Development of Evidence-Based Surveillance Intervals After Radiofrequency Ablation of Barrett's Esophagus

Abstract

Background & aims: Barrett's esophagus (BE) recurs in 25% or more of patients treated successfully with radiofrequency ablation (RFA), so surveillance endoscopy is recommended after complete eradication of intestinal metaplasia (CEIM). The frequency of surveillance is informed only by expert opinion. We aimed to model the incidence of neoplastic recurrence, validate the model in an independent cohort, and propose evidence-based surveillance intervals.

Methods: We collected data from the United States Radiofrequency Ablation Registry (US RFA, 2004-2013) and the United Kingdom National Halo Registry (UK NHR, 2007-2015) to build and validate models to predict the incidence of neoplasia recurrence after initially successful RFA. We developed 3 categories of risk and modeled intervals to yield 0.1% risk of recurrence with invasive adenocarcinoma. We fit Cox proportional hazards models assessing discrimination by C statistic and 95% confidence limits.

Results: The incidence of neoplastic recurrence was associated with most severe histologic grade before CEIM, age, endoscopic mucosal resection, sex, and baseline BE segment length. In multivariate analysis, a model based solely on most severe pre-CEIM histology predicted neoplastic recurrence with a C statistic of 0.892 (95% confidence limit, 0.863-0.921) in the US RFA registry. This model also performed well when we used data from the UK NHR. Our model divided patients into 3 risk groups based on baseline histologic grade: non-dysplastic BE; indefinite for dysplasia, low-grade dysplasia, and high-grade dysplasia; or intramucosal adenocarcinoma. For patients with low-grade dysplasia, we propose surveillance endoscopy at 1 and 3 years after CEIM; for patients with high-grade dysplasia or intramucosal adenocarcinoma, we propose surveillance endoscopy at 0.25, 0.5, and 1 year after CEIM, then annually.

Conclusion: In analyses of data from the US RFA and UK NHR for BE, a much-attenuated schedule of surveillance endoscopy would provide protection from invasive adenocarcinoma. Adherence to the recommended surveillance intervals could decrease the number of endoscopies performed yet identify unresectable cancers at rates less than 1/1000 endoscopies.

Keywords: Esophageal Cancer; LGD; NDBE; Risk of Progression.

Figure 1

A) Inclusion of 3,105 Subjects in the Surveillance Cohort at Risk from 5,521 United States Radiofrequency Ablation Registry Subjects. B) Inclusion of 373 Subjects in the Surveillance Cohort at Risk from 577 United Kingdom National HALO Registry Subjects.

Figure 2

Kaplan-Meier Estimates of the Proportion of Subjects in the US RFA Registry without Recurrence of Neoplasia in Five Years after Complete Eradication of Intestinal Metaplasia by Most Severe Prior Histologic Grade.

Figure 3

The Rate of First Recurrence of Neoplasia with Low-grade Dysplasia, High-grade Dysplasia, Intramucosal Adenocarcinoma, and Invasive Adenocarcinoma among Simplified Categories of Surveillance Risk.

Figure 4

Kaplan-Meier Estimates of the Proportion of Subjects in the US RFA Registry and the UK National Halo Registry without Recurrence of Neoplasia in Five Years after Complete Eradication of Intestinal Metaplasia by Proposed Surveillance Risk Groups.