Recurrent disease following endoscopic ablation of Barrett’s high-grade dysplasia with spray cryotherapy

Background and aims: Recurrent disease after endoscopic ablation of Barrett’s esophagus should be detected early to prevent malignant progression. We assessed the incidence and patterns of disease recurrence in patients after liquid nitrogen spray cryotherapy ablation of Barrett‘s esophagus with high grade dysplasia (HGD), including the area below the neosquamocolumnar junction (NSCJ).

Patients and methods: This is a single-center, retrospective study of prospectively collected data on consecutive cases of endoscopic ablation with liquid nitrogen spray cryotherapy for Barrett’s HGD. Post-treatment surveillance biopsies were obtained of suspicious lesions and in 4 quadrants every 1 cm in the treated esophagus and just below the NSCJ. Primary outcome measures were location and histology of recurrent disease.

Results: 36 patients (median age 62 years, 92% men) were enrolled, and 11 (30%) developed recurrent disease in a median of 6.5 months; three developed a second recurrence. Ten recurrences (71%) were identified below the NSCJ in 9 patients, including HGD (4), low grade dysplasia (LGD) (2), and intestinal metaplasia (4). Six recurrences were identified in the treated esophagus in five patients, including intramucosal cancer (1), HGD (1), and intestinal metaplasia (4). Two patients had recurrent disease involving both locations. Ultimately 33 patients (92%) achieved a complete response. Diagnosis in the remaining three was LGD (1) and intestinal metaplasia (2).

Conclusion: Most patients with recurrent intestinal metaplasia with or without dysplasia after ablation achieve a complete response. Recurrent disease commonly involves the area just below the NSCJ. Surveillance endoscopies should include this area to accurately identify patients with disease recurrence.

• References

• 1 Shaheen NJ, Crosby MA, Bozymski EM, Sandler RS. Is there publication bias in the reporting of cancer risk in Barrett’s esophagus?. Gastroenterology 2000; 119: 333-338
• 2 Wani S, Puli SR, Shaheen NJ et al Esophageal adenocarcinoma in Barrett’s esophagus after endoscopic ablative therapy: A meta-analysis and systematic review. Am J Gastroenterol 2009; 104: 502-513
• 3 Overholt BF, Wang KK, Burdick JS et al Five-year efficacy and safety of photodynamic therapy with photofrin in Barrett’s high-grade dysplasia. Gastrointest Endosc 2007; 66: 460-468
• 4 Shaheen NJ, Sharma P, Overholt BF et al Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med 2009; 360: 2277-2288
• 5 Shaheen NJ, Greenwald BD, Peery AF et al Safety and efficacy of endoscopic spray cryotherapy for Barrett’s esophagus with high-grade dysplasia. Gastrointest Endosc 2010; 71: 680-685
• 6 Badreddine RJ, Prasad GA, Wang KK et al Prevalence and predictors of recurrent neoplasia after ablation of Barrett’s esophagus. Gastrointest Endosc 2010; 71: 697-703
• 7 Wolf C, Seldenrijk CA, Timmer R et al Epidemiological, clinical, and histological characteristics of intestinal metaplasia at the oesophagogastric junction compared to short segments of columnar-lined oesophagus. Eur J Gastroenterol Hepatol 2001; 13: 113-120
• 8 Ruol A, Parenti A, Zaninotto G et al Intestinal metaplasia is the probable common precursor of adenocarcinoma in Barrett esophagus and adenocarcinoma of the gastric cardia. Cancer 2000; 88: 2520-2528
• 9 Chandrasoma P. Controversies of the cardiac mucosa and Barrett’s oesophagus. Histopathology 2005; 46: 361-373
• 10 el-Zimaity HM, Verghese VJ, Ramchatesingh J, Graham DY. The gastric cardia in gastro-oesophageal disease. J Clin Pathol 2000; 53: 619-625
• 11 Liu GS, Gong J, Cheng P et al Distinction between short-segment Barrett’s esophageal and cardiac intestinal metaplasia. World J Gastroenterol 2005; 11: 6360-6365
• 12 Odze RD. Unraveling the mystery of the gastroesophageal junction: A pathologist’s perspective. Am J Gastroenterol 2005; 100: 1853-1867
• 13 Weston AP, Sharma P, Banerjee S et al Visible endoscopic and histologic changes in the cardia, before and after complete Barrett’s esophagus ablation. Gastrointest Endosc 2005; 61: 515-521
• 14 Pouw RE, Gondrie JJ, Sondermeijer CM et al Eradication of Barrett esophagus with early neoplasia by radiofrequency ablation, with or without endoscopic resection. J Gastrointest Surg 2008; 12: 1627-1636 discussion 1636–1637
• 15 Pouw R, Wirths K, Eisendrath P et al Efficacy of radiofrequency ablation combined with endoscopic resection for Barrett’s esophagus with early neoplasia. Clin Gastro Hep 2010; 8: 23-29
• 16 Dumot JA, Vargo 2nd JJ, Falk GW et al An open-label, prospective trial of cryospray ablation for Barrett’s esophagus high-grade dysplasia and early esophageal cancer in high-risk patients. Gastrointest Endosc 2009; 70: 635-644
• 17 Vaccaro BJ, Gonzalez S, Poneros PD et al Detection of intestinal metaplasia afer successful eradication of Barrett's esophagus with radiofrequency ablation. Dig Dis Sci 2011; 56: 1996-2000 [Epub ahead of print]
• 18 Inadomi JM, Somsouk M, Madanick RD et al A cost-utility analysis of ablative therapy for Barrett’s esophagus. Gastroenterology 2009; 136: 2101-2114 .e1–6