Dysplas'c Barre- s Esophagus: Cut, Burn, Freeze or Watch Very Very Closely

Transcription

1 Dysplas'c Barre- s Esophagus: Cut, Burn, Freeze or Watch Very Very Closely Felice Schnoll- Sussman, MD, FACG Director, Jay Monahan Center Associate Professor Clinical Medicine Weill Cornell Medical Center

2 We just want to do the right thing but Only 7% of the 10,000 EC dx in USA are iden'fied by screening or surveillance 40% of people with EC do not have reflux 90% of people with EC did not know they had Barre- s Screening and surveillance of BE have not been proven to prevent deaths Fatal cases nearly as likely to have received surveillance (55.3%) as were controls (60.4%) Nature Reviews Gastro & Hep 2015; 12;243 Gastro 2013;142:312

3 Before you treat it, you must find it Surveillance must be done me'culously and systema'cally BE early dysplasia oeen presents as subtle flat Paris type II- b Direct correla'on between 'me inspec'ng each cm of BE and neoplasia detec'on

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5 I p Pedunclated Paris Classifica'on I sp I s* II a II b II c III* Sub Pedunclated Sessile Slightly Elevated Flat Depressed Excavated *Likely to contain invasive Ca Hazewinkel, Y. & Dekker, E. (2011) Hepatol. 2011

6 How long should you take to look? 112 pa'ents surveillance endoscopy individual endoscopists Barre- s inspec'on 'me (BIT) measured BIT >1 minute per cm Barre- s mucosa Detec'on rate of HGD/EAC 40.2% vs 6.7% p = 0.06 Longer BIT correlated w/ detec'on HGD/EAC p = 0.63, p = Gupta et al. GIE 2012

7 What should we be repor'ng? Repor'ng should include: 1. Barre-' segment length Prague Criteria 2. Document presence and size of hiatal hernia 3. Document presence of esophagi's above BE segment

8 Prague Classifica'on Most reliable and validated classifica'on of Barre- s C = length of esophagus lined circumferen'ally M = maximal length of esophagus involved at any point

9 History of an endoscopist s view of Barre- s Esophagus regular light, bx, bx, bx, bx 2009 High defini'on white light bx, bx, bx, bx 2011 HDWL + NBI+ EMR bx,bx,bx 2012 HDWL +NBI +EMR + pcle + WATS...bx,bx 2013 HDWL + EMR + pcle + OCT + WATS bx Look longer...look be-er (maybe) biopsy less

10 Do we need multimodality advanced imaging? HD-WLE BE Patients NBI suspicious loca'ons marked w/ APC pcle OCT

11 Do we need mul'modality imaging? HR- WLE is 2-5 fold superior quality than SD- WLE Expert opinion: HR- WLE minimum standard HR + dye- based (ace'c,indigo carmine, methylene blue) Time consuming, tedious, need high- magnifica'on Limited added benefit to HR- WLE alone Op'cal chromoendoscopy (NBI, FICE, I- Scan) NBI w/target bx = detec'on rate IM vs. HR w/standard bx NBI detects higher propor'on dysplasia (30% vs 21%, P=.01) Requires fewer biopsies (3.6 vd 7.6 p<.0001) Useful as adjunc've tool to HR- WLE Benne- C. Gastro 2012;143: (Delphi Process) Sharma P Gut 2013:62:15-21

12 Do we need mul'modality imaging? Confocal Laser Endomicroscopy (CLE) Increases sensi'vity detec'ng dysplasia to HR- WLE alone from 40-60% (p<.001) Triples diagnos'c yield (22% vs 6%, P=.002) Requires 1/5 of biopsies BUT sampling error (small field), all studies from expert centers with high risk pa'ents May be imprac'cal for prac'cing GI Canto MI. Gastro Endosc 2014;79: Dunbar KB. Gastro Endosc 2009;70: Op'cal Coherence Tomography Preabla'on - Assess esophagus for predictors of prolonged or failed abla'on Ø BE thickness, buried glands Postabla'on assess for buried glands Desai. ACG 2015

13 What is the Best Biopsy Protocol? 1. Erosive esophagi's should be healed before biopsy Inflamma'on causes cytologic atypia in crypts; mimics dysplasia 2. Four quadrant biopsy every 1-2 cm (Sea-le) Each segment submi-ed in separate containers 3. Samples from any visible abnormali'es (nodules or suspicious areas ) 4. Wide angle transepithelial sampling (WATS 3D ) The Sad Truth: Biopsy guidelines followed in only 51.2% of pa'ents in community sexng Na'onal pathology database of 2200 surveillance cases Abrams. Clin Gastro Hep 2009;7(7);736

14 If you iden'fy a nodule it must undergo EMR EMR is an essen'al staging procedure Prospec've study of 75 pa'ents with biopsy- proven HGD or early cancer EMR altered the original grading or staging in 48% of pa'ents (down 28%, up 20%) Moss A, et al. Am J Gastroenterol 2010;105:

15 What is the risk of lymph node metastasis in HGD and Early Esophageal Cancer? HGD ~ 0 Tis ~ 0 T1m 1-2% T1sm1 ~ 9-20% T1sm3 ~ 24-50% Dunbar KB, Am J Gastro 2012;107:850-62

16 What is the risk of lymph node metastasis in HGD and Early Esophageal Cancer? HGD ~ 0 Tis ~ 0 T1m 1-2% T1sm1 ~ 9-20% T1sm3 ~ 24-50% Ablative techniques not appropriate Surgical resection indicated Dunbar KB, Am J Gastro 2012;107:850-62

17 The Barre- s Dysplasia Paradox Accurate diagnosis and staging is essen'al Interobserver agreement among expert pathologists can be less than 50%

18 What Really is Low- Grade Dysplasia? 147 subjects with a diagnosis of LGD made in a community prac'ce in the Netherlands Path reviewed by 2 expert pathologists Disagreements resolved by consensus 85% of cases were down- graded In remaining 15%: incidence rate of HGD or EAC was 13.4%/pt- yr (mean f/u: 51 mo) Curvers WL et al. Am J Gastroenterol 2010

19 Is EUS Necessary in Staging? Virtually no risk of LN metastasis in HGD 1-2% risk in ImCa Factors that predict risk of LN metastasis 1) Depth of tumor invasion (sm1 and deeper) 2) Tumor diameter > 3 cm 3) Lymph vascular invasion on ER specimen 4) Degree of differen'a'on (poorly or G3 tumor biology) Consider EUS in conjunc'on with EMR if concern for LNs or tumor has high risk features Dunbar KB, Am J Gastro 2012;107:850-62

20 Pardigm Shie in BE Treatment Those who treat pa'ents with Barre- s must think of themselves not only as gastroenterologists but as: Gastro- oncologicalsurgeons Accurate staging = Appropriate treatment

21 Now that you have detected dysplasia and staged it correctly what should you do? 1. EMR resec'on of all nodular disease - Diagnos'c and therapeu'c 2. Ablate all remaining Barre- s mucosa 3. Control acid 4. Lifelong surveillance

22 Endoscopic Eradica'on Therapies A. Endoscopic resec'on 1. EMR focal or complete 2. ESD B. Endoscopic abla'on 1. Radiofrequency abla'on 2. Cryotherapy 3. Photodynamic therapy 4. Argon plasma coagula'on

23 Endoscopic Eradica'on Therapies A. Endoscopic resec'on 1. EMR focal or complete 2. ESD B. Endoscopic abla'on 1. Radiofrequency abla'on 2. Cryotherapy 3. Photodynamic therapy 4. Argon plasma coagula'on

24 Radiofrequency Abla'on RCT of 127 pa'ents with LGD & HGD RFA+PPI vs Sham+PPI (2:1) 12 months follow up Bx s q3 mos (HGD)/ 6 mos (LGD) Complete eradica'on of all dysplasia: 81% of HGD 91% of LGD 19% of controls Complete eradica'on of IM 77% of Rx, 2% Sham Strictures occurred in 6% of pts Resolu'on with mean 2.6 dila'ons The AIM- D Trial % 2% Cancer Incidence (%) Sham +PPI RFA + PPI Shaheen NJ et al. N Engl J Med, 2009

25 3 year Durability Following RFA Shaheen NJ et al, Gastroenterology 2011

26 Is LGD an indica'on for abla'on? SURF study RCT, n=140 Surveillance EGD vs. RFA Primary outcome: Occurrence of HGD/EAC Phoa KN et al. JAMA 2014

27 Is Cryotherapy an Op'on? 98 subjects w/ HGD 10 ins'tu'ons 61 completed Rx, 27 ongoing 281 total procedures 4.0/pt No significant adverse events One progression to CA Shaheen NJ et al. Gastrointest Endosc, 2010

28 Is Cryotherapy an op'on? Cryospray abla'on using pressurized CO 2 Aimed to enroll 30 pts with HGD or IMC All nodules EMR ed Cryospray performed q month un'l CEBE or 7 sessions Aeer enrolling 10 pa'ents insufficient effect of cryo was observed study terminated 1 gastric perfora'on Verbeek RE. Endosc Internatl Open 2015;03:E107- E112

29 What about complete resec'on of IM with EMR? Mul'ple studies show high CEIM with stepwise EMR Risk of stricture forma'on higher if >3/4 circumferen'al tx EMR+RFA SRER Van Vilsteren FGI et al. Gut CR- IM Stricture Rate

30 Maintenance of acid suppression is essen'al to achieve abla'on 45 subjects underwent pre- RFA ph studies Degree of acid control correlated with abla'on outcomes Akiyama J et al. Dig Dis Sci 2012; 57:

31 Recurrences Unfortunately Do Occur Recurrence rates stra'ified by baseline histology RFA Registry Data Time after CEIM (years) Nondysplastic BE LGD IMC Indefinite dysplasia HGD Gupta M. Gastro 2013

32 Management of HGD/IMC

33 Management of LGD

34 What have we learned? High quality EGD essen'al to correctly stage Mul'modality advanced imaging helpful but may not be essen'al Endoscopic management of low and high grade dysplas'c BE is effec've Endotherapy with mul'modality approach, combining 'ssue- acquiring and abla've techniques Following eradica'on, surveillance and acid suppression must con'nue Recurrence can be managed endoscopically