Endoscopic Resection Without Subsequent Ablation Therapy for Early Barrett’s Neoplasia: Endoscopic Findings and Long-Term Mortality

Sanne N Van Munster ,A Alkhalaf,P.j.f De Jonge ,Bas L Weusten ,Jacques Bergman ,Martin H Houben ,Esther Nieuwenhuis ,Thjon J Tang ,Jessie Westerhof ,Lorenza Alvarez Herrero ,Auke Bogte ,Wb Nagengast ,Arjun D Koch ,B.e Schenk ,Erik J Schoon ,Frans Peters ,Steffi Elisabeth Maria Van De Ven ,Wouter L Curvers ,Roos E Pouw

doi:10.1007/s11605-020-04836-8

Abstract

IntroductionAfter endoscopic resection (ER) of neoplasia in Barrett’s esophagus (BE), it is recommended to ablate the remaining BE to minimize the risk for metachronous disease. However, we report long-term outcomes for a nationwide cohort of all patients who did not undergo ablation of the remaining BE after ER for early BE neoplasia, due to clinical reasons or performance status. MethodsEndoscopic therapy for BE neoplasia in the Netherlands is centralized in 8 expert centers with specifically trained endoscopists and pathologists. Uniformity is ensured by a joint protocol and regular group meetings. We report all patients who underwent ER for a neoplastic lesion between 2008 and 2018, without further ablation therapy. Outcomes include progression during endoscopic FU and all-cause mortality. ResultsNinety-four patients were included with mean age 74 (± 10) years. ER was performed for low-grade dysplasia (LGD) (10%), high-grade dysplasia (HGD) (25%), or low-risk esophageal adenocarcinoma (EAC) (65%). No additional ablation was performed for several reasons; in 73 patients (78%), the main argument was expected limited life expectancy. Median C2M5 BE persisted after ER, and during median 21 months (IQR 11–51) with 4 endoscopies per patient, no patient progressed to advanced cancer. Seventeen patients (18%) developed HGD/EAC: all were curatively treated endoscopically. In total, 29/73 patients (40%) with expected limited life expectancy died due to unrelated causes during FU, none of EAC. ConclusionIn selected patients, ER monotherapy with endoscopic surveillance of the residual BE is a valid alternative to eradication therapy with ablation.

Highlights

After endoscopic resection (ER) of neoplasia in Barrett’s esophagus (BE), it is recommended to ablate the remaining BE to minimize the risk for metachronous disease
Between 2008 and 2018, a total of 1962 patients with early BE neoplasia were referred to a Barrett Expert Centers (BECs)
After ER for low-grade dysplasia (LGD), high-grade dysplasia (HGD), or LR-esophageal adenocarcinoma (EAC) (n = 1140), a flat BE segment remained in 1034 patients

Summary

Introduction

After endoscopic resection (ER) of neoplasia in Barrett’s esophagus (BE), it is recommended to ablate the remaining BE to minimize the risk for metachronous disease. The first step in endoscopic treatment for BE-related neoplasia is removal of all visible lesions with endoscopic resection (ER) techniques, which serves both diagnostic and therapeutic purposes. It has been reported that the remaining flat BE that persists after ER of a neoplastic lesion has a risk of developing metachronous HGD/EAC between 15 and 30% in 3–5 years 1–3. Based on these data, most international guidelines advise additional ablation therapy after ER to eradicate the entire BE segment 4–7. Given the large amount of high-quality data supporting radiofrequency ablation (RFA), this is recommended as first-choice ablation technique 4, 8–10

Methods

Results

Conclusion