One-third recur after RFA in Barrett's esophagus

About one-third of patients with Barrett’s esophagus can expect recurrence of intestinal metaplasia by 2 years after obtaining complete remission with radiofrequency ablation.

The finding highlights the importance of frequent endoscopic surveillance in these patients, even after remission is achieved, wrote Dr. Milli Gupta and colleagues in the July issue of Gastroenterology, which was published online in March.

In the study, Dr. Gupta, of the Mayo Clinic’s division of gastroenterology and hepatology in Rochester, Minn., and her associates looked at 448 patients with Barrett’s esophagus treated with radiofrequency ablation (RFA) at three different tertiary referral centers ( doi: 10.1053/j.gastro.2013.03.008 ).

The data were collected from patients treated and followed up in these centers from January 2003 to November 2011 as part of the Barrett’s Esophagus Translational Research Network consortium.

The patients’ mean age was 64 years, 85% were men, and the mean length of Barrett’s esophagus that was treated was 4.1 cm, the authors reported.

Looking at the indication for RFA, 11% had intramucosal esophageal adenocarcinoma, 60% had high-grade dysplasia, 15% had low-grade dysplasia, and 14% had nondysplastic BE.

Slightly more than half (55%) of patients also underwent endoscopic mucosal resection before RFA, and 1% had received cryotherapy.

After RFA, the authors found that by 1 year, roughly 26% of patients achieved complete remission of intestinal metaplasia (CRIM), defined as two negative endoscopies and histology clear of intestinal metaplasia.

That figure climbed to 56% by 2 years, and to 71% by 3 years, with 29% of patients receiving one RFA treatment session, 35% receiving two sessions, and the remaining percentage of patients undergoing 3-10 sessions before remission.

Adverse events occurred in 6.5% of patients, with stricture formation being the most common, followed by bleeding, mucosal tears, and hospitalizations for dysrhythmias.

However, using a Kaplan-Meier survival curve, the authors found that after CRIM was attained, 20% of patients would go on to have recurrence of intestinal metaplasia by 1 year. Similarly, by 2 years after attainment of CRIM, the rate of recurrence was 33%.

"By 3 years, recurrences continued to occur, but precise estimates were difficult to establish because of the small number of at-risk subjects ( n = 11), which made estimates of recurrence less precise," Dr. Gupta and her colleagues wrote.

According to the authors, the most common type of recurrence was intestinal metaplasia without dysplasia, which was seen in 78% of patients who recurred after CRIM.

The remaining patients who recurred (22%) developed dysplastic Barrett’s esophagus, with 11% showing high-grade dysplasia, 8% showing low-grade dysplasia, and 3% developing cancer.

There were no discernable endoscopic or patient factors associated with time to recurrence on univariate and multivariate analyses, the authors added.

"Despite the ability of RFA to achieve CRIM, recurrence of intestinal metaplasia and dysplasia appears to occur in a substantial proportion of subjects," wrote Dr. Gupta.

She pointed out that current recommendations call for intense surveillance at 3- to 6-month intervals, and if no recurrence is found, "surveillance generally is decreased to 6- to 12-month intervals."

However, "until predictive biomarkers are identified and available for clinical practice, endoscopic surveillance directed at the gastroesophageal junction and original BE [Barrett’s esophagus] segment should be continued."

Dr. Gupta had no conflicts of interest. Several of her coauthors disclosed financial relationships with drug makers, including the makers of therapies for Barrett’s esophagus. The study was funded by a grant from the National Institutes of Health. The Barrett’s Esophagus Translational Research Network consortium is funded by the National Cancer Institute.