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?