基于证据的 Barrett 食管射频消融后监测间隔的制定。
Development of Evidence-Based Surveillance Intervals After Radiofrequency Ablation of Barrett's Esophagus.
机构信息
University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Chapel Hill, North Carolina.
University College Hospital, Department of Gastroenterology, Fitzrovia, London, UK; Division of Surgery & Interventional Science, University College London, London, UK.
出版信息
Gastroenterology. 2018 Aug;155(2):316-326.e6. doi: 10.1053/j.gastro.2018.04.011. Epub 2018 Apr 13.
BACKGROUND & AIMS: Barrett's esophagus (BE) recurs in 25% or more of patients treated successfully with radiofrequency ablation (RFA), so surveillance endoscopy is recommended after complete eradication of intestinal metaplasia (CEIM). The frequency of surveillance is informed only by expert opinion. We aimed to model the incidence of neoplastic recurrence, validate the model in an independent cohort, and propose evidence-based surveillance intervals.
METHODS
We collected data from the United States Radiofrequency Ablation Registry (US RFA, 2004-2013) and the United Kingdom National Halo Registry (UK NHR, 2007-2015) to build and validate models to predict the incidence of neoplasia recurrence after initially successful RFA. We developed 3 categories of risk and modeled intervals to yield 0.1% risk of recurrence with invasive adenocarcinoma. We fit Cox proportional hazards models assessing discrimination by C statistic and 95% confidence limits.
RESULTS
The incidence of neoplastic recurrence was associated with most severe histologic grade before CEIM, age, endoscopic mucosal resection, sex, and baseline BE segment length. In multivariate analysis, a model based solely on most severe pre-CEIM histology predicted neoplastic recurrence with a C statistic of 0.892 (95% confidence limit, 0.863-0.921) in the US RFA registry. This model also performed well when we used data from the UK NHR. Our model divided patients into 3 risk groups based on baseline histologic grade: non-dysplastic BE; indefinite for dysplasia, low-grade dysplasia, and high-grade dysplasia; or intramucosal adenocarcinoma. For patients with low-grade dysplasia, we propose surveillance endoscopy at 1 and 3 years after CEIM; for patients with high-grade dysplasia or intramucosal adenocarcinoma, we propose surveillance endoscopy at 0.25, 0.5, and 1 year after CEIM, then annually.
CONCLUSION
In analyses of data from the US RFA and UK NHR for BE, a much-attenuated schedule of surveillance endoscopy would provide protection from invasive adenocarcinoma. Adherence to the recommended surveillance intervals could decrease the number of endoscopies performed yet identify unresectable cancers at rates less than 1/1000 endoscopies.
背景与目的
射频消融（RFA）成功治疗后，25%或更多的患者会出现 Barrett 食管（BE）复发，因此建议在完全消除肠化生（CEIM）后进行内镜监测。监测的频率仅由专家意见决定。我们旨在建立并验证预测 RFA 初始成功后肿瘤复发发生率的模型，并提出基于证据的监测间隔。
方法
我们从美国射频消融登记处（US RFA，2004-2013 年）和英国国家 Halo 登记处（UK NHR，2007-2015 年）收集数据，建立和验证预测最初成功 RFA 后肿瘤复发发生率的模型。我们开发了 3 种风险类别，并对模型进行了建模，以达到 0.1%的浸润性腺癌复发风险。我们拟合了 Cox 比例风险模型，通过 C 统计量和 95%置信区间评估区分度。
结果
肿瘤复发的发生率与 CEIM 前最严重的组织学分级、年龄、内镜黏膜切除术、性别和基线 BE 段长度有关。多变量分析表明，仅基于最严重的 CEIM 前组织学建立的模型，在 US RFA 登记处预测肿瘤复发的 C 统计量为 0.892（95%置信区间，0.863-0.921）。当我们使用 UK NHR 的数据时，该模型也表现良好。我们的模型根据基线组织学分级将患者分为 3 个风险组：非异型增生 BE；异型增生、低级别异型增生和高级别异型增生不确定；或黏膜内腺癌。对于低级别异型增生患者，我们建议在 CEIM 后 1 年和 3 年进行内镜监测；对于高级别异型增生或黏膜内腺癌患者，我们建议在 CEIM 后 0.25 年、0.5 年和 1 年进行内镜监测，然后每年进行一次。
结论
对来自 US RFA 和 UK NHR 的 BE 数据分析表明，监测内镜的频率大大降低，可以预防浸润性腺癌。遵守推荐的监测间隔可以减少进行的内镜检查数量，但以低于 1/1000 次内镜检查的比例识别不可切除的癌症。
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