After successful endoscopic treatment for BO neoplasia, how frequently should patients undergo endoscopy?

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After successful endoscopic treatment for BO neoplasia, how frequently should patients undergo endoscopy?

Introduction

There has been a paradigm shift in the management of high grade dyplasia (HGD) and oesophageal intramucosal adenocarcinoma (IMCa) within Barrett’s Oesophagus. Previously this condition was managed with oesophagectomy, however endoscopic therapy with endoscopic mucosal resection (EMR), radiofrequency ablation (RFA) or both, is now more commonly used.[1][2][3][4] Endoscopic management of intramucosal malignant lesions requires EMR. This also provides the benefit of a histological specimen for accurate staging of the malignant lesion. Resected lesions that demonstrate submucosal involvment carry an unacceptable risk of lymphatic spread which indicates surgical intervention.[5] Several studies have demonstrated that clearance of intramucosal adenocarcinoma can be achieved by endoscopic mucosal resection alone or in combination with radiofrequency ablation to ablate residual Barrett’s.[6] Radiofrequency ablation alone is not considered a satisfactory modality for treatment of intramucosal adenocarcinoma. Integral to successful endoscopic management of Barrett’s HGD and IMCa is a commitment to long term endoscopic surveillance. Presently the surveillance intervals used vary by institution and are not evidence based.

A systematic review of the literature was performed to find consensus guidelines for endoscopic surveillance post successful endoscopic treatment of Barrett’s HGD and IMCa. This found that there is a paucity of literature in this area. A review of the available literature provides some consensus based (i.e. practice points) rather than evidence based recommendations.

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Confirmation of successful endoscopic treatment for BO neoplasia

A reasonable consensus recommendation for confirming successful eradication of Barrett’s HGD/IMCa would be three monthly endoscopic assessment with oesophageal biopsies as per the Seattle protocol. Some would advocate a more stringent protocol with 1cm/ four quadrant biopsies and/or targeted biopsies. Many would advocate the benefits of combining white light endoscopy and NBI, as well as spending additional time for a more thorough examination.[7] Further endoscopic treatment of any residual pathology would be performed on the basis of the endoscopic and histological findings. Three monthly endoscopic assessment and biopsies would be performed until endoscopic and histological clearance is achieved.[8]

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Suggested endoscopic surveillance recommendations after clearance of BO neoplasia

A reasonable consensus recommendation, after clearance is achieved, would be surveillance gastroscopy with Seattle protocol every six months for one year, then annually thereafter. Again some may advocate 1cm/four quadrant biopsies and/or targeted biopsies. Endoscopic resection of any nodularity in the squamous epithelium should be considered to clarify possible recurrent or metachronous IMCa from subsquamous glands.[8]

Higher risk patients may require closer surveillance gastroscopy after clearance of Barrett’s Oesophagus neoplasia is achieved (i.e. initially 3 monthly for a year). These would include patients with prior synchronous IMCa lesions, those who required multiple endoscopic resections to clear a single IMCa lesion, those with prior histologically deeper intramucosal adenocarcinoma (i.e. T1Am3) and those with prior background Barrett’s with multi-focal high grade dysplasia.[8]

There is presently no consensus about the potential benefits of other mucosal imaging modalities (e.g. confocal laser endomicroscopy). Ideally any further endoscopic management and ongoing surveillance should be discussed in a multi-disciplinary collaborative setting within an experienced tertiary setting.[8][9]

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Evidence summary and recommendations

Practice pointQuestion mark transparent.png

Consider three monthly surveillance gastroscopy with Seattle protocol during the endoscopic treatment phase to confirm clearance of intramucosal adenocarcinoma (IMCa) and residual Barrett’s. Once clearance has been achieved, consider 6 monthly endoscopic surveillance for one year, then annually. Higher risk patients (as outlined above) may require closer surveillance gastroscopy after clearance of Barrett’s Oesophagus neoplasia is achieved (i.e. initially 3 monthly for a year). Endoscopic resection of any nodularity in the squamous epithelium should be considered to clarify possible recurrent or metachronous IMCa from subsquamous glands.

The given value was not understood.

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Issues requiring more clinical research study

  • What are the evidence based recommendations for an endoscopic surveillance protocol post endoscopic management of Barrett’s HGD and IMCa to confirm clearance?
  • What are the evidence based recommendations for an optimal biopsy protocol for endoscopic surveillance post endoscopic management of Barrett’s HGD and IMCa?
  • What are the evidence based recommendations for an endoscopic surveillance protocol post endoscopic management of Barrett’s HGD and IMCa after confirmation of clearance?
  • What are the potential benefits of using other mucosal imaging modalities (ie confocal laser endomicroscopy) for surveillance post Barrett’s endotherapy?


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References

  1. Ell C, May A, Gossner L, Pech O, Günter E, Mayer G, et al. Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett's esophagus. Gastroenterology 2000 Apr;118(4):670-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10734018.
  2. Shaheen NJ, Sharma P, Overholt BF, Wolfsen HC, Sampliner RE, Wang KK, et al. Radiofrequency ablation in Barrett's esophagus with dysplasia. N Engl J Med 2009 May 28;360(22):2277-88 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19474425.
  3. Pouw RE, Seewald S, Gondrie JJ, Deprez PH, Piessevaux H, Pohl H, et al. Stepwise radical endoscopic resection for eradication of Barrett's oesophagus with early neoplasia in a cohort of 169 patients. Gut 2010 Sep;59(9):1169-77 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20525701.
  4. Chung A, Bourke MJ, Hourigan LF, Lim G, Moss A, Williams SJ, et al. Complete Barrett's excision by stepwise endoscopic resection in short-segment disease: long term outcomes and predictors of stricture. Endoscopy 2011 Dec 1;43(12):1025-32 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22068701.
  5. Dunbar KB, Spechler SJ. The risk of lymph-node metastases in patients with high-grade dysplasia or intramucosal carcinoma in Barrett's esophagus: a systematic review. Am J Gastroenterol 2012 Jun;107(6):850-62; quiz 863 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22488081.
  6. Gondrie JJ, Pouw RE, Sondermeijer CM, Peters FP, Curvers WL, Rosmolen WD, et al. Effective treatment of early Barrett's neoplasia with stepwise circumferential and focal ablation using the HALO system. Endoscopy 2008 May;40(5):370-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18494132.
  7. Gupta N, Gaddam S, Wani SB, Bansal A, Rastogi A, Sharma P. Longer inspection time is associated with increased detection of high-grade dysplasia and esophageal adenocarcinoma in Barrett's esophagus. Gastrointest Endosc 2012 Sep;76(3):531-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22732877.
  8. 8.0 8.1 8.2 8.3 Templeton A, Bodnar A, Gan SI, Irani S, Ross A, Low D. Occurrence of invasive cancer after endoscopic treatment of Barrett's esophagus with high-grade dysplasia and intramucosal cancer in physiologically fit patients: time for a review of surveillance and treatment guidelines. Gastrointest Endosc 2014 May;79(5):839-44 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24447341.
  9. Jayasekera C, Taylor AC, Desmond PV, Macrae F, Williams R. Added value of narrow band imaging and confocal laser endomicroscopy in detecting Barrett's esophagus neoplasia. Endoscopy 2012 Dec;44(12):1089-95 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23188660.

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Appendices


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