In the Journals

Stepwise radical endoscopic resection shows long-term benefits in early Barrett’s neoplasia

Patients who underwent successful stepwise radical endoscopic resection for Barrett’s esophagus with early neoplasia showed durable benefits through 6 years of follow-up, according to new research published in Gastrointestinal Endoscopy.

“Stepwise radical endoscopic resection [SRER] is a technique where the entire Barrett’s segment is removed by endoscopic resection during subsequent sessions, providing tissue samples for optimal histopathological diagnosis,” Kamar Belghazi, MD, of the department of gastroenterology and hepatology at the Academic Center in Amsterdam, the Netherlands, said in an accompanying video interview. “Previous studies have shown that [SRER] is highly effective in eradicating Barrett’s esophagus and its associated dysplasia. Complete eradication of neoplasia is achieved in 83% to 100% of cases and complete eradication of all intestinal metaplasia in 80% to 92% of patients.”

However, a high rate of stricture formation (in up to 88% of patients) is “a major drawback of this approach,” Belghazi and colleagues noted in the study manuscript.

Because most studies on SRER report only short-term outcomes, Belghazi and colleagues evaluated the long-term durability of successful SRER in 73 patients (64 men; mean age, 66 years; median follow-up, 76 months; BE 5 cm with early neoplasia).

They reported that cancer recurred in just one patient after 129 months (which was treated with curative surgery) for an annual incidence of 0.22% per patient-year of follow-up for recurrence of high grade dysplasia or cancer.

Additionally, dysplasia recurred in four patients — for an annual incidence of 0.87% per patient-year of follow-up — and endoscopically visible Barrett’s esophagus recurred in 12 patients after a median of 22 months, for an annual incidence of 2.6% per patient-year of follow-up.

Esophageal strictures developed in 41 (56%) patients.

In terms of secondary outcomes, investigators identified focal buried Barrett’s glands in five patients, for an annual incidence of 1.1% per patient-year. They also identified intestinal metaplasia in normal-appearing neoplasia-squamous columnar junction (neo-SCJ) biopsies in 27 patients, for an annual incidence of 5.9% per patient-year, but these findings were not reproduced during further follow-up in 56% of these patients. Nine patients required retreatment during follow-up.

Finally, 97% of all patients showed no neoplasia and 95% showed sustained complete eradication of all Barrett’s mucosa (excluding intestinal metaplasia in a normal-appearing neo-SCJ).

SRER “for Barrett’s esophagus smaller than 5 cm with early neoplasia results in excellent long-term efficacy with a very low recurrence rate of neoplasia,” Belghazi concluded in the video interview. “However, because of the high associated stenosis risk, [SRER] is nowadays not the treatment of choice, but it may be considered in ... selected cases,” such as patients with extensive physical abnormalities in a short Barrett’s segment, those with a poor response to radiofrequency ablation (RFA), and those being treated at centers where RFA treatment is not available, she added.

This study highlights both the promise and challenges of SRER, Vani J. A. Konda, MD, and Stuart J. Spechler, MD, both of the Center for Esophageal Diseases at Baylor University Medical Center and Baylor Scott and White Research Institute in Dallas, Texas, wrote in a related editorial.

“This report clearly demonstrates that SRER is an effective and durable treatment for high-grade dysplasia and early cancer, providing further support for societal recommendations that endoscopic eradication therapy is the treatment of choice for mucosal neoplasia in BE,” they wrote. “However, the report also documents the challenges in endoscopic eradication by SRER, because recurrences of metaplasia, dysplasia, and cancer can occur years after apparently successful SRER. In addition, the report confirms that there is a very high rate of esophageal stricture formation associated with SRER (56% in this study).”

The study can also “serve as a model for the kind of long-term data needed to establish meaningful, evidence-based surveillance guidelines for patients who have had endoscopic eradication therapy,” they added. – by Adam Leitenberger

 

Disclosures: Belghazi reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures. Spechler reports he has served as a consultant for Takeda and Ironwood. Konda reports no relevant financial disclosures.

Patients who underwent successful stepwise radical endoscopic resection for Barrett’s esophagus with early neoplasia showed durable benefits through 6 years of follow-up, according to new research published in Gastrointestinal Endoscopy.

“Stepwise radical endoscopic resection [SRER] is a technique where the entire Barrett’s segment is removed by endoscopic resection during subsequent sessions, providing tissue samples for optimal histopathological diagnosis,” Kamar Belghazi, MD, of the department of gastroenterology and hepatology at the Academic Center in Amsterdam, the Netherlands, said in an accompanying video interview. “Previous studies have shown that [SRER] is highly effective in eradicating Barrett’s esophagus and its associated dysplasia. Complete eradication of neoplasia is achieved in 83% to 100% of cases and complete eradication of all intestinal metaplasia in 80% to 92% of patients.”

However, a high rate of stricture formation (in up to 88% of patients) is “a major drawback of this approach,” Belghazi and colleagues noted in the study manuscript.

Because most studies on SRER report only short-term outcomes, Belghazi and colleagues evaluated the long-term durability of successful SRER in 73 patients (64 men; mean age, 66 years; median follow-up, 76 months; BE 5 cm with early neoplasia).

They reported that cancer recurred in just one patient after 129 months (which was treated with curative surgery) for an annual incidence of 0.22% per patient-year of follow-up for recurrence of high grade dysplasia or cancer.

Additionally, dysplasia recurred in four patients — for an annual incidence of 0.87% per patient-year of follow-up — and endoscopically visible Barrett’s esophagus recurred in 12 patients after a median of 22 months, for an annual incidence of 2.6% per patient-year of follow-up.

Esophageal strictures developed in 41 (56%) patients.

In terms of secondary outcomes, investigators identified focal buried Barrett’s glands in five patients, for an annual incidence of 1.1% per patient-year. They also identified intestinal metaplasia in normal-appearing neoplasia-squamous columnar junction (neo-SCJ) biopsies in 27 patients, for an annual incidence of 5.9% per patient-year, but these findings were not reproduced during further follow-up in 56% of these patients. Nine patients required retreatment during follow-up.

Finally, 97% of all patients showed no neoplasia and 95% showed sustained complete eradication of all Barrett’s mucosa (excluding intestinal metaplasia in a normal-appearing neo-SCJ).

SRER “for Barrett’s esophagus smaller than 5 cm with early neoplasia results in excellent long-term efficacy with a very low recurrence rate of neoplasia,” Belghazi concluded in the video interview. “However, because of the high associated stenosis risk, [SRER] is nowadays not the treatment of choice, but it may be considered in ... selected cases,” such as patients with extensive physical abnormalities in a short Barrett’s segment, those with a poor response to radiofrequency ablation (RFA), and those being treated at centers where RFA treatment is not available, she added.

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This study highlights both the promise and challenges of SRER, Vani J. A. Konda, MD, and Stuart J. Spechler, MD, both of the Center for Esophageal Diseases at Baylor University Medical Center and Baylor Scott and White Research Institute in Dallas, Texas, wrote in a related editorial.

“This report clearly demonstrates that SRER is an effective and durable treatment for high-grade dysplasia and early cancer, providing further support for societal recommendations that endoscopic eradication therapy is the treatment of choice for mucosal neoplasia in BE,” they wrote. “However, the report also documents the challenges in endoscopic eradication by SRER, because recurrences of metaplasia, dysplasia, and cancer can occur years after apparently successful SRER. In addition, the report confirms that there is a very high rate of esophageal stricture formation associated with SRER (56% in this study).”

The study can also “serve as a model for the kind of long-term data needed to establish meaningful, evidence-based surveillance guidelines for patients who have had endoscopic eradication therapy,” they added. – by Adam Leitenberger

 

Disclosures: Belghazi reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures. Spechler reports he has served as a consultant for Takeda and Ironwood. Konda reports no relevant financial disclosures.