Subsquamous Neoplasia After RFA of Barrett's Esophagus
Subsquamous Neoplasia After RFA of Barrett's Esophagus
Patients with Barrett's esophagus are frequently treated with radiofrequency ablation (RFA). Those that undergo this procedure have a low risk of developing subsquamous intestinal metaplasia, and none have been reported to develop subsquamous dysplasia or cancer. We report the development of subsquamous neoplasia in 3 patients who were treated with RFA for Barrett's esophagus (2 developed adenocarcinoma and 1 developed high-grade dysplasia). The identification of these cases indicates the need for continued surveillance following RFA, even after complete eradication of intestinal metaplasia, and caution for widespread use of ablation, especially in patients with low-risk Barrett's esophagus.
Barrett's esophagus is the only known precursor to esophageal adenocarcinoma, a cancer that continues to increase in incidence. Progression to adenocarcinoma may involve progressive histologic changes from intestinal metaplasia to low-grade dysplasia to high-grade dysplasia to adenocarcinoma. Neither medical nor surgical therapy has yet shown a major impact on cancer risk in Barrett's esophagus. In contrast, there has been much interest in techniques for Barrett's ablation in an effort to decrease or even eliminate cancer risk.
Increasing research is being directed to radiofrequency ablation (RFA) as an ideal ablation technique. However, one of the concerns after any ablation technique is development of subsquamous intestinal metaplasia, which could have the potential to progress to neoplasia. Thirty-four cases with subsquamous neoplasia have been described in the literature, with the majority occurring after photodynamic therapy (31 cases); the other 3 cases were after argon plasma coagulation or laser ablation. To date, no cases of subsquamous neoplasia have been reported after RFA.
We report 3 cases of subsquamous neoplasia: 2 with adenocarcinoma and 1 with high-grade dysplasia detected after apparently successful RFA. The reporting centers have been performing RFA for several years (approximately 215 cases total). All procedures in these cases were performed by the respective investigators at each center. All patients were being treated with a twice-daily dose of a proton pump inhibitor at the time of neoplasia occurrence; proton pump inhibitor therapy was initiated and continued during the ablation period. These patients had undergone surveillance biopsies per the Seattle protocol before undergoing endoscopic therapy. Finally, postablation biopsy specimens were obtained only when the investigator observed neosquamous mucosa without any evidence of columnar lining in the distal esophagus (Supplemantary Materials and Methods).
Abstract and Introduction
Abstract
Patients with Barrett's esophagus are frequently treated with radiofrequency ablation (RFA). Those that undergo this procedure have a low risk of developing subsquamous intestinal metaplasia, and none have been reported to develop subsquamous dysplasia or cancer. We report the development of subsquamous neoplasia in 3 patients who were treated with RFA for Barrett's esophagus (2 developed adenocarcinoma and 1 developed high-grade dysplasia). The identification of these cases indicates the need for continued surveillance following RFA, even after complete eradication of intestinal metaplasia, and caution for widespread use of ablation, especially in patients with low-risk Barrett's esophagus.
Introduction
Barrett's esophagus is the only known precursor to esophageal adenocarcinoma, a cancer that continues to increase in incidence. Progression to adenocarcinoma may involve progressive histologic changes from intestinal metaplasia to low-grade dysplasia to high-grade dysplasia to adenocarcinoma. Neither medical nor surgical therapy has yet shown a major impact on cancer risk in Barrett's esophagus. In contrast, there has been much interest in techniques for Barrett's ablation in an effort to decrease or even eliminate cancer risk.
Increasing research is being directed to radiofrequency ablation (RFA) as an ideal ablation technique. However, one of the concerns after any ablation technique is development of subsquamous intestinal metaplasia, which could have the potential to progress to neoplasia. Thirty-four cases with subsquamous neoplasia have been described in the literature, with the majority occurring after photodynamic therapy (31 cases); the other 3 cases were after argon plasma coagulation or laser ablation. To date, no cases of subsquamous neoplasia have been reported after RFA.
We report 3 cases of subsquamous neoplasia: 2 with adenocarcinoma and 1 with high-grade dysplasia detected after apparently successful RFA. The reporting centers have been performing RFA for several years (approximately 215 cases total). All procedures in these cases were performed by the respective investigators at each center. All patients were being treated with a twice-daily dose of a proton pump inhibitor at the time of neoplasia occurrence; proton pump inhibitor therapy was initiated and continued during the ablation period. These patients had undergone surveillance biopsies per the Seattle protocol before undergoing endoscopic therapy. Finally, postablation biopsy specimens were obtained only when the investigator observed neosquamous mucosa without any evidence of columnar lining in the distal esophagus (Supplemantary Materials and Methods).
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