Clin Endosc.  2019 May;52(3):269-272. 10.5946/ce.2018.124.

Buried Barrett's Esophagus with High-Grade Dysplasia after Radiofrequency Ablation

• Castela J
• Serrano M
• de Ferro S
• Pereira DV
• Chaves P
• Pereira AD

• KMID: 2449768
• DOI: http://doi.org/10.5946/ce.2018.124

Abstract

Radiofrequency ablation therapy is an effective endoscopic option for the eradication of Barrett's esophagus that appears to reduce the risk of esophageal cancer. A concern associated with this technique is the development of subsquamous/buried intestinal metaplasia, whose clinical relevance and malignant potential have not yet been fully elucidated. Fewer than 20 cases of subsquamous neoplasia after the successful radiofrequency ablation of Barrett's esophagus have been reported to date. Here, we describe a new case of subsquamous neoplasia (high-grade dysplasia) following radiofrequency ablation that was managed with endoscopic resection. Our experience suggests that a meticulous endoscopic inspection prior to and after radiofrequency ablation is fundamental to reduce the risk of buried neoplasia development.

Keyword

Barrett esophagus; Catheter ablation; Esophageal neoplasms

MeSH Terms

Barrett Esophagus*
Catheter Ablation*
Esophageal Neoplasms
Metaplasia

Figure

• 

  Fig. 1. Nodular lesion (0-IIa) covered by normal esophageal mucosa on white-light endoscopy (A) and i-Scan (B).

• 

  Fig. 2. Pathologic specimen (hematoxylin and eosin staining). (A) Mucosa with a squamous lining with features of re-epithelization and subjacent columnar epithelium (×40), (B) intestinal metaplasia (×100), and (C) focal high-grade dysplasia (HGD) (×100) consistent with buried Barrett with HGD.

Reference

1. Falk GW. Barrett’s esophagus. Gastroenterology. 2002; 122:1569–1591.

2. Simard EP, Ward EM, Siegel R, Jemal A. Cancers with increasing incidence trends in the United States: 1999 through 2008. CA Cancer J Clin. 2012; 62:118–128.

3. Stein HJ, Siewert JR. Barrett’s esophagus: pathogenesis, epidemiology, functional abnormalities, malignant degeneration, and surgical management. Dysphagia. 1993; 8:276–288.

4. Shaheen NJ, Sharma P, Overholt BF, et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med. 2009; 360:2277–2288.

5. Iyer PG. A “deeper” look at subsquamous structures beneath the neosquamous epithelium after Barrett’s esophagus endotherapy. Gastrointest Endosc. 2016; 83:89–91.

6. Titi M, Overhiser A, Ulusarac O, et al. Development of subsquamous high-grade dysplasia and adenocarcinoma after successful radiofrequency ablation of Barrett’s esophagus. Gastroenterology. 2012; 143:564–566. e1.

7. Pouw RE, Visser M, Odze RD, et al. Pseudo-buried Barrett’s post radiofrequency ablation for Barrett’s esophagus, with or without prior endoscopic resection. Endoscopy. 2014; 46:105–109.

8. Peters F, Kara M, Rosmolen W, et al. Poor results of 5-aminolevulinic acid-photodynamic therapy for residual high-grade dysplasia and early cancer in barrett esophagus after endoscopic resection. Endoscopy. 2005; 37:418–424.

9. Spechler SJ. Buried (but not dead) Barrett’s metaplasia: tales from the crypts. Gastrointest Endosc. 2012; 76:41–43.

10. Gray NA, Odze RD, Spechler SJ. Buried metaplasia after endoscopic ablation of Barrett’s esophagus: a systematic review. Am J Gastroenterol. 2011; 106:1899–1908. quiz 1909.

11. Shafa S, Shaheen NJ. Buried Barrett’s esophagus-a sheep in sheep’s clothing. J Gastrointest Surg. 2016; 20:1281–1283.

12. Konda VJ, Gonzalez Haba Ruiz M, Hart J, Waxman I. Development of subsquamous cancer after hybrid endoscopic therapy for intramucosal Barrett’s cancer. Endoscopy. 2012; 44 Suppl 2 UCTN:E390–E391.

13. Chabrun E, Marty M, Zerbib F. Development of esophageal adenocarcinoma on buried glands following radiofrequency ablation for Barrett’s esophagus. Endoscopy. 2012; 44 Suppl 2 UCTN:E392.

14. Lee JK, Cameron RG, Binmoeller KF, et al. Recurrence of subsquamous dysplasia and carcinoma after successful endoscopic and radiofrequency ablation therapy for dysplastic Barrett’s esophagus. Endoscopy. 2013; 45:571–574.

15. Kohoutova D, Haidry R, Banks M, et al. Esophageal neoplasia arising from subsquamous buried glands after an apparently successful photodynamic therapy or radiofrequency ablation for Barrett’s associated neoplasia. Scand J Gastroenterol. 2015; 50:1315–1321.

16. Prasad GA, Wang KK, Halling KC, et al. Utility of biomarkers in prediction of response to ablative therapy in Barrett’s esophagus. Gastroenterology. 2008; 135:370–379.

17. Hornick JL, Blount PL, Sanchez CA, et al. Biologic properties of columnar epithelium underneath reepithelialized squamous mucosa in Barrett’s esophagus. Am J Surg Pathol. 2005; 29:372–380.

18. Orlando RC. How good is the neosquamous epithelium? Dig Dis. 2014; 32:164–170.

19. Naini BV, Souza RF, Odze RD. Barrett’s esophagus: a comprehensive and contemporary review for pathologists. Am J Surg Pathol. 2016; 40:e45–e66.

20. Wani S, Rubenstein JH, Vieth M, Bergman J. Diagnosis and management of low-grade dysplasia in Barrett’s esophagus: expert review from the clinical practice updates committee of the American Gastroenterological Association. Gastroenterology. 2016; 151:822–835.