Treatment Of High-grade Intraepithelial Neoplasia Research Articles

Advances in Diagnosis and Treatment of High-Grade Intraepithelial Neoplasia in Colorectal Adenomas

Advances in Diagnosis and Treatment of High-Grade Intraepithelial Neoplasia in Colorectal Adenomas

More isn’t always better: Risk of recurrent high-grade squamous intraepithelial lesions after single-pass loop electrosurgical excision procedure (LEEP) versus LEEP with top hat (398)

<b>Objectives:</b> The preferred treatment for high-grade intraepithelial neoplasia (HSIL) is the excisional procedure. Single-pass LEEP (LEEP- SP) and LEEP with a top hat (LEEP-TH) are commonly used excisional procedures. There is limited evidence to show the superiority of one surgical technique to another in terms of treatment failure. The objective of this study was to determine the risk of recurrent HSIL at two years after LEEP-SP versus LEEP-TH. <b>Methods:</b> Following IRB approval, this single-institution retrospective cohort study included all patients undergoing LEEP-SP or LEEP-TH for HSIL between 2005 and 2019. Patient demographics and risk factors for cervical neoplasia were collected along with preoperative cytology and colposcopy results. Follow-up cytology, colposcopy, and repeat surgical excision data were collected over a two-year follow-up period. Qualitative and quantitative analyses of the two patient cohorts were performed using descriptive statistics, Chi-squared or Fischer's exact for categorical variables, and Mann- Whitney U test for continuous variables using IBM SPSS Statistics (version 28.0.0.0). <b>Results:</b> A total of 340 patients met the inclusion criteria; 178 patients underwent a LEEP-SP, and 162 patients underwent a LEEP- TH. Patients undergoing LEEP-TH were more likely to be older (mean age: 40.40 +/- 10.13 years vs 36.49 +/- 10.45 years; p < 0.001), and have had a positive pre-procedure endocervical sampling ECS (68.5% vs 11.8%; p < 0.001). HSIL histology was found in 126 patients undergoing LEEP-SP (70.7%) and in 125 patients who underwent LEEP-TH (74.4%; p=0.182). Positive margins were found in 23 patients who underwent LEEP-SP (12.9%) and 25 who underwent LEEP-TH (15.4%; p=0.507). There was no significant difference in depth of excision between LEEP-SP and LEEP-TH (13.21+/- 23.19 mm vs 17.37 +/- 28.26 mm; p=0.138). In eight (4.9%) patients undergoing LEEP-TH, the initial pathology of the first pass specimen was benign, and only the top hat had HSIL. Only two (25%) of those patients also had a positive ECS. At two years follow-up, there was no difference in the rates of HSIL cytology (7 patients [5.2%] vs 8 [6.3%]), any positive HPV test or HSIL cytology (27 patients [25%] vs 19 [15%]), or repeat excision (11 patients [8.9%] vs 16 [12.4%]) between LEEP-SP and LEEP-TH. Repeat excision was performed in 27 patients, who were more likely to be older (mean age: 42.26 +/- 10.75 years vs 36.77 +/- 10.36 years; p=0.016) and have initial cytology HSIL (63.0% vs 33.3%; p=0.003), compared to patients who did not undergo repeat excision. <b>Conclusions:</b> In this single-institution study, there is no difference in the rate of recurrent HSIL or repeat excision in patients who undergo LEEP-SP compared with LEEP-TH. Additionally, there appears to be no difference in the rate of positive margins or positive ECS at the time of excision between the two groups. This suggests that a LEEP-TH may have limited additional benefit over a single pass LEEP in the treatment of cervical HSIL.

Clinical effectiveness and cost-effectiveness of quadrivalent human papillomavirus vaccination in HIV-negative men who have sex with men to prevent recurrent high-grade anal intraepithelial neoplasia

We examined the long-term clinical and economic benefits of quadrivalent human papillomavirus (qHPV) vaccine as a secondary/adjunct prevention strategy in the prevention of recurrent high-grade intraepithelial neoplasia (HGAIN) in HIV-negative men who have sex with men (MSM) and are 27 years or older. We constructed a Markov model to evaluate the clinical effectiveness and cost-effectiveness of two strategies: (1) no qHPV vaccine after treatment for HGAIN versus (2) qHPV vaccine after treatment for HGAIN. Model parameters, including natural history of anal cancer, vaccine efficacy measured in terms of hazard ratio (HR) (decrease in the risk of recurrent HGAIN), HGAIN treatment efficacy, utilities, and costs, were obtained from the literature. The outcomes were measured in terms of lifetime risk of anal cancer, lifetime cost, quality-adjusted life years, and incremental cost-effectiveness ratios (ICERs). Sensitivity analysis was conducted on all model parameters. We found that vaccinating HIV-negative MSM reduced the lifetime risk of anal cancer by 60.77% at an ICER of US$87,240 per quality-adjusted life-year. The results were highly sensitive to vaccine efficacy, transition of HGAIN to anal cancer, cost of treatment for HGAIN, vaccine degree of protection over time, and the vaccine duration of protection and less sensitive to HPV clearance, cost of qHPV vaccine, and the transitions from normal to low-grade anal intraepithelial neoplasia (LGAIN) and normal to HGAIN. With an HR of 0.3, the ICER was well below a $50,000 willingness-to-pay threshold; with an HR of 0.5, the ICER was still below a threshold of $100,000. The most critical disease-related factor influencing the cost-effectiveness was the progression of HGAIN to anal cancer. At an annual transition probability below 0.001, the ICER was below $50,000. Vaccinating HIV-negative MSM treated for HGAIN decreases the lifetime risk of anal cancer and is likely to be a cost-effective intervention.

Cost-effectiveness of surveillance strategies after treatment for high-grade anal dysplasia in high-risk patients.

Anal cancer is one of the most common cancers affecting human immunodeficiency virus (HIV)-infected male patients. Currently, there is no consensus on posttreatment surveillance of HIV-infected men who have sex with men (MSM) who have been treated for high-grade intraepithelial neoplasia (HGAIN), the likely precursor to anal cancer. The aim of this study was to assess the cost-effectiveness of a range of strategies for anal cancer surveillance in HIV-infected MSM previously treated for HGAIN. We developed a Markov model to project quality-adjusted life expectancy, lifetime costs, and the incremental cost-effectiveness ratios of 5 strategies using high-resolution anoscopy (HRA) and/or anal cytology testing after treatment. Performing HRA alone at 6- and 12-month visits was associated with a cost-effectiveness ratio of $4446 per quality-adjusted life year gained. In comparison, combined HRA and anal cytology at both visits provided greater health benefit at a cost of $17,373 per quality-adjusted life year gained. Our results were robust over a number of scenarios and assumptions including patients' level of immunosuppression. Results were most sensitive to test characteristics and cost, as well as progression rates of normal to HGAIN and HGAIN to cancer. Our results suggest that combined HRA and anal cytology at 6 and 12 months may be a cost-effective surveillance strategy after treatment of HGAIN in HIV-infected MSM.

Randomized trial on endoscopic resection-cap versus multiband mucosectomy for piecemeal endoscopic resection of early Barrett's neoplasia

Endoscopic resection (ER) is an important treatment for high-grade intraepithelial neoplasia and early cancer in Barrett's esophagus. ER-cap requires submucosal lifting and positioning of a snare in the cap, making it technically demanding and laborious. Multiband mucosectomy (MBM) uses a modified variceal band ligator and requires no submucosal lifting or positioning of a snare. To compare ER-cap and MBM for piecemeal ER of early Barrett's neoplasia. Randomized, controlled trial. Tertiary-care and community-care centers. This study involved 84 patients (64 men; median age 70 years) undergoing piecemeal ER of Barrett's neoplasia. Piecemeal ER was performed by using ER-cap (n = 42) or MBM (n = 42). Safety, efficacy, procedure time, costs. Procedure time (34 vs 50 minutes; P = .02) and costs (€240 vs €322; P < .01) were significantly less with MBM compared with ER-cap. MBM resulted in smaller resection specimens than ER-cap (18 ×13 mm vs 20 × 15 mm; P < .01). Maximum thicknesses of specimens and resected submucosa were not significantly different. There were no clinically relevant bleeding episodes. Four perforations occurred, 3 with ER-cap, 1 with MBM (P = not significant). Potential bias because of different levels of experience among participating endoscopists. Piecemeal ER with MBM is faster and cheaper than with ER-cap. Despite the lack of submucosal lifting, MBM appears not to be associated with more perforations. Although MBM results in slightly smaller specimens, the clinical relevance of this may be limited because depth of resections does not differ between both techniques. MBM may thus be preferred for piecemeal ER of early Barrett's neoplasia. ( NTR1435.).

Endoscopic therapy of Barrettʼs esophagus

Endoscopic therapy for early neoplasia arising in Barrett's esophagus has gained wide acceptance in the USA and Europe, and long-term results of endoscopic resection and photodynamic therapy and new ablation techniques are available now. This review summarizes the different indications for endoscopic treatment and the recent data on the different endoscopic treatment techniques. Endoscopic treatment of high-grade intraepithelial neoplasia has proven to be well tolerated and effective even after a long-term follow-up of more than 5 years. Radiofrequency treatment seems to be an effective technique for ablation of Barrett's esophagus with low and high-grade intraepithelial neoplasia on short-term follow-up with a very low complication rate. Recent data were able to demonstrate that biomarkers can predict the treatment effect of photodynamic therapy and several risk factors for stricture formation after treatment could be identified. Endoscopic therapy of early Barrett's neoplasia has proven to be well tolerated and effective and can be considered as the treatment of choice for most patients with this disease. Visible lesions should be treated by endoscopic resection in order to obtain a specimen for histological work up. The remaining nondysplastic Barrett's epithelium after complete resection of all neoplastic lesions should be ablated, for example, by radiofrequency treatment, to prevent metachronous or recurrent neoplasia.

Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett’s oesophagus

Objective:Endoscopic therapy is increasingly being used in the treatment of high-grade intraepithelial neoplasia (HGIN) and mucosal adenocarcinoma (BC) in patients with Barrett’s oesophagus. This report provides 5 year follow-up data...

Barrett-Ösophagus mit hochgradiger intraepithelialer Neoplasie: Beobachtung, Ablation oder Resektion?

BACKGROUND: The treatment of high-grade intraepithelial neoplasia (HG-IN) within Barrett's oesophagus (BOe) is controversial. METHODS: Herein we highlight current data on HG-IN and evaluate adequacy of various treatment strategies (observation, ablation, resection). RESULTS: HG-IN within BOe has clearly (pre-)malignant character, is frequently multifocal and often already associated with synchronous invasive oesophageal (Barrett's) adenocarcinoma. Establishment of the diagnosis is challenging, due to substantial endoscopic 'sampling error' (even with new technologies like chromo- or magnification endoscopy) and 'intra-/interobserver variability' distinguishing different forms of intraepithelial neoplasia and early invasive carcinomas. Regarding the treatment of choice for this condition, there is plenty of evidence to suggest that an oncologically adequate approach should be chosen, including removal of the entire precancerous BOe and regional lymphadenectomy. CONCLUSIONS: Surgical resection is the 'treatment of choice' for BOe harbouring HG-IN. Limited resection of the oesophagogastric junction is superior to radical oesophagectomy, endoscopic mucosa resection, ablation or observational strategies.

Curative Treatment for High-Grade Intraepithelial Neoplasia in Barrett’s Esophagus

The incidence of premalignant and malignant lesions in specialized intestinal metaplasia of the esophagus has increased dramatically in the industrialized world in recent years. This report evaluates the efficacy and safety of local endoscopic therapy for high-grade intraepithelial neoplasia (HGIN) in Barrett's esophagus. Over a 5-year period between October 1996 and September 2001, a total of 379 patients were referred with a suspicion of early Barrett's cancer. In a prospective study, 44 patients with HGIN in Barrett's esophagus were selected for local endoscopic treatment. Endoscopic resection was carried out in 14 patients in whom the HGIN was re-detectable, and 27 patients in whom the HGIN was not re-detectable underwent photodynamic therapy (PDT). Endoscopic resection and PDT were combined in three patients. Complete remission was achieved in 43 of the 44 patients (97.7 %). No major complications occurred. A mean of 1 session was needed to achieve complete local remission. During a mean follow-up period of 36 months (range 7 - 61 months), recurrent or metachronous lesions were observed in six patients (17.1 %), all of whom received a second successful endoscopic treatment. Endoscopic therapy is a safe alternative treatment regimen for HGIN in Barrett's esophagus, providing a middle way between the widely promulgated options of a "watch-and-wait" policy and radical esophagectomy.