Barrett

Ablative Therapy for Barrett Esophagus: Caveat Emptor.

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Cancer can still occur after successful eradication of dysplasia with radiofrequency ablation.

Radiofrequency ablation (RFA) for patients with Barrett esophagus with high-grade dysplasia (HGD) has been clearly established as an acceptable and preferred treatment option for the majority of these patients. In the initial multicenter trial, RFA completely eradicated dysplasia in 91% of patients with HGD (JW Gastroenterol May 27 2009) and in 95% who were followed up for 2 years. Repeat RFA was performed in 55% of patients after the 1-year primary end point — mostly based on the discretion of the endoscopist rather than biopsy indication (JW Gastroenterol Nov 4 2011). No cancers were reported. The inference by some clinicians is that patients who have had successful ablative therapy can be considered cured and can be discontinued from surveillance. However, a new case report provides contrary evidence.

Three patients underwent successful RFA treatment of Barrett esophagus with HGD at tertiary academic centers; procedures were performed by nationally recognized experts in RFA. Two patients underwent endoscopic mucosal resection before RFA. The first patient had five post-RFA surveillance endoscopies during 2 years before subsquamous HGD was detected. The second patient had normal neosquamous epithelium at 3 months but subsquamous esophageal adenocarcinoma detected at 6 months. The third patient underwent two endoscopies at 3-month intervals, and at 9 months, a nodular area was noted and a subsquamous esophageal adenocarcinoma was detected.

Comment: This report emphasizes the ongoing risk for cancer following successful RFA treatment in patients with Barrett esophagus and HGD. These cases clearly demonstrate the need for meticulous surveillance. However, until the optimal surveillance schedule after ablative therapy is defined in national guidelines, experts currently recommend surveillance intervals of 3 months in year 1, 6 months in year 2, and 1 year thereafter. Quadrant biopsies should be taken every 1 cm in addition to separate biopsies of any visible lesions. Although RFA poses less risk than surgery, it is far from a cure.

Source: Journal Watch Gastroenterology

 

A Combination of Esomeprazole and Aspirin Reduce Tissue Concentrations of Prostaglandin E2 in Patients with Barrett’s Esophagus.

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Proton pump inhibitors (PPIs) and nonsteroidal anti-inflammatory drugs might prevent esophageal adenocarcinoma in patients with Barrett’s esophagus (BE), but there are limited data from clinical trials to support this concept. We conducted a randomized, double-blind, placebo-controlled phase II trial to assess the effects of the combination of aspirin (3 different doses) and esomeprazole on tissue concentrations of prostaglandin E2 (PGE2) in patients with BE with no dysplasia or low-grade dysplasia.

Methods

Participants were recruited through the multi-center Cancer Prevention Network and randomly assigned to groups that were given esomeprazole (40 mg, twice daily) in combination with an aspirin placebo (once daily) (Arm A; n=42), with 81 mg aspirin (once daily) (Arm B; n=63), or with 325 mg aspirin (once daily) (Arm C; n=63) for 28 days. We collected esophageal biopsies before and after the intervention period, to determine the absolute change in mean concentrations of PGE2 (the primary endpoint).

Results

Based on data from 114 patients, baseline characteristics were similar among groups. The absolute mean tissue concentrations of PGE2 was reduced by 67.6±229.68 pg/mL in Arm A, was reduced by 123.9±284.0 pg/mL in Arm B (P=.10 vs Arm A), and was reduced by 174.9 ±263.62 pg/mL in Arm C (P=.02 vs Arm A).

Conclusions

In combination with esomeprazole, short-term administration of higher doses of aspirin, but not lower doses or no aspirin, significantly reduced tissue concentrations of PGE2 patients with BE with either no dysplasia or low-grade dysplasia. These data support further evaluation of higher doses of aspirin and esomeprazole to prevent esophageal adenocarcinoma in these patients.

Source: Science Direct.

 

Keywords

  • esophageal cancer;
  • NSAIDs;
  • inflammation;
  • esophagus