Download The Difficult Patient With Non-Dysplastic Barrett`s Esophagus

The Difficult Patient With
Non-Dysplastic Barrett’s Esophagus
Charles J. Lightdale, MD
Columbia University Medical Center
New York, NY
The Patient with a Biopsy Diagnosis
“Indefinite for Dysplasia”
• Diagnosis should be confirmed by another
expert pathologist
• Indefinite for Dysplasia:
• Epithelial abnormalities insufficient to diagnose
dysplasia
• Epithelial abnormalities unclear due to
inflammation
Progression of Barrett’s Esophagus
Indefinite for Dysplasia
Study
N
Prevalence*
Incidence
Kestens, et al, 2014
842
Not Reported
1.4% per year
to HGD/EAC
Horvath, et al, 2015
107
Sinh, et al, 2015
83
Ma, et al, 2015**
106
4.7% HGD/EAC 1.2% per year
to HGD/EAC
Not Reported 0.8% per year
to HGD/EAC
5.7% HGD/EAC 0.9% per year
to HGD/EAC
*Progression to HGD/EAC within 12 months after diagnosis BE/IND
**Progression associated with long-segment BE and with smoking
ACG Guidelines 2015
• For patients with indefinite for dysplasia, a
repeat endoscopy after optimization of acid
suppressive medications for 3–6 months
should be performed. If the indefinite for
dysplasia reading is confirmed on this
examination, a surveillance interval of 12
months is recommended (strong
recommendation, low level of evidence).
Shaheen, et al. Am J Gastroenterol 2015;Epub ahead of print.
The difficult patient with non-dysplastic BE
who seeks radiofrequency ablation
RFA for NDBE
• Prospective, multicenter, AIM II trial, extension to
5 years (n = 50)
• Surveillance biopsies q 1 cm 4-quadrant
• Central pathology lab
• BE recurrence: focal RFA, continue surveillance
in 2 months
• 92% CR-IM at 5 years
• 8% (n = 4) CR-IM after 1 focal RFA
Fleischer, et al. Endoscopy 2010;42:781-789
AIM-II Kaplan-Meier CR-IM Durability Analysis
4.22 years mean time in CR-IM
(after first durable CR-IM and no touch-up RFA)
7
Incidence of Adenocarcinoma in NDBE
Year
1990
2000
2011
2011
2011
%/Year
1.00%
0.50%
0.27%
0.13%
0.12%
Shaheen. Gastroenterology 2000; de Jong. Gut 2010; Desai. Gut
2011. Bhat. J Natl Cancer Inst 2011; Hvid-Jensen. N Engl J Med
2011. Wani. Clin Gastroenterol Hepatol 2011.20
Rationale for RFA of NDBE
• Surveillance of NDBE is unproven and is
ineffective in reducing mortality in BE.
• Risk of neoplastic progression in NDBE is
artificially depressed in recent publications by
definitions of prevalent and incident disease.
• BE is overdiagnosed in clinical practice, resulting
in underestimates of cancer risk.
• RFA is safe and effective in eradicating BE
Ganz RA, et al. Gastrointest Endosc 2014;80:866-72.
Verbeek, et al. Am J Gastroenterol 2014:109:1215-22.
Why Not RFA for all NDBE?
•
•
•
•
Low risk of progression, great majority of NDBE would not benefit.
Recurrent intestinal metaplasia is common after RFA.
Need for continued surveillance = not cost effective.
Most NDBE patients are older, many with co-morbidities, that increase the
risk of adverse events from RFA.
• Low risk makes randomized controlled trial too expensive to fund.
• Need to develop biomarkers of increased risk in NDBE to identify those
likely to progress versus most who have indolent disease.
• Too much pain for too little gain
Hur, et al. Gastroenterology 2012;143:567-75
Pouw, Bergman. Clin Gastroenterol Hepatol 2013:11:1256-8.
Ganz, et al. Gastrointest Endosc 2014;80:866-72.
Lightdale. Gastrointest Endosc 2014;80:873-76.
.
Non-Dysplastic Barrett’s Esophagus:
Clinical Factors Risk Factors for Progression to Cancer
•
•
•
•
Caucasian
Male
Smoker
Obese
•
•
•
•
Young Age BE
Long Segment
Large Hiatal Hernia
Family History of BE & EAC
Chak, Gut, 2002
Gopal, Dig Dis Sci, 2003
Weston, Am J Gastroenterol, 2004
Hage, Scand J Gastroenterol, 2004
Iftikhar, Gut, 1992
Bani-Hani, World J Gastroenterol,
2005
Ramus, Eur J Cancer Prev, 2012
de Jonge, Gut, 2010
Prasad, Am J Gastroenterol, 2010
Reid, Am J Gastroenterol, 2000
Weston, Am J Gastroenterol, 2001
Suspiro, Am J Gastroenterol, 2003
Sikkema, Am J Gastroenterol, 2011
Sappati Biyyani , Dis Esophagus,
2007
Munitiz, J Clin Gastroenterol, 2008
Abnet, Eur J Cancer, 2008
de Jonge, Am J Gastroenterol, 2006
Jung, Am J Gastroenterol, 2011
Anaparthy, Clin Gastroenterol
Hepatol, 2013
AGA and ASGE Guidelines
• Non-Dysplastic Barrett’s Esophagus:
Surveillance for most, but RFA an option
based on physician assessment of clinical risk
factors and co-morbidities.
AGA MPS on BE: Gastroenterology 2011;140:1084-1091
ASGE Guidelines: Gastrointest Endosc 2012;76:1087-109
ACG Guidelines
• Endoscopic ablative therapies should not be
routinely applied to patients with
nondysplastic BE because of their low risk
of progression to EAC (strong
recommendation, very low level of evidence).
Am J Gastroenterol 2015; Epub ahead of print.
Screening: Only 5-8% of Patients
with EAC Have Known BE
Proportion of EAC Patients with
Known BE
No BE
BE
Dulai GS, Gastroenterology 2002
Corley DA, Gastroenterology 2002.
Verbeek,RE, Am J Gastroenterol 2014