endoscopic treatment of barrett’s esophagus and early esophageal cancer ctop retreat 2014...
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Endoscopic Treatment of Barrett’s Esophagus and Early Esophageal Cancer
CTOP Retreat 2014
Dartmouth-Hitchcock Medical Center
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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
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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
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Why are we talking about Barrett’s esophagus?
Barrett’s Esophagus
Esophageal Adenocarcinoma
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• Non-dysplastic
• Low-grade dysplasia
• High Grade Dysplasia
0.25% per year
?
4-8% per year
Cancer Risk for Barrett’s:
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• Endoscopic Mucosal Resection (EMR)
• Radiofrequency Ablation• Cryoablation• Photodynamic Therapy• Other thermal (APC, Bicap)• Surgery
Treatment Options for EAC
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73 year old man referred for management of 12 cm of Barrett’s associated with HGD and IMC in a nodule:
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EMREMR
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• 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?
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Pathology showed IMC/HGD (no invasive component). HGD at lateral margin.
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Barrx RFA
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• CE-IM 78%• CE-D 91%• Recurrent IM 13%• Progression to cancer
- during treatment 0.2%
- after CE-IM 0.7%• Esophageal Stricture 3%
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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
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Spray Cryotherapy
2 published studies:-CE-HGD 97-100%-CE-IM 57-84%-strictures 9%
GIE 2010GIE 2013
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2/11
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3/14
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Questions?