Persistent intestinal metaplasia after endoscopic eradication therapy of neoplastic Barrett’s esophagus increases the risk of dysplasia recurrence: meta-analysis - 19/04/19

Doi : 10.1016/j.gie.2018.11.035

Tarek Sawas, MD, MPH ¹, Mouaz Alsawas, MD ², Fateh Bazerbachi, MD ¹, Prasad G. Iyer, MD ¹, Kenneth K. Wang, MD ¹, M. Hassan Murad, MD, MPH ², David A. Katzka, MD ^1,^⁎
¹ Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
² Evidence Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA

^∗Reprint requests: David A. Katzka, MD, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Avenue, SW, Rochester, MN 55905.Division of Gastroenterology and HepatologyMayo Clinic200 First Avenue, SWRochesterMN55905

Abstract

Background and Aims

Endoscopic eradication therapy (EET) is the main treatment for dysplastic Barrett’s esophagus and intramucosal adenocarcinoma. Although the goal of EET is to achieve complete remission of intestinal metaplasia (CRIM), treatment might achieve complete remission of dysplasia (CR-D) only, without achieving CRIM. Persistent intestinal metaplasia after eradication of dysplasia might carry a higher risk for progression into advanced neoplasia.

Methods

We performed a systematic review and meta-analysis after searching multiple databases to identify studies that evaluated dysplasia recurrence risk after successful eradication of neoplasia with EET. We calculated the pooled cumulative incidence of dysplasia and advanced neoplasia recurrence after CRIM and CR-D only and then compared the two using risk ratios.

Results

Forty studies were included (4410 patients with total follow-up of 12,976 patient-years). A total of 4061 achieved CRIM and 349 achieved CR-D only. The cumulative incidence of CR-D only was 14% (95% confidence interval [CI], 10%-19%). The pooled cumulative incidence of any dysplasia recurrence after achieving CRIM was 5% (95% CI, 3%-7%) and 12% (95% CI, 4%-23%) after achieving CR-D only. Comparing dysplasia detection after achieving CR-D only with CRIM, there was a significantly higher risk for detection after CR-D (risk ratio [RR], 2.8; 95% CI, 1.7-4.6). The pooled cumulative incidence rate of high-grade dysplasia (HGD)/esophageal adenocarcinoma (EAC) recurrence was 3% (95% CI, 2%-4%) after achieving CRIM and 6% (95% CI, 0%-16%) after achieving CR-D only. Comparing HGD/EAC recurrence after achieving CR-D only with CRIM, there was a significantly higher risk for recurrence after CR-D (RR, 3.6; 95% CI, 1.45-9). When excluding patients who underwent ablation for non-dysplastic Barrett’s esophagus only, these differences persisted with dysplasia recurrence after achieving CR-D only compared with CRIM showing a significantly higher risk for recurrence after CR-D (RR, 2.9; 95% CI, 1.66-5).

Conclusions

CRIM was associated with a lower risk of dysplasia and advanced neoplasia recurrence compared with CR-D only. Achieving CRIM should remain the goal of EET in dysplastic Barrett’s esophagus.

Le texte complet de cet article est disponible en PDF.

Graphical abstract

Le texte complet de cet article est disponible en PDF.

Abbreviations : BE, CI, CR-D, CRIM, EAC, EET, GEJ, HGD, IM, IMC, LGD, NDBE, NOS, RFA, RR

Plan

Background

Methods

Search strategy and study selection

Data abstraction

Definitions and outcomes

Statistical methods

Results

Dysplasia recurrence

Sensitivity and subgroup analysis

Discussion

	DISCLOSURE: Dr Katzka has undertaken a pharmaceutical trial with Shire. Dr Iyer has received research funding from Exact Sciences, Pentax, and Medtronic and has been a consultant for Medtronic and Pentax. All other authors disclosed no financial relationships relevant to this publication.
	If you would like to chat with an author of this article, you may contact Dr Katzka at katzka.david@mayo.edu.
	See CME section; p. 1044.