1. Endoscopic Treatment of Barrett’s Esophagus and Early Esophageal Cancer CTOP Retreat 2014 Dartmouth-Hitchcock Medical Center

2. Overall incidence trend in esophageal adenocarcinoma (1973-2006). Pohl H et al. Cancer Epidemiol Biomarkers Prev 2010;19:1468-1470 ©2010 by American Association for Cancer Research

3. Incidence of Esophageal Adenocarcinoma 0 1 2 3 4 5 6 7 8 1975 19801985199019952000 year of diagnosis Relative change Esophageal Adenocarcinoma Lung AC Prostate Cancer Breast Cancer Melanoma Pohl, Welch, JNCI 2005

4. Why are we talking about Barrett’s esophagus?

5. Non-dysplastic Low-grade dysplasia High Grade Dysplasia 0.25% per year ? 4-8% per year Cancer Risk for Barrett’s:

8. Endoscopic Mucosal Resection (EMR) Radiofrequency Ablation Cryoablation Photodynamic Therapy Other thermal (APC, Bicap) Surgery Treatment Options for EAC

9. 73 year old man referred for management of 12 cm of Barrett’s associated with HGD and IMC in a nodule:

11. EMR

15. Pathology showed IMC/HGD (no invasive component). HGD at lateral margin. How effective is EMR for mucosal adenocarcinoma? How would you manage his residual Barrett’s?

16. Pathology showed IMC/HGD (no invasive component). HGD at lateral margin.

18. Barrx RFA

21. CE-IM78% CE-D91% Recurrent IM13% Progression to cancer - during treatment0.2% - after CE-IM0.7% Esophageal Stricture3%

23. Barrett’s HGD/IMCLGD/ND Staging EUS InvasiveNon-invasive Esophagectomy NodularFlat EMR 6-8 weeks prior to RFA RFA treatment protocol 2-3 mo follow-up Repeat biopsies Visible disease Normal appearing mucosa Dysplasia or IM on biopsy CR-D, CR-IM PRE-TREATMENT PHASE RFA TREATMENT PHASE HGD/IMCLGDND Endoscopy every 3 mo Endoscopy every 6 mo Endoscopy every 9-12 mo FOLLOW-UP PHASE Recurrence EMR, Duette® RFA: Halo 360 BÂRRX® RFA: Halo 90 BÂRRX® Narrow Band Imaging Pathology Complete Response (CR): eradication of intestinal metaplasia (CR-IM) and/or dysplasia (CR-D) in all biopsies Recurrence: Presence of intestinal metaplasia or dysplasia in any biopsy Treatment failure: poor mucosal healing and inability to eradication or downgrade dysplasia after 3 sessions Treatment Algorithm

27. Spray Cryotherapy 2 published studies: -CE-HGD 97-100% -CE-IM 57-84% -strictures 9% GIE 2010 GIE 2013

28. 2/11

29. 3/14

30. Questions?