The radiofrequency ablation has been shown to be very effective for the treatment of flat neoplastic lesions in Barrett’s oesophagus irrespective of histology. In particular, this has been shown to be associated with less disease progression (3.6% vs. 16.3%, P=0.03) when compared with sham. [1] The aim of our study was to identify the frequency of patients with invisible or completely flat neoplasia, treatment modality used and ultimate outcome of these patients.

This is a retrospective analysis of a prospectively collected data of the last 250 consecutive Barrett’s neoplasia patients treated at a tertiary referral center for Barrett’s endotherapy in the UK. The endoscopy, histology and clinical records were analysed to identify all patients with invisible (biopsy proven neoplasia) or flat (IIb) lesions. Data was collected on lesion morphology, histology, treatment modality (ablation vs endoscopic resection) and overall outcome was collected. Patients were broadly divided into two group 1(Ablation only) vs group 2 (endoscopic resection).

We evaluated a total of 250 consecutive patients with Barrett’s neoplasia treated in our centre. 87/250 (35%) were found to be either flat IIb or with invisible / indistinct margins.

47/87 (54.02%) underwent ablation without resection (group 1). 40/87 (45.97%) underwent up-front resection (group 2). The median follow-up time was 1758 [1016; 2769] and 1185 [705;1899] days for group 1 and 2, respectively.

Pre-intervention histology demonstrated High grade dysplasia (HGD) in 23/47 (48.93%) and 29/40 (72.50%) patient in group 1 and group 2, respectively.

In group 2(EMR); comparison of post-resection histology with pre-resection histology revealed a disease upgrade in 29/40 (72.5%) patients.

11/40 patients in group 2 had LGD pre-resection; 5/11(45.5%) upgraded to HGD and 3/11(27.3%) upgraded to carcinoma after resection.

Similarly, 29/40 patients had pre-resection histology of HGD. After resection, 11/29 (38%) were upgraded to cancer.

Metachronous lesions developed in 8/47 (10.81%) and 2/40 (5.0%) in group 1 and group 2, respectively. The difference became more significant when stratified by index histology as patients with HGD on index histology developed more metachronous lesion (21.74%) when treated by ablation as compared to resection (6.89%).

RFA remains a valid treatment option of flat (IIb) lesions with indistinct margins and invisible but biopsy proven Barrett’s neoplasia but the risk of metachronous neoplasia is high in patients with index histology of HGD so they require very careful follow up if ablated.

The resection cohort revealed a significant upgrade in disease stage both in LGD and HGD cohort despite having flat lesions with no nodules.