Correspondence
Radiofrequency Ablation in Barrett's Esophagus
N Engl J Med 2009; 361:1021-1022September 3, 2009
- Article
To the Editor:
Shaheen et al. (May 28 issue)1 report on radiofrequency ablation of endoscopically evident, non-nodular, dysplastic Barrett's esophagus as compared with a sham procedure. Unfortunately, the article omits any information about endoscopic resection, a well-established alternative treatment. Since 2000, our group and others have reported on several prospectively assessed case series including up to 1000 patients with high-grade dysplasia and mucosal cancer.2-4 Removing any endoscopically evident, non-nodular and nodular dysplasia or neoplasia with the use of endoscopic resection provides an opportunity to obtain precise histopathological assessment with regard to infiltration depth, differentiation, and lymphatic or blood-vessel involvement — all important risk factors for lymph-node metastasis. From the surgical point of view, precise histopathological assessment is a fundamental prerequisite for treating neoplasia and dysplasia with curative intent. A recent study reported that submucosal cancer was detected in 12.7% of patients referred to surgery for high-grade dysplasia.5 After complete resection of all neoplastic lesions, the remaining Barrett's epithelium should be treated with thermal ablative methods to minimize the risk of recurrence.2
5 ReferencesChristian Ell, M.D., Ph.D.
Oliver Pech, M.D., Ph.D.
Andrea May, M.D., Ph.D.
Horst Schmidt Klinik, Wiesbaden, Germany
ell.hsk-wiesbaden@arcor. de 1
Shaheen NJ ,Sharma P ,Overholt BF , et al. Radiofrequency ablation in Barrett's esophagus with dysplasia. N Engl J Med 2009;360:2277-2288
Full Text | Web of Science | Medline2
Pech O ,Behrens A ,May AD , et al. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus. Gut 2008;57:1200-1206
CrossRef | Web of Science | Medline3
Peters FP ,Kara MA ,Rosmolen WD , et al. Stepwise radical endoscopic resection is effective for complete removal of Barrett's esophagus with early neoplasia: a prospective study. Am J Gastroenterol 2006;101:1449-1457
CrossRef | Web of Science | Medline4
Pech O ,Manner H ,May A ,Pohl J ,Ell C . Endoscopic therapy in 1059 patients with high grade dysplasia and early adenocarcinoma in Barrett's esophagus -- lessons we have learned. Gastrointest Endosc 2009;5:AB114-AB115
CrossRef5
Konda VJ ,Ross AS ,Ferguson MK , et al. Is the risk of concomitant invasive esophageal cancer in high-grade dysplasia in Barrett's esophagus overestimated? Clin Gastroenterol Hepatol 2008;6:159-164
CrossRef | Web of Science | Medline
To the Editor:
In the study reported on by Shaheen et al., the eradication of 19.0% of the high-grade dysplasia and 22.7% of the low-grade dysplasia after the sham procedure might be an indication that the primary histologic diagnosis was an “overdiagnosis.” It is well known from the older literature that the histologic diagnosis of Barrett's neoplasia is associated with considerable intraobserver and interobserver variability. Barrett's adenocarcinoma is detected in 40 to 70% of surgical specimens obtained from patients with a diagnosis of high-grade dysplasia. In our own pathological material obtained from patients with a primary biopsy-based diagnosis of high-grade dysplasia, Barrett's carcinoma was detected in 81 of 93 specimens. From the scientific point of view, the study would have been better advised to have used a control group of patients undergoing endoscopic resection rather than the sham procedure.
Manfred Stolte, M.D., Ph.D.
Klinikum Kulmbach, Bayreuth, Germany
prof.m. stolte@t-online. de Author/Editor Response
We appreciate the comments by Ell et al. and note their contributions in the area of endoscopic resection. We agree that endoscopic resection is of great use both as a staging procedure and with curative intent for nodular Barrett's esophagus. Patients who had undergone endoscopic resection for nodular Barrett's esophagus were eligible for our study, and, as we reported, 11 patients underwent previous endoscopic resection (7 in the ablation group and 4 in the control group).
The focus of our study was treatment of non-nodular, dysplastic Barrett's esophagus. As a treatment option for non-nodular, dysplastic disease, circumferential endoscopic resection of Barrett's esophagus has been associated in some studies with high rates of esophageal stricturing1; for this reason, it may be a less attractive treatment option than other forms of ablation.
Stolte suggests that we perform a study comparing radiofrequency ablation with endoscopic resection; however, this study already has been performed and reported on in abstract form.2 It showed that radiofrequency ablation and endoscopic resection were similarly effective in inducing complete eradication of intestinal metaplasia (95% and 96%, respectively), but endoscopic resection required more endoscopy sessions and was associated with more complications (including an 86% stricture rate) than radiofrequency ablation.
With respect to the seeming “disappearance” of dysplasia in our sham-procedure group, the most likely explanation is sampling error. Histopathological analysis of esophagectomy specimens obtained from subjects with dysplastic Barrett's esophagus shows that dysplasia may involve only a small percentage of the total surface area of Barrett's esophagus.3,4 Even with rigorous sampling, it is expected that some subjects with minute amounts of dysplasia might appear to be “healed” of dysplasia simply because the biopsy forceps did not land on the area of worst disease in the subsequent biopsy session.
As Stolte notes, intraobserver and interobserver variability is well documented in the interpretation of endoscopic biopsy specimens of Barrett's esophagus. To minimize variability, our three expert pathologists who specialize in gastroenterology used standardized histopathological criteria.5 In addition, we required independent confirmation of all readings of dysplasia by a second pathologist who was unaware of the findings of the first pathologist, and, in cases of disagreement, we required a review by a third pathologist with assignment by concordance. Although these processes do not completely obviate variability in histologic interpretation, they were designed to address this important problem.
5 ReferencesNicholas J. Shaheen, M.D., M.P.H.
Ryan D. Madanick, M.D.
University of North Carolina School of Medicine, Chapel Hill, NC
nshaheen@med.unc. edu David E. Fleischer, M.D.
Mayo Clinic Arizona, Scottsdale, AZ1
Seewald S ,Ang TL ,Gotoda T ,Soehendra N . Total endoscopic resection of Barrett esophagus. Endoscopy 2008;40:1016-1020
CrossRef | Web of Science | Medline2
Van Vilsteren FG ,Pouw RE ,Seewald S , et al. A multi-center randomized trial comparing stepwise radical endoscopic resection versus radiofrequency ablation for Barrett esophagus containing high-grade dysplasia and/or early cancer. Gastrointest Endosc 2009;69:AB133-AB134
CrossRef | Web of Science3
Chatelain D ,Flejou JF . High-grade dysplasia and superficial adenocarcinoma in Barrett's esophagus: histological mapping and expression of p53, p21 and Bcl-2 oncoproteins. Virchows Arch 2003;442:18-24
Web of Science | Medline4
Cameron AJ ,Carpenter HA . Barrett's esophagus, high-grade dysplasia, and early adenocarcinoma: a pathological study. Am J Gastroenterol 1997;92:586-591
Web of Science | Medline5
Montgomery E ,Bronner MP ,Goldblum JR , et al. Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation. Hum Pathol 2001;32:368-378
CrossRef | Web of Science | Medline
