Esophageal Cancers Reported After Radiofrequency Ablation

Two cases of adenocarcinoma and one case of subsquamous high-grade dysplasia have been reported after radiofrequency ablation for Barrett’s esophagus, wrote Dr. Mohammad Titi and colleagues in the September issue of Gastroenterology.

The findings point to a need for "continued meticulous surveillance with biopsies of neosquamous epithelium, even after apparently successful eradication of intestinal metaplasia," the authors wrote.

The three cases of subsquamous neoplasia following "successful" radiofrequency ablation (RFA) are the only cases reported to date, said Dr. Titi of the Veterans Affairs Medical Center, Kansas City, Mo., and colleagues (Gastroenterology 2012 [doi: 10.1053/j.gastro.2012.04.051]).

The first case detailed by the investigators occurred in a 65-year-old patient with Barrett’s esophagus who had been undergoing surveillance for 2 years. An intramucosal adenocarcinoma was detected, and the patient underwent esophagectomy. The margins were positive for high-grade dysplasia.

RFA was performed in three sessions, "leading to complete eradication of dysplasia and intestinal metaplasia," the authors wrote, and for 2 years and over five surveillance biopsies, no endoscopic or histologic evidence of intestinal metaplasia was seen.

"Finally, almost two years post RFA, surveillance biopsies from the neosquamous epithelium 2 cm above surgical anastomosis showed subsquamous intestinal metaplasia with high-grade dysplasia."

In the second case, a 59-year-old patient with a 10-year Barrett’s history was found to have focal high-grade dysplasia and underwent two RFA sessions with complete eradication of dysplasia and intestinal metaplasia. Surveillance at 3 months was normal.

"Surveillance endoscopy at 6 months post RFA showed normal neosquamous epithelium; however, biopsies 1 cm above the gastroesophageal junction revealed subsquamous adenocarcinoma," wrote the authors. The patient underwent esophagectomy, revealing residual subsquamous carcinoma. The lymph nodes were negative.

The third and final case was a 76-year-old Barrett’s patient with focal, high-grade dysplasia initially treated with endoscopic mucosal resection (EMR) followed by four sessions of RFA, with complete eradication of dysplasia and intestinal metaplasia.

Two surveillance endoscopies at 3-month intervals showed no evidence of intestinal metaplasia. "The third surveillance endoscopy per protocol was at 9 months post RFA, and showed a nodular area in the neosquamous epithelium above the gastroesophageal junction, 1 cm distal to the site of previous EMR." Biopsies confirmed subsquamous adenocarcinoma; the patient underwent esophagectomy.

According to the authors, all patients were on twice-daily proton pump inhibitor therapy at the time of neoplasia occurrence. All patients underwent surveillance biopsies per the Seattle protocol.

"This report illustrates an important fact that must be remembered about any ablative therapy, including RFA: High-grade dysplasia or cancer can develop in some patients even after apparently successful eradication of neoplasia and intestinal metaplasia," the authors wrote.

"A prudent approach is performing surveillance every 3 months for the first year post ablation; every 6 months for the next year; and then annually," they wrote. "These reports should also temper our enthusiasm to apply ablation to all patients with Barrett’s esophagus."

The authors stated that they had no conflicts of interest related to this report, and no grant support.

Two cases of adenocarcinoma and one case of subsquamous high-grade dysplasia have been reported after radiofrequency ablation for Barrett’s esophagus, wrote Dr. Mohammad Titi and colleagues in the September issue of Gastroenterology.

The findings point to a need for "continued meticulous surveillance with biopsies of neosquamous epithelium, even after apparently successful eradication of intestinal metaplasia," the authors wrote.

The three cases of subsquamous neoplasia following "successful" radiofrequency ablation (RFA) are the only cases reported to date, said Dr. Titi of the Veterans Affairs Medical Center, Kansas City, Mo., and colleagues (Gastroenterology 2012 [doi: 10.1053/j.gastro.2012.04.051]).

The first case detailed by the investigators occurred in a 65-year-old patient with Barrett’s esophagus who had been undergoing surveillance for 2 years. An intramucosal adenocarcinoma was detected, and the patient underwent esophagectomy. The margins were positive for high-grade dysplasia.

RFA was performed in three sessions, "leading to complete eradication of dysplasia and intestinal metaplasia," the authors wrote, and for 2 years and over five surveillance biopsies, no endoscopic or histologic evidence of intestinal metaplasia was seen.

"Finally, almost two years post RFA, surveillance biopsies from the neosquamous epithelium 2 cm above surgical anastomosis showed subsquamous intestinal metaplasia with high-grade dysplasia."

In the second case, a 59-year-old patient with a 10-year Barrett’s history was found to have focal high-grade dysplasia and underwent two RFA sessions with complete eradication of dysplasia and intestinal metaplasia. Surveillance at 3 months was normal.

"Surveillance endoscopy at 6 months post RFA showed normal neosquamous epithelium; however, biopsies 1 cm above the gastroesophageal junction revealed subsquamous adenocarcinoma," wrote the authors. The patient underwent esophagectomy, revealing residual subsquamous carcinoma. The lymph nodes were negative.

The third and final case was a 76-year-old Barrett’s patient with focal, high-grade dysplasia initially treated with endoscopic mucosal resection (EMR) followed by four sessions of RFA, with complete eradication of dysplasia and intestinal metaplasia.

Two surveillance endoscopies at 3-month intervals showed no evidence of intestinal metaplasia. "The third surveillance endoscopy per protocol was at 9 months post RFA, and showed a nodular area in the neosquamous epithelium above the gastroesophageal junction, 1 cm distal to the site of previous EMR." Biopsies confirmed subsquamous adenocarcinoma; the patient underwent esophagectomy.

According to the authors, all patients were on twice-daily proton pump inhibitor therapy at the time of neoplasia occurrence. All patients underwent surveillance biopsies per the Seattle protocol.

"This report illustrates an important fact that must be remembered about any ablative therapy, including RFA: High-grade dysplasia or cancer can develop in some patients even after apparently successful eradication of neoplasia and intestinal metaplasia," the authors wrote.

"A prudent approach is performing surveillance every 3 months for the first year post ablation; every 6 months for the next year; and then annually," they wrote. "These reports should also temper our enthusiasm to apply ablation to all patients with Barrett’s esophagus."

The authors stated that they had no conflicts of interest related to this report, and no grant support.

Two cases of adenocarcinoma and one case of subsquamous high-grade dysplasia have been reported after radiofrequency ablation for Barrett’s esophagus, wrote Dr. Mohammad Titi and colleagues in the September issue of Gastroenterology.

The findings point to a need for "continued meticulous surveillance with biopsies of neosquamous epithelium, even after apparently successful eradication of intestinal metaplasia," the authors wrote.

The three cases of subsquamous neoplasia following "successful" radiofrequency ablation (RFA) are the only cases reported to date, said Dr. Titi of the Veterans Affairs Medical Center, Kansas City, Mo., and colleagues (Gastroenterology 2012 [doi: 10.1053/j.gastro.2012.04.051]).

The first case detailed by the investigators occurred in a 65-year-old patient with Barrett’s esophagus who had been undergoing surveillance for 2 years. An intramucosal adenocarcinoma was detected, and the patient underwent esophagectomy. The margins were positive for high-grade dysplasia.

RFA was performed in three sessions, "leading to complete eradication of dysplasia and intestinal metaplasia," the authors wrote, and for 2 years and over five surveillance biopsies, no endoscopic or histologic evidence of intestinal metaplasia was seen.

"Finally, almost two years post RFA, surveillance biopsies from the neosquamous epithelium 2 cm above surgical anastomosis showed subsquamous intestinal metaplasia with high-grade dysplasia."

In the second case, a 59-year-old patient with a 10-year Barrett’s history was found to have focal high-grade dysplasia and underwent two RFA sessions with complete eradication of dysplasia and intestinal metaplasia. Surveillance at 3 months was normal.

"Surveillance endoscopy at 6 months post RFA showed normal neosquamous epithelium; however, biopsies 1 cm above the gastroesophageal junction revealed subsquamous adenocarcinoma," wrote the authors. The patient underwent esophagectomy, revealing residual subsquamous carcinoma. The lymph nodes were negative.

The third and final case was a 76-year-old Barrett’s patient with focal, high-grade dysplasia initially treated with endoscopic mucosal resection (EMR) followed by four sessions of RFA, with complete eradication of dysplasia and intestinal metaplasia.

Two surveillance endoscopies at 3-month intervals showed no evidence of intestinal metaplasia. "The third surveillance endoscopy per protocol was at 9 months post RFA, and showed a nodular area in the neosquamous epithelium above the gastroesophageal junction, 1 cm distal to the site of previous EMR." Biopsies confirmed subsquamous adenocarcinoma; the patient underwent esophagectomy.

According to the authors, all patients were on twice-daily proton pump inhibitor therapy at the time of neoplasia occurrence. All patients underwent surveillance biopsies per the Seattle protocol.

"This report illustrates an important fact that must be remembered about any ablative therapy, including RFA: High-grade dysplasia or cancer can develop in some patients even after apparently successful eradication of neoplasia and intestinal metaplasia," the authors wrote.

"A prudent approach is performing surveillance every 3 months for the first year post ablation; every 6 months for the next year; and then annually," they wrote. "These reports should also temper our enthusiasm to apply ablation to all patients with Barrett’s esophagus."

The authors stated that they had no conflicts of interest related to this report, and no grant support.