurrence risk 1%), all were detected as endoscopically visible abnormalities. Random biopsies from a normal appearing cardia showed intestinal metaplasia (IM) in 14% and neoplasia in 0%. A finding of IM in the cardia was reproduced during further FU in only 33%, none progressed to neoplasia. Frequent FU visits in the first year of FU were not associated with recurrence risk. CONCLUSION In a setting of centralised care, RFA±ER is effective for eradication of Barrett's related neoplasia and has remarkably low rates of dysplastic recurrence. Our data support more lenient FU intervals, with emphasis on careful endoscopic inspection. Random biopsies from neosquamous epithelium and cardia are of questionable value. NETHERLANDS TRIAL REGISTER NUMBER NL7039.
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Affiliation(s)
- Sanne van Munster
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
- Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Esther Nieuwenhuis
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Bas L A M Weusten
- Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
- Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Auke Bogte
- Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alaa Alkhalaf
- Gastroenterology and Hepatology, Isala Klinieken, Zwolle, Overijssel, The Netherlands
| | - B E Schenk
- Gastroenterology and Hepatology, Isala Klinieken, Zwolle, Overijssel, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Wouter Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Arjun D Koch
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - Tjon J Tang
- Department of Gastroenterology and Hepatology, IJsselland Ziekenhuis, Capelle aan den IJssel, Zuid-Holland, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frans T M Peters
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin H M G Houben
- Gastroenterology and Hepatology, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Jacques Jghm Bergman
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Roos E Pouw
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
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Staudenmann DA, Skacel EP, Tsoutsman T, Kaffes AJ, Saxena P. Safety and long-term efficacy of hybrid-argon plasma coagulation for the treatment of Barrett's esophagus: An Australian pilot study (with video). INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii200050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | - Tatiana Tsoutsman
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
- The University of Sydney School of Medicine, Sydney, Australia
| | - Arthur John Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
- The University of Sydney School of Medicine, Sydney, Australia
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
- The University of Sydney School of Medicine, Sydney, Australia
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9
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Fang T, Xiao J, Zhang Y, Hu H, Zhu Y, Cheng Y. Combined with interventional therapy, immunotherapy can create a new outlook for tumor treatment. Quant Imaging Med Surg 2021; 11:2837-2860. [PMID: 34079746 PMCID: PMC8107298 DOI: 10.21037/qims-20-173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/01/2021] [Indexed: 02/06/2023]
Abstract
Recent progress in immunotherapy provides hope of a complete cure to cancer patients. However, recent studies have reported that only a limited number of cancer patients with a specific immune status, known as "cold tumor", can benefit from a single immune agent. Although the combination of immune agents with different mechanisms can partially increase the low response rate and improve efficacy, it can also result in more side effects. Therefore, discovering therapies that can improve tumors' response rate to immunotherapy without increasing toxicity for patients is urgently needed. Tumor interventional therapy is promising. It mainly includes transcatheter arterial chemoembolization, ablation, radioactive particle internal irradiation, and photodynamic interventional therapy based on a luminal stent. Interventional therapy can directly kill tumor cells by targeted drug delivery in situ, thus reducing drug dosage and systemic toxicity like cytokine release syndrome. More importantly, interventional therapy can regulate the immune system through numerous mechanisms, making it a suitable choice for immunotherapy to combine with. In this review, we provide a brief description of immunotherapies (and their side effects) on tumors of different immune types and preliminarily elaborate on interventional therapy mechanisms to improve immune efficacy. We also discuss the progress and challenges of the combination of interventional therapy and immunotherapy.
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Affiliation(s)
- Tonglei Fang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Junyuan Xiao
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yiran Zhang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Haiyan Hu
- Department of Oncology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yingsheng Cheng
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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10
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Kahn A, Priyan H, Dierkhising RA, Johnson ML, Lansing RM, Maixner KA, Wolfsen HC, Wallace MB, Ramirez FC, Fleischer DE, Leggett CL, Wang KK, Iyer PG. Outcomes of radiofrequency ablation by manual versus self-sizing circumferential balloon catheters for the treatment of dysplastic Barrett's esophagus: a multicenter comparative cohort study. Gastrointest Endosc 2021; 93:880-887.e1. [PMID: 32739482 DOI: 10.1016/j.gie.2020.07.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 07/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Radiofrequency ablation (RFA) is the preferred ablative modality for treating dysplastic Barrett's esophagus. The recently introduced self-sizing circumferential ablation catheter eliminates the need for a sizing balloon. Although it enhances efficiency, outcomes have not been compared with the previous manual-sizing catheter. We evaluated the comparative safety and efficacy of these 2 ablation systems in a large, multicenter cohort. METHODS Patients undergoing RFA at 3 tertiary care centers from 2005 to 2018 were included. Circumferential RFA was performed in a standard fashion, followed by focal RFA as needed. Outcomes were compared between the self-sizing and manual-sizing groups. The primary outcome was the rate of adverse events, including strictures, perforation, and bleeding. Secondary outcomes were procedure time and treatment efficacy, as assessed by rates and time to complete eradication of dysplasia (CE-D) and intestinal metaplasia (CE-IM). RESULTS Three hundred eighteen patients were included, 90 (28.3%) treated with the self-sizing catheter and 228 (71.7%) with the manual-sizing catheter. Twenty-one patients (6.6%) developed strictures (8 [8.9%] in the self-sizing group and 13 [5.7%] in the manual-sizing group, P = .32). Of the self-sizing strictures, 75% occurred at the 12J dose before widespread adoption of the current 10J treatment standard. One patient developed bleeding, and no perforations were encountered. Procedure time was significantly shorter in the self-sizing group. No significant differences were observed in rates of and time to CE-D and CE-IM. CONCLUSIONS These findings suggest that both systems are comparable in safety and efficacy. The use of the self-sizing system may enhance the efficiency of RFA for treating dysplastic Barrett's esophagus.
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Affiliation(s)
- Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Harshith Priyan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ross A Dierkhising
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Michele L Johnson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ramona M Lansing
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristyn A Maixner
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Francisco C Ramirez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - David E Fleischer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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11
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Farina DA, Condon A, Komanduri S, Muthusamy VR. A Practical Approach to Refractory and Recurrent Barrett's Esophagus. Gastrointest Endosc Clin N Am 2021; 31:183-203. [PMID: 33213795 DOI: 10.1016/j.giec.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic eradication therapy (EET) is recommended for patients with Barrett's esophagus (BE)-associated neoplasia and is effective in achieving complete eradication of intestinal metaplasia (CE-IM). However, BE that is refractory to EET, defined as partial or no improvement in dysplasia after less than or equal to 3 ablative sessions, and the development of recurrence post-EET is not uncommon. Identification of refractory BE or recurrent intestinal metaplasia should prompt esophageal physiologic testing and modification of antireflux strategy, as appropriate. In patients who ultimately fail standard EET despite optimization of reflux control, salvage EET with alternate modalities may need to be considered.
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Affiliation(s)
- Domenico A Farina
- Department of Gastroenterology and Hepatology, Northwestern University, 676 North St. Clair Street, Arkes Pavilion Suite 1400, Chicago, IL 60611, USA
| | - Ashwinee Condon
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA
| | - Srinadh Komanduri
- Department of Gastroenterology and Hepatology, Northwestern University, 676 North St. Clair Street, Arkes Pavilion Suite 1400, Chicago, IL 60611, USA
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA.
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12
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Optimizing Outcomes with Radiofrequency Ablation of Barrett's Esophagus: Candidates, Efficacy and Durability. Gastrointest Endosc Clin N Am 2021; 31:131-154. [PMID: 33213792 DOI: 10.1016/j.giec.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The treatment of early Barrett's esophagus (BE) has undergone a paradigm shift from surgical subtotal esophagectomy to organ-saving endoluminal treatment. Over the past 15 years, several high-quality studies were conducted to assess safe oncological outcome of endoscopic resection of mucosal adenocarcinoma and high-grade dysplasia. It became clear that add-on ablative therapy with radiofrequency ablation (RFA) significantly reduces recurrence risk of neoplasia after resection. In this review, we highlight the most essential elements to optimize outcomes of RFA of BE, addressing the correct indication and patient selection in combination with the most efficient and safest treatment protocols to obtain long-term durability.
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13
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Abstract
Because of the rising incidence and lethality of esophageal adenocarcinoma, Barrett's esophagus (BE) is an increasingly important premalignant target for cancer prevention. BE-associated neoplasia can be safely and effectively treated with endoscopic eradication therapy (EET), incorporating tissue resection and ablation. Because EET has proliferated, managing patients after complete eradication of intestinal metaplasia has taken on increasing importance. Recurrence after complete eradication of intestinal metaplasia occurs in 8%-10% of the patients yearly, and the incidence may remain constant over time. Most recurrences occur at the gastroesophageal junction, whereas those in the tubular esophagus are endoscopically visible and distally located. A simplified biopsy protocol limited to the distal aspect of the BE segment, in addition to gastroesophageal junction sampling, may enhance efficiency and cost without significantly reducing recurrence detection. Similarly, research suggests that current surveillance intervals may be excessively frequent, failing to reflect the cancer risk reduction of EET. If validated, longer surveillance intervals could reduce the burden of resource-intensive endoscopic surveillance. Several important questions in post-EET management remain unanswered, including surveillance duration, the significance of gastric cardia intestinal metaplasia, and the role of advanced imaging and nonendoscopic sampling techniques in detecting recurrence. These merit further research to enhance quality of care and promote a more evidence-based approach.
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14
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Li S, Zeng Y, Chapman WC, Erfanzadeh M, Nandy S, Mutch M, Zhu Q. Adaptive Boosting (AdaBoost)-based multiwavelength spatial frequency domain imaging and characterization for ex vivo human colorectal tissue assessment. JOURNAL OF BIOPHOTONICS 2020; 13:e201960241. [PMID: 32125775 PMCID: PMC7593835 DOI: 10.1002/jbio.201960241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/13/2020] [Accepted: 02/29/2020] [Indexed: 05/05/2023]
Abstract
The current gold standard diagnostic test for colorectal cancer remains histological inspections of endoluminal neoplasia in biopsy specimens. However, biopsy site selection requires visual inspection of the bowel, typically with a white-light endoscope. Therefore, this technique is poorly suited to detect small or innocuous-appearing lesions. We hypothesize that an alternative modality-multiwavelength spatial frequency domain imaging (SFDI)-would be able to differentiate various colorectal neoplasia from normal tissue. In this ex vivo study of human colorectal tissues, we report the optical absorption and scattering signatures of normal, adenomatous polyp and cancer specimens. An abnormal vs. normal adaptive boosting (AdaBoost) classifier is trained to dichotomize tissue based on SFDI imaging characteristics, and an area under the receiver operating characteristic (ROC) curve (AUC) of 0.95 is achieved. We conclude that AdaBoost-based multiwavelength SFDI can differentiate abnormal from normal colorectal tissues, potentially improving endoluminal screening of the distal gastrointestinal tract in the future.
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Affiliation(s)
- Shuying Li
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri
| | - Yifeng Zeng
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri
| | - William C. Chapman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mohsen Erfanzadeh
- Department of Biomedical Engineering, University of Connecticut, Storrs, Connecticut
| | - Sreyankar Nandy
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri
| | - Matthew Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Quing Zhu
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
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15
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Zeng Y, Xu S, Chapman WC, Li S, Alipour Z, Abdelal H, Chatterjee D, Mutch M, Zhu Q. Real-time colorectal cancer diagnosis using PR-OCT with deep learning. Theranostics 2020; 10:2587-2596. [PMID: 32194821 PMCID: PMC7052898 DOI: 10.7150/thno.40099] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 11/08/2019] [Indexed: 12/24/2022] Open
Abstract
Prior reports have shown optical coherence tomography (OCT) can differentiate normal colonic mucosa from neoplasia, potentially offering an alternative technique to endoscopic biopsy - the current gold-standard colorectal cancer screening and surveillance modality. To help clinical translation limited by processing the large volume of generated data, we designed a deep learning-based pattern recognition (PR) OCT system that automates image processing and provides accurate diagnosis potentially in real-time. Method: OCT is an emerging imaging technique to obtain 3-dimensional (3D) "optical biopsies" of biological samples with high resolution. We designed a convolutional neural network to capture the structure patterns in human colon OCT images. The network is trained and tested using around 26,000 OCT images acquired from 20 tumor areas, 16 benign areas, and 6 other abnormal areas. Results: The trained network successfully detected patterns that identify normal and neoplastic colorectal tissue. Experimental diagnoses predicted by the PR-OCT system were compared to the known histologic findings and quantitatively evaluated. A sensitivity of 100% and specificity of 99.7% can be reached. Further, the area under the receiver operating characteristic (ROC) curves (AUC) of 0.998 is achieved. Conclusions: Our results demonstrate that PR-OCT can be used to give an accurate real-time computer-aided diagnosis of colonic neoplastic mucosa. Future development of this system as an "optical biopsy" tool to assist doctors in real-time for early mucosal neoplasms screening and treatment evaluation following initial oncologic therapy is planned.
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Affiliation(s)
- Yifeng Zeng
- Department of Biomedical Engineering, Washington University in St. Louis
| | - Shiqi Xu
- Department of Electrical & System Engineering, Washington University in St. Louis
| | - William C. Chapman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine
| | - Shuying Li
- Department of Biomedical Engineering, Washington University in St. Louis
| | - Zahra Alipour
- Department of Pathology and Immunology, Washington University School of Medicine
| | - Heba Abdelal
- Department of Pathology and Immunology, Washington University School of Medicine
| | - Deyali Chatterjee
- Department of Pathology and Immunology, Washington University School of Medicine
| | - Matthew Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine
| | - Quing Zhu
- Department of Biomedical Engineering, Washington University in St. Louis
- Department of Radiology, Washington University School of Medicine
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16
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Tsoi EH, Cameron G, Williams R, Desmond P, Taylor A. Factors that predict a poor response to radiofrequency ablation for Barrett's oesophagus with dysplasia. ANZ J Surg 2020; 90:272-276. [PMID: 31970858 DOI: 10.1111/ans.15687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/18/2019] [Accepted: 12/23/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Radiofrequency ablation (RFA) can eradicate dysplasia and intestinal metaplasia in patients with dysplastic Barrett's oesophagus (BO). This study aimed to determine the factors that affect response to RFA for BO with dysplasia in a tertiary metropolitan referral centre. METHODS All patients with dysplastic BO treated with regular proton pump inhibitor twice a day and RFA from November 2008 to July 2019 were identified. These patients were sorted into good responders (GR) (defined as eradication of dysplasia and intestinal metaplasia within three or less treatment sessions) and poor responders (PR) (defined as patients requiring four or more treatment sessions). The following features were compared between the groups: age, gender, presence of hiatus hernia, hiatus hernia size, circumferential and maximal length of BO, grade of dysplasia on histology at referral and presence of endoscopically visible reflux oesophagitis. RESULTS A total of 152 patients received RFA for dysplastic BO, of whom 125 (82%) patients were classified as GR and 27 (18%) patients were classified as PR. PR had a longer circumferential length of BO compared to GR (mean length of 8.3 versus 3.3 cm, P < 0.0001). PR also had a longer maximal length of BO compared to GR (mean length of 8.7 versus 4.8 cm, P < 0.0001). More patients had reflux oesophagitis identified on gastroscopy in the PR group compared to GR group (12 (44%) versus 20 (16%), P = 0.001). CONCLUSION Factors such as circumferential and maximal length of BO and presence of reflux oesophagitis on gastroscopy are associated with poorer response to RFA.
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Affiliation(s)
- Edward H Tsoi
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Georgina Cameron
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Richard Williams
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Pathology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Paul Desmond
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Taylor
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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18
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Patel V, Ritchie CA, Padula C, McKinney JM. Radiofrequency Ablation, Where It Stands in Interventional Radiology Today. Semin Intervent Radiol 2019; 36:398-404. [PMID: 31798214 PMCID: PMC6887522 DOI: 10.1055/s-0039-1697945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Radiofrequency ablation (RFA) is one of the first developed minimally invasive definitive cancer therapies. The safety and efficacy of RFA is well documented and has led to its incorporation into multiple international societal guidelines. By expanding on the body of knowledge acquired during the clinical use of RFA, alternative ablative technologies have emerged and are successfully competing for locoregional therapy market share. The adaption of newer ablative technologies is leading to a rapid decline in the utilization of RFA by interventional radiologists despite the lack of proven superiority. In their 2010 article, Hong and Georgiades stated "… RFA is likely to remain the mainstay of ablations for small tumors until sufficient experience emerges for the widespread acceptance for alternative ablative modalities." Within a decade of this publication, has this time arrived?
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Affiliation(s)
| | | | - Carlos Padula
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
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19
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Omar M, Thaker AM, Wani S, Simon V, Ezekwe E, Boniface M, Edmundowicz S, Obuch J, Cinnor B, Brauer BC, Wood M, Early DS, Lang GD, Mullady D, Hollander T, Kushnir V, Komanduri S, Muthusamy VR. Anatomic location of Barrett's esophagus recurrence after endoscopic eradication therapy: development of a simplified surveillance biopsy strategy. Gastrointest Endosc 2019; 90:395-403. [PMID: 31004598 DOI: 10.1016/j.gie.2019.04.216] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/02/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Surveillance endoscopy is recommended after endoscopic eradication therapy (EET) for Barrett's esophagus (BE) because of the risk of recurrence. Currently recommended biopsy protocols are based on expert opinion and consist of sampling visible lesions followed by random 4-quadrant biopsy sampling throughout the length of the original BE segment. Despite this protocol, some recurrences are not visibly identified. We aimed to identify the anatomic location and histology of recurrences after successful EET with the goal of developing a more efficient and evidence-based surveillance biopsy protocol. METHODS We performed an analysis of a large multicenter database of 443 patients who underwent EET and achieved complete eradication of intestinal metaplasia (CE-IM) from 2005 to 2015. The endoscopic location of recurrence relative to the squamocolumnar junction (SCJ), visible recurrence identified during surveillance endoscopy, and time to recurrence after CE-IM were assessed. RESULTS Fifty patients with BE recurrence were studied in the final analysis. Seventeen patients (34%) had nonvisible recurrences. In this group, biopsy specimens demonstrating recurrence were taken from within 2 cm of the SCJ in 16 of these 17 patients (94%). Overall, 49 of 50 recurrences (98%) occurred either within 2 cm of the SCJ or at the site of a visible lesion. Late recurrences (>1 year) were more likely to be visible than early (<1 year) recurrences (P = .006). CONCLUSIONS Recurrence after EET detected by random biopsy sampling is identified predominately in the distal esophagus and occurs earlier than visible recurrences. As such, we suggest a modified biopsy protocol with targeted sampling of visible lesions followed by random biopsy sampling within 2 cm of the SCJ to optimize detection of recurrence after EET. (Clinical trial registration number: NCT02634645.).
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Affiliation(s)
- Mahmoud Omar
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California, USA
| | - Adarsh M Thaker
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Violette Simon
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Eze Ezekwe
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Megan Boniface
- Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Steven Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Joshua Obuch
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Birtukan Cinnor
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Brian C Brauer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Mariah Wood
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gabriel D Lang
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Mullady
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Thomas Hollander
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Srinadh Komanduri
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - V Raman Muthusamy
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California, USA
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20
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Alzoubaidi D, Ragunath K, Wani S, Penman ID, Trudgill NJ, Jansen M, Banks M, Bhandari P, Morris AJ, Willert R, Boger P, Smart HL, Ravi N, Dunn J, Gordon C, Mannath J, Mainie I, di Pietro M, Veitch AM, Thorpe S, Magee C, Everson M, Sami S, Bassett P, Graham D, Attwood S, Pech O, Sharma P, Lovat LB, Haidry R. Quality indicators for Barrett's endotherapy (QBET): UK consensus statements for patients undergoing endoscopic therapy for Barrett's neoplasia. Frontline Gastroenterol 2019; 11:259-271. [PMID: 32587669 PMCID: PMC7307052 DOI: 10.1136/flgastro-2019-101247] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/25/2019] [Accepted: 07/29/2019] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Endoscopic therapy for the management of patients with Barrett's oesophagus (BE) neoplasia has significantly developed in the past decade; however, significant variation in clinical practice exists. The aim of this project was to develop expert physician-lead quality indicators (QIs) for Barrett's endoscopic therapy. METHODS The RAND/UCLA Appropriateness Method was used to combine the best available scientific evidence with the collective judgement of experts to develop quality indicators for Barrett's endotherapy in four subgroups: pre-endoscopy, intraprocedure (resection and ablation) and postendoscopy. International experts, including gastroenterologists, surgeons, BE pathologist, clinical nurse specialist and patient representative, participated in a three-round process to develop 15 QIs that fulfilled the RAND/UCLA definition of appropriateness. RESULTS 17 experts participated in round 1 and 20 in round 2. Of the 24 proposed QIs in round 1, 20 were ranked as appropriate (put through to round 2) and 4 as uncertain (discarded). At the end of round 2, a final list of 15 QIs were scored as appropriate. CONCLUSIONS This UK national consensus project has successfully developed QIs for patients undergoing Barrett's endotherapy. These QIs can be used by service providers to ensure that all patients with BE neoplasia receive uniform and high-quality care.
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Affiliation(s)
- Durayd Alzoubaidi
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Krish Ragunath
- Department of Gastroenterology, Queens Medical Centre, University Hospital Nottingham, Nottingham, UK
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ian D Penman
- Gastrointestinal Unit, Western General Hospital, Edinburgh, UK
| | | | - Marnix Jansen
- Department of Histopathology, University College London Hospital, London, UK
| | - Matthew Banks
- Department of Gastroenterology, University College London Hospital, London, UK
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital Portsmouth, Portsmouth, UK
| | - Allan John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Robert Willert
- Department of Gastroenterology, Manchester Royal Infirmary, Manchester, UK
| | - Phil Boger
- Department of Gastroenterology, University Hospital Southampton, Southampton, UK
| | - Howard L Smart
- Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, Merseyside, UK
| | | | - Jason Dunn
- Department of Gastroenterology, Guy's and St Thomas' Hospital, London, UK
| | - Charles Gordon
- Department of Gastroenterology, Royal Bournemouth Hospital, Bournemouth, UK
| | - Jayan Mannath
- Department of Gastroenterology, Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Inder Mainie
- Department of Gastroenterology, Belfast City Hospital, Belfast, UK
| | | | - Andrew M Veitch
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Sally Thorpe
- Department of Gastroenterology, University Colleg London Hospital, London, UK
| | - Cormac Magee
- Department of Gastroenterology, University College London Hospital, Londons, UK
- Metabolism and Experimental Therapeutic, University College London Division of Biosciences, London, UK
| | - Martin Everson
- Department of Gastroenterology, University Colleg London Hospital, London, UK
| | - Sarmed Sami
- Department of Gastroenterology, University Colleg London Hospital, London, UK
| | | | - David Graham
- Department of Gastroenterology, University Colleg London Hospital, London, UK
| | - Stephen Attwood
- Department of Health Services Research, Durham University, Durham, UK
| | - Oliver Pech
- Department of Medicine, HSK Wiesbaden, Wiesbaden, Germany
| | - Prateek Sharma
- Department of Gastroenterology, University of Kansas, Kansas City, Kansas, USA
| | - Laurence B Lovat
- Division of Surgery and Interventional Science, University College London (UCL), Londons, UK
| | - Rehan Haidry
- Department of Gastroenterology and Division of Surgery and Interventional Science, University College London Hospitals NHS Foundation Trust, London, UK
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21
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Barthet M. Endoscopic ultrasound-guided radiofrequency ablation for pancreatic neuroendocrine tumor. ANNALES D'ENDOCRINOLOGIE 2019; 80:182-184. [PMID: 31053252 DOI: 10.1016/j.ando.2019.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Marc Barthet
- Service de gastro-entérologie, hôpital Nord, chemin des Bourrely, 13915 Marseille cedex 20, France.
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Zeng Y, Rao B, Chapman WC, Nandy S, Rais R, González I, Chatterjee D, Mutch M, Zhu Q. The Angular Spectrum of the Scattering Coefficient Map Reveals Subsurface Colorectal Cancer. Sci Rep 2019; 9:2998. [PMID: 30816153 PMCID: PMC6395629 DOI: 10.1038/s41598-019-39146-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 01/14/2019] [Indexed: 12/11/2022] Open
Abstract
Colorectal cancer diagnosis currently relies on histological detection of endoluminal neoplasia in biopsy specimens. However, clinical visual endoscopy provides no quantitative subsurface cancer information. In this ex vivo study of nine fresh human colon specimens, we report the first use of quantified subsurface scattering coefficient maps acquired by swept-source optical coherence tomography to reveal subsurface abnormities. We generate subsurface scattering coefficient maps with a novel wavelet-based-curve-fitting method that provides significantly improved accuracy. The angular spectra of scattering coefficient maps of normal tissues exhibit a spatial feature distinct from those of abnormal tissues. An angular spectrum index to quantify the differences between the normal and abnormal tissues is derived, and its strength in revealing subsurface cancer in ex vivo samples is statistically analyzed. The study demonstrates that the angular spectrum of the scattering coefficient map can effectively reveal subsurface colorectal cancer and potentially provide a fast and more accurate diagnosis.
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Affiliation(s)
- Yifeng Zeng
- Department of Biomedical Engineering, Washington University, St. Louis, MO, USA
| | - Bin Rao
- Department of Biomedical Engineering, Washington University, St. Louis, MO, USA
| | - William C Chapman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sreyankar Nandy
- Department of Biomedical Engineering, Washington University, St. Louis, MO, USA
| | - Rehan Rais
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Iván González
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Deyali Chatterjee
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Quing Zhu
- Department of Biomedical Engineering, Washington University, St. Louis, MO, USA.
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA.
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Rajaram R, Hofstetter WL. Mucosal Ablation Techniques for Barrett's Esophagus and Early Esophageal Cancer. Thorac Surg Clin 2018; 28:473-480. [PMID: 30268293 DOI: 10.1016/j.thorsurg.2018.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with esophageal intestinal metaplasia, or Barrett's esophagus, may undergo dysplastic changes that eventually lead to invasive adenocarcinoma. Endoscopic therapy in the form of radiofrequency ablation and cryoablation has been described as a minimally invasive intervention to halt this sequence of dysplasia to carcinoma. Studies demonstrate that the use of radiofrequency ablation and cryoablation is highly successful at eradicating intestinal metaplasia and dysplasia and reducing the risk of disease progression. Furthermore, these modalities also may be used in combination with endoscopic mucosal resection, or as stand-alone therapy, for the treatment of intramucosal carcinoma, potentially circumventing the need for surgery.
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Affiliation(s)
- Ravi Rajaram
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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24
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van Munster SN, Overwater A, Haidry R, Bisschops R, Bergman JJGHM, Weusten BLAM. Focal cryoballoon versus radiofrequency ablation of dysplastic Barrett's esophagus: impact on treatment response and postprocedural pain. Gastrointest Endosc 2018; 88:795-803.e2. [PMID: 29928869 DOI: 10.1016/j.gie.2018.06.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/05/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Radiofrequency ablation (RFA) is safe and effective for eradicating Barrett's esophagus (BE) but is associated with significant postprocedural pain. Alternatively, balloon-based focal cryoablation (CRYO) has recently been developed, which preserves the extracellular matrix and might therefore be less painful. Although data for CRYO are still limited, uncontrolled studies suggest comparable safety and efficacy to RFA in eradicating limited BE areas. Therefore, secondary endpoints such as pain might become decisive for treatment selection. We aimed to compare efficacy and tolerability between focal CRYO and RFA. METHODS We identified BE patients undergoing focal ablation (either RFA or CRYO) of all visible BE from our prospective cohort in 2 Dutch referral centers. After ablation, patients completed a 14-day digital diary to assess chest pain (0-10), dysphagia (0-4), and analgesics use. A follow-up endoscopy was scheduled after 3 months to assess the BE surface regression (blindly scored by 2 independent BE expert endoscopists). Outcomes were BE surface regression; 14-day cumulative scores (area under the curves [AUCs]) for pain, dysphagia, analgesics, and peak pain. RESULTS We identified 46 patients (20 CRYO, 26 RFA) with similar baseline characteristics. The BE regression was comparable (88% vs 90%, P = .62). AUCs for pain, dysphagia, and analgesics were significantly smaller after CRYO versus RFA (all P < .01). Peak pain was lower after CRYO (visual analog scale 2 vs 4, P < .01), and the duration of pain was also shorter after CRYO (2 vs 4 days, P < .01). CRYO patients used analgesics for 2 days versus 4 days for RFA (P < .01). CONCLUSIONS In this multicenter, nonrandomized cohort study, we found no differences in efficacy after a single treatment with CRYO and RFA for short-segment BE. Patients reported less pain after CRYO as compared with RFA. Moreover, CRYO patients used fewer analgesics. Our results suggest a different pain course favoring CRYO over RFA, but a randomized trial is needed for definitive conclusions. (Clinical trial registration number: NCT02249975.).
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Affiliation(s)
- Sanne N van Munster
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Anouk Overwater
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rehan Haidry
- Department of Gastroenterology, University College London Hospital, London, United Kingdom
| | - Raf Bisschops
- Department Of Gastroenterology, University Hospital Leuven, Leuven, Belgium
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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25
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Higher Rate of Barrett's Detection in the First Year After Successful Endoscopic Therapy: Meta-analysis. Am J Gastroenterol 2018; 113:959-971. [PMID: 29899439 DOI: 10.1038/s41395-018-0090-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/19/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic eradication therapy (EET) is highly effective in treating dysplastic Barrett's esophagus (BE). Current surveillance intervals after complete remission of intestinal metaplasia (CRIM) are based on expert opinion. We performed a meta-analysis to compare BE detection in the first year to the subsequent ones METHODS: We searched MEDLINE, EMBASE, Scopus and Cochrane Central Register of Controlled Trials through 1 August 2017 for studies reporting IM and neoplasia detection after CRIM. Pooled incidence rate (IR) of IM detection was calculated for each year after CRIM. We compared IM, dysplasia, and high grade dysplasia (HGD)/esophageal adenocarcinoma (EAC) detection in the first year after CRIM to the years after. RESULTS Twenty two studies were included involving 1973 patients with follow-up of 5176 patient-years. IM detection IR per patient-year in the 1st year was 12% (95% CI: 8-17%), in the 2nd year 7% (95% CI: 4-11%), and in the 3rd year 3% (95% CI: 1-7%). IM detection rate in the first year was significantly higher compared to the years after (relative risk (RR) 1.8 (95% CI: 1.29-2.49)). Dysplasia detection IR in the first year after achieving CRIM was 3% per patient-year (95% CI: 2-5%). Dysplasia detection IR after the first year was 1% (95% CI: 1-2%) and significantly higher in the first year compared to the years after (RR: 1.92 (95% CI: 1.32-2.8). HGD/EAC detection was 1 %/patient-year (95% CI: 0-2%) in the first year after CRIM compared to 0%/patient-year (95% CI: 0-1%) in subsequent years. HGD/EAC IR was higher in the first year (RR: 1.58 (95% CI: 0.94-2.65)). CONCLUSION Neoplasia detection after successful treatment of BE appears more common within the first year of surveillance. This appears to be due to incompletely treated prevalent rather than recurrent disease. More intensive surveillance in the first year following CRIM is warranted.
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Pouw RE, Künzli HT, Bisschops R, Sondermeijer CM, Koch AD, Didden P, Gotink AW, Schoon EJ, Curvers WL, Bergman JJGHM, Weusten BLAM. Simplified versus standard regimen for focal radiofrequency ablation of dysplastic Barrett's oesophagus: a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol 2018; 3:566-574. [PMID: 29934224 DOI: 10.1016/s2468-1253(18)30157-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 04/19/2018] [Accepted: 04/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND For focal radiofrequency ablation of Barrett's oesophagus, a simplified regimen (3 × 15 J/cm2, without cleaning) has proven to be as effective as the standard regimen (2 × 15 J/cm2, followed by cleaning, followed by 2 × 15 J/cm2). However, this simplified regimen seemed to be associated with a higher stenosis rate. Therefore, we lowered the radiofrequency energy and hypothesised that this new simplified regimen would be as effective and safe as the standard regimen. METHODS This randomised non-inferiority trial included patients with dysplastic Barrett's oesophagus or residual Barrett's oesophagus after endoscopic resection or circumferential radiofrequency ablation, in five European tertiary referral centres. Patients were randomly assigned (1:1) to the new simplified regimen (3 × 12 J/cm2, without cleaning) or the standard regimen, with variable block sizes of four, six, and eight patients, stratified by participating hospital. Focal radiofrequency ablation was done every 3 months, up to a maximum of three treatments, until all Barrett's oesophagus was eradicated. The primary outcome was complete endoscopic and histological regression of dysplasia and intestinal metaplasia after two focal radiofrequency ablation treatments, assessed in the intention-to-treat population. Non-inferiority was assessed on the basis of the difference between groups in the median percentage of Barrett's oesophagus surface regression, with a non-inferiority margin of -15%. This study is registered with www.trialregister.nl, number NTR4994, and is completed. FINDINGS Between March 25, 2015, and July 25, 2016, 84 patients were randomly assigned to treatment: 44 to receive the simplified regimen and 40 to receive the standard regimen. One patient assigned to the simplified regimen and four assigned to the standard regimen were excluded because they weree found not to be eligible; therefore the final intention-to-treat population consisted of 43 patients in the simplified ablation group and 36 in the standard ablation group. Complete endoscopic and histological regression of dysplasia and intestinal metaplasia after two focal radiofrequency ablation treatments was achieved in 32 (74%, 95% CI 59-87) patients treated with the simplified protocol, versus 30 (83%, 95% CI 67-94) patients treated with the standard protocol (p=0·34). Median Barrett's oesophagus surface regression after two focal radiofrequency ablation sessions was 98% (IQR 95-100) in the simplified regimen group and 100% (97-100) in the standard regimen group. The difference between medians was 2% (95% CI -0·562 to 3·162); thus the simplified regimen was deemed non-inferior to the standard regimen. Stenoses requiring dilatation were observed in four (9%) of 43 patients in the simplified regimen group and four (11%) of 36 in the standard regimen group. Post-procedural bleeding requiring repeat endoscopy occurred in one (2%) patient in the simplified ablation group and three (8%) patients in the standard ablation group. One patient (2%) in the simplified treatment group died 36 days after the second radiofrequency ablation procedure, due to an unknown cause. INTERPRETATION Based on the results of this study, we conclude that the simplified regimen is the preferred regimen for focal radiofrequency ablation of Barrett's oesophagus. FUNDING None.
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Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Hannah T Künzli
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Carine M Sondermeijer
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Anniek W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands.
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Rieder E, Riegler M, Simić AP, Skrobić OM, Bonavina L, Gurski R, Paireder M, Castell DO, Schoppmann SF. Alternative therapies for GERD: a way to personalized antireflux surgery. Ann N Y Acad Sci 2018; 1434:360-369. [PMID: 29774563 DOI: 10.1111/nyas.13851] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 04/02/2018] [Accepted: 04/06/2018] [Indexed: 12/14/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a common disorder, known to affect about 20% of the Western population. Although conventional medical or surgical treatment has proven effective, there is certainly room for improvements. As only 10% of GERD patients are finally treated by antireflux surgery, a large therapeutic window exists. This treatment gap consists of patients who are not effectively treated with proton pump inhibitor but do not want to run the potential risks of conventional surgery. During the last two decades, several novel and intriguing options for the surgical treatment of GERD have been introduced and found their way into clinical use. The following summary will give an update of certain alternative therapeutic options to treat GERD or its pathological consequences.
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Affiliation(s)
- Erwin Rieder
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Aleksandar P Simić
- University Hospital for Digestive Surgery, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Ognjan M Skrobić
- University Hospital for Digestive Surgery, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Luigi Bonavina
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milano School of Medicine, IRCCS Policlinico San Donato, Milano, Italy
| | - Richard Gurski
- Department of Surgery, Universidade Federal do Rio Grande do Sul, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Matthias Paireder
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Donald O Castell
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
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Komanduri S, Muthusamy VR, Wani S. Controversies in Endoscopic Eradication Therapy for Barrett's Esophagus. Gastroenterology 2018; 154:1861-1875.e1. [PMID: 29458152 DOI: 10.1053/j.gastro.2017.12.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/05/2017] [Accepted: 12/20/2017] [Indexed: 02/07/2023]
Abstract
Advances in endoscopic eradication therapy for Barrett's Esophagus-associated neoplasia have resulted in a significant paradigm shift in the diagnosis and management of this complex disease. A robust body of literature critically evaluating outcomes of resection and ablative strategies has allowed gastroenterologists to make quality, evidence-based decisions for their patients. Despite this progress, there are still many unanswered questions and challenges that remain. Ultimately, identification of a cost-effective screening modality, biomarkers for risk stratification, and strides to eliminate post surveillance endoscopy after endoscopic eradication therapy are essential to reach our long-term goal for eradication of esophageal adenocarcinoma.
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Affiliation(s)
- Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois.
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Belghazi K, van Vilsteren FGI, Weusten BLAM, Meijer SL, Bergman JJGHM, Pouw RE. Long-term follow-up results of stepwise radical endoscopic resection for Barrett's esophagus with early neoplasia. Gastrointest Endosc 2018; 87:77-84. [PMID: 28455160 DOI: 10.1016/j.gie.2017.04.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/09/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Stepwise radical endoscopic resection (SRER) has shown to be effective in eradicating Barrett's esophagus (BE) and its associated dysplasia. The aim of this study was to assess the long-term durability after successful SRER for early Barrett's neoplasia. METHODS Patients treated with SRER for BE ≤5 cm with high-grade dysplasia (HGD) or early cancer (EC) and who had reached complete eradication of intestinal metaplasia (CE-IM) and neoplasia (CE-neo) were included. Primary outcomes were recurrence of neoplasia (HGD/EC), recurrence of dysplasia (indefinite for dysplasia included), and recurrence of endoscopically visible BE. Secondary outcomes were buried Barrett's glands, IM in biopsy specimens obtained distal to a normal-appearing neo-squamocolumnar junction (neo-SCJ), need for retreatment, and sustained CE-IM and CE-neo at the last follow-up endoscopy. RESULTS Seventy-three patients were included (64 men; mean age, 66 years; median BE, C2M3). Median follow-up was 76 months. Recurrence of neoplasia was observed in 1 patient (T1bN0M0) after 129 months of follow-up and was treated with curative surgery (annual incidence of .22% per patient-year of follow-up). In 4 patients, recurrence of dysplasia was found (.87% per patient-year of follow-up). Twelve patients had recurrent endoscopically visible BE after a median follow-up of 22 months (2.6% per patient-year of follow-up), mostly small islands or tongues. Five patients had a single finding of buried Barrett's glands (1.1% per patient-year of follow-up), and 27 patients (5.9% per patient-year of follow-up) showed IM in biopsy specimens just distal to the neo-SCJ, which was not reproduced in 56%. Retreatment was performed in 9 patients. CE-IM and CE-neo (excluding IM in the neo-SCJ) at the last follow-up endoscopy was seen in 95% and 97% of patients, respectively. CONCLUSIONS This study presents the longest published follow-up data on SRER to date. The 6-year outcomes show that successful SRER is a durable treatment for BE ≤5 cm with HGD/EC.
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Affiliation(s)
- Kamar Belghazi
- Department of Gastroenterology, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Bas L A M Weusten
- Department of Gastroenterology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Sybren L Meijer
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Roos E Pouw
- Department of Gastroenterology, Academic Medical Center, Amsterdam, the Netherlands
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Bartel MJ, Srivastava A, Gordon S, Rothstein RI, Pohl H. Subsquamous intestinal metaplasia is common in treatment-naïve Barrett's esophagus. Gastrointest Endosc 2018; 87:67-74. [PMID: 28687439 DOI: 10.1016/j.gie.2017.06.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 06/26/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Barrett's intestinal metaplasia may extend beneath normal squamous epithelium at the squamocolumnar junction (SCJ) and therefore escape surveillance biopsy sampling. The prevalence of subsquamous intestinal metaplasia (SSIM) in patients undergoing Barrett's esophagus (BE) surveillance is unknown. Our aim was to examine the prevalence and distribution of SSIM proximal to the SCJ in patients undergoing BE surveillance. METHODS We enrolled consecutive patients with biopsy specimen-proven BE. Biopsy specimens were obtained from the squamous epithelium at 5 mm and 10 mm above the SCJ. The primary outcomes were the proportion of patients with SSIM at each level. We further assessed factors associated with SSIM. RESULTS We examined 515 squamous epithelial biopsy specimens from 106 BE patients (95% men; mean age, 66 years) with a mean Barrett's length of 3.0 cm. SSIM was present in 39% at 5 mm (95% CI, 29.4-48.6) and 21% (95% CI, 11.7-32.1) at 10 mm proximal to the SCJ. Among all biopsy specimens, 13% (95% CI, 10.6-16.6) contained SSIM: 17% (95% CI, 13-21.6) of biopsy samples at 5 mm and 8% (95% CI, 4.3-12.2) at 10 mm proximal to the SCJ. SSIM was more common in the anterior/right lateral position compared with the posterior/left lateral position (21% vs 11%, P = .001). None of the biopsy specimens showed dysplasia. Length of BE or duration of reflux symptoms were not associated with the presence of SSIM. CONCLUSIONS This cross-sectional study found a surprisingly high proportion of SSIM in treatment-naïve patients proximal to the SCJ. These findings raise questions regarding BE management and the prevalence of SSIM in normal-appearing esophagus.
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Affiliation(s)
- Michael J Bartel
- Section of Gastroenterology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Amitabh Srivastava
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stuart Gordon
- Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Richard I Rothstein
- Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Heiko Pohl
- Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; Department of Gastroenterology, VA Medical Center, White River Junction, Vermont, USA
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Tsai TH, Leggett CL, Trindade AJ, Sethi A, Swager AF, Joshi V, Bergman JJ, Mashimo H, Nishioka NS, Namati E. Optical coherence tomography in gastroenterology: a review and future outlook. JOURNAL OF BIOMEDICAL OPTICS 2017; 22:1-17. [PMID: 29260538 DOI: 10.1117/1.jbo.22.12.121716] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 12/05/2017] [Indexed: 05/18/2023]
Abstract
Optical coherence tomography (OCT) is an imaging technique optically analogous to ultrasound that can generate depth-resolved images with micrometer-scale resolution. Advances in fiber optics and miniaturized actuation technologies allow OCT imaging of the human body and further expand OCT utilization in applications including but not limited to cardiology and gastroenterology. This review article provides an overview of current OCT development and its clinical utility in the gastrointestinal tract, including disease detection/differentiation and endoscopic therapy guidance, as well as a discussion of its future applications.
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Affiliation(s)
- Tsung-Han Tsai
- NinePoint Medical, Inc., Bedford, Massachusetts, United States
| | - Cadman L Leggett
- Mayo Clinics, Division of Gastroenterology and Hepatology, Rochester, Minnesota, United States
| | - Arvind J Trindade
- North Shore University Hospital and Hofstra Northwell School of Medicine, Division of Gastroenterolo, United States
| | - Amrita Sethi
- Columbia University Medical Center, Department of Gastroenterology, New York City, New York, United States
| | - Anne-Fré Swager
- Spaarne Gasthuis and Free University Medical Center, Amsterdam, The Netherlands
| | - Virendra Joshi
- Ochsner Clinic Foundation, Department of Gastroenterology, New Orleans, Louisiana, United States
| | - Jacques J Bergman
- Academic Medical Center, Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - Hiroshi Mashimo
- Veterans Affairs Boston Healthcare System and Harvard Medical School, Department of Gastroenterology, United States
| | - Norman S Nishioka
- Massachusetts General Hospital, Gastrointestinal Unit, Boston, Massachusetts, United States
| | - Eman Namati
- NinePoint Medical, Inc., Bedford, Massachusetts, United States
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Esteban JM, González-Carro P, Gornals JB, Collados C, Álvarez M, Pérez-Mitru A, Serip S. Economic evaluation of endoscopic radiofrequency ablation for the treatment of dysplastic Barrett's esophagus in Spain. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 110:145-154. [PMID: 29168641 DOI: 10.17235/reed.2017.5087/2017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND STUDY AIMS To assess the cost-effectiveness of introducing endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection in selected patients into the standard of care of Barrett's esophagus patients with high-grade dysplasia or low-grade dysplasia in Spain. METHODS The disease evolution was modeled via a semi-Markov model. The treatment strategies compared included endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection and the Standard of Care (esophagectomy or palliative chemoradiotherapy according to disease status for high-grade dysplasia and endoscopic surveillance for low-grade dysplasia). Efficacy rates, transition probabilities and utility values were obtained from the literature. Clinical management patterns and resource use were modeled according to Spanish clinical expert opinion. Costs were expressed in euros (€) from 2016 reflecting the Spanish National Health System perspective. Sensitivity analyses were performed to assess the robustness of the model. RESULTS With respect to the Spanish Standard of Care, endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection was a dominant strategy for high-grade dysplasia patients. When a willingness-to-pay threshold of €30,000 per quality-adjusted life-years gained was considered, this was cost-effective for low-grade dysplasia patients (€12,865 per quality-adjusted life-years gained). The sensitivity analyses supported the base case analysis results and pointed towards the main drivers of uncertainty in the model. CONCLUSIONS From a health care decision-maker, endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection is the intervention of choice for dysplasic Barrett's esophagus patients in Spain.
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Affiliation(s)
| | | | - Joan B Gornals
- Digestive Endoscopy Unit, Digestive Department, Hospital Universitari de Bellvitge, IDIBELL, Spain
| | - Carlos Collados
- Health Economics and Outcomes Research Department, Medtronic Ibérica, S.A., Spain
| | - María Álvarez
- Health Economics and Outcomes Research Department, Medtronic Ibérica, S.A., Spain
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Upchurch E, Griffiths S, Lloyd GR, Isabelle M, Kendall C, Barr H. Developments in optical imaging for gastrointestinal surgery. Future Oncol 2017; 13:2363-2382. [PMID: 29121775 DOI: 10.2217/fon-2017-0181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
To improve outcomes for patients with cancer, in terms of both survival and a reduction in the morbidity and mortality that results from surgical resection and treatment, there are two main areas that require improvement. Accurate early diagnosis of the cancer, at a stage where curative and, ideally, minimally invasive treatment is achievable, is desired as well as identification of tumor margins, lymphatic and distant disease, enabling complete, but not unnecessarily extensive, resection. Optical imaging is making progress in achieving these aims. This review discusses the principles of optical imaging, focusing on fluorescence and spectroscopy, and the current research that is underway in GI tract carcinomas.
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Affiliation(s)
- Emma Upchurch
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN.,Department of Upper GI Surgery, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
| | - Shelly Griffiths
- Department of Upper GI Surgery, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
| | - Gavin-Rhys Lloyd
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
| | - Martin Isabelle
- Renishaw plc, New Mills, Wotton-under-Edge, Gloucestershire, UK, GL12 8JR
| | - Catherine Kendall
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
| | - Hugh Barr
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN.,Department of Upper GI Surgery, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
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Wani S, Muthusamy VR, Shaheen NJ, Yadlapati R, Wilson R, Abrams JA, Bergman J, Chak A, Chang K, Das A, Dumot J, Edmundowicz SA, Eisen G, Falk GW, Fennerty MB, Gerson L, Ginsberg GG, Grande D, Hall M, Harnke B, Inadomi J, Jankowski J, Lightdale CJ, Makker J, Odze RD, Pech O, Sampliner RE, Spechler S, Triadafilopoulos G, Wallace MB, Wang K, Waxman I, Komanduri S. Development of Quality Indicators for Endoscopic Eradication Therapies in Barrett's Esophagus: The TREAT-BE (Treatment With Resection and Endoscopic Ablation Techniques for Barrett's Esophagus) Consortium. Am J Gastroenterol 2017; 112:1032-1048. [PMID: 28570552 DOI: 10.1038/ajg.2017.166] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - V Raman Muthusamy
- University of California in Los Angeles, Los Angeles, California, USA
| | | | | | - Robert Wilson
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | | | | | | | - Kenneth Chang
- University of California in Irvine, Irvine, California, USA
| | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, Arizona, USA
| | - John Dumot
- University Hospitals, Cleveland, Ohio, USA
| | | | | | - Gary W Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Lauren Gerson
- California Pacific Medical Center, San Francisco, California, USA
| | - Gregory G Ginsberg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Matt Hall
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Ben Harnke
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - John Inadomi
- University of Washington, Seattle, Washington, USA
| | | | | | - Jitin Makker
- University of California in Los Angeles, Los Angeles, California, USA
| | - Robert D Odze
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Oliver Pech
- St. John of God Hospital, Regensburg, Germany
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Care of the Postablation Patient: Surveillance, Acid Suppression, and Treatment of Recurrence. Gastrointest Endosc Clin N Am 2017; 27:515-529. [PMID: 28577772 DOI: 10.1016/j.giec.2017.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic eradication therapy is effective and durable for the treatment of Barrett's esophagus (BE), with low rates of recurrence of dysplasia but significant rates of recurrence of intestinal metaplasia. Identified risk factors for recurrence include age and length of BE before treatment and may also include presence of a large hiatal hernia, higher grade of dysplasia before treatment, and history of smoking. Current guidelines for surveillance following ablation are limited, with recommendations based on low-quality evidence and expert opinion. New modalities including optical coherence tomography and wide-area tissue sampling with computer-assisted analysis show promise as adjunctive surveillance modalities.
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36
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Wani S, Muthusamy VR, Shaheen NJ, Yadlapati R, Wilson R, Abrams JA, Bergman J, Chak A, Chang K, Das A, Dumot J, Edmundowicz SA, Eisen G, Falk GW, Fennerty MB, Gerson L, Ginsberg GG, Grande D, Hall M, Harnke B, Inadomi J, Jankowski J, Lightdale CJ, Makker J, Odze RD, Pech O, Sampliner RE, Spechler S, Triadafilopoulos G, Wallace MB, Wang K, Waxman I, Komanduri S. Development of quality indicators for endoscopic eradication therapies in Barrett's esophagus: the TREAT-BE (Treatment with Resection and Endoscopic Ablation Techniques for Barrett's Esophagus) Consortium. Gastrointest Endosc 2017; 86:1-17.e3. [PMID: 28576294 DOI: 10.1016/j.gie.2017.03.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.
| | - V Raman Muthusamy
- University of California in Los Angeles, Los Angeles, California, USA
| | | | | | - Robert Wilson
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | | | | | | | - Kenneth Chang
- University of California in Irvine, Irvine, California, USA
| | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, Arizona, USA
| | - John Dumot
- University Hospitals, Cleveland, Ohio, USA
| | | | | | - Gary W Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Lauren Gerson
- California Pacific Medical Center, San Francisco, California, USA
| | - Gregory G Ginsberg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Matt Hall
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Ben Harnke
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - John Inadomi
- University of Washington, Seattle, Washington, USA
| | | | | | - Jitin Makker
- University of California in Los Angeles, Los Angeles, California, USA
| | - Robert D Odze
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Oliver Pech
- St. John of God Hospital, Regensburg, Germany
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Visrodia K, Zakko L, Wang KK. Radiofrequency Ablation of Barrett's Esophagus: Efficacy, Complications, and Durability. Gastrointest Endosc Clin N Am 2017; 27:491-501. [PMID: 28577770 DOI: 10.1016/j.giec.2017.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In the last decade, radiofrequency ablation in combination with endoscopic mucosal resection has simplified and improved the treatment of Barrett's esophagus. These treatments not only reduced the progression of dysplastic Barrett's esophagus to esophageal adenocarcinoma but also decreased treatment-related complications. More recent data from larger series with extended follow-up periods are emerging to refine expectations in patients treated with radiofrequency ablation. Although most patients achieve eradication of neoplasia and intestinal metaplasia, in the long-term a substantial portion of patients develop recurrent disease. This article provides an updated review of radiofrequency ablation efficacy, complications, and durability.
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Affiliation(s)
- Kavel Visrodia
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, 200 First Avenue, Southwest, Rochester, MN 55905, USA
| | - Liam Zakko
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, 200 First Avenue, Southwest, Rochester, MN 55905, USA
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, 200 First Avenue, Southwest, Rochester, MN 55905, USA.
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Phoa KN, Rosmolen WD, Weusten BLAM, Bisschops R, Schoon EJ, Das S, Ragunath K, Fullarton G, DiPietro M, Ravi N, Tijssen JGP, Dijkgraaf MGW, Bergman JJGHM. The cost-effectiveness of radiofrequency ablation for Barrett's esophagus with low-grade dysplasia: results from a randomized controlled trial (SURF trial). Gastrointest Endosc 2017; 86:120-129.e2. [PMID: 27956164 DOI: 10.1016/j.gie.2016.12.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 12/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The Surveillance versus Radiofrequency Ablation (SURF) trial randomized 136 patients with Barrett's esophagus (BE) containing low-grade dysplasia (LGD), to receive radiofrequency ablation (ablation, n = 68) or endoscopic surveillance (control, n = 68). Ablation reduced the risk of neoplastic progression to high-grade dysplasia and esophageal adenocarcinoma (EAC) by 25% over 3 years (1.5% for ablation vs 26.5% for control). We performed a cost-effectiveness analysis from a provider perspective alongside this trial. METHODS Patients were followed for 3 years to quantify their use of health care services, including therapeutic and surveillance endoscopies, treatment of adverse events, and medication. Costs for treatment of progression were analyzed separately. Incremental cost-effectiveness ratios (ICER) were calculated by dividing the difference in costs (excluding and including the downstream costs for treatment of progression) by the difference in prevented events of progression. Bootstrap analysis (1000 samples) was used to construct 95% confidence intervals (CIs). RESULTS Patients who underwent ablation generated mean costs of U.S.$13,503 during the trial versus $2236 for controls (difference $11,267; 95% CI, $9996-$12,378), with an ICER per prevented event of progression of $45,066. Including the costs for treatment of progression, ablation patients generated mean costs of $13,523 versus $4,930 for controls (difference $8593; 95% CI, $6881-$10,153) with an ICER of $34,373. Based on the various ICER estimates derived from the bootstrap analysis, one can be reasonably certain (>75%) that ablation is efficient at a willingness to pay of $51,664 per prevented event of progression or $40,915 including downstream costs of progression. CONCLUSIONS Ablation for patients with confirmed BE-LGD is more effective and more expensive than endoscopic surveillance in reducing the risk of progression to high-grade dysplasia/EAC. The increase in costs of ablation can be justified to avoid a serious event such as neoplastic progression. At a willingness to pay of $40,915 per prevented event of progression, one can be reasonably certain that ablation is efficient. (www.trialregister.nl number: NTR 1198.).
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Affiliation(s)
- K Nadine Phoa
- Department of Gastroenterology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Wilda D Rosmolen
- Department of Gastroenterology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands; Department of Gastroenterology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Raf Bisschops
- Department of Gastroenterology, University Hospital Leuven, Leuven, Belgium
| | - Erik J Schoon
- Department of Gastroenterology, Catharina Hospital, Eindhoven, the Netherlands
| | - Shefali Das
- Department of Gastroenterology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Krish Ragunath
- Department of Gastroenterology, Queens Medical Centre, Nottingham, United Kingdom
| | - G Fullarton
- Department of Surgical Gastroenterology, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Massimiliano DiPietro
- Medical Research Council, Cancer Unit, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Narayanasamy Ravi
- Department of Clinical Medicine & Gastroenterology, St James's Hospital, Dublin, Ireland
| | - Jan G P Tijssen
- Department of Cardiology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Marcel G W Dijkgraaf
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
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Saxena N, Inadomi JM. Effectiveness and Cost-Effectiveness of Endoscopic Screening and Surveillance. Gastrointest Endosc Clin N Am 2017; 27:397-421. [PMID: 28577764 DOI: 10.1016/j.giec.2017.02.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Guidelines for the screening and surveillance of Barrett's esophagus continue to evolve as the incidence of esophageal adenocarcinoma increases, identification of individuals at highest risk for cancer improves, and management of dysplasia evolves. This article reviews related studies and economic analyses. Advances in diagnosis offer promising strategies to help focus screening efforts on those individuals who are most likely to develop esophageal adenocarcinoma.
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Affiliation(s)
- Nina Saxena
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Box 356424, Seattle, WA 98195, USA
| | - John M Inadomi
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Box 356424, Seattle, WA 98195, USA.
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40
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Lee HC, Ahsen OO, Liu JJ, Tsai TH, Huang Q, Mashimo H, Fujimoto JG. Assessment of the radiofrequency ablation dynamics of esophageal tissue with optical coherence tomography. JOURNAL OF BIOMEDICAL OPTICS 2017; 22:76001. [PMID: 28687822 PMCID: PMC5499807 DOI: 10.1117/1.jbo.22.7.076001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 06/08/2017] [Indexed: 05/08/2023]
Abstract
Radiofrequency ablation (RFA) is widely used for the eradication of dysplasia and the treatment of early stage esophageal carcinoma in patients with Barrett’s esophagus (BE). However, there are several factors, such as variation of BE epithelium (EP) thickness among individual patients and varying RFA catheter-tissue contact, which may compromise RFA efficacy. We used a high-speed optical coherence tomography (OCT) system to identify and monitor changes in the esophageal tissue architecture from RFA. Two different OCT imaging/RFA application protocols were performed using an <italic<ex vivo</italic< swine esophagus model: (1) post-RFA volumetric OCT imaging for quantitative analysis of the coagulum formation using RFA applications with different energy settings, and (2) M-mode OCT imaging for monitoring the dynamics of tissue architectural changes in real time during RFA application. Post-RFA volumetric OCT measurements showed an increase in the coagulum thickness with respect to the increasing RFA energies. Using a subset of the specimens, OCT measurements of coagulum and coagulum + residual EP thickness were shown to agree with histology, which accounted for specimen shrinkage during histological processing. In addition, we demonstrated the feasibility of OCT for real-time visualization of the architectural changes during RFA application with different energy settings. Results suggest feasibility of using OCT for RFA treatment planning and guidance.
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Affiliation(s)
- Hsiang-Chieh Lee
- Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics, Cambridge, Massachusetts, United States
| | - Osman O. Ahsen
- Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics, Cambridge, Massachusetts, United States
| | - Jonathan J. Liu
- Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics, Cambridge, Massachusetts, United States
| | - Tsung-Han Tsai
- Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics, Cambridge, Massachusetts, United States
| | - Qin Huang
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Hiroshi Mashimo
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - James G. Fujimoto
- Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics, Cambridge, Massachusetts, United States
- Address all correspondence to: James G. Fujimoto, E-mail:
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Fujii-Lau LL, Cinnor B, Shaheen N, Gaddam S, Komanduri S, Muthusamy VR, Das A, Wilson R, Simon VC, Kushnir V, Mullady D, Edmundowicz SA, Early DS, Wani S. Recurrence of intestinal metaplasia and early neoplasia after endoscopic eradication therapy for Barrett's esophagus: a systematic review and meta-analysis. Endosc Int Open 2017; 5:E430-E449. [PMID: 28573176 PMCID: PMC5451278 DOI: 10.1055/s-0043-106578] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/15/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Conflicting data exist with regard to recurrence rates of intestinal metaplasia (IM) and dysplasia after achieving complete eradication of intestinal metaplasia (CE-IM) in Barrett's esophagus (BE) patients. AIM (i) To determine the incidence of recurrent IM and dysplasia achieving CE-IM and (ii) to compare recurrence rates between treatment modalities [radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) vs stepwise complete EMR (SRER)]. METHODS A systematic search was performed for studies reporting on outcomes and estimates of recurrence rates after achieving CE-IM. Pooled incidence [per 100-patient-years (PY)] and risk ratios with 95 %CI were obtained. Heterogeneity was measured using the I2 statistic. Subgroup analyses, decided a priori, were performed to explore heterogeneity in results. RESULTS A total of 39 studies were identified (25-RFA, 13-SRER, and 2 combined). The pooled incidence of any recurrence was 7.5 (95 %CI 6.1 - 9.0)/100 PY with a pooled incidence of IM recurrence rate of 4.8 (95 %CI 3.8 - 5.9)/100 PY, and dysplasia recurrence rate of 2.0 (95 %CI 1.5 - 2.5)/100 PY. Compared to the SRER group, the RFA group had significantly higher overall [8.6 (6.7 - 10.5)/100 PY vs. 5.1 (3.1 - 7)/100 PY, P = 0.01] and IM recurrence rates [5.8 (4.3 - 7.3)/100 PY vs. 3.1 (1.7 - 4)/100 PY, P < 0.01] with no difference in recurrence rates of dysplasia. Significant heterogeneity between studies was identified. The majority of recurrences were amenable to repeat endoscopic eradication therapy (EET). CONCLUSION The results of this study demonstrate that the incidence rates of overall, IM, and dysplasia recurrence rates post-EET are not inconsiderable and reinforce the importance of close surveillance after achieving CE-IM.
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Affiliation(s)
| | - Birtukan Cinnor
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Srinivas Gaddam
- Washington University School of Medicine, St. Louis, MO, USA
| | - Srinadh Komanduri
- Feinberg School of Medicine Northwestern University, Chicago, IL, USA
| | | | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, AZ, USA
| | - Robert Wilson
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Daniel Mullady
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Dayna S. Early
- Washington University School of Medicine, St. Louis, MO, USA
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA,Corresponding author Sachin Wani, MD Division of Gastroenterology and HepatologyUniversity of Colorado Anschutz Medical CenterMail Stop F7351635 Aurora CourtRm 2.031AuroraCO 80045USA+1-720-848-2749
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Han S, Wani S. Quality Indicators in Endoscopic Ablation for Barrett's Esophagus. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2017; 15:241-255. [PMID: 28421454 DOI: 10.1007/s11938-017-0136-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT Barrett's esophagus (BE) is a well-established premalignant condition for esophageal adenocarcinoma (EAC); a cancer that is associated with a poor 5-year survival rate. Several strategies have been explored in the context of reducing the burden of EAC. Endoscopic eradication therapy (EET) is considered the standard of care for the management of patients with BE with dysplasia and early neoplasia; a practice that has been endorsed by all gastroenterology societal guidelines. The effectiveness of EET has been demonstrated in multiple studies and contemporary management includes a combination of endoscopic mucosal resection (EMR) of all visible lesions followed by eradication of the remaining BE using ablative techniques of which radiofrequency ablation (RFA) has the best evidence supporting effectiveness and safety. These techniques are being used increasingly at academic tertiary care centers and community practices. In this era of value-based health care, there is increased focus on the establishment, documentation, and reporting of quality indicators; indicators that are important to physicians, patients, and payers. The purpose of this review is to highlight the current status of quality indicators in EET for the management of patients with BE-related neoplasia and discuss the future steps required to ensure that these quality indicators are uniformly incorporated into practice.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, Rm 2.031, Aurora, CO, 80045, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, Rm 2.031, Aurora, CO, 80045, USA.
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Komanduri S, Kahrilas PJ, Krishnan K, McGorisk T, Bidari K, Grande D, Keefer L, Pandolfino J. Recurrence of Barrett's Esophagus is Rare Following Endoscopic Eradication Therapy Coupled With Effective Reflux Control. Am J Gastroenterol 2017; 112:556-566. [PMID: 28195178 DOI: 10.1038/ajg.2017.13] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 01/06/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Recent data suggest that effective control of gastroesophageal reflux improves outcomes associated with endoscopic eradication therapy (EET) for Barrett's esophagus (BE). However, the impact of reflux control on preventing recurrent intestinal metaplasia and/or dysplasia is unclear. The aims of the study were: (a) to determine the effectiveness and durability of EET under a structured reflux management protocol and (b) to determine the impact of optimizing anti-reflux therapy on achieving complete eradication of intestinal metaplasia (CE-IM). METHODS Consecutive BE patients referred for EET were enrolled and managed with a standardized reflux management protocol including twice-daily PPI therapy during eradication. Primary outcomes were rates of CE-IM and IM or dysplasia recurrence. RESULTS Out of 221 patients enrolled (46.0% with high-grade dysplasia/intramucosal carcinoma, 34.0% with low-grade dysplasia, and 20.0% with non-dysplastic BE) an overall CE-IM of 93% was achieved within 11.6±10.2 months. Forty-eight patients did not achieve CE-IM in 3 sessions. After modification of their reflux management, 45 (93.7%) achieved CE-IM in a mean of 1.1 RFA sessions. Recurrence occurred in 13 patients (IM in 10(4.8%), dysplasia in 3 (1.5%)) during a mean follow-up of 44±18.5 months. The only significant predictor of recurrence was the presence of a hiatal hernia. Recurrence of IM was significantly lower than historical controls (10.9 vs. 4.8%, P=0.04). CONCLUSIONS The current study highlights the importance of reflux control in patients with BE undergoing EET. In this setting, EET has long-term durability with low recurrence rates providing early evidence for extending endoscopic surveillance intervals after EET.
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Affiliation(s)
- Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kumar Krishnan
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Tim McGorisk
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kiran Bidari
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - David Grande
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Laurie Keefer
- Ichan School of Medicine at Mount Sinai, New York, New York, USA
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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44
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Rosmolen WD, Nieuwkerk PT, Pouw RE, van Berge Henegouwen MI, Bergman JJGHM, Sprangers MAG. Quality of life and fear of cancer recurrence after endoscopic treatment for early Barrett's neoplasia: a prospective study. Dis Esophagus 2017; 30:1-9. [PMID: 27766707 DOI: 10.1111/dote.12512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Endoscopic therapy is the treatment of choice for high grade intraepithelial neoplasia (HGIN) or early cancer (≤T1sm1) in Barrett's esophagus (BE). We prospectively evaluated the effect of endoscopic treatment on quality of life (QOL) and fear of cancer (recurrence) and compared this with the effect of Barrett's surveillance or surgery. Patients treated endoscopically for early Barrett's neoplasia (n = 42, HGIN - T1sm1N0M0) were compared with three groups: patients with non-dysplastic BE undergoing surveillance (n = 44); patients treated surgically for early BE neoplasia (HGIN - T2N0M0, n = 21); patients treated surgically for advanced BE cancer (T1N1M0 - T3N1M0, n = 19). QOL (SF-36; EORTC-QLQ-C30; EORTC-QLQ-OES18) and fear of cancer recurrence (Worry of Cancer Scale [WOCS] and the Hospital Anxiety and Depression Scale [HADS]) were measured at baseline, 2 and 6 months after treatment. The endoscopic treatment group reported significantly better QOL in both physical and mental scales of SF-36 and EORTC-QLQ-C30 and less esophageal cancer related symptoms compared to both surgical groups. The endoscopic treatment group reported significant more worry for cancer recurrence (WOCS) compared to the early surgical group. Their scores on the WOCS were comparable with the scores of the advanced surgical group. Endoscopic treatment of early esophageal cancer has less negative impact on QOL and esophageal cancer symptoms than surgery. However, endoscopically treated patients worry as much about cancer recurrence as patients treated surgically for advanced cancer.
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Affiliation(s)
- Wilda D Rosmolen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Pythia T Nieuwkerk
- Department of Medical Psychology, Academic Medical Center, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Mirjam A G Sprangers
- Department of Medical Psychology, Academic Medical Center, Amsterdam, The Netherlands
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Clinical Outcomes Following Recurrence of Intestinal Metaplasia After Successful Treatment of Barrett's Esophagus With Radiofrequency Ablation. Am J Gastroenterol 2017; 112:87-94. [PMID: 27725648 PMCID: PMC9470085 DOI: 10.1038/ajg.2016.451] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 08/14/2016] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Radiofrequency ablation (RFA) is an effective treatment for Barrett's esophagus (BE). However, recurrence of BE after initially successful RFA is common, and outcomes following recurrence not well described. We report the outcomes associated with recurrence following initially successful RFA. METHODS We performed a retrospective cohort study of 306 patients treated with RFA for dysplastic BE. Complete eradication of intestinal metaplasia (CE-IM) was defined as complete histological and endoscopic remission of IM. Recurrence was defined as any presence of IM or dysplasia in the tubular esophagus or dysplasia in the gastric cardia subsequent to CE-IM. We examined rates and risk factors for recurrence, dysplastic recurrence, and invasive adenocarcinoma after CE-IM. We also describe the clinical course of patients following recurrence. RESULTS Of the 306 eligible patients undergoing RFA, 218 achieved CE-IM and also had subsequent surveillance endoscopy. Of these, 52 (24%) experienced recurrence of IM or Barrett's-associated neoplasia over 540.6 person-years (incidence rate 9.6%/year). Thirty (58%) of these achieved second CE-IM; 4 (1.8% of total, 7.7% of recurrences) ultimately progressed to invasive adenocarcinoma (incidence rate 0.65%/year). Longer Prague M was a strong risk factor for invasive adenocarcinoma (rate ratio of 1.34/cm). Most dysplastic recurrences were in the cardia, and the majority were not visible but detected on random biopsies. CONCLUSIONS Most patients with recurrent BE after initially successful RFA achieve second CE-IM; however, 1.8% progressed to invasive adenocarcinoma. Longer Prague M was predictive of invasive adenocarcinoma. Four-quadrant random biopsy of the cardia is advisable during surveillance endoscopy after CE-IM.
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Gatenby P, Bhattacharjee S, Wall C, Caygill C, Watson A. Risk stratification for malignant progression in Barrett’s esophagus: Gender, age, duration and year of surveillance. World J Gastroenterol 2016; 22:10592-10600. [PMID: 28082811 PMCID: PMC5192270 DOI: 10.3748/wjg.v22.i48.10592] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/17/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To clarify risk based upon segment length, diagnostic histological findings, patient age and year of surveillance, duration of surveillance and gender.
METHODS Patients registered with the United Kingdom Barrett’s Oesophagus Registry from 9 United Kingdom centers were included. The outcome measures were (1) development of all grades of dysplasia; (2) development of high-grade of dysplasia or adenocarcinoma; and (3) development of adenocarcinoma. Prevalent cases and subjects with < 1 year of follow-up were excluded. The covariates examined were segment length, previous biopsy findings, age at surveillance, duration of surveillance, year of surveillance and gender.
RESULTS One thousand and one hundred thirty six patients were included (total 6474 patient-years). Fifty-four patients developed adenocarcinoma (0.83% per annum), 70 developed high-grade dysplasia/adenocarcinoma (1.1% per annum) and 190 developed any grade of dysplasia (3.5% per annum). High grade dysplasia and adenocarcinoma increased with age and duration of surveillance. The risk of low-grade dysplasia development was not dependent on age at surveillance. Segment length and previous biopsy findings were also significant factors for development of dysplasia and adenocarcinoma.
CONCLUSION The risk of development of low-grade dysplasia is independent of age at surveillance, but high-grade dysplasia and adenocarcinoma were more commonly found at older age. Segment length and previous biopsy findings are also markers of risk. This study did not demonstrate stabilisation of the metaplastic segment with prolonged surveillance.
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Tang Q, Wang J, Frank A, Lin J, Li Z, Chen CW, Jin L, Wu T, Greenwald BD, Mashimo H, Chen Y. Depth-resolved imaging of colon tumor using optical coherence tomography and fluorescence laminar optical tomography. BIOMEDICAL OPTICS EXPRESS 2016; 7:5218-5232. [PMID: 28018738 PMCID: PMC5175565 DOI: 10.1364/boe.7.005218] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/16/2016] [Accepted: 11/16/2016] [Indexed: 05/02/2023]
Abstract
Early detection of neoplastic changes remains a critical challenge in clinical cancer diagnosis and treatment. Many cancers arise from epithelial layers such as those of the gastrointestinal (GI) tract. Current standard endoscopic technology is difficult to detect the subsurface lesions. In this research, we investigated the feasibility of a novel multi-modal optical imaging approach including high-resolution optical coherence tomography (OCT) and high-sensitivity fluorescence laminar optical tomography (FLOT) for structural and molecular imaging. The C57BL/6J-ApcMin/J mice were imaged using OCT and FLOT, and the correlated histopathological diagnosis was obtained. Quantitative structural (scattering coefficient) and molecular (relative enzyme activity) parameters were obtained from OCT and FLOT images for multi-parametric analysis. This multi-modal imaging method has demonstrated the feasibility for more accurate diagnosis with 88.23% (82.35%) for sensitivity (specificity) compared to either modality alone. This study suggested that combining OCT and FLOT is promising for subsurface cancer detection, diagnosis, and characterization.
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Affiliation(s)
- Qinggong Tang
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, USA
| | - Jianting Wang
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, USA
| | - Aaron Frank
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, USA
| | - Jonathan Lin
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, USA
| | - Zhifang Li
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, USA
- Key Laboratory of Optoelectronic Science and Technology for Medicine, Ministry of Education, College of Photonic and Electronic Engineering, Fujian Normal University, Fuzhou 350007, China
| | - Chao-wei Chen
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, USA
| | - Lily Jin
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, USA
| | - Tongtong Wu
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY 14642, USA
| | - Bruce D. Greenwald
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Hiroshi Mashimo
- Department of Medicine, Veterans Affairs Boston Healthcare System, Harvard Medical School, West Roxbury, MA 02132, USA
| | - Yu Chen
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, USA
- Key Laboratory of Optoelectronic Science and Technology for Medicine, Ministry of Education, College of Photonic and Electronic Engineering, Fujian Normal University, Fuzhou 350007, China
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Qumseya BJ, Wani S, Desai M, Qumseya A, Bain P, Sharma P, Wolfsen H. Adverse Events After Radiofrequency Ablation in Patients With Barrett's Esophagus: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2016; 14:1086-1095.e6. [PMID: 27068041 DOI: 10.1016/j.cgh.2016.04.001] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/29/2016] [Accepted: 04/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) is routinely used for treatment of Barrett's esophagus with dysplasia. Despite the relative safety of this method, there have been imprecise estimates of the rate of adverse events. We performed a systematic review and meta-analysis to assess the rate of adverse events associated with RFA with and without EMR. METHODS We searched MEDLINE, Embase, Web of Science, and Cochrane Central through October 22, 2014. The primary outcome of interest was the overall rate of adverse events after RFA with or without EMR. We used forest plots to contrast effect sizes among studies. RESULTS Of 1521 articles assessed, 37 met our inclusion criteria (comprising 9200 patients). The pooled rate of all adverse events from RFA with or without EMR was 8.8% (95% confidence interval [CI], 6.5%-11.9%); 5.6% of patients developed strictures (95% CI, 4.2%-7.4%), 1% had bleeding (95% CI, 0.8%-1.3%), and 0.6% developed a perforation (95% CI, 0.4%-0.9%). In studies that compared RFA with vs without EMR, the relative risk for adverse events was significantly higher for RFA with EMR (4.4) (P = .015). There was a trend toward higher proportions of adverse events in prospective studies compared with retrospective studies (11.3% vs 7.8%, P = .20). Other factors associated with adverse events included Barrett's esophagus and length and baseline histology. CONCLUSIONS In a systematic review and meta-analysis, we found the relative risk for adverse events from RFA to be about 4-fold higher with EMR than without; we identified factors associated with these events. Endoscopists should discuss these risks with patients before endoscopic eradication therapy.
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Affiliation(s)
- Bashar J Qumseya
- Division of Gastroenterology and Hepatology, Archbold Medical Group/Florida State University, Thomasville, Georgia.
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Madhav Desai
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Kansas
| | - Amira Qumseya
- Department of Biostatistics, Florida State University, Tallahassee, Florida
| | - Paul Bain
- Harvard School of Public Health, Boston, Massachusetts
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Kansas
| | - Herbert Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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Cameron GR, Desmond PV, Jayasekera CS, Amico F, Williams R, Macrae FA, Taylor ACF. Recurrent intestinal metaplasia at the gastroesophageal junction following endoscopic eradication of dysplastic Barrett's esophagus may not be benign. Endosc Int Open 2016; 4:E849-58. [PMID: 27540572 PMCID: PMC4988840 DOI: 10.1055/s-0042-109608] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 05/23/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Radiofrequency ablation (RFA) combined with endoscopic mucosal resection (EMR) is effective for eradicating dysplastic Barrett's esophagus. The durability of response is reported to be variable. We aimed to determine the effectiveness and durability of RFA with or without EMR for patients with dysplastic Barrett's esophagus. PATIENTS AND METHODS Patients with dysplastic Barrett's esophagus referred to two academic hospitals were assessed with high definition white-light endoscopy, narrow-band imaging, and Seattle protocol biopsies. EMR was performed in visible lesions. RFA was performed at 3-month intervals until complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM) was achieved. RESULTS In total, 137 patients received RFA (78 with EMR); 75 with over 12 months follow-up since commencing RFA. Pretreatment histology was intramucosal cancer (IMC) 21 %, high grade dysplasia (HGD) 54 %, low grade dysplasia (LGD) 25 %. CR-D rates were 88 %, 92 %, and 100 % at 1, 2, and 3 years; CR-IM rates were 69 %, 74 %, and 81 %. Kaplan-Meier analysis showed increasing probability of achieving CR-D/CR-IM over time. Of 26 patients maintaining CR-IM for > 12 months, five relapsed with intestinal metaplasia (19 %), and three with dysplasia (12 %). Recurrences occurred in patients with prior HGD/IMC, predominantly at the gastroesophageal junction (GEJ). None relapsed with cancer. Adverse events occurred in 4 % of RFA and 6.5 % of EMR procedures. CONCLUSIONS RFA combined with EMR is effective in achieving CR-D/CR-IM in the majority of patients with dysplastic Barrett's esophagus, with an incremental response over time. While durable in the majority, recurrent intestinal metaplasia and dysplasia, frequently occurring at the GEJ, suggest long-term surveillance is warranted in high risk groups.
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Affiliation(s)
- Georgina R. Cameron
- St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia,Corresponding author Georgina R. Cameron, MBBS (Hons) BMus (Hons) St Vincent’s Hospital Melbourne – GastroenterologyLevel 4Daly Wing41 Victoria ParadeFitzroyMelbourneVictoria 3065Australia+61-3-92883590
| | - Paul V. Desmond
- St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Chatura S. Jayasekera
- St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia,The Royal Melbourne Hospital, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Francesco Amico
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Richard Williams
- St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Finlay A. Macrae
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew C. F. Taylor
- St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
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Schölvinck DW, Bergman JJGHM, Visser M, Weusten BLAM. Circumferential cryoablation in a strictured esophagus: a feasibility and dose-finding study in a porcine model after inducing stenosis by endoscopic mucosal resection. Dis Esophagus 2016; 29:528-36. [PMID: 26315973 DOI: 10.1111/dote.12379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the treatment of early esophageal Barrett's neoplasia, radiofrequency ablation may be hindered by stenosis due to prior endoscopic resection (ER). The flexible balloon-based circumferential CryoBalloon Ablation System (CBAS) may overcome this problem by the conformability of the compliant balloon which might enable circumferential cryoablation in a stenosis. The aim of the current study was to evaluate the feasibility of the CBAS as well as the dose-response effect of cryoablation in a strictured esophagus model. In six pigs, a stenosis was induced by ER (3 cm in length, 75% of circumference) in the proximal, mid, and distal esophagus. After 28 days, cryoablation with the CBAS was performed, with the length of ablation time (6, 8, or 10 seconds) randomly assigned per stricture location within the esophagus. Four days post-ablation, the esophagi were harvested for histopathological assessment of the percentage of the total circumference affected by cryoablation and the maximum depth of necrosis. At 28 days, all 18 ER areas had transformed into strictures with ±50% of its original diameter remaining. In 9 of 18 strictures, more than one attempt for cryoablation was necessary due to displacement of the balloon. Histopathological evaluation showed a wide range in circumferential uniformity (0-100%) and maximum necrosis depth (epithelium to external proper muscle layer) of cryoablation, both independent of ablation times. Deepest ablation effects were seen at the center of the resection-induced scar. This first generation CryoBalloon Focal Ablation System was not feasible for ablation within severe stenoses, since it results in inconsistent circumferential uniformity of cryoablation with subsequent differences in depth of ablation. Further research with a next generation CBAS in a more realistic stricture model is warranted.
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Affiliation(s)
- D W Schölvinck
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - J J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - M Visser
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - B L A M Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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