Adam C Strauss, MD, Agoston Agoston, MD, PhD, Parambir S Dulai, MD, Thadeus L Trus, MD, Amitabh Srivastava, MD, Richard I Rothstein, MD. Dartmouth Hitchcock Medical Center; Brigham and Women’s Hospital.
Purpose: Radiofrequency ablation (RFA), with or without endoscopic mucosal resection (EMR), has been validated as a safe, effective and durable treatment option for dysplastic Barrett’s esophagus. Its durability in eradicating Barrett’s associated intramucosal carcinoma (IMC), however, is unclear. We set out to assess the long-term safety and efficacy of RFA for IMC.
Methods: Retrospective review of two tertiary care facility records for patients undergoing RFA, with or without EMR, for biopsy proven IMC. Our primary outcome of interest was to quantify the rate of durable complete eradication for intestinal metaplasia and/or IMC in this high risk group. IMC eradication was defined as eradication of IMC and all co-existing dysplasia. Durable eradication was defined as completed eradication without recurrence to date. A multi-variate regression analysis was performed to identify features which correlate with durable eradication of IMC. Our secondary outcome of interest was complications.
Results: 36 patients (26 male; mean age 64 ± 12 yrs), with a mean Barrett’s length of 3.5 ± 2.5 cm, underwent RFA for biopsy proven IMC. 35 (97%) patients had co-existing high-grade dysplasia at index biopsy and EMR was performed in 31 (86%) prior to RFA. Complete eradication of IMC and intestinal metaplasia was achieved in 32/36 (89%) and 27/36 (75%) patients, respectively. Patients required a mean of 1 ± 1 EMR and 2 ± 1 RFA sessions to achieve eradication of IMC. During a mean follow-up period of 24 ± 19 months, durable complete eradication of IMC and intestinal metaplasia was achieved in 29/36 (81%) and 22/36 (61%) patients, respectively. On multi-variate regression analysis, undergoing an EMR prior to RFA was associated with an increased likelihood of maintaining durable eradication of IMC (p=0.03; 95% CI 0.060 to 0.818). Treatment related complications included: bleeding (5%) and stricture formation (19%). Patients developing strictures underwent more EMR sessions (p=0.07).
Conclusion: Radiofrequency ablation is an effective and durable treatment option for Barrett’s associated intramucosal carcinoma. Greater than 80% of patients will achieve and maintain complete eradication of IMC at a mean of 2 years follow-up. Patients should undergo EMR prior to RFA to improve treatment durability.