- Email: [email protected]
Tu1556 Role of Spray Cryotherapy and Wats in Dysplastic Barrett's Esophagus Refractory to Radiofrequency Ablation
Abstracts
Length of BE, Prague M, cm, mean SD CEIM rate, % No. of RFAs to achieve CEIM, mean SD IM-recurrence rate, %(/) Time to IM-recurrence, yrs, mean SD
Normal/ Underweight N[61
Overweight N[121
Obese N[132
Pvalue
4.63.7
5.23.4
4.63.3
0.38
67.2 2.61.5
81.8 2.41.4
80.3 2.21.6
0.07 0.47
14.6 (6/41)
9.1 (9/99)
0.29
1.51.3
2.42.2
16.0 (17/ 106) 2.21.6
0.61
Figure 1. Kaplan-Meier curves of durability of CEIM by BMI status.
Tu1554 Quantity of Focal Radiofrequency Ablation Treatments At the Esophagogastric Junction Does Not Correlate With Recurrence of Intestinal Metaplasia Emily Walzer*, Natalya Iorio, Michael S. Smith Medicine/Gastroenterology, Temple University School of Medicine, Philadelphia, PA Background: Barrett’s esophagus (BE) is a pre-malignant condition defined as intestinal metaplasia (IM) of the tubular esophagus. Radiofrequency ablation (RFA) is an effective technique for endoscopic BE ablation. However, studies have shown recurrent IM and/or dysplasia even after achieving complete remission (CR). Most recurrences are at the esophagogastric junction (EGJ). Multiple RFA treatments focusing at that site could decrease the risk of recurrence. Our aim was to evaluate whether the likelihood of recurrent IM is affected by the number of focal RFA treatments at the EGJ. Methods: All patients at our institution undergoing RFA for BE eradication from 2009 to 2014 were identified. Our protocol requires circumferential RFA with a BarrxÔ 360 catheter for at least the initial treatment of long segment BE, after which focal RFA (BarrxTM 90 catheter) is used during subsequent sessions. Short segment BE was treated only with focal RFA. During all focal RFA sessions, the EGJ was ablated, even if the Z-line appeared regular. Post-ablation surveillance was performed using a modified Seattle protocol, with 4-quadrant biopsies every 1 centimeter (cm) throughout the original BE segment. Patients were included in the analysis if they achieved CR of IM, defined as the absence of endoscopic and histologic evidence of BE on at least two consecutive post-ablation endoscopies. Prior endoscopic mucosal resection (EMR) was allowed but other field treatments such as spray cryotherapy were not. Demographic, endoscopic and histologic data were collected prior to completion of statistical analysis. Results: Fifty patients achieved CR of IM during the study period. Original BE grades included intramucosal carcinoma (6%), high grade dysplasia (30%), low grade dysplasia (24%) and nondysplastic IM (40%). The mean pre-ablation BE length was 4.04 cm. Seven patients (14%) had EMR before RFA. Nine patients (18%) had recurrent IM, and none had recurrent dysplasia or neoplasia. Patients with recurrence had an average of 2.25 focal RFA treatments, compared to 2.76 treatments for patients without recurrence (pZ0.735). Recurrent BE was detected an average of 25.5 months after the last ablation. Patients who did not recur were followed for an average of 21.7 months after their last treatment. Conclusions: Recurrence after RFA was detected in nearly 1 in 5 patients who achieved CR of IM. However, neither dysplasia nor neoplasia recurred in any patients even though 68% had advanced BE prior to RFA. Analysis
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showed no statistical difference in the number of focal RFA treatments performed at the GEJ for patients who had recurrent IM versus those who remained in remission. On average, both groups received more than 2 RFA treatments at the GEJ, suggesting that this number of treatments eliminates inadequate ablation as the etiology of recurrence in this patient population.
Tu1555 Buried Barrett’s Dysplasia: RFA Is Not the Only Culprit Rupam Bhattacharyya*1, Fergus Chedgy1, Kesavan Kandiah1, Asma A. Alkandari1, Shareef Tholoor2, Pradeep Bhandari1 1 Portsmouth Hospitals NHS Trust, Cosham, Portsmouth, United Kingdom; 2Gastroenterology, St. Mark’s Hospital and Academic Institute, London, United Kingdom Introduction: Buried Barrett’s’ or Subsquamous Intestinal Metaplasia (SSIM) refers to glands which are ‘buried’ underneath the squamous epithelium. Buried Barrett’s can pose significant diagnostic and surveillance challenges. Buried Barrett’s has mainly been reported in the post ablation context (APC, RFA, PDT). We aim to evaluate its prevalence in patients who are ablation naïve, and understand the reasons behind it. Methods: This is a prospective cohort study. We investigated our Barrett’s database for patients who were referred for endoscopic treatment (EMR) of Barrett’s neoplasia between June 2006 to June 2014. We assessed histology reports before and after endoscopic therapy (EMR), specifically looking for evidence of buried Barrett’s. Biopsy:- Biopsies were first obtained from any suspicious looking area. Following this, biopsies were then obtained from the neosquamous area. Finally, random biopsies were obtained. These were sent in separate cassettes. Histopathology was reported by two independent GI pathologists and was prospectively recorded on a central pathology database.- Buried Barrett’s was defined as any metaplastic or glandular tissue beneath the squamous epithelium. Pathology specimens were reported by 2 independent, accredited GI pathologists. Results: Our study shows that in the pre-EMR cohort, there was an overall prevalence of 12.2% of buried Barrett’s and a 9.1% prevalence of buried Barrett’s with high grade neoplasia (HGD or IMC).Our results in the post EMR cohort shows an overall prevalence of 16.8% of buried Barrett’s with 6.1% prevalence of buried high grade neoplasia (HGD or IMC). This has significant implications for post EMR endoscopic assessment and surveillance. Conclusion: 1) Buried Barrett’s and Barrett’s cancer are seen in endotherapy naïve patients. This is likely to be related to intensive biopsies. 2) EMR, despite being a non ablation technique, still results in buried Barrett’s and Barrett’s cancer. 3) The overall prevalence of buried Barrett’s is higher than previously reported. We need to be aware of this while assessing Barrett’s patients. Buried Barrett’s glands after ablation (APC/RFA/PDT) are well reported. This is the first study to report on the prevalence of Barrett’s in endotherapy naïve patients and in the post EMR cohort.
Buried Barrett’s with and without dysplasia
Total Buried Barrett’s with no dysplasia Buried Barrett’s dysplasia HGD IMC HGD + IMC LGD
Buried Barrett’s diagnosed in endoscopic therapy naïve patients
Buried Barrett’s diagnosed in patients post EMR procedure
16/131 (12.2%) 2/131 (1.5%)
22/131 (16.8%) 10/131 (7.6%)
14/131 (10.7%)
13/131 (9.9%)
9/131 (6.9%) 3/131 (2.3%) 12/131 (9.1%) 2/131 (1.5%)
4/131 4/131 8/131 5/131
(3.0%) (3.0%) (6.1%) (3.8%)
Tu1556 Role of Spray Cryotherapy and Wats in Dysplastic Barrett’s Esophagus Refractory to Radiofrequency Ablation Brandon Sprung*, Christine M. Granato, Shivangi Kothari, Truptesh H. Kothari, Vivek Kaul Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology and Hepatology, University of Rochester, Rochester, NY Background: Radiofrequency ablation (RFA) is the most commonly used endoscopic ablation technique to manage dysplastic Barrett’s esophagus (BE). Despite this, up to 33% of patients develop persistent or recurrent intestinal metaplasia (IM) or dysplasia following RFA (RFA failure). RFA treatment failures represent a clinical challenge. Spray cryotherapy has shown complete remission of intestinal metaplasia (CR-IM) in 57-78% of patients in this population. We evaluated the outcomes of RFA treatment failures treated with endoscopic cryotherapy at our center. Methods: We retrospectively reviewed the endoscopic cryotherapy database at our center. We identified 5 patients who underwent spray cryotherapy specifically for the indication
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB507
Abstracts of “failed RFA therapy” and had adequate follow up. RFA treatment failure was defined as the pathologic finding of persistent IM with/without dysplasia/neoplasia or progression of disease based on biopsy results after 5 RFA sessions. Patient demographics, BE characteristics, and endoscopic/pathologic measures were recorded (see table). All patients had at least one post-cryotherapy surveillance EGD with Seattle protocol based forceps biopsy and Wide Area Transepithelial Sampling (WATS) brush biopsy. Results: Five subjects met inclusion criteria (see table); all were Caucasian males, mean age 72.8 years, and mean BMI 30.5kg/m2. Patients underwent an average of 7.4 RFA sessions BEFORE undergoing cryotherapy. CR-IM was achieved in all 5 patients after an average of 4 cryotherapy sessions. Pre-cryotherapy, patients #1 and #2 also underwent multiband mucosectomy for nodular Barrett’s lesions. All patients remained on high-dose PPI pre and post-cryotherapy. Patient # 5 did eventually develop recurrence of focal IM+LGD and underwent repeat session with ablation. Discussion: We present a cohort of 5 patients with dysplastic BE who underwent successful cryoablation after initial failed RFA. Previous reports in a similar cohort revealed an overall improvement in dysplasia in 25-90% of patients (CR-IM not reported). In our cohort, CR-IM was achieved initially in 5/5 (100%) patients; one patient had recurrent IM in follow-up post cryotherapy (patient # 5), underwent repeat ablation and is undergoing surveillance exams. Conclusions: Spray cryotherapy appears to be an effective therapy for dysplastic BE refractory to RFA treatment. Despite the difficult to eradicate IM and dysplasia in this population, 100 % CR-IM was achieved, with fewer sessions needed to achieve this using cryotherapy. In addition, WATS brush biopsy is useful in post-ablation surveillance in this patient population and adds incremental value over forceps biopsy alone, to assess for durable response. Importantly, this remains a challenging patient population, where disease recurrence can develop and continued close, multimodal surveillance is required.
Pre-RFA Histology
# RFA Sessions
Duration of RFA (months)
BE+LGD+ HGD+ImCa BE+LGD+HGD
5
2
7
3
BE+LGD
4
BE+LGD
5
BE+LGD
7
Patient Number 1
Post-RFA Histology
# Cryotherapy Sessions
Postcryotherapy Histology
31
BE+HGD
1
15
BE+LGD+HGD
6
8
33
BE+LGD+HGD
5
10
36
BE+LGD
6
10
BE+LGD
2
Neosquamous mucosa Neosquamous mucosa Neosquamous mucosa Neosquamous mucosa Neosquamous mucosa
Followup After First Negative Biopsy (months) 13 33 9 3 7
BEZBarrett’s esophagus; LGDZLow Grade Dysplasia; HGDZHigh Grade Dysplasia; ImCaZIntramucosal Carcinoma
Tu1557 Cryotherapy With Endoscopic Mucosal Resection (EMR) for Barrett’s Neoplasia: Does Cryotherapy Interfere With Pathological Evaluation? Norio Fukami*1, Jeffrey B. Kaplan2, Mikhail Lisovsky3, Alissa Bults1, Stuart R. Gordon4 1 Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO; 2Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO; 3Pathology, Dartmouth College, Hanover, NH; 4Gastroenterology, Dartmouth College, Hanover, NH Background: Ablation therapy in conjunction with EMR is well-accepted first modality to treat Barrett’s esophagus (BE) with dysplasia. EMR is typically performed first to remove the nodularity and evaluate the tumor stage (pathological evaluation), then, ablation is applied to eradicate all areas of BE. A separate session is usually set up for those two treatments; however, single session EMR and ablation would reduce the number of procedures needed to eradicate the BE. Due to a scarcity of data, it remains unknown if pre-treatment with cryotherapy interferes with the crucial pathological assessment of the EMR specimen and consequently it is unknown if recommendation should be made to perform pre- vs. post-EMR cryotherapy. Aim: Evaluate EMR specimens pre- and post-cryotherapy to define the possible interference of cryotherapy on pathological evaluation. Methods: A single GI pathologist blindly evaluated six patients’ slides from two academic centers. These consist of 3 pre-cryotherapy EMR patients and 3 immediate post-cryotherapy EMR patients. Tissue slides (13 sites: 4 pre-cryo EMRs, 2 biopsies; 5 post-cryo EMRs, 2 biopsies) were evaluated for histological grade, depth of invasion, margins, and lymphovascular invasion. Results: Pathological diagnosis originally reported were 5 carcinoma (CA), 3 high grade dysplasia (HGD), 4 BE, and 1 gastric mucosa. Blinded
AB508 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
evaluation agreed on degree of dysplasia in 10 sites, disagreement on HGD vs. CA in one, and was unable to be evaluated in 2. Both sites unable to be evaluated were post-cryo EMRs that did not contain cancer. Margins of EMR specimens were reported in 6 sites, mostly for slides containing CA. Margins were in agreement in 3/6 sites (2 pre-cryo EMR, 1 post-cryo EMR). All disagreement was in post-cryo EMR specimens. Two EMRs were not evaluable for margins and one was judged positive for CA but original report was negative. There was no disagreement in lymphovascular invasion. Significant surface glandular structure damage and denudation was noted in post-cryo specimens, yet squamous mucosa was fairly preserved. Conclusions: Cryotherapy appears to interfere with tissue evaluation even though the mucosa was immediately removed after cryotherapy. The primary effect was glandular surface destruction and it does not appear to affect deeper structures. Margin assessment was frequently affected by the cryotherapy (50%), and this may limit assessment for complete resection of CA. Pre-cryotherapy EMR would be preferable for patients suspected to have carcinoma.
Tu1558 Safety and Efficacy of Same Session Spray Cryotherapy and Endoscopic Mucosal Resection for Barrett’s Esophagus and Early Esophageal Neoplasia: a Multicenter Experience Zilla H. Hussain*1, Norio Fukami2, Michael S. Smith3, Jayaprakash Sreenarasimhaiah4, Vivek Kaul5, Shivangi Kothari5, Bruce D. Greenwald6, Nicholas J. Shaheen7, John M. Levenick8, Steven A. Edmundowicz9, Vladimir M. Kushnir9, Virendra Joshi10, Hiroshi Mashimo11, Sarah M. Hyder1, Timothy B. Gardner1, Richard I. Rothstein1, Stuart R. Gordon1 1 Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; 2 University of Colorado Medical Center, Denver, CO; 3Temple University Hospital, Philadelphia, PA; 4University of Texas Southwestern Medical Center, Dallas, TX; 5University of Rochester Medical Center, Rochester, NY; 6University of Maryland Medical Center, Baltimore, MD; 7University of North Carolina Medical Center, Chapel Hill, NC; 8Penn State Hershey Medical Center, Hershey, PA; 9Washington University St. Louis Medical Center, St. Louis, MO; 10Ochsner Medical Center, New Orleans, LA; 11VA Boston Healthcare, Boston, MA Background/Study Aims: Endoscopic mucosal resection (EMR) and spray cryotherapy (SCT) are effective endoscopic therapies to eradicate Barrett’s esophagus (BE) and early esophageal neoplasia. Typically, when EMR is performed as initial therapy for nodular disease and/or esophageal neoplasia, the ablation of residual flat Barrett’s is performed at subsequent endoscopies. However, it is unknown if SCT and EMR in the same session is clinically safe and effective. We aimed to assess the safety and outcomes of such an approach. Methods: Demographic, procedural and outcomes data were prepared at eleven high volume BE ablation centers and the results were aggregated for analysis for patients who underwent same session SCT and EMR for BE and/or early esophageal neoplasia between 2008 and 2014. Results: A total of 28 patients (23 male, 5 female, mean age 67 years, BE mean length 4.5 cm) underwent same session SCT (27 liquid nitrogen, 1 liquid carbon dioxide) and EMR (21 multiband mucosectomy device, 7 cap assisted device). Nodularity was recorded in 27/28 patients. Mean aggregate nodularity size was 10.3 mm. EMR was performed before SCT in 7 patients and after SCT in 21 patients. Mean diameter of the resected tissue was 1.9 cm with an average of 1.9 specimens per resection. Pathology was interpreted without difficulty in all but 2 patients (both post SCT): 6 patients had non-dysplastic BE, 12 patients had dysplastic BE (3 low grade dysplasia, 9 high grade dysplasia), and 10 patients had early esophageal cancer (8 patients intramucosal carcinoma; IMC/T1a, 2 patients invasive adenocarcinoma/T1b). The deep resection margin was negative in 26/28 patients (93%) and positive in 2 patients (1 with T1a, 1 with T1b carcinoma). Complications occurred in 4 patients: 2 patients had post procedural stricture and 2 patients had intra-procedural bleeding controlled with endoscopic clips. No other adverse events noted. The 2 patients with positive deep margins (1 T1a, 1 T1b) were referred for surgical and oncologic management. So far, 18 of the remaining 26 patients have had at least one follow-up endoscopy, none having residual nodularity. 6 patients had no evidence for residual BE and 12 patients had residual flat BE: 8 with non-dysplastic BE (7 treated with repeat SCT, 1 treated with radiofrequency ablation;RFA), 3 with low grade BE (1 lost to follow-up, 1 treated with repeat SCT, 1 treated with RFA), and 1 with residual IMC (treated with repeat SCT). Conclusions: Same session SCT and EMR for the endoscopic management of BE and/or early esophageal neoplasia is a safe and effective treatment strategy and may expedite the eradication of dysplasia and BE by performing field ablation at the same time as nodule resection rather than waiting 6-8 weeks as per the current standard. Further studies are needed to determine whether EMR pre- or post-SCT is superior.
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Length of BE, Prague M, cm, mean SD CEIM rate, % No. of RFAs to achieve CEIM, mean SD IM-recurrence rate, %(/) Time to IM-recurrence, yrs, mean SD
Normal/ Underweight N[61
Overweight N[121
Obese N[132
Pvalue
4.63.7
5.23.4
4.63.3
0.38
67.2 2.61.5
81.8 2.41.4
80.3 2.21.6
0.07 0.47
14.6 (6/41)
9.1 (9/99)
0.29
1.51.3
2.42.2
16.0 (17/ 106) 2.21.6
0.61
Figure 1. Kaplan-Meier curves of durability of CEIM by BMI status.
Tu1554 Quantity of Focal Radiofrequency Ablation Treatments At the Esophagogastric Junction Does Not Correlate With Recurrence of Intestinal Metaplasia Emily Walzer*, Natalya Iorio, Michael S. Smith Medicine/Gastroenterology, Temple University School of Medicine, Philadelphia, PA Background: Barrett’s esophagus (BE) is a pre-malignant condition defined as intestinal metaplasia (IM) of the tubular esophagus. Radiofrequency ablation (RFA) is an effective technique for endoscopic BE ablation. However, studies have shown recurrent IM and/or dysplasia even after achieving complete remission (CR). Most recurrences are at the esophagogastric junction (EGJ). Multiple RFA treatments focusing at that site could decrease the risk of recurrence. Our aim was to evaluate whether the likelihood of recurrent IM is affected by the number of focal RFA treatments at the EGJ. Methods: All patients at our institution undergoing RFA for BE eradication from 2009 to 2014 were identified. Our protocol requires circumferential RFA with a BarrxÔ 360 catheter for at least the initial treatment of long segment BE, after which focal RFA (BarrxTM 90 catheter) is used during subsequent sessions. Short segment BE was treated only with focal RFA. During all focal RFA sessions, the EGJ was ablated, even if the Z-line appeared regular. Post-ablation surveillance was performed using a modified Seattle protocol, with 4-quadrant biopsies every 1 centimeter (cm) throughout the original BE segment. Patients were included in the analysis if they achieved CR of IM, defined as the absence of endoscopic and histologic evidence of BE on at least two consecutive post-ablation endoscopies. Prior endoscopic mucosal resection (EMR) was allowed but other field treatments such as spray cryotherapy were not. Demographic, endoscopic and histologic data were collected prior to completion of statistical analysis. Results: Fifty patients achieved CR of IM during the study period. Original BE grades included intramucosal carcinoma (6%), high grade dysplasia (30%), low grade dysplasia (24%) and nondysplastic IM (40%). The mean pre-ablation BE length was 4.04 cm. Seven patients (14%) had EMR before RFA. Nine patients (18%) had recurrent IM, and none had recurrent dysplasia or neoplasia. Patients with recurrence had an average of 2.25 focal RFA treatments, compared to 2.76 treatments for patients without recurrence (pZ0.735). Recurrent BE was detected an average of 25.5 months after the last ablation. Patients who did not recur were followed for an average of 21.7 months after their last treatment. Conclusions: Recurrence after RFA was detected in nearly 1 in 5 patients who achieved CR of IM. However, neither dysplasia nor neoplasia recurred in any patients even though 68% had advanced BE prior to RFA. Analysis
www.giejournal.org
showed no statistical difference in the number of focal RFA treatments performed at the GEJ for patients who had recurrent IM versus those who remained in remission. On average, both groups received more than 2 RFA treatments at the GEJ, suggesting that this number of treatments eliminates inadequate ablation as the etiology of recurrence in this patient population.
Tu1555 Buried Barrett’s Dysplasia: RFA Is Not the Only Culprit Rupam Bhattacharyya*1, Fergus Chedgy1, Kesavan Kandiah1, Asma A. Alkandari1, Shareef Tholoor2, Pradeep Bhandari1 1 Portsmouth Hospitals NHS Trust, Cosham, Portsmouth, United Kingdom; 2Gastroenterology, St. Mark’s Hospital and Academic Institute, London, United Kingdom Introduction: Buried Barrett’s’ or Subsquamous Intestinal Metaplasia (SSIM) refers to glands which are ‘buried’ underneath the squamous epithelium. Buried Barrett’s can pose significant diagnostic and surveillance challenges. Buried Barrett’s has mainly been reported in the post ablation context (APC, RFA, PDT). We aim to evaluate its prevalence in patients who are ablation naïve, and understand the reasons behind it. Methods: This is a prospective cohort study. We investigated our Barrett’s database for patients who were referred for endoscopic treatment (EMR) of Barrett’s neoplasia between June 2006 to June 2014. We assessed histology reports before and after endoscopic therapy (EMR), specifically looking for evidence of buried Barrett’s. Biopsy:- Biopsies were first obtained from any suspicious looking area. Following this, biopsies were then obtained from the neosquamous area. Finally, random biopsies were obtained. These were sent in separate cassettes. Histopathology was reported by two independent GI pathologists and was prospectively recorded on a central pathology database.- Buried Barrett’s was defined as any metaplastic or glandular tissue beneath the squamous epithelium. Pathology specimens were reported by 2 independent, accredited GI pathologists. Results: Our study shows that in the pre-EMR cohort, there was an overall prevalence of 12.2% of buried Barrett’s and a 9.1% prevalence of buried Barrett’s with high grade neoplasia (HGD or IMC).Our results in the post EMR cohort shows an overall prevalence of 16.8% of buried Barrett’s with 6.1% prevalence of buried high grade neoplasia (HGD or IMC). This has significant implications for post EMR endoscopic assessment and surveillance. Conclusion: 1) Buried Barrett’s and Barrett’s cancer are seen in endotherapy naïve patients. This is likely to be related to intensive biopsies. 2) EMR, despite being a non ablation technique, still results in buried Barrett’s and Barrett’s cancer. 3) The overall prevalence of buried Barrett’s is higher than previously reported. We need to be aware of this while assessing Barrett’s patients. Buried Barrett’s glands after ablation (APC/RFA/PDT) are well reported. This is the first study to report on the prevalence of Barrett’s in endotherapy naïve patients and in the post EMR cohort.
Buried Barrett’s with and without dysplasia
Total Buried Barrett’s with no dysplasia Buried Barrett’s dysplasia HGD IMC HGD + IMC LGD
Buried Barrett’s diagnosed in endoscopic therapy naïve patients
Buried Barrett’s diagnosed in patients post EMR procedure
16/131 (12.2%) 2/131 (1.5%)
22/131 (16.8%) 10/131 (7.6%)
14/131 (10.7%)
13/131 (9.9%)
9/131 (6.9%) 3/131 (2.3%) 12/131 (9.1%) 2/131 (1.5%)
4/131 4/131 8/131 5/131
(3.0%) (3.0%) (6.1%) (3.8%)
Tu1556 Role of Spray Cryotherapy and Wats in Dysplastic Barrett’s Esophagus Refractory to Radiofrequency Ablation Brandon Sprung*, Christine M. Granato, Shivangi Kothari, Truptesh H. Kothari, Vivek Kaul Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology and Hepatology, University of Rochester, Rochester, NY Background: Radiofrequency ablation (RFA) is the most commonly used endoscopic ablation technique to manage dysplastic Barrett’s esophagus (BE). Despite this, up to 33% of patients develop persistent or recurrent intestinal metaplasia (IM) or dysplasia following RFA (RFA failure). RFA treatment failures represent a clinical challenge. Spray cryotherapy has shown complete remission of intestinal metaplasia (CR-IM) in 57-78% of patients in this population. We evaluated the outcomes of RFA treatment failures treated with endoscopic cryotherapy at our center. Methods: We retrospectively reviewed the endoscopic cryotherapy database at our center. We identified 5 patients who underwent spray cryotherapy specifically for the indication
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB507
Abstracts of “failed RFA therapy” and had adequate follow up. RFA treatment failure was defined as the pathologic finding of persistent IM with/without dysplasia/neoplasia or progression of disease based on biopsy results after 5 RFA sessions. Patient demographics, BE characteristics, and endoscopic/pathologic measures were recorded (see table). All patients had at least one post-cryotherapy surveillance EGD with Seattle protocol based forceps biopsy and Wide Area Transepithelial Sampling (WATS) brush biopsy. Results: Five subjects met inclusion criteria (see table); all were Caucasian males, mean age 72.8 years, and mean BMI 30.5kg/m2. Patients underwent an average of 7.4 RFA sessions BEFORE undergoing cryotherapy. CR-IM was achieved in all 5 patients after an average of 4 cryotherapy sessions. Pre-cryotherapy, patients #1 and #2 also underwent multiband mucosectomy for nodular Barrett’s lesions. All patients remained on high-dose PPI pre and post-cryotherapy. Patient # 5 did eventually develop recurrence of focal IM+LGD and underwent repeat session with ablation. Discussion: We present a cohort of 5 patients with dysplastic BE who underwent successful cryoablation after initial failed RFA. Previous reports in a similar cohort revealed an overall improvement in dysplasia in 25-90% of patients (CR-IM not reported). In our cohort, CR-IM was achieved initially in 5/5 (100%) patients; one patient had recurrent IM in follow-up post cryotherapy (patient # 5), underwent repeat ablation and is undergoing surveillance exams. Conclusions: Spray cryotherapy appears to be an effective therapy for dysplastic BE refractory to RFA treatment. Despite the difficult to eradicate IM and dysplasia in this population, 100 % CR-IM was achieved, with fewer sessions needed to achieve this using cryotherapy. In addition, WATS brush biopsy is useful in post-ablation surveillance in this patient population and adds incremental value over forceps biopsy alone, to assess for durable response. Importantly, this remains a challenging patient population, where disease recurrence can develop and continued close, multimodal surveillance is required.
Pre-RFA Histology
# RFA Sessions
Duration of RFA (months)
BE+LGD+ HGD+ImCa BE+LGD+HGD
5
2
7
3
BE+LGD
4
BE+LGD
5
BE+LGD
7
Patient Number 1
Post-RFA Histology
# Cryotherapy Sessions
Postcryotherapy Histology
31
BE+HGD
1
15
BE+LGD+HGD
6
8
33
BE+LGD+HGD
5
10
36
BE+LGD
6
10
BE+LGD
2
Neosquamous mucosa Neosquamous mucosa Neosquamous mucosa Neosquamous mucosa Neosquamous mucosa
Followup After First Negative Biopsy (months) 13 33 9 3 7
BEZBarrett’s esophagus; LGDZLow Grade Dysplasia; HGDZHigh Grade Dysplasia; ImCaZIntramucosal Carcinoma
Tu1557 Cryotherapy With Endoscopic Mucosal Resection (EMR) for Barrett’s Neoplasia: Does Cryotherapy Interfere With Pathological Evaluation? Norio Fukami*1, Jeffrey B. Kaplan2, Mikhail Lisovsky3, Alissa Bults1, Stuart R. Gordon4 1 Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO; 2Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO; 3Pathology, Dartmouth College, Hanover, NH; 4Gastroenterology, Dartmouth College, Hanover, NH Background: Ablation therapy in conjunction with EMR is well-accepted first modality to treat Barrett’s esophagus (BE) with dysplasia. EMR is typically performed first to remove the nodularity and evaluate the tumor stage (pathological evaluation), then, ablation is applied to eradicate all areas of BE. A separate session is usually set up for those two treatments; however, single session EMR and ablation would reduce the number of procedures needed to eradicate the BE. Due to a scarcity of data, it remains unknown if pre-treatment with cryotherapy interferes with the crucial pathological assessment of the EMR specimen and consequently it is unknown if recommendation should be made to perform pre- vs. post-EMR cryotherapy. Aim: Evaluate EMR specimens pre- and post-cryotherapy to define the possible interference of cryotherapy on pathological evaluation. Methods: A single GI pathologist blindly evaluated six patients’ slides from two academic centers. These consist of 3 pre-cryotherapy EMR patients and 3 immediate post-cryotherapy EMR patients. Tissue slides (13 sites: 4 pre-cryo EMRs, 2 biopsies; 5 post-cryo EMRs, 2 biopsies) were evaluated for histological grade, depth of invasion, margins, and lymphovascular invasion. Results: Pathological diagnosis originally reported were 5 carcinoma (CA), 3 high grade dysplasia (HGD), 4 BE, and 1 gastric mucosa. Blinded
AB508 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
evaluation agreed on degree of dysplasia in 10 sites, disagreement on HGD vs. CA in one, and was unable to be evaluated in 2. Both sites unable to be evaluated were post-cryo EMRs that did not contain cancer. Margins of EMR specimens were reported in 6 sites, mostly for slides containing CA. Margins were in agreement in 3/6 sites (2 pre-cryo EMR, 1 post-cryo EMR). All disagreement was in post-cryo EMR specimens. Two EMRs were not evaluable for margins and one was judged positive for CA but original report was negative. There was no disagreement in lymphovascular invasion. Significant surface glandular structure damage and denudation was noted in post-cryo specimens, yet squamous mucosa was fairly preserved. Conclusions: Cryotherapy appears to interfere with tissue evaluation even though the mucosa was immediately removed after cryotherapy. The primary effect was glandular surface destruction and it does not appear to affect deeper structures. Margin assessment was frequently affected by the cryotherapy (50%), and this may limit assessment for complete resection of CA. Pre-cryotherapy EMR would be preferable for patients suspected to have carcinoma.
Tu1558 Safety and Efficacy of Same Session Spray Cryotherapy and Endoscopic Mucosal Resection for Barrett’s Esophagus and Early Esophageal Neoplasia: a Multicenter Experience Zilla H. Hussain*1, Norio Fukami2, Michael S. Smith3, Jayaprakash Sreenarasimhaiah4, Vivek Kaul5, Shivangi Kothari5, Bruce D. Greenwald6, Nicholas J. Shaheen7, John M. Levenick8, Steven A. Edmundowicz9, Vladimir M. Kushnir9, Virendra Joshi10, Hiroshi Mashimo11, Sarah M. Hyder1, Timothy B. Gardner1, Richard I. Rothstein1, Stuart R. Gordon1 1 Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; 2 University of Colorado Medical Center, Denver, CO; 3Temple University Hospital, Philadelphia, PA; 4University of Texas Southwestern Medical Center, Dallas, TX; 5University of Rochester Medical Center, Rochester, NY; 6University of Maryland Medical Center, Baltimore, MD; 7University of North Carolina Medical Center, Chapel Hill, NC; 8Penn State Hershey Medical Center, Hershey, PA; 9Washington University St. Louis Medical Center, St. Louis, MO; 10Ochsner Medical Center, New Orleans, LA; 11VA Boston Healthcare, Boston, MA Background/Study Aims: Endoscopic mucosal resection (EMR) and spray cryotherapy (SCT) are effective endoscopic therapies to eradicate Barrett’s esophagus (BE) and early esophageal neoplasia. Typically, when EMR is performed as initial therapy for nodular disease and/or esophageal neoplasia, the ablation of residual flat Barrett’s is performed at subsequent endoscopies. However, it is unknown if SCT and EMR in the same session is clinically safe and effective. We aimed to assess the safety and outcomes of such an approach. Methods: Demographic, procedural and outcomes data were prepared at eleven high volume BE ablation centers and the results were aggregated for analysis for patients who underwent same session SCT and EMR for BE and/or early esophageal neoplasia between 2008 and 2014. Results: A total of 28 patients (23 male, 5 female, mean age 67 years, BE mean length 4.5 cm) underwent same session SCT (27 liquid nitrogen, 1 liquid carbon dioxide) and EMR (21 multiband mucosectomy device, 7 cap assisted device). Nodularity was recorded in 27/28 patients. Mean aggregate nodularity size was 10.3 mm. EMR was performed before SCT in 7 patients and after SCT in 21 patients. Mean diameter of the resected tissue was 1.9 cm with an average of 1.9 specimens per resection. Pathology was interpreted without difficulty in all but 2 patients (both post SCT): 6 patients had non-dysplastic BE, 12 patients had dysplastic BE (3 low grade dysplasia, 9 high grade dysplasia), and 10 patients had early esophageal cancer (8 patients intramucosal carcinoma; IMC/T1a, 2 patients invasive adenocarcinoma/T1b). The deep resection margin was negative in 26/28 patients (93%) and positive in 2 patients (1 with T1a, 1 with T1b carcinoma). Complications occurred in 4 patients: 2 patients had post procedural stricture and 2 patients had intra-procedural bleeding controlled with endoscopic clips. No other adverse events noted. The 2 patients with positive deep margins (1 T1a, 1 T1b) were referred for surgical and oncologic management. So far, 18 of the remaining 26 patients have had at least one follow-up endoscopy, none having residual nodularity. 6 patients had no evidence for residual BE and 12 patients had residual flat BE: 8 with non-dysplastic BE (7 treated with repeat SCT, 1 treated with radiofrequency ablation;RFA), 3 with low grade BE (1 lost to follow-up, 1 treated with repeat SCT, 1 treated with RFA), and 1 with residual IMC (treated with repeat SCT). Conclusions: Same session SCT and EMR for the endoscopic management of BE and/or early esophageal neoplasia is a safe and effective treatment strategy and may expedite the eradication of dysplasia and BE by performing field ablation at the same time as nodule resection rather than waiting 6-8 weeks as per the current standard. Further studies are needed to determine whether EMR pre- or post-SCT is superior.
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