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Tu1164 Risk of Malignant Progression in Barrett's Esophagus With Indefinite Dysplasia: A Systematic Review and Meta-Analysis
Abstracts
Tu1164 Risk of Malignant Progression in Barrett’s Esophagus With Indefinite Dysplasia: A Systematic Review and Meta-Analysis Rajesh Krishnamoorthi*1,4, Mahendran Jayaraj2, Babu Pappu Mohan3, Varun K. Thiagarajan1, Kenneth K. Wang4, David A. Katzka4, Andrew S. Ross1, Prasad G. Iyer4 1 Digestive Disease Institue, Virginia Mason Medical Center, Seattle, WA; 2 University Of Nevada School of Medicine, Las Vegas, NV; 3University of Alabama, Tuscaloosa, AL; 4Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN Background: Risk of malignant progression in patients with Barrett’s esophagus (BE) with low grade dysplasia (BE-LGD) and high grade dysplasia (BE-HGD) has been established. However, the natural history of BE with indefinite dysplasia (BE-IND) remains unclear. We performed a systematic review and meta-analysis to estimate the pooled incidence of HGD and/or esophageal adenocarcinoma (EAC) in patients with BE-IND. Methods: A comprehensive search of several databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (earliest inception to October 2016) was conducted in accordance with PRISMA guidelines to identify studies reporting incidence of HGD, EAC, or HGD/EAC as an outcome in patients with BE-IND undergoing endoscopic surveillance. A meta-analysis of the identified studies were performed to estimate the pooled annual incidence rate of EAC alone and HGD and/or EAC in patients with BE-IND. Results: Six studies reporting incidence of EAC alone and 8 studies reporting incidence of HGD and/or EAC in patients with BE-IND were identified from the systematic review. The pooled annual incidence of EAC alone (42 cases of EAC in 1289 patients over 4938 personyears) was 0.6% (95% CI, 0.2-1.0; 6 studies) [Forest plot – figure 1]. The pooled annual incidence of HGD and/or EAC (90 cases in 1464 patients over 5662 personyears) was 1.3% (95%CI, 0.8-1.9; 8 studies) [Forest plot – figure 2]. Substantial heterogeneity was noted in the analysis. On subgroup analysis, the annual incidence of EAC in studies from US [0.3% (95% CI, 0-0.6); 3 studies] was numerically lower compared to Europe [0.9% (95% CI, 0.6-1.3); 3 studies] but the difference was not statistically significant. The studies included in the review did not report adequate data on risk factors for progression in BE-IND, which limited the ability to perform a pooled analysis of risk factors. Conclusion: The annual incidence of progression (to EAC alone and HGD and/or EAC) in patients with BE-IND appears to be similar to the risk of progression in BE- LGD. Hence, endoscopic therapy might be a consideration for patients with persistent BE-IND who have additional risk factors for progression.
Figure 1: Risk of EAC in patients with BE-IND
Figure 2: Risk of HGD and/or EAC in patients with BE-IND2
AB564 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Tu1165 Optical Coherence Tomography With Laser Cautery Marking Is a Safe and Effective Part of a Barrett’s Esophagus Monitoring Strategy Michael L. DeSimone*2, Douglas Grunwald1, Jonah Cohen1, Meir Mizrahi1, Tyler M. Berzin1, Mandeep Sawhney1, Ram Chuttani1, Douglas K. Pleskow1 1 Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; 2Internal Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA Introduction: Rates of esophageal cancer continue to rise with a 30-fold increased risk for the development of esophageal adenocarcinoma in the setting of Barrett’s esophagus (BE). Optical Coherence Tomography (OCT) is an imaging technique that allows the user to visualize the micro-architecture of mucosa to a depth of 23mm with a resolution of 1-15 micrometers. Volumetric Laser Endomicroscopy (VLE) is a technology that provides OCT images of the esophagus via a balloonbased catheter passed through the working channel of an endoscope. One thousand two hundred images are generated providing a three dimensional reconstruction of the esophageal mucosa. VLE allows real time localization of metaplastic and dysplastic mucosa. The most recent development in VLE technology gives the endoscopist the ability to mark an area of possible dysplasia with laser cautery. The mark is visible under white light endoscopy (WLE) enabling the physician to return to the area of interest for targeted biopsy or treatment. Here we present our initial experience using this novel technology. Methods: Data was collected retrospectively from a prospective database at a tertiary care academic medical center. Cases were sequential, spanning from April to August 2016. All cases were performed by a single endoscopist. Results: 26 subjects underwent the procedure over a 4-month period. All subjects had a diagnosis of BE. 8 subjects (31%) had a history of low grade dysplasia, 8 (31%) had high grade dysplasia, 7 (27%) had intramucosal carcinoma, while 3 (12%) had non-dysplastic BE as their highest histologic grade. 20 subjects (77%) had received one or more forms of prior therapy: radiofrequency ablation (RFA), cryotherapy, or endoscopic mucosal resection (EMR). RFA was performed preferentially (62%). 11 subjects (42%) had completed their treatment at the time of the VLE scan. 9 (35%) were receiving ongoing treatment. 3 (12%) were scanned prior to treatment. 3 (12%) had no treatment. The laser marking system was utilized 57 times over 26 cases (mean 2 marks per case). In 25 cases it was used to guide biopsies. In one case, the technology was utilized to guide EMR. In all cases, the marking technology was successful, with the marks being visible under WLE and/or VLE. Of the 57 specimens collected under VLE guidance, 5 samples were positive for dysplasia (8.8%). All dysplastic specimens had a score of 3 by Evans criteria. There were no complications. Conclusions: We used VLE with laser marking to guide biopsies in patients with all histologic grades of BE and a wide variety of previous endoscopic therapy. Limitations of this study include small sample size and the inclusion of learning curve cases. With additional experience, we anticipate improvement in identification of dysplasia. In all of these cases, the latest VLE technology with mucosal marking was safe and reliable.
Tu1166 Liquid Nitrogen Spray Cryotherapy Effectively Eradicates Barrett’s Esophagus Irrespective of Severity of Baseline Histology: Results of a U.S. Multicenter Registry Swathi Eluri*2, Cary C. Cotton1, Vivek Kaul3, Virendra Joshi5, Brenda J. Hoffman4, Nicholas J. Shaheen2 1 University of North Carolina at Chapel Hill, Durham, NC; 2Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC; 3Division of Gastroenterology and Hepatology, University of Rochester Medical Center & Strong Memorial Hospital, Rochester, NY; 4Department of Gastroenterology, Medical University of South Carolina, Charleston, SC; 5Department of Gastroenterology, Ochsner Clinic Foundation, New Orleans, LA Background: Liquid nitrogen spray cryotherapy (SCT) has been shown to be a safe and effective mode of treatment of Barrett’s esophagus (BE) based on data from clinical trials. However, there is limited data on treatment efficacy and factors impacting treatment outcomes outside of clinical trials. Aim: The primary aim is to assess rates of complete eradication of intestinal metaplasia (CEIM) in registry participants with BE. The secondary aim is to determine if baseline histology affects CEIM rates. Methods: This is a multicenter prospective registry of adults with esophageal lesions managed with truFreeze SCT from community and academic sites in the United States. The registry enrolled patients at the time of their first SCT treatment from 2013 to the present. For this analysis, the sample was restricted to patients with baseline non-dysplastic BE (NDBE), indefinite dysplasia (IND), lowgrade dysplasia (LGD), high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC). For the efficacy analysis, the sample was restricted to participants who were at least 270 days from treatment initiation to exclude those still under active treatment. The proportion of subjects achieving CEIM by baseline pathology was compared using bivariate analyses. Results: Among 160 subjects, mean age was 6811 years with a majority being white (95%) men (78%) (Table 1). The most
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Tu1164 Risk of Malignant Progression in Barrett’s Esophagus With Indefinite Dysplasia: A Systematic Review and Meta-Analysis Rajesh Krishnamoorthi*1,4, Mahendran Jayaraj2, Babu Pappu Mohan3, Varun K. Thiagarajan1, Kenneth K. Wang4, David A. Katzka4, Andrew S. Ross1, Prasad G. Iyer4 1 Digestive Disease Institue, Virginia Mason Medical Center, Seattle, WA; 2 University Of Nevada School of Medicine, Las Vegas, NV; 3University of Alabama, Tuscaloosa, AL; 4Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN Background: Risk of malignant progression in patients with Barrett’s esophagus (BE) with low grade dysplasia (BE-LGD) and high grade dysplasia (BE-HGD) has been established. However, the natural history of BE with indefinite dysplasia (BE-IND) remains unclear. We performed a systematic review and meta-analysis to estimate the pooled incidence of HGD and/or esophageal adenocarcinoma (EAC) in patients with BE-IND. Methods: A comprehensive search of several databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (earliest inception to October 2016) was conducted in accordance with PRISMA guidelines to identify studies reporting incidence of HGD, EAC, or HGD/EAC as an outcome in patients with BE-IND undergoing endoscopic surveillance. A meta-analysis of the identified studies were performed to estimate the pooled annual incidence rate of EAC alone and HGD and/or EAC in patients with BE-IND. Results: Six studies reporting incidence of EAC alone and 8 studies reporting incidence of HGD and/or EAC in patients with BE-IND were identified from the systematic review. The pooled annual incidence of EAC alone (42 cases of EAC in 1289 patients over 4938 personyears) was 0.6% (95% CI, 0.2-1.0; 6 studies) [Forest plot – figure 1]. The pooled annual incidence of HGD and/or EAC (90 cases in 1464 patients over 5662 personyears) was 1.3% (95%CI, 0.8-1.9; 8 studies) [Forest plot – figure 2]. Substantial heterogeneity was noted in the analysis. On subgroup analysis, the annual incidence of EAC in studies from US [0.3% (95% CI, 0-0.6); 3 studies] was numerically lower compared to Europe [0.9% (95% CI, 0.6-1.3); 3 studies] but the difference was not statistically significant. The studies included in the review did not report adequate data on risk factors for progression in BE-IND, which limited the ability to perform a pooled analysis of risk factors. Conclusion: The annual incidence of progression (to EAC alone and HGD and/or EAC) in patients with BE-IND appears to be similar to the risk of progression in BE- LGD. Hence, endoscopic therapy might be a consideration for patients with persistent BE-IND who have additional risk factors for progression.
Figure 1: Risk of EAC in patients with BE-IND
Figure 2: Risk of HGD and/or EAC in patients with BE-IND2
AB564 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Tu1165 Optical Coherence Tomography With Laser Cautery Marking Is a Safe and Effective Part of a Barrett’s Esophagus Monitoring Strategy Michael L. DeSimone*2, Douglas Grunwald1, Jonah Cohen1, Meir Mizrahi1, Tyler M. Berzin1, Mandeep Sawhney1, Ram Chuttani1, Douglas K. Pleskow1 1 Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; 2Internal Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA Introduction: Rates of esophageal cancer continue to rise with a 30-fold increased risk for the development of esophageal adenocarcinoma in the setting of Barrett’s esophagus (BE). Optical Coherence Tomography (OCT) is an imaging technique that allows the user to visualize the micro-architecture of mucosa to a depth of 23mm with a resolution of 1-15 micrometers. Volumetric Laser Endomicroscopy (VLE) is a technology that provides OCT images of the esophagus via a balloonbased catheter passed through the working channel of an endoscope. One thousand two hundred images are generated providing a three dimensional reconstruction of the esophageal mucosa. VLE allows real time localization of metaplastic and dysplastic mucosa. The most recent development in VLE technology gives the endoscopist the ability to mark an area of possible dysplasia with laser cautery. The mark is visible under white light endoscopy (WLE) enabling the physician to return to the area of interest for targeted biopsy or treatment. Here we present our initial experience using this novel technology. Methods: Data was collected retrospectively from a prospective database at a tertiary care academic medical center. Cases were sequential, spanning from April to August 2016. All cases were performed by a single endoscopist. Results: 26 subjects underwent the procedure over a 4-month period. All subjects had a diagnosis of BE. 8 subjects (31%) had a history of low grade dysplasia, 8 (31%) had high grade dysplasia, 7 (27%) had intramucosal carcinoma, while 3 (12%) had non-dysplastic BE as their highest histologic grade. 20 subjects (77%) had received one or more forms of prior therapy: radiofrequency ablation (RFA), cryotherapy, or endoscopic mucosal resection (EMR). RFA was performed preferentially (62%). 11 subjects (42%) had completed their treatment at the time of the VLE scan. 9 (35%) were receiving ongoing treatment. 3 (12%) were scanned prior to treatment. 3 (12%) had no treatment. The laser marking system was utilized 57 times over 26 cases (mean 2 marks per case). In 25 cases it was used to guide biopsies. In one case, the technology was utilized to guide EMR. In all cases, the marking technology was successful, with the marks being visible under WLE and/or VLE. Of the 57 specimens collected under VLE guidance, 5 samples were positive for dysplasia (8.8%). All dysplastic specimens had a score of 3 by Evans criteria. There were no complications. Conclusions: We used VLE with laser marking to guide biopsies in patients with all histologic grades of BE and a wide variety of previous endoscopic therapy. Limitations of this study include small sample size and the inclusion of learning curve cases. With additional experience, we anticipate improvement in identification of dysplasia. In all of these cases, the latest VLE technology with mucosal marking was safe and reliable.
Tu1166 Liquid Nitrogen Spray Cryotherapy Effectively Eradicates Barrett’s Esophagus Irrespective of Severity of Baseline Histology: Results of a U.S. Multicenter Registry Swathi Eluri*2, Cary C. Cotton1, Vivek Kaul3, Virendra Joshi5, Brenda J. Hoffman4, Nicholas J. Shaheen2 1 University of North Carolina at Chapel Hill, Durham, NC; 2Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC; 3Division of Gastroenterology and Hepatology, University of Rochester Medical Center & Strong Memorial Hospital, Rochester, NY; 4Department of Gastroenterology, Medical University of South Carolina, Charleston, SC; 5Department of Gastroenterology, Ochsner Clinic Foundation, New Orleans, LA Background: Liquid nitrogen spray cryotherapy (SCT) has been shown to be a safe and effective mode of treatment of Barrett’s esophagus (BE) based on data from clinical trials. However, there is limited data on treatment efficacy and factors impacting treatment outcomes outside of clinical trials. Aim: The primary aim is to assess rates of complete eradication of intestinal metaplasia (CEIM) in registry participants with BE. The secondary aim is to determine if baseline histology affects CEIM rates. Methods: This is a multicenter prospective registry of adults with esophageal lesions managed with truFreeze SCT from community and academic sites in the United States. The registry enrolled patients at the time of their first SCT treatment from 2013 to the present. For this analysis, the sample was restricted to patients with baseline non-dysplastic BE (NDBE), indefinite dysplasia (IND), lowgrade dysplasia (LGD), high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC). For the efficacy analysis, the sample was restricted to participants who were at least 270 days from treatment initiation to exclude those still under active treatment. The proportion of subjects achieving CEIM by baseline pathology was compared using bivariate analyses. Results: Among 160 subjects, mean age was 6811 years with a majority being white (95%) men (78%) (Table 1). The most
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