Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies

Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.     

Is amiodarone still a reasonable therapeutic option for rhythm control in atrial fibrillation?

Amiodarone is the most potent antiarrhythmic drug available and is commonly prescribed to treat and prevent not only life-threatening ventricular arrhythmias but also atrial fibrillation (AF). The latest European Society of Cardiology AF guidelines state that amiodarone is recommended for long-term rhythm control in all AF patients but that other antiarrhythmic drugs should be considered first whenever possible, due to its extracardiac toxicity. In patients without significant or with only minimal structural heart disease, amiodarone is not listed as a possibility in their therapeutic scheme. Still, amiodarone is widely and liberally used, and is the most prescribed antiarrhythmic drug for patients with AF despite its high toxicity profile. Non-cardiovascular death was more frequent with amiodarone treatment than with a rate control strategy in AFFIRM, while meta-analyses suggest an association between amiodarone use in patients without structural heart disease and increased non-cardiovascular mortality. Severe or even fatal outcomes due to amiodarone may occur years after treatment initiation and are often not acknowledged by the prescribing physician, who may no longer be following the patient. The lack of widely accepted diagnostic criteria and symptom definitions may lead to underestimation of the incidence of severe side effects and of its toxicity. Unlike the underestimated risk of toxicity with amiodarone, severe complications associated with catheter ablation are usually directly ascribed to the treatment even by non-medical personnel, possibly resulting in overestimation of risks. This brief review will address the issue of amiodarone overuse and the frequent underestimation of its toxicity, while suggesting scenarios in which its use is entirely reasonable, and compare it with catheter ablation.     

The impact of additional margin coagulation with radiofrequency in liver resections with subcentimetric margin: can we improve the oncological results? A propensity score matching study

BackgroundWhereas the usefulness of radiofrequency (RF) energy as haemostatic method in liver surgery has become well established in the last decades, its intentional application on resection margins with the aim of reducing local recurrence is still debatable. Our goal was to compare the impact of an additional application of RF energy on the top of the resection surface, namely additional margin coagulation (AMC), on local recurrence (LR) when subjected to a subcentimeter margin.MethodsWe retrospectively analyzed 185 patients out of a whole cohort of 283 patients who underwent radical hepatic resection with subcentimetric margin. After propensity score adjustment, patients were classified into two balanced groups according to whether RF was applied or not.ResultsNo significant differences were observed within groups in baseline characteristics after PSM adjustment. The LR rate was significantly higher in the Control than AMC Group: 12 patients (14.5%) vs. 4 patients (4.8%) (p = 0.039). The estimated 1, 3, and 5-year LR-free survival rates of patients in the Control and AMC Group were: 93.5%, 86.0%, 81.0% and 98.8%, 97.2%, 91.9%, respectively (p = 0.049). Univariate Cox analyses indicated that the use of the RF applicator was significantly associated with lower LR (HR = 0.29, 95% confidence interval 0.093–0.906, p = 0.033). The Control Group showed smaller coagulation widths than the AMC group (p < 0.001).ConclusionsAn additional application of RF on the top of the resection surface is associated with less local hepatic recurrence than the use of conventional techniques.     

Microwave Ablation versus Stereotactic Body Radiotherapy for Stage I Non–Small Cell Lung Cancer: A Cost-Effectiveness Analysis

PurposeTo assess the cost effectiveness of microwave ablation (MWA) and stereotactic body radiotherapy (SBRT) for patients with inoperable stage I non–small cell lung cancer (NSCLC).Materials and MethodsA literature search was performed in MEDLINE with broad search clusters. A decision-analytic model was constructed over a 5-year period. The model incorporated treatment-related complications and long-term recurrence. All clinical parameters were derived from the literature with preference to long-term prospective trials. A healthcare payers’ perspective was adopted. Outcomes were measured in quality-adjusted life years (QALYs) extracted from prior studies and U.S. dollars from Medicare reimbursements and prior studies. Base case calculations, probabilistic sensitivity analysis with 10,000 Monte Carlo simulations, and multiple 1- and 2-way sensitivity analyses were performed.ResultsMWA yielded a health benefit of 2.31 QALYs at a cost of $195,331, whereas SBRT yielded a health benefit of 2.33 QALYs at a cost of $225,271. The incremental cost-effectiveness ratio was $1,480,597/QALY, indicating that MWA is the more cost-effective strategy. The conclusion remains unchanged in probabilistic sensitivity analysis with MWA being the optimal cost strategy in 99.84% simulations. One-way sensitivity analyses revealed that MWA remains cost effective when its annual recurrence risk is <18.4% averaged over 5 years, when the SBRT annual recurrence risk is >1.44% averaged over 5 years, or when MWA is at least $7,500 cheaper than SBRT.ConclusionsMWA appears to be more cost effective than SBRT for patients with inoperable stage I NSCLC.     

Iterative treatment with surgery and radiofrequency ablation of uveal melanoma liver metastasis: Retrospective analysis of a series of very long-term survivors

BackgroundAfter treatment of primary ocular uveal melanoma (UM), up to 50% of patients will develop metastases, mostly in the liver. Systemic treatments do not provide any overall survival benefit for these patients and surgery remains the most effective therapy for selected patients. Radiofrequency ablation (RFA) alone or in combination with surgery is frequently used to spare hepatic parenchyma. When patients relapse after treatment of their first metastases, and when the liver recurrence is limited, new local liver treatment is questionable.MethodsA total of 14 patients with liver metastases from uveal melanoma (LMUM) were retrospectively evaluated. All patients had a complete first liver resection and a second treatment with RFA. Overall survival, recurrence-free interval after the first and the second treatment was evaluated.ResultsTreatment of hepatic recurrence was percutaneous RFA for ten patients and per-operative RFA for four patients associated with new metastasectomy. The median time to onset of LMUMs after ocular UM treatment was 50 months, and the median time to recurrence of hepatic metastasis after the first liver treatment was 20 months. The overall survival was 70% at five years and 35% at ten years. The recurrence-free interval was 50% and 56% at two years after the first and the second treatment, respectively.ConclusionProlonged survival can be achieved by exclusive and iterative local treatment combining surgery and RFA in a small proportion of patients with a first recurrence of isolated LMUM.     

左、右半结肠癌肝转移患者射频消融治疗疗效及生存的对比分析

目的:探讨原发部位分别位于左、右半结肠的结肠癌肝转移患者行超声引导下肝转移瘤射频消融术后的生存差异及预后影响因素分析。方法:回顾性分析2010年1月至2015年12月于我科行射频消融治疗的结肠癌肝转移患者100例，其中左半结肠癌62例，右半结肠癌38例，分析原发部位不同的结肠癌肝转移患者在进行超声引导下射频消融治疗后的生存情况。结果:左半结肠癌肝转移患者射频消融术后1、3、5年总体生存率及中位生存期均高于右半结肠癌肝转移患者（88.71% vs 73.68%、62.90% vs 30.02%、49.72% vs 26.33%、55个月 vs 23个月），且二者生存曲线差异具有统计学意义（P＜0.05）。经Log-rank检验及COX多因素分析，左、右半结肠癌肝转移患者射频消融治疗术后的生存情况存在差异。此外，原发灶淋巴结转移情况、患者术前CA199水平及原发灶分化程度是患者射频消融治疗术后生存情况的影响因素。结论:左半结肠癌肝转移患者射频消融术后整体生存率明显高于右半结肠癌肝转移患者，左半结肠癌与右半结肠癌肝转移患者在射频消融治疗术后生存状况存在明显差异。     

射频消融辅助肝切除术在巨大肝脏肿瘤治疗中的应用

目的:比较射频消融辅助肝切除术与嵌夹结扎法在巨大肝脏肿瘤切除中的有效性及安全性。方法:共31例诊断为巨大肝脏肿瘤的患者纳入回顾性研究，其中15例采用射频消融辅助肝切除术（RF-LR组），16例采用传统的嵌夹结扎法（CC-LR组）。比较两组间出血量、输血情况、手术时间、术后并发症发生情况及生存率。结果:两组患者术前评估未见明显差异。CC-LR组患者中位术中出血量（1 000 ml vs 600 ml，P=0.005）及需输血患者例数（13例 vs 6例，P=0.029）较RF-LR组显著升高，但两组间手术时间、肝门阻断、术后并发症发生情况、围手术期死亡例数并无统计学差异。RF-LR组术后1年、2年、3年总体生存率分别为80.0%、70.0%、35.0%，与CC-LR组患者（76.9%、61.5%、38.5%）比较未见统计学差异（P>0.05）。结论:射频消融辅助肝切除术能有效减少巨大肝脏肿瘤患者术中出血量及输血患者例数，尤其对合并肝硬化患者适用，且与嵌夹结扎法具有相似的长期生存率。