Transcript Radiofrequency ablation for long and ultra

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
8
Esophageal
Adenocarcinoma
Relative change
7
6
5
Melanoma
4
3
Prostate Cancer
Lung AC
2
1
Breast Cancer
0
1975 1980 1985 1990 1995 2000
year of diagnosis
Pohl, Welch, JNCI 2005
Why are we talking about Barrett’s
esophagus?
Cancer Risk for Barrett’s:
• Non-dysplastic
• Low-grade dysplasia
• High Grade Dysplasia
0.25% per year
?
4-8% per year
Treatment Options for EAC
• Endoscopic Mucosal Resection
(EMR)
• Radiofrequency Ablation
• Cryoablation
• Photodynamic Therapy
• Other thermal (APC, Bicap)
• Surgery
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
CE-D
Recurrent IM
Progression to cancer
- during treatment
- after CE-IM
Esophageal Stricture
78%
91%
13%
0.2%
0.7%
3%
PRE-TREATMENT PHASE
HGD/IMC
Barrett’s
Narrow Band Imaging
RFA: Halo 360 BÂRRX®
EMR, Duette®
Treatment Algorithm
LGD/ND
Staging EUS
Invasive
Esophagectomy
Non-invasive
Nodular
Flat
EMR 6-8 weeks
prior to RFA
RFA TREATMENT PHASE
Dysplasia or IM
on biopsy
Pathology
RFA treatment
protocol
Treatment failure: poor mucosal healing
RFA: Halo
90 BÂRRX®
and inability
to eradication
or
downgrade dysplasia after 3 sessions
2-3 mo follow-up
Repeat biopsies
Visible disease
Normal appearing mucosa
FOLLOW-UP PHASE
Recurrence
CR-D, CR-IM
HGD/IMC
LGD
ND
Endoscopy
every 3 mo
Endoscopy
every 6 mo
Endoscopy
every 9-12 mo
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
Spray Cryotherapy
2 published studies:
-CE-HGD 97-100%
-CE-IM 57-84%
-strictures 9%
GIE 2010
GIE 2013
2/11
3/14
Questions?