Hybrid Therapy with EMR and RFA Throughout Treatment Sessions for Barrettʼs Neoplasia

Abstract

Purpose: Patients with high grade dysplasia (HGD) and intramucosal carcinoma (IMC) in the setting of Barrett's esophagus (BE) may undergo a combination of modalities to achieve total Barrett's eradication (TBE). Initial EMR of any visible lesions followed by a radiofrequency ablation (RFA) in repeated sessions is emerging as a method to achieve TBE. Our aim is to report our initial experience with a combined approach of EMR and RFA to treat both initial and follow up lesions in the management of HGD and IMC in BE. Methods: Patients referred to our institution for the treatment of BE with HGD and IMC were enrolled in a protocol for treating long segment BE with EMR of any suspicious abnormalities in initial or follow up visits and ablation of remaining epithelium with RFA. Detailed white light exams and exams with narrow band imaging and acetic acid were performed to look for suspicious abnormalities. Follow-up sessions were performed at 3-6 month intervals. Results: Sixteen patients entered the hybrid protocol between February 2007 and May 2009 (mean age 66.9 y; 3 F: 13 M). The average length of BE was 7.8 cm. Ten patients had visible lesions. Two patients were referred with a biopsy diagnosis of IMC, and the rest had HGD. A total of 61 treatment sessions were performed with 40 EMR sessions, 20 circumferential RFA sessions, and 21 focal RFA applications. 16 sessions employed a combination of EMR and RFA. An average of 7 EMRs were performed per patient with total of 111 EMR specimens. The 2 patients with IMC had only HGD on their first EMR, whereas 3 patients with a pretreatment diagnosis of HGD were upstaged to IMC after initial EMR. Thirty-five EMR sessions were performed after an RFA session to diagnose and treat the residual BE, and 16 of these yielded pathology of HGD. Eradication of dysplasia has been achieved in 4 patients, 3 of whom also have eradication of BE. The remaining patients were still undergoing treatment sessions. Six patients have experience esophageal stenoses, managed with endoscopic dilations (median 1.5). One patient required multiple dilations and steroid injection. Conclusion: The accurate histopathologic diagnosis and deliberate treatment of neoplasia in BE may require a combination of EMR and RFA not only at the initial sessions, but also in the treatment of follow-up sessions. The most effective way to manage residual areas of neoplasia needs to be addressed.