Radiofrequency Ablation Fights Barrett’s Oesophagus Progression

Endoscopic radiofrequency ablation reduces the malignancy risk of patients diagnosed with Barrett’s oesophagus and low-grade dysplasia

medwireNews: Radiofrequency ablation could replace endoscopic surveillance as the standard of care for Barrett’s oesophagus patients with low-grade dysplasia, trial findings suggest.

The 68 patients randomly assigned to receive up to five sessions of endoscopic ablation were significantly less likely to develop high-grade dysplasia (1.5 vs 26.5%) or adenocarcinoma (1.5 vs 8.8%) over 3 years of follow-up than 68 patients assigned to standard care consisting of endoscopic surveillance.

This gave a number needed to treat (NNT) for ablation of 4.0 to reduce the risk of high-grade dysplasia or adenocarcinoma and 13.6 to reduce the risk of adenocarcinoma alone, report Jacque Bergman, from Academic Medical Center Amsterdam in the Netherlands, and co-authors.

“Our data suggest that endoscopic ablative therapy is a superior management strategy to endoscopic surveillance in patients with Barrett esophagus and confirmed low-grade dysplasia”, the team writes in JAMA.

“Given the high rate of malignant degeneration in our control group, and the relatively low NNT to avert a single progression, as well as the acceptable safety profile, a shift to earlier endoscopic intervention in this patient population deserves consideration.”

The researchers found that ablation completely eradicated dysplasia in 92.6% of the treated patients and intestinal metaplasia in 88.2%, whereas these precancerous changes spontaneously regressed in 27.9% and 0.0% of patients undergoing surveillance.

Overall, 19.1% of patients treated with ablation had adverse events; stricture was the most common, affecting 11.8% of patients and was successfully treated using endoscopic dilation.

Indeed, the trial was terminated early on the recommendation of the data and safety monitoring board following superiority of patient outcomes with ablation and concerns about patient safety due to the risk of progression.

In an accompanying editorial, Klaus Mönkemüller, from the University of Alabama in Birmingham, USA, says that biological, histological and molecular markers must now be found to identify which patients are least likely to have spontaneous regression and be at greatest risk of progression and, therefore, most likely to benefit from ablation.

Nevertheless, the study results provide “important evidence to support the use of radiofrequency ablation not only for patients with high-grade dysplasia and early cancer, but also for carefully selected patients with Barrett esophagus and confirmed low-grade dysplasia”, he writes.

“A proactive endoscopic approach to eliminate dysplasia may result in reduced morbidity and mortality related to the progression of this disease.”

References

Phoa N, van Vilsteren F, Weusten B, et al. Radiofrequency ablation vs endoscopic surveillance for patients with Barrett esophagus and low-grade dysplasia. A randomized clinical trial. JAMA 2014; 311: 1209–1217. doi:10.1001/jama.2014.2511.

Mönkemüller K. Radiofrequency ablation for Barrett esophagus with confirmed low-grade dysplasia. JAMA 2014; 311: 1205–1206. doi:10.1001/jama.2014.2512.

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