Endoscopic Management of Barrett s Esophagus

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1 Endoscopic Management of Barrett s Esophagus Sammy Ho, MD Director of Pancreaticobiliary Services and Endoscopic Ultrasound Montefiore Medical Center

2 Barrett s Esophagus Consequence of chronic GERD Mean age of dx: 55 Caucasians & Hispanics Male to female (2:1) Prevalence: 1 to 4.5%

3 Pohl H, Natl Cancer Inst 2005 Relative Change in Incidence Esophagus Melanoma Prostate Lung/Breast Colorectal

4 Esophageal Adenocarcinoma Intestinal metaplasia Low grade dysplasia High grade dysplasia Adenocarcinoma

5 Progression of Intestinal Metaplasia Prospective study: 1376 patients Mean follow up: 4 years Intestinal metaplasia advancing to low grade dysplasia: 16% (4%/yr) high grade dysplasia: 4% (1%/yr) adenocarcinoma: 2% (0.5%/yr) Sharma P et al. Clin Gastroenterol Hepatol 2006

6 Risk of adenocarcinoma Patients without dysplasia: 0.5%/yr Patients with high-grade dysplasia: 4-6%/yr Patients with low-grade dysplasia:?? Colon polyp progressing to cancer 0.5%/yr

7 Management of Dysplasia Esophagectomy Intensive endoscopic surveillance Endoscopic mucosal resection (EMR)/ESD Endoscopic ablation Thermal (laser, APC) Photodynamic therapy (PDT) Radiofrequency ablation (Barrx) Cryotherapy

8 Endoscopic Mucosal Resection Allows for a definitive histologic diagnosis

9 EMR-C EMR-L Equal efficacy and safety May A, et al. Gastrointest Endosc 2003

10 Wilson Cook Multi-Band Mucosectomy System

11 75 patients with HGD or early esophageal CA underwent EMR EMR histology resulted in altered staging in 48% Technical success rate: 94% No recurrence at EMR sites (F/U: 31 months) Complication: 6 strictures requiring dilations Moss A, et al. Am J Gastroenterol 2010

12 100 patients with early esophageal adenocarcinoma Complete local remission: 99% Recurrence: 11% (F/U 36 months) All successfully treated with endoscopic resections 5-year survival rate: 98% (2 died of unrelated causes) Ell C, et al. Gastrointest Endosc 2007

13 Goals of Barrett s Ablation 1. Complete and durable ablation of columnar epithelium 2. Reduce incidence of esophageal adenocarcinoma

14 Photodynamic Therapy Photosensitizer: Photofrin (2mg/kg) Given 48 hours before treatment Activated by visible red light at 630nm Avoid direct sunlight for up to 4 weeks

15 208 patients with high-grade dysplasia PDT and omeprazole (138) Omeprazole only (70) Max 3 treatments 90 days apart HGD elimination (77% vs. 39%) Cancer incidence (15% vs. 29%) Strictures: 12% with one treatment 36% with two treatments Overholt, BF. Gastrointest Endosc 2007

16 Complications with PDT Strictures up to 40% Severe skin photosensitivity Post-procedural dysphagia/chest pain

17 Radiofrequency Ablation

18 Radiofrequency Ablation (Barrx) Halo 360 Halo 90

19 Circumferential Ablation (Halo 360)

20 20

21 Focal Ablation (Halo 90)

22 Focal RFA 22

23 142 patients with Barrett s and HGD CR-HGD: 90% CR-D: 80% CR-IM: 54% Median: 1 session Complication: 1 stricture

24 127 with dysplastic Barrett s esophagus Ablation vs. sham Max: 4 RFA sessions Primary outcome (12mon): Eradication of dysplasia Cancer incidence: 1.2% vs. 9.3% Esophageal stricture: 5 (6%) Shaheen NJ, et al. N Engl J Med 2009

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26 Long-term Outcomes Baseline Post-RFA: 2 years

27 Long-term Outcomes Baseline Post-RFA: 2 years

28 Cryoablation GI Supply CSA Medical

29 Procedure Cryogen delivered at low pressure (<4 psi) Liquid nitrogen (-196 C ) 7 French catheter Decompression tube to evacuate gas Frequent abdominal examinations Direct visualization Standard patient discharge instructions

30 Procedure

31 30 patients with Barrett s with HGD and early CA Cryoablation every 6 weeks Median F/U: 12 months Downgrading of pathology stage: 90% Elimination of CA: 80% Downgrading of HGD: 68% Stricture: 3 (10%) Dumont JA, et al. Gastrointest Endosc 2009

32 Take Home Points Multiple endoscopic techniques are effective in treating Barrett s with dysplasia EMR should be performed in Barrett s with mucosal nodularity/visible abnormalities to allow exact histopathological assessment EMR is safe and provides a definitive therapy for patients with high grade dysplastic Barrett s and early esophageal adenocarcinoma

33 Take Home Points PDT has been replaced by newer ablative techniques with fewer side-effects Radiofrequency ablation and cryotherapy appear to be effective and safe modalities for treating Barrett s with dysplasia. Both can reduce the incidence of adenocarcinoma Barrett s without dysplasia should not be treated outside of clinical trials

34 Areas of Uncertainty Role of advanced imaging technigues Recurrence of dysplasia and cancer after EMR and ablation Surveillance intervals after EMR and ablation Biomarkers to identify patients at highest risk of recurrence

35 Thank you for your attention