Barrett's Esophagus (cont.)
In this Article
How is low grade dysplasia managed?
Low grade dysplasia is managed by continuing endoscopic biopsy surveillance. For these patients, however, the follow-up interval is shortened from every two to three years (which is done for Barrett's with no dysplasia) to every six months for an indefinite period of time. Esophagectomy is not considered for low grade dysplasia unless the patient develops high grade dysplasia or cancer during the surveillance.
What are the experimental approaches for treatment of high grade dysplasia?
Several experimental options are available. Patients entertaining these experimental treatments should seek out a research team that is doing studies with these techniques. For example, with these treatments, some patients need to be retreated, but long-term studies are needed to define how often retreatment is needed. Nevertheless, because they avoid the need for esophagectomy, these techniques may eventually prove to be ideal for patients who are medically not fit for surgery.
Ablation therapy
Ablation therapy involves the removal of the target tissue (for example, Barrett's mucosa, high grade dysplasia, or cancer) by procedures (such
as, laser or electrocoagulation) that literally destroy
the tissue. The results of ablation therapy in Barrett's with dysplasia (as well as without dysplasia, which is discussed in the next section) have produced two conclusions. One is that ablation succeeds in more than half the cases. The second is that the recurrence rates at different centers differ widely.
Photodynamic therapy
(PDT)
Photodynamic therapy is a powerful method of ablation therapy. This
technique involves the intravenous administration of a photosensitizing agent
(for example, sodium porfimer) that is taken up by the dysplastic Barrett's cells. Approximately 48 hours later, a laser is used to burn the photosensitized Barrett's cells which are sensitive to the laser because of the photosensitizing agent. Normal tissue is not burned because it has not taken up the photosensitizing agent and is not sensitive to the laser. The dysplasia is eliminated in more than 75% of patients. However, some Barrett's esophagus remains untreated and need biopsy follow-up or additional ablation. Long-term studies will be necessary to demonstrate whether this technique prevents esophageal adenocarcinoma on a long term basis (for
example, five years and longer after treatment).
One disadvantage of photosensitizing therapy is that
skin takes up some of the photosensitizing agent, and this makes the skin
sensitive to normal sunlight. The sensitivity may persist for six weeks or more
and can result in sunburn even with minimal exposure to direct sunlight. Patients, therefore, must remain out of the sunlight for this period. Other photosensitizing agents being tested have much less skin sensitivity, but studies are needed to determine if they are effective in eliminating the dysplasia. Esophageal narrowings (strictures) are a common complication of PDT but can be managed by endoscopically stretching (dilating) them.
Other methods of ablation
Other experimental methods of ablation are less powerful
than PDT and have, therefore, been applied more often to low grade dysplasia and
shorter segments of Barrett's with dysplasia (as well as to Barrett's without
dysplasia, which is discussed in the next section). These methods of ablation
include argon (flame) plasma coagulation (APC) and multipolar electrocoagulation (MPEC). They work by burning off the dysplasia and the Barrett's lining cells using devices that are introduced through the endoscope.
Endoscopic mucosal resection
(EMR)
Another experimental method to treat dysplasia,
especially high grade dysplasia, is the removal of dysplastic or cancerous areas
of the mucosa by cutting (resecting) them out. The resection is done using
snares at endoscopy, in a manner similar to the way polyps of the colon are
removed at colonoscopy. Again, 5-year follow-up data
is necessary to determine if EMR is effective.
Chemoprevention with drugs
The newer drugs used to treat arthritis, the
COX-2
inhibitors, have been studied in Barrett's-associated dysplasia. The purpose of
these studies is to see if these drugs can downgrade the severity of dysplasia
or prevent dysplasia. This approach, which is called chemoprevention, is based
upon the observation that adenomatous polyps of the colon in patients with
familial polyposis (hereditary multiple colonic polyps) decrease (regress) after
treatment with these drugs or even with the older nonsteroidal antiinflammatory
drugs (NSAIDs). The theoretical reason to try COX-2
inhibitors in Barrett's dysplasia is that the enzyme cyclooxygenase (COX), which these drugs inhibit, is
present in large amounts in Barrett's dysplasia, as it is in adenomatous
polyps of the colon.
It should be stressed that long-term therapy with these
drugs in Barrett's esophagus should remain in the experimental arena because of
the complications or side effects associated with these drugs (for example,
cardiac, kidney and gastrointestinal problems).
Next: What experimental options are there for Barrett's esophagus WITHOUT
dysplasia? »
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