Revisiting Radio-Frequency Ablation for Recurrent High Grade Dysplasia in Barrettʼs Esophagus

Abstract

Introduction: Barrett's Esophagus (BE) is a pre-malignant condition for esophageal carcinoma, the incidence of which has increased by 500% over the past four decades. Various studies have shown that radio-frequency ablation (RFA) using BARRx ablation catheter is successful in the management of BE. We report successful use of RFA to completely eradicate recurrence of high-grade dysplasia (HGD) in a 68-year-old female with BE. Case: A 65-year-old female with history of BE for more than 10 years was found to be have high-grade dysplasia at one of her annual surveillance esophagogastroduodenoscopies (EGD). She underwent 4 RFA sessions using HALO360 and HALO90 over a period of 9 months. Surveillance EGDs with biopsies at 3, 8, and 24 months after the last RFA session were negative for any metaplasia or dysplasia in the esophagus. Next surveillance EGD, 40 months after last RFA session and 16 months after last surveillance EGD showed short segment BE. Pathology confirmed intestinal metaplasia and also showed high-grade dysplasia. She was offered surgical resection of the esophagus but she declined it and hence we continued with RFA. She received one more session of RFA using HALO90. Ultra and biopsy was repeated after 2 months which showed complete eradication of metaplasia and dysplasia. Discussion: RFA is a well-established treatment of choice for BE including HGD. Even after the metaplasia and/or dysplasia is ablated, the basic pathogenesis for the development of BE, which is the reflux from the stomach, continues. This implies that BE can reappear and hence continuous surveillance is necessary. In 2012 Titi et al and in 2013 Lee et al published case series with 3 and 4 patients respectively, mentioning the recurrence of the HGD and subsquamous neoplasia after successful ablation. All of those patients were treated with either endoscopic mucosal resection (EMR) or esophagectomy. Our patient had repeated RFA for this recurrence and is now free of both metaplasia and dysplasia. She did not develop any complications due to repeated RFA sessions, but she will need to have long-term follow up and surveillance EGDs with biopsies to look for any further recurrences. Conclusion: Continuous surveillance of BE is necessary even after complete elimination of metaplasia/dysplasia is achieved by using RFA. Our case report supports the use of RFA to treat recurrence of HGD in patients who are not candidates for endoscopic mucosal resection or further surgery. Further studies need to be conducted to compare the different treatment options in such cases