In patients with dysplastic Barrett’s oesophagus or early-stage adenocarcinoma, endoscopic treatment of disease is recommended. Endoscopic-based treatments can be divided into two broad categories (2):
- Tissue-acquiring: in these therapies, diseased tissue is physically removed (resected) and is subsequently analysed histologically. Examples of tissue-acquiring therapies include:
- Endoscopic mucosal resection
- Non-tissue acquiring: in these therapies, diseased tissue is destroyed using heat or light. No tissue is removed for histological analysis. Examples of non-tissue acquiring therapies include:
- Photodynamic therapy (PDT)
- Radiofrequency ablation (RFA)
Often, two or more therapies are combined to provide an effective treatment plan (1).
Endoscopic mucosal resection (EMR) (1,2)
The oesophagus is composed of several microscopic layers. Early-stage oesophageal adenocarcinoma and Barrett’s oesophagus that is restricted to the mucosa, the most superficial layer, can be treated using the minimally invasive therapy EMR. EMR not only eliminates disease, but it also allows the accurate staging of cancer. EMR is associated with 90% complete eradication of disease, but suffers from a 6.2% recurrence of dysplasia or adenocarcinoma at 5 years. Unfortunately just under 50% of patients treated with EMR suffer from the complication oesophageal strictures, which is a narrowing of the oesophagus (3).
Photodynamic therapy (PDT) and Radiofrequency ablation (RFA) (1,2)
In photodynamic therapy, light-sensitive chemicals are used to destroy diseased tissue when they are exposed to a particular frequency of laser light. The side-effects of PDT include:
- A need to avoid direct sunlight for 6 weeks post PDT therapy
- Chest pain
- Disease recurrence
PDT is now largely replaced by radiofrequency ablation (RFA), which destroys diseased tissues by heat, delivered with electrodes operating at high frequencies. RFA is associated with few side-effects, 91% of patients with dysplasia benefit from complete disease eradication (4).
However, the five-year recurrence rate for dysplastic Barrett’s oesophagus is approximately 8% (5).
Cryotherapy uses liquid CO¬2 or nitrogen. Both gasses are extremely cold and able to destroy diseased tissue. In one study of 98 patients, 97% of patients with high-grade dysplasia demonstrated complete disease eradication (6). The recurrence rate of non-dysplastic Barrett’s oesophagus is approximately 20% at 36 months and the recurrence rate of dysplasia or adenocarcinoma is 3% at 36 months (7,8). Cryotherapy is often used when other endoscopic therapies, such as RFA, fail (8). In a study involving 32 patients, cryotherapy was associated with no serious side-effects; minor side-effects included strictures (all of which dilated post-therapy), haemorrhages and difficulty swallowing (dysphagia) (7).
Although many endoscopic therapies are associated with complete disease eradication, surveillance is recommended to detect disease recurrence.
High-grade dysplasia is associated with a recurrence rate of 10% within 5 years: as such, surveillance should be performed (5,9):
- Year 1: every 3 months
- Year 2: every 6 months
- Year 3 onwards: annually
Patients who previously suffered from low-grade dysplastic Barrett’s oesophagus, prior to therapy, should undergo surveillance bi-annually in the first year and annually from year 2, onwards (9).
- Dunbar KB. Endoscopic eradication therapy for mucosal neoplasia in Barrettʼs esophagus. Curr Opin Gastroenterol [Internet]. 2013 Jul;29(4):446–53. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage%7B&%7Dan=00001574-201307000-00017
- Pophali P, Halland M. Barrett’s oesophagus: diagnosis and management. BMJ [Internet]. British Medical Journal Publishing Group; 2016;353(6):i2373. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27169585
- Anders M, Bähr C, El-Masry MA, Marx AH, Koch M, Seewald S, et al. Long-term recurrence of neoplasia and Barrett’s epithelium after complete endoscopic resection. Gut [Internet]. 2014 Oct;63(10):1535–43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24389236
- Orman ES, Li N, Shaheen NJ. Efficacy and durability of radiofrequency ablation for Barrett’s Esophagus: systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2013 Oct;11(10):1245–55.
- Small AJ, Sutherland SE, Hightower JS, Guarner-Argente C, Furth EE, Kochman ML, et al. Comparative risk of recurrence of dysplasia and carcinoma after endoluminal eradication therapy of high-grade dysplasia versus intramucosal carcinoma in Barrett’s esophagus. Gastrointest Endosc [Internet]. 2015 May;81(5):1154–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25650071
- Shaheen NJ, Greenwald BD, Peery AF, Dumot JA, Nishioka NS, Wolfsen HC, et al. Safety and efficacy of endoscopic spray cryotherapy for Barrett’s esophagus with high-grade dysplasia. Gastrointest Endosc [Internet]. 2010 Apr;71(4):680–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20363409
- Gosain S, Mercer K, Twaddell WS, Uradomo L, Greenwald BD. Liquid nitrogen spray cryotherapy in Barrett’s esophagus with high-grade dysplasia: long-term results. Gastrointest Endosc [Internet]. 2013 Aug;78(2):260–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23622979
- Ghorbani S, Tsai FC, Greenwald BD, Jang S, Dumot JA, McKinley MJ, et al. Safety and efficacy of endoscopic spray cryotherapy for Barrett’s dysplasia: results of the National Cryospray Registry. Dis Esophagus. 2016 Apr;29(3):241–7.
- Shaheen NJ, Falk GW, Iyer PG, Gerson LB, American College of Gastroenterology. ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus. Am J Gastroenterol [Internet]. 2016 Jan;111(1):30--50; quiz 51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26526079