HGD to LGD and LGD to HR Flashcards
What does DDS say about the behavior of NDBE?
Review of treatment strategies relating to LGD and NDBE
- NDBE displays neoplastic behavior and these changes occur prior to morphologic expression of neoplasia (dysplasia).
- Morphologic evaluation of dysplasia is fraught with error, and, as a result, often leads to false-negative and false-positive diagnoses.
- Surveillance is cost-ineffective and dangerously permissive of the development of EAC
DDS (LGD to HR)
Title: Case for Endoscopic Treatment of Title: Non-Dysplasia and Low Grade Dysplastic BE
Journal: Digestive Disease Science, 2010
Authors: Fleischer (+ 16 KOL - GI, Surgery and Path)
Use: LGD to HR
discuss Surveillance; Pathology; Prog; Anxiety
DDS - 5 reasons to consider RFA
- ) Inability to predict what patients will progress to HGD
- ) Inability to predict the time course of such progression.
- ) Risk for mis-diagnosis due to poor sampling; lack of consistent sampling and pathology discordanance
- ) Patient anxiety for harboring a pre-malignant lesion and impact in their QOL.
- ) Availability of safe effective methods compared to surveillance only.
ASGE - Peer Review {HGD to LGD and LGD to HR}
Title: The role of endoscopy in B.E. and other pre-malignant conditions of the esophagus.
Journal: Gastrointestinal Endoscopy; Dec 2012
Authors: ASGE Standards of Practice Committee (23 members)
Use: HGD to LGD and LGD to HR
What is the ASGE recommendation for treatment of LGD/ NDBE
LGD - abaltion as an alternative should be considered and discussed in select patients with LGD.
NDBE- No recommendation is included in the section that pertains to ablation.
However, the authors comment “Endoscopic eradication therapy as an alternative to surveillance in NDBE has been suggested to be cost effective in a cost utility model and may be a preferred management option in select patients with NDBE such as those with a family history of EAC
**No recommendation against using RFA”
Name the risk factors the ASGE list for BE and EAC
Male, White, Age (older than 50); Family History of BE; Smoking; Obesity; Increased Duration of Reflux Symptoms
AGA - Peer Review {HGD to LGD and LGD to HR}
Title: American Gastroenterology Association (AGA) Medical Position Statement on the management of B.E.
Journal: Gastroenterology; 2011
Authors: 14 panel members (P. Sharma; Shaheen; Inodami; Spechler; Souza), one community based physician (Pruitt), one Gen. surgeon, PCP, Pathologist, Ins. provider rep (BC of CA)
Use: HGD to LGD and LGD to HR
What does AGA recommend for HGD?
We recommend endoscopic eradication therapy with RFA, PDT or EMR rather than surveillance for treatment of patients with confirmed HGD within B.E.
What does AGA recommend for LGD?
Endoscopic Eradication Therapy with RFA should be a therapeutic option for treatment of patients with confirmed LGD in B.E.
What does AGA recommend for NDBE?
Although endoscopic eradication therapy is not suggested for the general population of BE patients in the absence of dysplasia. We suggest RFA with or without EMR as a therapeutic option for select individuals who are at an increased risk for progression to HGD or Cancer
What does the AGA state about progression?
Because Dysplasia progresses to cancer in a manner that lacks definitive markers of progression there are no well defined cutoff points that separate LGD from HGD at this time.
Risk Factors - age, BMI
BEst Study {HGD to LGD and LGD to HR}
Title: Dysplasia and Cancer in a Multicenter Cohort of patients with BE
Journal: Clinical Gastro and Hepatology 2006
Author: P. Sharma et. al.
Use: HGD to LGD and LDG to HR
Discussion on Pathology
What are the Summary Points of the BEST 2006 study
Multicenter (5) study to determine the time and progression rate of NDBE to LGD/HGD/EAC
- 3 VA/1 Naval/1,376 patients with 1st diagnosis of B.E.
-83% NDBE (1,142); 17% LGD/HGD/EAC
-618 met inclusion criteria of 1yr repeat endo and NDBE.
-Surveillance with biopsy and mean follow up of 4.12 years
-Findings: .
-.5% pp/yr IM to EAC (12 pts)
-.9% pp/rm IM to HGD (22 pts)
-.6% pp/yr LGD to EAC
-1.4% pp/yr to HGD or EAC
-Of the 34 patients whom progressed to HGD or EAC; 53% with two consecutive endoscopies had only prior finding of NDBE.
-Sharma agrees that the major (suggesting sampling error). ~ 4-6 %
problems with LGD include variable pathologic classifications and the interobserver disagreement in the reading of
LGD.
-
Wani “Continuation of best” {LGD to HR}
Title: Patients with NDBE have Low Risks for Developing Dysplasia or EAC
Journal - Clinical Gastro and Hepatology; 2011
Author: Wani et al.
Use: HGD to LGD and LDG to HR
discuss progression
What are the summary points 2011 Wani (BEst) continuation study.
Continuation study of BEst (2006 - Sharma).
-5 Centers (3 VA/1 Naval) and Clev. Clinic
-3300 Patients with1204 meeting criteria (greater than 1 year of follow up with no LGD/HGD or EAC).
-Followed for a mean of 5.52 years
FINDINGS:
-.27%/yr IM to EAC (18 pts)
-.48%/yr IM to HGD (32 pts)
-.63%/yr IM to HGD/EAC (44 pts)
Using Kaplan Meyer Survival Graphs:
2.9% risk for NDBE to EAC progression 10 years and
7.3% risk for NDBE to HGD/EAC progression 10 years
- Of 32 pts who developed HGD - 25% prog to EAC
- NNT was 769 / 1 yr. (calculate that out to 5 yrs - 139)
- No central pathology - but authors state even discordance with expert GI
- NDBE greater than 6cm .65% prog to EAC
AIM II (LGD to HR)
Title: Endoscopic RFA of BE - 5 year outcomes from a prospective multi-center trial
Journal: Endoscopy - Sept 2010
Authors: Fleischer (+ 13 KOL) Overhold, V.K. Sharma; Chutanni; Chang; Muth; Lightdale; Pleskow
Use: LGD to HR
discuss durability
Key Point Summary AIM II
Prospective Multi-Center US Trial. Follow up to AIM (I) which was 2.5 years
-5 year data of NDBE patients after RFA
-60 eligible patients and 50 consented
-CR-IM was 92% (98.2 @ 21/2 yrs).
8% (4pts) had focal NDBE and converted to CR-IM after one session.
-No BG (5000 biopsies) / No Strictures (170 procedures).
Orman (HGD to LGD)
Title: Intestinal Metaplasia recurs infrequently in patients successfully treated for BE with RFA
Journal: American Gastro; Dec 2012
Author: Orman, Cotton, Shaheen
Use: HGD to LGD
discuss progression
Key Point Summary of Orman study?
Retrospective study for the recurrence of BE. Largest study reporting RFA outcomes and durability HGD/IMC.
262 patients - Univ. of NC between 2006 and 2011 who received RFA.
-Expert GI path and 2nd for discordance.
-231 met criteria: with 119 CE-D 112 CE-IM
-Surveillance median 397 days
-8 recurred who had pre ablation grade HGD (1 IMC, 2 EAC and 5 NDBE)
-Annual recurrence 2.4% for LGD; 5.5% HGD; 9.4% IMC
-Overall recurrence was 5.2%/yr
-97% CE-D / 89% CE-IM
75% (6/8) were successfully retreated or kept in surveillance.
85% of CE-D patients remained D free after 1 year.
**No pre ablated LGDpt had ever recurred
**Only 63% had Halo 360.
Skacel (HGD to LGD)
Title: The diagnosis of LGD in BE and it’s implications for disease progression.
Journal: American Journal of Gastroenterology 2000
Author: Skacel et. al.
Use: HGD to LGD
discuss pathology
What are the Key Points of Skacel paper?
Retrospective review from Cleveland Clinic between 1986 and 1997
-43 randomized and blindly reviewed LGD diagnosis by 3 GI pathologists
-Follow up in 25 pts.
-Discovered that if 2 of the pathologists agreed on the original diagnosis that 41% (7/17) of the patients progressed to HGD/EAC
If 3 of the pathologist agreed 80% (4/5) of subjects had progressed to HGD/EAC
-Over 11 months
-If no agreement, no progression
Thus - consensus diagnosis between pathologists suggest higher progression rates.
*Among the GI path, only 65% had agreed with their own original diagnosis (35% discordance).
NEJM AIM Dysplasia Trial (HGD to LGD)
Title: RFA in BE with Dysplasia
Author: Shaheen et. al. (P. Sharma, Overholt, Jobe, Fleischer, Chang, 2009
Use: HGD to LGD
discuss effectiveness/BG/progresssion
Key Point Summary AIM Dysplasia Trial - NEJM
RCT comparing RFA to sham to assess whether RFA could erradicate Dysp and decrease progression. 19 centers
-127 subjects and 2:1 (RFA to sham) with primary outcomes @ 12 mo.
LGD-CE
91% RFA vs. 23% sham (ITT) - 95% ppp
HGD-CE
81% RFA vs. 19% sham (ITT) - 90% ppp
77% overall IM-CE (ITT) - 83%ppp
-87% lower incidence of cancer (1.2 vs 9.3) and 78% lower incidence of disease progression (3.6 vs 16.3)
-25% with BG - 5% after RFA and 40% sham
30% discordance between pathology
RCT Extension Trial - Shaheen (HGD to LGD)
Title: Durability in BE with Dysplasia
Journal: Gastroenterology 2011
Authors: Shaheen et. al
Use: HGD to LGD
discuss durability, progression
