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Barrett’s esophagus recurrence common after RFA, endoscopic mucosal resection
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Patients with Barrett’s esophagus following treatment with radiofrequency ablation experienced frequent but manageable disease recurrence within 2 years of remission in a recent study.
Researchers evaluated data from 448 adult patients with Barrett’s esophagus (BE) who received radiofrequency ablation (RFA) between 2003 and 2011 at three medical facilities. Seventy-one percent of the cohort had esophageal adenocarcinoma or high-grade dysplasia, with low-grade dysplasia observed in 15% and nondysplastic BE in the remaining 14% before RFA. Participants received RFA at 2- to 3-month intervals until achieving histologic and endoscopic remission. Fifty-five percent of participants also received endoscopic mucosal resection (EMR) before RFA.
Complete remission of intestinal metaplasia (CRIM) occurred in 51% of the entire cohort, with 56% of these patients achieving CRIM within 2 years and 71% within 3 years (median 22 months). Shorter BE length (HR=0.92; 95% CI, 0.87-0.97 per cm) and younger age (HR=0.98; 95% CI, 0.97-0.99 per year) were significantly associated with a shorter time to CRIM, while EMR or other treatment before RFA was not.
Recurrence occurred in 20% of patients within 1 year and 33% of patients within 2 years of CRIM. Intestinal metaplasia without dysplasia was the most common form (78%), with 11% developing high-grade dysplasia, 8% low-grade dysplasia and 3% cancer. No significant associations were observed between BE recurrence and any evaluated endoscopic or demographic factors.
Adverse events occurred in 39 cases, including strictures in 27 patients. Other common events were bleeding (eight cases) and mucosal tears and hospitalization due to dysrhythmia (two cases each). Increased risk for complication was associated with a longer BE segment (OR=1.1; 95% CI, 1.01-1.21), and investigators noted a trend toward increased risk with pre-RFA EMR use (P=.06).
“RFA is likely the leading modality for the treatment of neoplasia in BE,” researcher Prasad G. Iyer, MD, gastroenterology and hepatology division of the Mayo Clinic in Rochester, Minn., told Healio.com. “Though RFA is successful in eradicating neoplasia in patients with BE, there is a possibility of recurrence. Careful surveillance following RFA is important to detect recurrences which can be dysplastic.”
Perspective
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Prateek Sharma, MD
In recent years, there has been a paradigm shift in the management of patients with high-grade dysplasia and/or early adenocarinoma in Barrett's esophagus. The majority of these patients are now treated with endosopic therapy rather than esophagectomy. With this increasing use of endoscopic therapy, it is critical to examine long term results after therapy.
In this important paper by Gupta et al, the impact of RFA therapy in patients with Barrett's esophagus was examined. At the end of 2 years, the investigators determined that only 56% of patients had complete eradication of Barrett's esophagus and a third of the patients had recurrence of the precancerous condition after initial response. These and other similar studies highlight the effectiveness results after RFA and the need for close monitoring of the patients after endoscopic therapy.
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