New studies provide insight into treatments for Barrett's esophagus

Oct 6 2017

The October issue of GIE: Gastrointestinal Endoscopy features several new studies evaluating various treatments for Barrett's esophagus (BE). Two of these studies are highlighted below.

BE is a condition in which there are unusual changes to the cells lining the esophagus. It is believed to be most commonly due to inflammation from gastroesophageal reflux disease (GERD). Some of the cellular changes may be referred to as neoplasia or dysplasia, and sometimes these may be considered precancerous. Endoscopic treatments for BE focus on removing or destroying the problematic tissue.

Largest U.S. Multicenter Study of ESD for Barrett's Early Neoplasia Shows the Procedure Is Safe and Effective

The role of endoscopic submucosal dissection (ESD) in Barrett's early neoplasia has not previously been well defined, with most studies originating from Asia and Europe. A new study, 'Endoscopic submucosal dissection for Barrett's early neoplasia; a multicenter study in the United States," published in the October issue of GIE: Gastrointestinal Endoscopy, shows the procedure is safe and effective for addressing cellular changes from Barrett's esophagus (BE), including high-grade dysplasia (HGD) and early adenocarcinoma (EAC).

The study was a multicenter retrospective analysis on 46 patients with BE who underwent ESD for BE-HGD or EAC, or both, between January 2010 and April 2015. The goal was to determine the rate of (1) removal of the problematic tissue in one piece (en-bloc resection), (2) completeness of removal (R0 resection), (3) curative resection; and to determine adverse events as well as remission at follow-up.

The median age of patients was 69 years (range, 42-82 years). The median resected specimen size was 45 mm (range, 13-125 mm). En-bloc and curative resection rates were 96 percent (44/46) and 70 percent (32/46), respectively. Most lesions (11/20; 55 percent) diagnosed as BE-HGD on biopsy were upstaged to intramucosal or invasive EAC on post-ESD analysis.

There were four early (<48 hours) adverse events, and all were treated endoscopically. Seven patients (15 percent) developed esophageal strictures that were managed endoscopically. Complete remission of BE neoplasia was found in 100% (32/32) of patients with curative resection at median follow-up of 11 months (range, 2-25 months).

The authors concluded that ESD appears to be safe and effective, with high en-bloc and curative resection rates in the treatment of early BE neoplasia.

Liquid Nitrogen Cryotherapy Shows Good Long-Term Results for Treating Barrett's Esophagus

Liquid nitrogen spray cryotherapy (LNSCT) has been shown to be a safe, well-tolerated, and effective therapy for cellular changes occurring with Barrett's esophagus (BE). A new study, "Outcomes after liquid nitrogen spray cryotherapy in Barrett's esophagus-associated high-grade dysplasia and intramucosal adenocarcinoma: 5-year follow-up," provided previously lacking follow-up to determine long-term efficacy of the treatment. The study appears in the October issue of GIE: Gastrointestinal Endoscopy.

LNSCT uses liquid nitrogen to "freeze" and destroy diseased tissue. The study looked at treatment of BE-associated high-grade dysplasia (BE-HGD) and intramucosal (within the esophageal lining) adenocarcinoma (IMC).

In this single-center, retrospective study, patients with BE-HGD/IMC of any length treated with LNSCT were followed with surveillance endoscopy with biopsy for three to five years. Patients with IMC completely removed by endoscopic resection were included. Outcome measures included complete eradication of HGD (CE-HGD), dysplasia, and intestinal metaplasia; incidence rates; durability of response; location of recurrent intestinal metaplasia and dysplasia; and rate of disease progression.

There were 50 patients in the three-year analysis, and 40 patients in the five-year analysis. Initial complete eradication of HGD, dysplasia, and intestinal metaplasia was achieved in 98 percent, 90 percent, and 60 percent, respectively. At the three-year follow-up, these measures were 96 percent (48/50), 94 percent (47/50), and 82 percent (41/50). At five years, they were 93 percent (37/40), 88 percent (35/40), and 75 percent (30/40). These results allow for retreatment or interval touch-up with ablation during the follow-up period.

Incidence rates of recurrent intestinal metaplasia, dysplasia, and HGD/esophageal adenocarcinoma after initial complete eradication of intestinal metaplasia (CE-IM) were 12.2%, 4.0%, and 1.4% per person-year for the 5-year cohort. Two of seven HGD recurrences occurred later than four years after initial eradication, and two patients (4 percent) progressed to adenocarcinoma despite treatment.

The authors concluded that, in patients with BE-HGD/IMC, LNSCT is effective in eliminating dysplasia and intestinal metaplasia. Progression to adenocarcinoma was uncommon, and recurrence of dysplasia was successfully treated in most cases. Long-term surveillance is necessary to detect late recurrence of dysplasia.