- 1 After successful endoscopic treatment for BO neoplasia, how frequently should patients undergo endoscopy?
- 2 Evidence summary and recommendations
- 3 Issues requiring more clinical research study
- 4 References
- 5 Appendices
After successful endoscopic treatment for BO neoplasia, how frequently should patients undergo endoscopy?
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. 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. 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. 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.
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. 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.
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.
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.
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.
Evidence summary and recommendations
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.
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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