Gastroenterology Grand Rounds October 31, 2013 Fellow: David Tang, M.D. Faculty: Clark Hair, M.D.
Gastroenterology Grand Rounds February 20, 2014 Fellow: David Tang, M.D. Faculty: Marcelo Vela, M.D.
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Transcript of Gastroenterology Grand Rounds February 20, 2014 Fellow: David Tang, M.D. Faculty: Marcelo Vela, M.D.
Gastroenterology Grand Rounds
February 20, 2014Fellow: David Tang, M.D.
Faculty: Marcelo Vela, M.D.
Case Presentation
• 36 year old White man• Heartburn x 10 years• Intermittent dysphagia and chest pressure x 2
years• EGD in 2011– Long segment Barrett’s Esophagus, Prague C10M10,
without dysplasia– Eosinophilic esophagitis
• Symptoms resolved with twice daily Nexium
EGD 2013
EGD 2013
Case Presentation
• Histology
– Esophagus at 34 cm to 28 cm Intestinal metaplasia with low grade dysplasia at multiple levels
– Esophagus at 25 cm Squamous mucosa with > 40 intraepithelial eosinophils per high power field
Diagnosis
Eosinophilic EsophagitisAnd
Barrett’s Esophagus with Low Grade Dysplasia
Clinical Questions
• What is the difference in recommendations for RFA in patients with LGD vs HGD?
• What is the efficacy and durability of RFA for Barrett’s Esophagus with LGD?
• Should RFA be performed for Barrett’s Esophagus with LGD?
• What is the relationship between Barrett’s Esophagus and Eosinophilic Esophagitis?
• How safe is RFA of dysplastic Barrett’s in Eosinophilic Esophagitis?
Carcinogenesis in BE
Incidence of EAC in BE
• Non dysplastic BE EAC – 0.12% - 0.50% per year
• LGD EAC– 1.7% per year
• HGD EAC– 6.6% per year
Sikkema Am J Gastroenterol 2011Hvid-jensen NEJM 2011
Wani Am J Gastroenterol 2009
Inter-observer Variability in LGD
• 147 patients with a community diagnosis of LGD during BE surveillance– 15% with LGD confirmation by two other expert
pathologists– 85 % down-staged to non dysplastic BE
• Incidence rate of progression to HGD/EAC– 13.4% in patients with confirmed LGD– 0.49% in patients down-staged to NDBE
Curvers Am J Gastroenterol 2010
2011 AGA Guidelines
• “We recommend endoscopic eradication therapy with radiofrequency ablation (RFA) … rather than surveillance for treatment of patients with confirmed high-grade dysplasia”
2011 AGA Guidelines
• “Endoscopic eradication therapy with RFA should also be a therapeutic option for treatment of patients with confirmed low-grade dysplasia in Barrett’s esophagus.”
• “In the absence of long-term studies showing efficacy, it is not clear that the potential benefit of ablation in reducing cancer risk for patients who have Barrett’s esophagus with low-grade dysplasia warrants the risks and substantial expense of the ablative procedures.”
AIM Dysplasia Trial
• Multicenter RCT of RFA vs Sham procedure in dysplastic Barrett’s Esophagus
• N = 127– randomized in 2:1 ratio
• Primary outcomes– Complete eradication of LGD @ 12 mos– Complete eradication of HGD @ 12 mos– Complete eradication of IM @ 12 mos
Shaheen NEJM 2009
AIM Dysplasia Trial
Intention to Treat Per Protocol0%
10%20%30%40%50%60%70%80%90%
100%81%
90%
19% 20%
RFASham
Eradication of HGD (N=43) @ 12 mos
Shaheen NEJM 2009
AIM Dysplasia Trial
Intention to Treat Per Protocol0%
10%20%30%40%50%60%70%80%90%
100% 90% 95%
23% 26%
RFASham
Eradication of LGD (N=58) @ 12 mos
Shaheen NEJM 2009
AIM Dysplasia Trial
LGD to HGD LGD to CA HGD to CA0%2%4%6%8%
10%12%14%16%18%20%
5%
0%2%
14%
0%
19%
RFASham
Progression of Dysplasia
Shaheen NEJM 2009
AIM Dysplasia Extension
Shaheen Gastro 2011
LGD HGD68%
73%
78%
83%
88%
93%
98%98%
93%93%89%
CE-DCE-IM
Eradication @ 24 mos
Allowed for 1 session of “touch up” RFA @ 15 mos
AIM Dysplasia Extension
Shaheen Gastro 2011
Durability of CE-D
AIM Dysplasia Extension
Shaheen Gastro 2011Wani Am J Gastroenterol 2009
Incidence of Progression to EAC [per year]
LGD HGD
0.51% 0.60%
1.7%
6.6%
Post RFA
Natural History
RFA Meta-analysis
Shaheen Gastroenterology 2011 Shaheen Gastrointest Endosc 2012
Orman Clin Gastroenterol Hepatol 2013
LGD HGD
93% 89%
68%56%
72% 68%AIM DysplasiaCommunity RegistryMeta-analysis
Eradication of Dysplasia
RFA Meta-analysis
Adverse Events
Stricture Pain Bleeding
7.6%
2.5%
0.8%
5%
3%
1%
AIM Dysplasia
Meta-analysis
Shaheen Gastroenterology 2011 Orman Clin Gastroenterol Hepatol 2013
AIM Dysplasia Extension
Shaheen Gastro 2011Orman Clin Gastroenterol Hepatol 2013
Wani Am J Gastroenterol 2009
Incidence of Progression to EAC
LGD HGD
0.51% 0.60%0.20% 0.40%
1.7%
6.6%
RFA - AIMRFA - Meta-analysisNatural History
SURF Trial
Phoa Gastroenterology 2013
• European multicenter RCT of RFA vs Surveillance in LGD
• N = 136 randomized in 1:1• Primary outcome– Neoplastic progression (HGD or EAC) at 3 years
after randomization• Interim results at median 21 mos follow up
presented at DDW 2013
SURF Trial
Phoa Gastroenterology 2013
CE-D CE-IM
98% 98%
37%
0%
RFASurveillance
Efficacy of RFA @ 12 mos
SURF Trial
Phoa Gastroenterology 2013
Incidence Rate of Progression to ECA
LGD
0.9%
4%
1.7%
RFASurveillanceNatural History
Cost Effectiveness of RFA
Hur Gastroenterology 2012
• Computer model RFA and surveillance strategies of 50 year old “patients” followed until age 80 or death.
• Possible causes of death– Age related all cause mortality– RFA complications– Surgical esophagectomy mortality– Esophageal adenocarcinoma
Cost Effectiveness of RFA
Hur Gastroenterology 2012
• LGD cohort– Confirmed assume no initial diagnostic error– Stable LGD found on more than one EGD at least
6 months apart• Management– Endoscopic surveillance q 6 months x 1 year, then
yearly– RFA at 0, 2, 4, 9 mos, then “touch up” RFA as
needed
Cost Effectiveness of RFA
Hur Gastroenterology 2012
• RFA Outcomes– Residual dysplasia– CE-D– CE-IM– Recurrence of IM– Sub squamous intestinal metaplasia
• Incremental cost effective ratio (ICER)• Willingness to pay (WTP) set at
$100,000/QALY
Cost Effectiveness of RFA
Hur Gastroenterology 2012
Surgery
RFA
RFA
Cost Effectiveness of RFA
Hur Gastroenterology 2012
Willingness to Pay < $ 100,000 per QALY
Barrett’s Esophagus and EoE
Ravi Am J Gastroenterol 2011
• Cross sectional study of 200 patients with BE
• 14 of 200 patients with BE (7%) found to have > 15 eosinophils/hpf on squamous biopsy
Post RFA Esophageal Eosinophilia
Villa Dis Esophagus 2013
• Retrospective review of 148 patients with pre and post RFA esophageal biopsies
• 4 of 148 patients (2.7%) developed esophageal eosinophilia at 12 months– All four had LGD– None had clinical or endoscopic findings
suggestive of EoE– No pre RFA biopsies of squamous epithelium– Adverse events not reported
Safety of Esophageal Dilation in EoE
Jung GIE 2011Cohen Clin Gastroenterol Hepatol 2007
• Retrospective single center study• N = 293 dilations in 161 patients– 9.2% mucosal tear– 0.3% major bleeding– 1% immediate perforation• All treated without surgery
• Prior study of 36 patients with complication rate of 31% and perforation rate of 8%
Thank you
Dr. Marcelo VelaDr. Nicolas Villa
Prasad G, Talley N, Romero Y, et al. Prevalence and predictive factors of eosinophilic esophagitis in patients presenting with dysphagia: a prospective study. The American journal of gastroenterology 2007;102:2627-2632.
Wolfsen H, Hemminger L, Achem S. Eosinophilic esophagitis and Barrett's esophagus with dysplasia. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 2007;5.
Rodrigo S, Abboud G, Oh D, et al. High intraepithelial eosinophil counts in esophageal squamous epithelium are not specific for eosinophilic esophagitis in adults. The American journal of gastroenterology 2008;103:435-442.
Shaheen N, Sharma P, Overholt B, et al. Radiofrequency ablation in Barrett's esophagus with dysplasia. The New England journal of medicine 2009;360:2277-2288.
Wani S, Puli S, Shaheen N, et al. Esophageal adenocarcinoma in Barrett's esophagus after endoscopic ablative therapy: a meta-analysis and systematic review. The American journal of gastroenterology 2009;104:502-513.
Jacobs J, Spechler S. A systematic review of the risk of perforation during esophageal dilation for patients with eosinophilic esophagitis. Digestive diseases and sciences 2010;55:1512-1515.
American Gastroenterological A, Spechler S, Sharma P, et al. American Gastroenterological Association medical position statement on the management of Barrett's esophagus. Gastroenterology 2011;140:1084-1091.
Hvid-Jensen F, Pedersen L, Drewes A, et al. Incidence of adenocarcinoma among patients with Barrett's esophagus. The New England journal of medicine 2011;365:1375-1383.
Ravi K, Katzka D, Smyrk T, et al. Prevalence of esophageal eosinophils in patients with Barrett's esophagus. The American journal of gastroenterology 2011;106:851-857.
References
Shaheen N, Overholt B, Sampliner R, et al. Durability of radiofrequency ablation in Barrett's esophagus with dysplasia. Gastroenterology 2011;141:460-468.
Spechler S, Sharma P, Souza R, et al. American Gastroenterological Association technical review on the management of Barrett's esophagus. Gastroenterology 2011;140.
Hur C, Choi S, Rubenstein J, et al. The cost effectiveness of radiofrequency ablation for Barrett's esophagus. Gastroenterology 2012;143:567-575.
Dellon E, Gonsalves N, Hirano I, et al. ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). The American journal of
gastroenterology 2013;108:679.
Orman E, Li N, Shaheen N. Efficacy and durability of radiofrequency ablation for Barrett's Esophagus: systematic review and meta-analysis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 2013;11:1245-1255.
Villa N, El-Serag H, Younes M, et al. Esophageal eosinophilia after radiofrequency ablation for Barrett's esophagus. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus / I.S.D.E 2013;26:674-677.
Falk G. Update on ablation for Barrett's esophagus. Current gastroenterology reports 2014;16:368.Fitzgerald R, di Pietro M, Ragunath K, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut 2014;63:7-42.
References
AIM Dysplasia Trial
Intention to Treat Per Protocol0%
10%20%30%40%50%60%70%80%90%
77%83%
2% 3%
RFASham
Eradication of IM @ 12 mos
Shaheen NEJM 2009
AIM Dysplasia Extension
Shaheen Gastro 2011
• 2 year extension of AIM Dysplasia• Original control arm offered cross over to RFA• N = 119– 106 patients completed 2nd year of follow up• 100 eligible for extension through year 5
– 56 completed 3rd year of follow up at time of publication
• Durability of eradication of both dysplasia and metaplasia assessed at 2nd and 3rd year
AIM Dysplasia Extension
Shaheen Gastro 2011
Durability of CE-IM
AIM Dysplasia Extension
Shaheen Gastro 2011
Progression of Dysplasia
• 5 of 119 (4.3%) with progression of any type• 3 LGD HGD
– 2 with eventual CE-IM– 1 with EMR of focal HGD and withdrew from study
• 1 LGD to EAC– Initially randomized to Sham arm x 12 mos– RFA x 3 after crossing over– Eventual EMR of focal EAC
• 1 HGD to EAC– EMR of focal EAC– Eventual CE-IM at 3 years
RFA Meta-analysis
• Efficacy of RFA– 3802 patients• 2135 patients in RFA registry from 148 community and
academic practices
• Durability of RFA– 540 patients
Orman Clin Gastroenterol Hepatol 2013
RFA Meta-analysis
Orman Clin Gastroenterol Hepatol 2013
IM Recurrence
Cost Effectiveness of RFA
Hur Gastroenterology 2012
• Assumptions– NDBE EAC 0.12%, 0.33%, 0.50%– LGD EAC 0.19%, 0.5%, 0.75%
Eosinophilic Esophagitis
• Symptoms– Dysphagia, Food impaction– Reflux– Dyspepsia
• Associated with atopy • Requires > 15 eos per HPF on biopsy
Overlap of EoE and GERD
Attwood Am J Gastroenterol 1993
Overlap of EoE and GERD
Rodrigo Am J Gastroenterol 2008
Diagnosis of EoE
Dellon Am J Gastroenterol 2013