Clinical Outcomes Following Recurrence of Intestinal Metaplasia After Successful Treatment of Barrett’s Esophagus With Radiofrequency Ablation

Guthikonda, Athidi; Cotton, Cary C.; Madanick, Ryan D.; Spacek, Melissa; Moist, Susan E.; Ferrell, Kathleen; Dellon, Evan S.; Shaheen, Nicholas J.

doi:10.1038/ajg.2016.451

Cited by 55 publications

(50 citation statements)

References 15 publications

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“…11,16–18 However, the shape of the recurrence curve has varied, with some studies suggesting a relatively constant rate of recurrence, 18 while the present data suggest a front-loaded risk of recurrence in year one. The long follow up period of dysplastic BE in the current study is unique in the literature, as is the statistical approach which tests (and rejects) the hypothesis that the rate of recurrence after ablation is constant.…”

Section: Discussionmentioning

confidence: 50%

Late Recurrence of Barrett’s Esophagus After Complete Eradication of Intestinal Metaplasia is Rare: Final Report From Ablation in Intestinal Metaplasia Containing Dysplasia Trial

Cotton

Wolf

Overholt³

et al. 2017

Gastroenterology

105

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Background & Aims The goal of treatment for Barrett’s esophagus (BE) with dysplasia is complete eradication of intestinal metaplasia (CEIM). The long-term durability of CEIM has not been well characterized, so the frequency and duration of surveillance are unclear. We report results from a 5-year follow-up analysis of patients with BE and dysplasia treated by radiofrequency ablation (RFA) in the randomized controlled Ablation of Intestinal Metaplasia Containing Dysplasia (AIM) trial. Methods Participants for the AIM dysplasia trial (18–80 years old) were recruited from 19 sites in the United States and had endoscopic evidence of non-nodular dysplastic BE ≤8 cm in length. Subjects (n=127) were randomly assigned (2:1 ratio) to receive either RFA (entire BE segment ablated circumferentially) or a sham endoscopic procedure; patients in the sham group were offered RFA treatment 1 year later, and all patients were followed for 5 years. We collected data on BE recurrence (defined as intestinal metaplasia in the tubular esophagus) and dysplastic BE recurrence among patients who achieved CEIM. We constructed Kaplan-Meier estimates and applied parametric survival analysis to examine proportions of patients without any recurrence and without dysplastic recurrence. Results Of 127 patients in the AIM Dysplasia trial, 119 received RFA and met inclusion criteria. Of those 119, 110 (92%) achieved CEIM. Over 401 person-years of follow-up (mean 3.6 years per patient, range 0.2 – 5.8 years), 35 of 110 (32%) patients had recurrence of BE or dysplasia, and 19 (17%) had dysplasia recurrence. The incidence rate of BE recurrence was 10.8 per 100 person-years overall (95% CI, 7.8 – 15.0); 8.3 per 100 person-years among patients with baseline low-grade dysplasia (95% CI, 4.9 – 14.0), and 13.5 per 100 person-years among patients with baseline high-grade dysplasia (95% CI 8.8 – 20.7). The incidence rate of dysplasia recurrence was 5.2 per 100 person-years overall (95% CI 3.3 – 8.2); 3.3 per 100 person-years among patients with baseline low-grade dysplasia (95% CI 1.5 – 7.2), and 7.3 per 100 personyears among patients with baseline high-grade dysplasia (95% CI 4.2 – 12.5). Neither BE nor dysplasia recurred at a constant rate. There was a greater probability of recurrence in the first year following CEIM than in the following 4 years combined. Conclusions In this analysis of prospective cohort data from the AIM dysplasia trial, we found BE to recur after CEIM by RFA in almost one-third of patients with baseline dysplastic disease; most recurrences occurred during the first year after CEIM. However, patients who achieved CEIM and remained BE free at 1 year after RFA had a low risk of BE recurrence. Studies are needed to determine when surveillance can be decreased or discontinued; our study did not identify any BE or dysplasia recurrence after 4 years of surveillance.

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Section: Discussionmentioning

confidence: 50%

Late Recurrence of Barrett’s Esophagus After Complete Eradication of Intestinal Metaplasia is Rare: Final Report From Ablation in Intestinal Metaplasia Containing Dysplasia Trial

Cotton

Wolf

Overholt³

et al. 2017

Gastroenterology

105

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“…Eighty per cent of recurrences in the tubular oesophagus were visible endoscopically,10 and random biopsies >1 cm proximal to the GOJ had no yield for any recurrence 15. Data from the current larger multicentre cohort show that 82% of tubular oesophageal recurrences were visible, and the yield of random biopsies >1 cm proximal to the GOJ was extremely low (1.2% yield for any recurrence and 0.2% for dysplastic recurrence).…”

Section: Discussionmentioning

confidence: 71%

Timeline and location of recurrence following successful ablation in Barrett’s oesophagus: an international multicentre study

Sami

Ravindran

Kahn

et al. 2019

Gut

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ObjectiveSurveillance interval protocols after complete remission of intestinal metaplasia (CRIM) post radiofrequency ablation (RFA) in Barrett’s oesophagus (BE) are currently empiric and not based on substantial evidence. We aimed to assess the timeline, location and patterns of recurrence following CRIM to inform these guidelines.DesignData on patients undergoing RFA for BE were obtained from prospectively maintained databases of five (three USA and two UK) tertiary referral centres. RFA was performed until CRIM was confirmed on two consecutive endoscopies.Results594 patients achieved CRIM as of 1 May 2017. 151 subjects developed recurrent BE over a median (IQR) follow-up of 2.8 (1.4–4.4) years. There was 19% cumulative recurrence risk of any BE within 2 years and an additional 49% risk over the next 8.6 years. There was no evidence of a clinically meaningful change in the recurrence hazard rate of any BE, dysplastic BE or high-grade dysplasia/cancer over the duration of follow-up, with an estimated 2% (95% CI −7% to 12%) change in recurrence rate of any BE in a doubling of follow-up time. 74% of BE recurrences developed at the gastro-oesophageal junction (GOJ) (24.1% were dysplastic) and 26% in the tubular oesophagus. The yield of random biopsies from the tubular oesophagus, in the absence of visible lesions, was 1% (BE) and 0.2% (dysplasia).ConclusionsBE recurrence risk following CRIM remained constant over time, suggesting that lengthening of follow-up intervals, at least in the first 5 years after CRIM, may not be advisable. Sampling the GOJ is critical to detecting recurrence. The requirement for random biopsies of the neosquamous epithelium in the absence of visible lesions may need to be re-evaluated.

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“…Ablative approaches, such as radiofrequency ablation and endoscopic mucosal resection, are employed in dysplastic states 29,30 and result in diminished progression to EAC. Interestingly, even after ablation, there is a risk of recurrence of Barrett oesophagus 31,32 . One might speculate that all abnormal tissue was not ablated successfully, allowing expansion of residual Barrett oesophageal tissue, and/or that squamous progenitor cells have been reprogrammed to an intestinal metaplasia fate.…”

Section: Tissue Metaplasiamentioning

confidence: 99%

Metaplasia: tissue injury adaptation and a precursor to the dysplasia–cancer sequence

2017

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Metaplasia is the replacement of one differentiated somatic cell type with another differentiated somatic cell type in the same tissue. Typically, metaplasia is triggered by environmental stimuli, which may act in concert with the deleterious effects of microorganisms and inflammation. The cell of origin for intestinal metaplasia in the oesophagus and stomach and for pancreatic acinar–ductal metaplasia has been posited through genetic mouse models and lineage tracing but has not been identified in other types of metaplasia, such as squamous metaplasia. A hallmark of metaplasia is a change in cellular identity, and this process can be regulated by transcription factors that initiate and/or maintain cellular identity, perhaps in concert with epigenetic reprogramming. Universally, metaplasia is a precursor to low-grade dysplasia, which can culminate in high-grade dysplasia and carcinoma. Improved clinical screening for and surveillance of metaplasia might lead to better prevention or early detection of dysplasia and cancer.

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Clinical Outcomes Following Recurrence of Intestinal Metaplasia After Successful Treatment of Barrett’s Esophagus With Radiofrequency Ablation

Cited by 55 publications

References 15 publications

Late Recurrence of Barrett’s Esophagus After Complete Eradication of Intestinal Metaplasia is Rare: Final Report From Ablation in Intestinal Metaplasia Containing Dysplasia Trial

Late Recurrence of Barrett’s Esophagus After Complete Eradication of Intestinal Metaplasia is Rare: Final Report From Ablation in Intestinal Metaplasia Containing Dysplasia Trial

Timeline and location of recurrence following successful ablation in Barrett’s oesophagus: an international multicentre study

Metaplasia: tissue injury adaptation and a precursor to the dysplasia–cancer sequence

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