LONG-TERM OUTCOMES AFTER ENDOSCOPIC RESECTION WITHOUT SUBSEQUENT ABLATION THERAPY FOR EARLY BARRETT'S NEOPLASIA
Sanne N. van Munster*1, Esther Nieuwenhuis1, Bas L. Weusten2,3, L. Alvarez Herrero3, Auke Bogte2, A. Alkhalaf4, B. E. Schenk4, Erik. J. Schoon5, Wouter Curvers5, Arjun D. Koch6, Steffi E. van de Ven6, P.J.F. de Jonge6, Thjon J. Tang7, Wouter B. Nagengast8, Frans Peters8, Jessie Westerhof8, Martin H. Houben9, Jacques Bergman1, Roos E. Pouw1
1Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; 2UMC Utrecht, Utrecht, Netherlands; 3Antonius hospital Nieuwegein, Nieuwegein, Netherlands; 4Isala Clinics Zwolle, Zwolle, Netherlands; 5Catharina Hospital, Eindhoven, Netherlands; 6Erasmus MC, University Medical Center, Rotterdam, Netherlands; 7IJsselland hospital, Capelle aan den IJssel, Netherlands; 8UMCGroningen, Groningen, Netherlands; 9Haga Teaching Hospital, Den Haag, Netherlands
Background
After endoscopic resection (ER) of neoplastic lesions in Barrett’s esophagus (BE), it is generally recommended to ablate the remaining flat BE to minimize the risk for metachronous disease. However, the majority of patients will not develop metachronous disease and if it occurs, it is generally detected at an early stage that allows re-ER. Ablation is still accompanied by complications and requires multiple hospital visits. We report the long-term outcomes for all patients treated in the Netherlands(NL) from 2008-2018 who did not undergo ablation after ER for early BE neoplasia.
Methods
Endoscopic therapy for BE neoplasia in NL is centralized in 9 expert centers with specifically trained endoscopists and pathologists. Uniformity is further ensured by a joint protocol and regular group meetings. Prospectively collected treatment/FU data are registered in a uniform database. We report all patients who underwent ER for a neoplastic lesion and in whom subsequently no ablation therapy was applied. We aimed to report progression rates during endoscopic FU and mortality after endoscopic FU was stopped. Data on date and cause of death were extracted from Statistics Netherlands(CBS).
Results
Of the 2,098 BE patients with early neoplasia, 1,305 underwent ER for a visible neoplastic lesion and 95 (7%) entered endoscopic surveillance without additional ablation. 78% was male with a mean age of 74(±10) yrs, mean BMI 27(±6) kg/cm2 and ASA classification II (64%) or ≥III (29%). 76% had a history of smoking. Median BE was C4M6 with ER performed for LGD(12%), HGD(23%) or EAC(65%). Reasons for not proceeding to ablation therapy were: age, comorbidity and extent of residual BE (88%); anticipated poor response upon ablation therapy (e.g. BE regeneration of the ER-scar)(14%); other treatment protocols by that time(13%); patient preference(7%); and/or complications after ER (4%). After ER, median BE was C2M5 with IM(52%), LGD(31%) or HGD(6%) (no histology obtained: 12%). During median 25mo of endoscopic FU (IQR 12-53) with median 4 endoscopies per pt, 0 pts progressed to advanced cancer. 17 pts (18%) developed HGD/EAC after median 29mo: 14 with a visible lesion were successfully treated with ER for HGD (n=6) or EAC (n=8). The other 3 had flat HGD and were successfully treated with ablation. Of the 78 non-progressors, 4 underwent ablation for persistent multifocal LGD and achieved a complete remission of BE. In 62 pts (64%), endoscopic surveillance was stopped median 20mo after ER (5-59) because of comorbidity and anticipated limited life expectancy. During median 44mo (28-77) after endoscopic FU was stopped, no patient developed symptomatic disease or had a tumor-related death, whilst 45% died of unrelated causes.
Conclusion
In selected patients, ER monotherapy with endoscopic surveillance of the residual BE is a valid alternative to prophylactic ablation therapy.
Worst pathology during endoscopic Follow-up, stratified for worst pathology in the remaining flat Barrett's segment after endoscopic resection of all visible lesions
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