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?