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Endoscopic Treatment of Barrett’s Esophagus and Early Esophageal Cancer
CTOP Retreat 2014
Dartmouth-Hitchcock Medical Center
Overall incidence trend in esophageal adenocarcinoma (1973-2006).
Pohl H et al. Cancer Epidemiol Biomarkers Prev 2010;19:1468-1470
©2010 by American Association for Cancer Research
Incidence of Esophageal Adenocarcinoma
0
1
2
3
4
5
6
7
8
1975 1980 1985 1990 1995 2000
year of diagnosis
Rel
ativ
e ch
ange
Esophageal Adenocarcinoma
Lung AC
Prostate Cancer
Breast Cancer
Melanoma
Pohl, Welch, JNCI 2005
Why are we talking about Barrett’s esophagus?
Barrett’s Esophagus
Esophageal Adenocarcinoma
• Non-dysplastic
• Low-grade dysplasia
• High Grade Dysplasia
0.25% per year
?
4-8% per year
Cancer Risk for Barrett’s:
• Endoscopic Mucosal Resection (EMR)
• Radiofrequency Ablation• Cryoablation• Photodynamic Therapy• Other thermal (APC, Bicap)• Surgery
Treatment Options for EAC
73 year old man referred for management of 12 cm of Barrett’s associated with HGD and IMC in a nodule:
EMREMR
• Pathology showed IMC/HGD (no invasive component). HGD at lateral margin.
• How effective is EMR for mucosal adenocarcinoma?
• How would you manage his residual Barrett’s?
Pathology showed IMC/HGD (no invasive component). HGD at lateral margin.
Barrx RFA
• CE-IM 78%• CE-D 91%• Recurrent IM 13%• Progression to cancer
- during treatment 0.2%
- after CE-IM 0.7%• Esophageal Stricture 3%
Barrett’s
HGD/IMC LGD/ND
Staging EUS
Invasive Non-invasive
Esophagectomy Nodular Flat
EMR 6-8 weeks prior to RFA
RFA treatment protocol
2-3 mo follow-upRepeat biopsies
Visible disease
Normal appearing mucosa
Dysplasia or IMon biopsy
CR-D, CR-IM
PRE-TREATMENT PHASE
RFA TREATMENT PHASE
HGD/IMC LGD ND
Endoscopy every 3 mo
Endoscopy every 6 mo
Endoscopy every 9-12 mo
FOLLOW-UP PHASE
Recurrence
EMR, Duette®RFA: Halo 360 BÂRRX®
RFA: Halo 90 BÂRRX®
Narrow Band Imaging
Pathology
Complete Response (CR): eradication of intestinal metaplasia (CR-IM) and/or dysplasia (CR-D) in all biopsies
Recurrence: Presence of intestinal metaplasia or dysplasia in any biopsy
Treatment failure: poor mucosal healing and inability to eradication or downgrade dysplasia after 3 sessions
Treatment Algorithm
Spray Cryotherapy
2 published studies:-CE-HGD 97-100%-CE-IM 57-84%-strictures 9%
GIE 2010GIE 2013
2/11
3/14
Questions?