Cryotherapy versus radiofrequency ablation in the treatment of post-chemoradiotherapy patients with recurrence of Barrett’s dysplasia
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We read with great interest the recent article by Gomes et al.,1 which demonstrates no differences between radiofrequency ablation (RFA) and cryotherapy in achieving complete eradication of intestinal metaplasia, complete eradication of dysplasia (CE-D), or recurrence rates in treatment-naïve Barratt’s dysplasia patients.
However, patients referred for endoscopic eradication may be more heterogeneous in a wider population than those in the cohort of this study. We found that patients who are not surgical candidates and have had previous definitive chemoradiotherapy with curative intent for esophageal adenocarcinoma treatment but subsequently experience Barrett’s dysplasia recurrence can prove challenging to manage.
Between May 2020 and June 2023, the South Barrett’s RFA center received 85 new patient referrals for dysplastic Barrett’s disease, of which 8 had underwent chemoradiotherapy for esophageal cancer (Table 1).
Comparison of patients with treatment-naïve dysplastic or neoplastic Barrett’s and those who had previously received definitive chemoradiotherapy
We noted that patients who had previously received chemoradiotherapy had a significantly lower CE-D rate (12.5%) than treatment-naïve patients (80.5%, p<0.001) when RFA was used to eradicate Barrett’s dysplasia following initial endoscopic resection for visible lesions.
The reasons for this are unclear but are likely to reflect a biologically more unstable disease in which the recurrence of dysplasia following systemic chemotherapy is unlikely to respond to superficial ablative techniques. Endoscopic resection was also proven to be more challenging in our dataset, which was likely attributable to the significant submucosal fibrosis from radiotherapy.
Lal et al.2 reported that cryotherapy ablates at a deeper level of the esophageal tissue and has a lower stricture rate than RFA. Furthermore, a recent article by Aintabi et al.3 highlighted the effectiveness of cryotherapy in the palliation of squamous cell esophageal cancer and posed interesting questions about whether this effectiveness is because of its ability to control deeper mucosal and submucosal diseases.
Based on this literature and our abovementioned findings, we propose that in patients who received chemoradiotherapy for non-surgically viable esophageal adenocarcinoma and experienced a recurrence of dysplastic Barrett’s disease, alternative therapy to RFA such as cryotherapy should be considered, and further research in this area is necessary.
Notes
Conflicts of Interest
The authors have no potential conflicts of interest.
Funding
None.
Author Contributions
Conceptualization: SKh, HH; Data Curation: all authors; Formal analysis: all authors; Methodology: all authors; Software: HH, SKh; Supervision: HH; Writing–original draft: SKh; Writing–reviewing & editing: SKh, HH.