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Radiofrequency Ablation Therapy for BE with Dysplasia

Radiofrequency ablation completely eradicated dysplasia and intestinal metaplasia in most patients and lowered risk for disease progression.

Although Barrett esophagus is typically a metaplasia of the epithelium, it can progress to low-grade dysplasia (LGD), high-grade dysplasia (HGD), and cancer. Radiofrequency ablation (RFA) has emerged as an alternative to radical esophagectomy in patients with HGD or early cancer. Now, researchers have assessed the ability of RFA to eradicate dysplastic BE and decrease the rate of neoplastic progression.

In this industry-sponsored, multicenter study, 127 patients with dysplastic BE were randomly assigned in a 2:1 ratio to receive either RFA or a sham procedure. Participants were stratified by the grade of their dysplasia; 64 had LGD and 63 had HGD. Those in the RFA group could receive up to four ablation sessions. BE was initially ablated with a circumferential RFA device; residual BE was treated with focal ablation. Biopsy samples were collected at 6 and 12 months in patients with LGD and at 3, 6, 9, and 12 months in patients with HGD.

An intent-to-treat analysis showed that RFA completely eradicated dysplasia in 91% and 81% of patients with LGD and HGD, respectively, versus 23% and 19% in the sham group at 12-month follow-up (P<0.001 for both). The rate of complete eradication of intestinal metaplasia was 77% for all RFA-treated patients versus 2% for the sham group. Patients who received RFA had a lower rate of disease progression than the sham group (4% vs. 16%; P=0.03) and fewer cancers (1% vs. 9%; P=0.045). At baseline, 25% of patients had subsquamous intestinal metaplasia (either LGD or HGD). At 12 months, subsquamous intestinal metaplasia was evident in 5% of the RFA group versus 40% of the sham group (P<0.001).

Comment: These data are consistent with recent study findings demonstrating the effectiveness of photodynamic ablative therapy for patients with HGD and mucosal adenocarcinoma (JW Gastroenterol Oct 10 2008). Less-radical strategies, such as ablation and endoscopic mucosal resection only of visible lesions, seem to offer patients excellent efficacy with negligible morbidity or mortality. However, the current study’s finding of decreased incidence of cancer in the RFA group should be viewed with caution. Malignancies were so rare in this cohort that a single incident cancer would have resulted in a loss of statistical significance.

Although a growing amount of data seems to support the use of endoscopic ablative therapy in BE with HGD, advocating the same therapy for LGD might be premature. The implications of these two diagnoses are markedly different, and more data on the natural history and appropriate management of LGD are needed. Furthermore, whether the excellent results achieved by these expert academic investigators can be extrapolated to procedures performed by less-experienced endoscopists in a community-practice setting remains to be seen.

— David A. Johnson, MD

Dr. Brian Fennerty, a coauthor of this study, is Editor-in-Chief of Journal Watch Gastroenterology but had no input into the writing of this summary and comment.

Published in Journal Watch Gastroenterology May 27, 2009

Citation(s):

Shaheen NJ et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med 2009 May 28; 360:2277.

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