Ablation of Barrett's oesophagus: towards improved outcomes for oesophageal cancer?

Abstract

Barrett's oesophagus is the major risk factor for oesophageal adenocarcinoma. The management of Barrett's oesophagus entails treating reflux symptoms with acid-suppressing medication or surgery (fundoplication). However neither form of anti-reflux therapy produces predictable regression, or prevents cancer development. Patients with Barrett's oesophagus usually undergo endoscopic surveillance which aims to identify dysplastic changes or cancer at its earliest stage, when treatment outcomes should be better. Alternative endoscopic interventions are now available and are suggested for the treatment of early cancer, and prevention of progression of Barrett's oesophagus to cancer. Such treatments could minimize the risks associated with oesophagectomy. The current status of these interventions is reviewed.Various endoscopic interventions have been described, but with long term outcomes uncertain, they remain somewhat controversial. Radiofrequency ablation (RFA) of dysplastic Barrett's oesophagus might reduce the risk of cancer progression, although cancer development has been reported after this treatment. Endoscopic mucosal resection (EMR) allows a 1.5 to 2 cm diameter piece of oesophageal mucosa to be removed. This provides better pathology for diagnosis and staging, and if the lesion is confined to the mucosa and fully excised, EMR can be curative. The combination of EMR and RFA has been used for multifocal lesions, but long term outcomes are unknown. The new endoscopic interventions for Barrett's oesophagus and early oesophageal cancer have potential to improve clinical outcomes, although evidence which confirms superiority over oesphagectomy is limited. Longer term outcome data and data from larger cohorts is required to confirm the appropriateness of these procedures.

Endoscopic radiofrequency ablation therapy for the prevention of esophageal cancer in Barrett’s esophagus

“…During this process, the photosensitizer is activated by a specific wavelength of light, resulting in mucosal injury. 49,50 This…”

“…14,66,68,69,[71][72][73][74]77 As the depth of injury is generally shallower after RFA, with the muscularis mucosae and submucosa generally remaining intact, the risk of stricture is lower than following circumferential EMR or ESD. 49,50 For example, stricture rates after total endoscopic mucosa resections have been reported to be as high as up to 88%, 66 and these strictures are described as more severe and require more dilatations than strictures caused by RFA. 49 Strictures from RFA have generally been reported to resolve with endoscopic dilation in 1-3 sessions.…”

“…90 Other studies have investigated genetic changes in neosquamous epithelium following ablation, [91][92][93][94] and suggested that neosquamous epithelium following RFA might be genetically closer to the original squamous epithelium, compared to the neosquamous epithelium that repopulates the esophagus after other ablation therapies such as PDT and APC. 50,94 Taken together, there appears to be some risk of progression to cancer remaining even after successful ablation of Barrett's esophagus with RFA. The actual rate of recurrence of Barrett's esophagus or risk of cancer progression is unknown, and until larger studies with longer term followup are available, it will be important to manage the risk of problems arising after ablation, even though this risk is almost certainly less than the risk associated with nonablated dysplastic Barrett's esophagus.…”

“…However, surgery is not feasible in individuals with significant comorbidities, and it is associated with significant perioperative morbidity, mortality risk, and reduced quality of life in the early follow-up period. 50,[60][61][62] Nevertheless, esophagectomy performed for HGD or intramucosal cancer is a lower risk procedure than when undertaken for advanced cancer, with lower mortality outcomes of approximately 1%-2% in this patient group. 63,64 However, there is no doubt that endoscopic treatments preserve the normal esophageal anatomy, are safer, and are associated with lower morbidity and mortality than esophagectomy, and for these reasons endoscopic interventions are replacing surgery as first-line therapy in patients with HGD or intramucosal cancer.…”

Oesophageal adenocarcinoma: the men's health problem you do not want to have!

“…Surgical outcomes are better in this group and newer endoscopic interventions are also feasible. The latter offer the potential to cure early cancer and avoid surgery . By preserving the oesophagus, endoscopic interventions should better preserve the quality of life and reduced treatment‐related morbidity means that patients with co‐morbidities, which previously precluded oesophagectomy can now be considered for definitive endoscopic treatment.…”