The incidence of esophageal cancer and high-grade dysplasia in Barrett's esophagus: a systematic review and meta-analysis

Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus

BACKGROUND

Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy).

OBJECTIVES

We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)).

SEARCH METHODS

We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012.

SELECTION CRITERIA

Types of studies: RCTs comparing endotherapies with surgery in the treatment of high-grade dysplasia or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately.

TYPES OF PARTICIPANTS

patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus. Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent.

DATA COLLECTION AND ANALYSIS

Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9.

MAIN RESULTS

We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies.

AUTHORS' CONCLUSIONS

This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.

Establishing spectrochemical changes in the natural history of oesophageal adenocarcinoma from tissue Raman mapping analysis

Raman spectroscopy is a fast and sensitive technique able to identify molecular changes in biological specimens. Herein, we report on three cases where Raman microspectroscopy was used to distinguish normal vs. oesophageal adenocarcinoma (OAC) (case 1) and Barrett’s oesophagus vs. OAC (cases 2 and 3) in a non-destructive and highly accurate fashion. Normal and OAC tissues were discriminated using principal component analysis plus linear discriminant analysis (PCA-LDA) with 97% accuracy (94% sensitivity and 100% specificity) (case 1); Barrett’s oesophagus vs. OAC tissues were discriminated with accuracies ranging from 98 to 100% (97–100% sensitivity and 100% specificity). Spectral markers responsible for class differentiation were obtained through the difference-between-mean spectrum for each group and the PCA loadings, where C–O–C skeletal mode in β-glucose (900 cm⁻¹), lipids (967 cm⁻¹), phosphodioxy (1296 cm⁻¹), deoxyribose (1456 cm⁻¹) and collagen (1445, 1665 cm⁻¹) were associated with normal and OAC tissue differences. Phenylalanine (1003 cm⁻¹), proline/collagen (1066, 1445 cm⁻¹), phospholipids (1130 cm⁻¹), CH₂ angular deformation (1295 cm⁻¹), disaccharides (1462 cm⁻¹) and proteins (amide I, 1672/5 cm⁻¹) were associated with Barrett’s oesophagus and OAC tissue differences. These findings show the potential of using Raman microspectroscopy imaging for fast and accurate diagnoses of oesophageal pathologies and establishing subtle molecular changes predisposing to adenocarcinoma in a clinical setting.

Graphical abstract

Interaction of epidermal growth factor with COX-2 products and peroxisome proliferator-activated receptor-γ system in experimental rat Barrett's esophagus

Mixed acidic-alkaline refluxate is a major pathogenic factor in chronic esophagitis progressing to Barrett's esophagus (BE). We hypothesized that epidermal growth factor (EGF) can interact with COX-2 and peroxisome proliferator-activated receptor-γ (PPARγ) in rats surgically prepared with esophagogastroduodenal anastomosis (EGDA) with healthy or removed salivary glands to deplete salivary EGF. EGDA rats were treated with 1) vehicle, 2) EGF or PPARγ agonist pioglitazone with or without EGFR kinase inhibitor tyrphostin A46, EGF or PPARγ antagonist GW9662 respectively, 3) ranitidine or pantoprazole, and 4) the selective COX-2 inhibitor celecoxib combined with pioglitazone. At 3 mo, the esophageal damage and the esophageal blood flow (EBF) were determined, the mucosal expression of EGF, EGFR, COX-2, TNFα, and PPARγ mRNA and phospho-EGFR/EGFR protein was analyzed. All EGDA rats developed chronic esophagitis, esophageal ulcerations, and intestinal metaplasia followed by a fall in the EBF, an increase in the plasma of IL-1β, TNFα, and mucosal PGE₂ content, the overexpression of COX-2-, and EGF-EGFR mRNAs, and proteins, and these effects were aggravated by EGF and attenuated by pioglitazone. The rise in EGF and COX-2 mRNA was inhibited by pioglitazone but reversed by pioglitazone cotreated with GW9662. We conclude that 1) EGF can interact with PG/COX-2 and the PPARγ system in the mechanism of chronic esophagitis; 2) the deleterious effect of EGF involves an impairment of EBF and the overexpression of COX-2 and EGFR, and 3) agonists of PPARγ and inhibitors of EGFR may be useful in the treatment of chronic esophagitis progressing to BE.NEW & NOTEWORTHY Rats with EGDA exhibited chronic esophagitis accompanied by a fall in EBF and an increase in mucosal expression of mRNAs for EGF, COX-2, and TNFα, and these effects were exacerbated by exogenous EGF and reduced by removal of a major source of endogenous EGF with salivectomy or concurrent treatment with tyrphostin A46 or pioglitazone combined with EGF. Beneficial effects of salivectomy in an experimental model of BE were counteracted by PPARγ antagonist, whereas selective COX-2 inhibitor celecoxib synergistically with pioglitazone reduced severity of esophageal damage and protected esophageal mucosa from reflux. We propose the cross talk among EGF/EGFR, PG/COX-2, and proinflammatory cytokines with PPARγ pathway in the mechanism of pathogenesis of chronic esophagitis progressing to BE and EAC.

Impact of Gastroesophageal Reflux Disease on Mucosal Immunity and Atopic Disorders

Atopic disorders and gastroesophageal reflux disease (GERD) are some of the most common medical conditions treated by primary care physicians and specialists alike. The observation that atopic disorders, like asthma, allergic rhinitis and sinusitis, food allergies, atopic dermatitis, contact dermatitis, and eosinophilic esophagitis are common comorbidities in patients with GERD raises the question of the nature of the relationship that may exist between GERD and atopic disorders. In this article, we review the pathophysiology of GERD, its effect on the immune system, the effect of acid-blocking medications on allergic responses, as well as several common atopic conditions that have been associated with GERD including asthma, chronic rhinosinusitis (CRS), allergic rhinitis (AR), atopic dermatitis (AD), contact dermatitis (CD), food allergies, proton pump inhibitor (PPI)-responsive esophageal eosinophilia (PPI-REE), and eosinophilic esophagitis (EoE). In each condition, the evidence of a causal link is not definitive. Although the relationship between asthma and GERD remains controversial, evidence suggests that a subset of asthma patients with documented GERD may experience improved asthma control following appropriate treatment of GERD. The relationship of GERD to allergic rhinitis and chronic sinusitis is weak; however, studies support the concept that treatment of frequent episodes of GERD can have a positive effect on rhinitis and sinusitis overall. The relationship between allergic sensitization and GERD is likely bidirectional. GERD may induce changes in the mucosal immune system that may favor the development of food allergy and allergic sensitization to aeroallergens; however, the underlying mechanisms have not been established.

Liquid nitrogen spray cryotherapy-based multimodal endoscopic management of dysplastic Barrett's esophagus and early esophageal neoplasia: retrospective review and long-term follow-up at an academic tertiary care referral center

BACKGROUND

Endoscopic eradication therapy of dysplastic Barrett's esophagus (BE) and early esophageal neoplasia has emerged as an effective treatment option. Data for the role of spray cryotherapy (SCT) in this setting is relatively limited.

OBJECTIVE

To evaluate the safety and long-term outcomes of SCT-based multimodal therapy in the management of dysplastic BE and early esophageal neoplasia.

DESIGN

Single-center, retrospective, cohort study.

SETTING

Academic, tertiary care center between August 2008 and February 2019.

METHODS

A retrospective chart review was conducted of the prospectively maintained endoscopic cryotherapy database at our center. Fifty-seven patients were identified who underwent SCT treatment for dysplastic BE and esophageal or Gastro-esophageal (GE) junction adenocarcinoma during the study period. Primary outcome was complete eradication of intestinal metaplasia (CE-IM); secondary outcome was complete eradication of dysplasia (CE-D).

RESULTS

A total of 171 SCT procedures were performed in 57 patients. The majority of patients were male (89.5%) with long-segment BE (93%; mean segment length 6.2 cm). Complete follow-up data was available for 56 of these 57 patients. 43.9% (25/57) of patients underwent radiofrequency ablation (RFA) during the course of treatment (e.g. after initiating SCT). 33.3% of patients (19/57) were RFA failures prior to SCT. Additionally, 68.4% (39/57) of patients underwent endoscopic resection (EMR) prior to SCT as part of our multimodal approach to treatment of BE dysplasia/neoplasia. Four patients (7%) are currently undergoing active ablation and/or EMR treatment. CE-IM was achieved in 75% (39/52) of patients, and CE-D in 98.1% (51/52). Mean duration of overall follow-up was 4.8 years, with mean CE-IM durability of 2.6 years.

LIMITATIONS

Single-center only, retrospective study design.

CONCLUSION

SCT-based multimodal endoscopic therapy can achieve very high CE-IM (75%) and CE-D (>98%) rates in a high-risk population with esophageal dysplasia and/or neoplasia.

Incidence of Dysplasia in Obese vs Nonobese Patients With Nondysplastic Barrett Esophagus

Background: Obesity is a known independent risk factor for both Barrett esophagus and esophageal adenocarcinoma. However, data about the effect of obesity on the risk of progression from nondysplastic Barrett esophagus to dysplasia or esophageal adenocarcinoma are lacking. The aim of this study was to evaluate whether obese patients with nondysplastic Barrett esophagus had a higher incidence of dysplasia development during routine surveillance than nonobese patients. Methods: In a retrospective review, 1,999 patients who had a first diagnosis of nondysplastic Barrett esophagus made by esophagogastroduodenoscopy (EGD) at a single community hospital were tracked to their surveillance EGD 3 to 5 years later to evaluate for dysplasia (low grade, high grade, or adenocarcinoma). We compared the incidence of dysplasia development in obese patients (body mass index [BMI] ≥30 kg/m²) with nonobese patients (BMI <30 kg/m²). Results: The sample population included 1,019 obese patients (51.0%) and 980 nonobese patients (49.0%) with nondysplastic Barrett esophagus. Their mean age was 56.5 ± 11.6 years, 1,228 (61.4%) were male, and 1,853 (92.7%) were Caucasian. At surveillance endoscopy performed at a mean follow-up of 3.7 years after their first EGD, 51 obese patients (incidence of 15.3 cases per 1,000 person-years, 95% confidence interval [CI], 11.5-19.9) and 15 nonobese patients (incidence of 4.6 cases per 1,000 person-years, 95% CI, 2.7-7.4) had developed dysplasia (P=0.0001). Conclusion: We found a significant increase in the incidence of dysplasia development in obese patients with nondysplastic Barrett esophagus at 3- to 5-year follow-up compared to nonobese patients. This finding suggests that more frequent surveillance in obese patients with nondysplastic Barrett esophagus may be warranted for early detection of dysplasia.

Inflammatory bowel disease- and Barrett's esophagus-associated neoplasia: the old, the new, and the persistent struggles

Early diagnosis of and adequate therapy for premalignant lesions in patients with inflammatory bowel disease (IBD) and Barrett's esophagus (BE) has been shown to decrease mortality. Endoscopic examination with histologic evaluation of random and targeted biopsies remains the gold standard for early detection and adequate treatment of neoplasia in both these diseases. Although eventual patient management (including surveillance and treatment) depends upon a precise histologic assessment of the initial biopsy, accurately diagnosing and grading IBD- and BE-associated dysplasia is still considered challenging by many general as well as subspecialized pathologists. Additionally, there are continuing updates in the literature regarding the diagnosis, surveillance, and treatment of these disease entities. This comprehensive review discusses the cancer risk, detailed histopathological features, diagnostic challenges, and updates as well as the latest surveillance and treatment recommendations in IBD- and BE-associated dysplasia.

Global Incidence of Frailty and Prefrailty Among Community-Dwelling Older Adults: A Systematic Review and Meta-analysis

IMPORTANCE

Frailty is a common geriatric syndrome of significant public health importance, yet there is limited understanding of the risk of frailty development at a population level.

OBJECTIVE

To estimate the global incidence of frailty and prefrailty among community-dwelling adults 60 years or older.

DATA SOURCES

MEDLINE, Embase, PsycINFO, Web of Science, CINAHL Plus, and AMED (Allied and Complementary Medicine Database) were searched from inception to January 2019 without language restrictions using combinations of the keywords frailty, older adults, and incidence. The reference lists of eligible studies were hand searched.

STUDY SELECTION

In the systematic review, 2 authors undertook the search, article screening, and study selection. Cohort studies that reported or had sufficient data to compute incidence of frailty or prefrailty among community-dwelling adults 60 years or older at baseline were eligible.

DATA EXTRACTION AND SYNTHESIS

The methodological quality of included studies was assessed using The Joanna Briggs Institute's Critical Appraisal Checklist for Prevalence and Incidence Studies. Meta-analysis was conducted using a random-effects (DerSimonian and Laird) model.

MAIN OUTCOMES AND MEASURES

Incidence of frailty (defined as new cases of frailty among robust or prefrail individuals) and incidence of prefrailty (defined as new cases of prefrailty among robust individuals), both over a specified duration.

RESULTS

Of 15 176 retrieved references, 46 observational studies involving 120 805 nonfrail (robust or prefrail) participants from 28 countries were included in this systematic review. Among the nonfrail individuals who survived a median follow-up of 3.0 (range, 1.0-11.7) years, 13.6% (13 678 of 100 313) became frail, with the pooled incidence rate being 43.4 (95% CI, 37.3-50.4; I2 = 98.5%) cases per 1000 person-years. The incidence of frailty was significantly higher in prefrail individuals than robust individuals (pooled incidence rates, 62.7 [95% CI, 49.2-79.8; I2 = 97.8%] vs 12.0 [95% CI, 8.2-17.5; I2 = 94.9%] cases per 1000 person-years, respectively; P for difference < .001). Among robust individuals in 21 studies who survived a median follow-up of 2.5 (range, 1.0-10.0) years, 30.9% (9974 of 32 268) became prefrail, with the pooled incidence rate being 150.6 (95% CI, 123.3-184.1; I2 = 98.9%) cases per 1000 person-years. The frailty and prefrailty incidence rates were significantly higher in women than men (frailty: 44.8 [95% CI, 36.7-61.3; I2 = 97.9%] vs 24.3 [95% CI, 19.6-30.1; I2 = 8.94%] cases per 1000 person-years; prefrailty: 173.2 [95% CI, 87.9-341.2; I2 = 99.1%] vs 129.0 [95% CI, 73.8-225.0; I2 = 98.5%] cases per 1000 person-years). The incidence rates varied by diagnostic criteria and country income level. The frailty and prefrailty incidence rates were significantly reduced when accounting for the risk of death.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that community-dwelling older adults are prone to developing frailty. Increased awareness of the factors that confer high risk of frailty in this population subgroup is vital to inform the design of interventions to prevent frailty and to minimize its consequences.

Barretts's carcinogenesis

Barrett's esophagus is considered a precancerous lesion of esophageal adenocarcinoma (EAC). Long‐segment Barrett's esophagus, which is generally associated with intestinal metaplasia, has a higher rate of carcinogenesis than short‐segment Barrett's esophagus, which is mainly composed of cardiac‐type mucosa. However, a large number of cases reportedly develop EAC from the cardiac‐type mucosa which has the potential to involve intestinal phenotypes. There is no consensus regarding whether the definition of Barrett's epithelium should include intestinal metaplasia. Basic researches using rodent models have provided information regarding the origins of Barrett's epithelium. Nevertheless, it remains unclear whether differentiated gastric columnar epithelium or stratified esophageal squamous epithelium undergo transdifferentiation into the intestinal‐type columnar epithelium, transcommittment into the columnar epithelium, or whether the other pathways exist. Reflux of duodenal fluid including bile acids into the stomach may occur when an individual lies down after eating, which could cause the digestive juices to collect in the fornix of the stomach. N‐nitroso‐bile acids are produced with nitrites that are secreted from the salivary glands, and bile acids can drive expression of pro‐inflammatory cytokines via EGFR or the NF‐κB pathway. These steps may contribute significantly to carcinogenesis.

Flow based single cell analysis of the immune landscape distinguishes Barrett's esophagus from adjacent normal tissue

Barrett’s esophagus (BE) is metaplasia of the squamous epithelium to a specialized columnar epithelium. BE progresses through low- and high-grade dysplasia before developing into esophageal adenocarcinoma. The BE microenvironment is not well defined. We compare 12 human clinical BE and adjacent normal squamous epithelium biopsies using single cell immunophenotyping by flow cytometry. A cassette of 19 epithelial and immune cell markers was used to detect differences between cellular compartments in normal and BE tissues. We found that the BE microenvironment has an immunological landscape distinct from adjacent normal epithelium. BE has an increased percentage of epithelial cells with a concomitant decrease in the percentage of immune cells, accompanied by a shift in the immune landscape from a predominantly T cell rich microenvironment in normal tissue to a B cell rich landscape in BE tissue. Hierarchical clustering separates BE and normal samples into two discrete groups based upon our 19-marker panel, but also reveals unexpected, shared phenotypes for three patients. Our results suggest that flow based single cell analysis may have the potential for revealing clinically relevant differences between BE and normal adjacent tissue, and that surface immunophenotypes could identify specific subpopulations from dysplastic tissue for further investigation.

Persistent intestinal metaplasia after endoscopic eradication therapy of neoplastic Barrett's esophagus increases the risk of dysplasia recurrence: meta-analysis

BACKGROUND AND AIMS

Endoscopic eradication therapy (EET) is the main treatment for dysplastic Barrett's esophagus and intramucosal adenocarcinoma. Although the goal of EET is to achieve complete remission of intestinal metaplasia (CRIM), treatment might achieve complete remission of dysplasia (CR-D) only, without achieving CRIM. Persistent intestinal metaplasia after eradication of dysplasia might carry a higher risk for progression into advanced neoplasia.

METHODS

We performed a systematic review and meta-analysis after searching multiple databases to identify studies that evaluated dysplasia recurrence risk after successful eradication of neoplasia with EET. We calculated the pooled cumulative incidence of dysplasia and advanced neoplasia recurrence after CRIM and CR-D only and then compared the two using risk ratios.

RESULTS

Forty studies were included (4410 patients with total follow-up of 12,976 patient-years). A total of 4061 achieved CRIM and 349 achieved CR-D only. The cumulative incidence of CR-D only was 14% (95% confidence interval [CI], 10%-19%). The pooled cumulative incidence of any dysplasia recurrence after achieving CRIM was 5% (95% CI, 3%-7%) and 12% (95% CI, 4%-23%) after achieving CR-D only. Comparing dysplasia detection after achieving CR-D only with CRIM, there was a significantly higher risk for detection after CR-D (risk ratio [RR], 2.8; 95% CI, 1.7-4.6). The pooled cumulative incidence rate of high-grade dysplasia (HGD)/esophageal adenocarcinoma (EAC) recurrence was 3% (95% CI, 2%-4%) after achieving CRIM and 6% (95% CI, 0%-16%) after achieving CR-D only. Comparing HGD/EAC recurrence after achieving CR-D only with CRIM, there was a significantly higher risk for recurrence after CR-D (RR, 3.6; 95% CI, 1.45-9). When excluding patients who underwent ablation for non-dysplastic Barrett's esophagus only, these differences persisted with dysplasia recurrence after achieving CR-D only compared with CRIM showing a significantly higher risk for recurrence after CR-D (RR, 2.9; 95% CI, 1.66-5).

CONCLUSIONS

CRIM was associated with a lower risk of dysplasia and advanced neoplasia recurrence compared with CR-D only. Achieving CRIM should remain the goal of EET in dysplastic Barrett's esophagus.

Racial Disparity in the Sex Distribution, the Prevalence, and the Incidence of Dysplasia in Barrett's Esophagus

GOALS

Our aim was to study the prevalence of dysplasia and progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) in African Americans (AA) with Barrett's esophagus (BE) and compare it with that of non-Hispanic white (NHW) controls.

BACKGROUND

BE, a precursor of EAC, is a disease of predominantly white men and is uncommon in AA. The prevalence of dysplasia and progression to HGD and EAC in AA patients with BE is not clearly known.

STUDY

All AA or NHW patients with confirmed BE, that is specialized intestinal metaplasia, seen between 2002 and 2013 at our institution were included. Variables such as age, gender, medication use, the body mass index, the date of endoscopy, the hiatal hernia size, the BE length, and histologic findings were noted. Progression to HGD/EAC was evaluated.

RESULTS

Fifty-two AA and 2394 NHW patients with BE were identified. There was a higher percentage of women in the AA cohort (46.2%) than in the NHW cohort (24.9%, P<0.001). Nondysplastic BE was more prevalent in AA than in NHW (80.8% vs. 68.4%, P=0.058). In the surveillance cohort of 20 AA and 991 NHW, no racial differences in progression to HGD/EAC were observed during a median follow-up of 43 months.

CONCLUSIONS

This study includes the largest number of AA with histologically confirmed BE reported so far. About 46.2% of the AA cohort with BE in our study consisted of women. There was a trend toward a higher prevalence of nondysplastic BE in AA compared with NHW.

Geographic distribution and time trends of esophageal cancer in Brazil from 2005 to 2015

The purpose of the present study was to investigate the geographical distribution and time trends of the incidence and lethality of esophageal cancer (EC) in Brazil. The present study conducted an ecological study of EC using records from January 2005 to December 2015 in the Health Informatics Department of the Brazilian Ministry of Health (DATASUS) registry. In addition to demographical data on the population, EC incidence and lethality rates were estimated from hospitalizations and in-hospital mortalities and were adjusted by total available hospital beds. The adjusted EC rates per 100,000 increased from 9.1 in 2005 to 12.1 in 2015. The prevalence among males increased from 69 to 78%, while the female rates remained stable over the same period. Although EC was the most common in South and Southeast Brazil, the rates increased proportionately more in the other regions of the country, especially among males. Geographical analysis revealed higher rates of EC in more urbanized areas, with a coast-to-inland gradient. While rates increased in people older than 50 years, they decreased among people below this age. However, the lethality rates remained stable and high during the study period, overlapping with hospital admission rates. The recent increasing trend in the EC incidence, with shifts from the south towards the north and from more urbanized towards rural areas, suggests that environmental factors are crucial in EC pathogenesis. The concentration of EC in South Brazil may reflect the presence of major environmental factors in association with a possible genetic predisposition. The unchanging high mortality associated with EC in the rapidly aging population suggests that EC will continue to impose a significant social and economic burden in the future.

Lower Annual Rate of Progression of Short-Segment vs Long-Segment Barrett's Esophagus to Esophageal Adenocarcinoma

BACKGROUND & AIMS

European guidelines recommend different surveillance intervals of non-dysplastic Barrett's esophagus (NDBE) based on segment length, as opposed to guidelines in the United States, which do recommend surveillance intervals based on BE length. We studied rates of progression of NDBE to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in patients with short-segment BE using the definition of BE in the latest guidelines (length ≥1 cm).

METHODS

We collected demographic, clinical, endoscopy, and histopathology data from 1883 patients with endoscopic evidence of NDBE (mean age, 57.3 years; 83.5% male; 88.1% Caucasians) seen at 7 tertiary referral centers. Patients were followed for a median 6.4 years. Cases of dysplasia or EAC detected within 1 year of index endoscopy were considered prevalent and were excluded. Unadjusted rates of progression to HGD or EAC were compared between patients with short (≥1 and <3) and long (≥3) BE lengths using log-rank tests. A subgroup analysis was performed on patients with a documented Prague C&M classification. We used a multivariable proportional hazards model to evaluate the association between BE length and progression. Adjusted hazards ratios were calculated after adjusting for variables associated with progression.

RESULTS

We found 822 patients to have a short-segment BE (SSBE) and 1061 to have long segment BE (LSBE). We found patients with SSBE to have a significantly lower annual rate of progression to EAC (0.07%) than of patients with LSBE (0.25%) (P = .001). For the combined endpoint of HGD or EAC, annual progression rates were significantly lower among patients with SSBE (0.29%) compared to compared to LSBE (0.91%) (P < .001). This effect persisted in multivariable analysis (hazard ratio, 0.32; 95% CI, 0.18-0.57; P < .001).

CONCLUSION

We analyzed progression of BE (length ≥1 cm) to HGD or EAC in a large cohort of patients seen at multiple centers and followed for a median 6.4 years. We found a lower annual rate of progression of SSBE to EAC (0.07%/year) than of LSBE (0.25%/year). We propose lengthening current surveillance intervals for patients with SSBE.

Endoscopic resection for early esophageal carcinoma

Endoscopic resection for early esophageal cancer is a very precise endoscopic surgical technique and having experience in endoscopic resection is mandatory to perform these kinds of procedures safely. In case of adequate resection and favorable histological outcome, long-term prognosis of the patient is excellent. The basic principle for endoscopic treatment of early adenocarcinoma is based on the fact that the risk of lymph node metastasis gradually increases with the depth of invasion. Inspection and evaluation of all mucosal and submucosal lesions need to be done carefully before endoscopic resection. Endoscopic resection of mucosal (T1m1-3) and superficial submucosal (T1sm1) adenocarcinoma can be curative as well as for superficial mucosal (T1m1-m2) squamous cell carcinoma. In Paris type I lesions in Barrett's esophagus and for early squamous cell carcinoma endoscopic submucosal dissection (ESD) is the preferred option. The risk of severe adverse events associated with endoscopic resection are low. Most adverse events are managed endoscopically and can be treated conservatively. Endoscopic radiofrequency ablation is the most widely used ablation technique for Barrett's epithelium and highly effective to achieve full remission of dysplasia and intestinal metaplasia. The role of radiofrequency ablation in the treatment armamentarium in squamous cell carcinoma of the esophagus has still to be determined.

Gastrointestinal Tract Disorders in Older Age

Considering an increase in the life expectancy leading to a rise in the elderly population, it is important to recognize the changes that occur along the process of aging. Gastrointestinal (GI) changes in the elderly are common, and despite some GI disorders being more prevalent in the elderly, there is no GI disease that is limited to this age group. While some changes associated with aging GI system are physiologic, others are pathological and particularly more prevalent among those above age 65 years. This article reviews the most important GI disorders in the elderly that clinicians encounter on a daily basis. We highlight age-related changes of the oral cavity, esophagus, stomach, small and large bowels, and the clinical implications of these changes. We review epidemiology and pathophysiology of common diseases, especially as they relate to clinical manifestation in elderly. Details regarding management of specific disease are discussed in detail if they significantly differ from the management for younger groups or if they are associated with significant challenges due to side effects or polypharmacy. Cancers of GI tract are not included in the scope of this article.

Incidence of sexually transmitted infections in men who have sex with men and who are at substantial risk of HIV infection - A meta-analysis of data from trials and observational studies of HIV pre-exposure prophylaxis

BACKGROUND

Men who have sex with men (MSM) and who engage in condomless anal intercourse with casual partners are at high risk of acquiring sexually transmitted infections (STIs), but reliable epidemiological data are scarce. Studies on HIV pre-exposure prophylaxis (PrEP) enrol MSM who indicate that they engage in behaviour that puts them at high risk of acquiring HIV. Because they also screen for STIs at regular intervals, these studies may serve as a valuable source to estimate incidence rates of STIs in this subpopulation of MSM.

METHODS

We systematically searched for trials and observational studies of PrEP in MSM that reported data on the incidence of STIs during the study period. Incidence rates were calculated as events per 100 person-years (py) with 95% confidence intervals (CI). Data from individual studies were pooled building subgroups along study types and geography. We performed sensitivity analyses, including data only from studies that met pre-defined quality criteria.

RESULTS

Twenty-four publications on 20 studies were included. The majority of studies reported that sexual behaviour and/or STI incidence remained stable or decreased during the study period. For syphilis, incidence rates ranged from 1.8/100py to 14.9/100py, the pooled estimate was 9.1/100py (95%-CI: 7.7-10.9). Incidence rates for gonorrhoea and chlamydia of any site ranged from 13.3/100py to 43.0/100py and 15.1/100py to 48.5/100py, respectively. Considering only studies that met the criteria for sensitivity analysis yielded pooled estimates of 39.6/100py (95%-CI: 32.9-47.6) and 41.8/100py (95%-CI: 33.9-51.5), respectively. The overall estimate for hepatitis C incidence was 1.3/100py (95%-CI: 1.0-1.8).

CONCLUSIONS

Despite partly heterogeneous results, the data depict high incidence rates of STIs among MSM who engage in higher-risk sexual behaviours such as condomless sex with casual partners. This subpopulation of MSM requires access to STI screening at close intervals. By offering access to structures that provide regular STI monitoring and prompt treatment, PrEP may not only decrease HIV incidence but also have beneficial effects in decreasing the burden of STIs.

The incidence of esophageal cancer and dysplasia in a Chinese population with nondysplastic Barrett's esophagus

Aim

The aim of this study was to investigate the incidence of dysplastic transformation of Barrett's esophagus (BE) in a Chinese population.

Method

Data from nondysplastic BE patients at Taichung Veterans General Hospital were collected from May 2008 to June 2017. The enrolled individuals received regular upper gastrointestinal (UGI) endoscopy during follow up. The pathological transformations, including low-grade dysplasia (LGD), high-grade dysplasia (HGD), or esophageal adenocarcinoma (EAC), were collected prospectively until June 2017. Rates of progression were calculated in cases with a diagnosis of dysplasia or EAC.

Results

There were 51 subjects who met the inclusion criteria, with a mean follow up of 3.71 years (SD, 1.61) and a total follow up of 189.1 patient-years. Eight cases (15.7%) developed LGD, with a calculated incidence rate of 2.9% per year. The mean time to development of LGD was 3.26 years (SD, 2.68-3.84). One subject (2%) developed EAC, with a calculated incidence rate of 0.4% per year. No case with HGD was detected.

Conclusion

In a Chinese population with nondysplastic BE, 15.7% of cases developed LGD, with an incidence rate of 2.9% per year, and 2% of cases developed EAC, with an incidence rate of 0.4% per year.

Cancer risk perception in relation to associated symptoms in Barrett's patients: A cross sectional study on quality of life

Background

Barrett's oesophagus affects patients' quality of life and may be a psychological burden due to the threat of developing an oesophageal adenocarcinoma.

Objective

Assessing the oesophageal adenocarcinoma risk perceived by non-dysplastic Barrett's oesophagus patients and its association with quality of life, illness perception and reflux symptoms.

Methods

This cross-sectional questionnaire study included 158 Barrett's oesophagus non-dysplastic patients aged 18-75 years. Based on their annual and lifetime oesophageal adenocarcinoma risk estimations measured with the Magnifier Scale, patients were classified as overestimating or underestimating. Associations between the groups where assed on demographics, reflux symptoms and results of the Outcomes Study Short-Form-36 (SF-36) and the Brief Illness Perception Questionnaire (B-IPQ).

Results

The annual oesophageal adenocarcinoma risk was overestimated by 41%. Overestimating patients had lower means on the SF-36 domains: bodily pain (annual p = 0.007 and lifetime p = 0.014), general health (annual p = 0.011 and lifetime p = 0.014), vitality (annual p = 0.030), physical functioning (lifetime p = 0.028), worse illness perception (total score p = 0.001) and significantly more reflux symptoms.

Conclusions

Overestimation of the oesophageal adenocarcinoma risk by Barrett's oesophagus patients was associated with decreased quality of life and worse illness perceptions, which is most likely caused by symptoms of dyspepsia and reflux. These symptoms should be adequately treated, and patients may be in need of extra support and specific information about their oesophageal adenocarcinoma risk.

Screening and Surveillance for Barrett's Esophagus: Is It Cost-Effective?

The cost-effectiveness of screening and surveillance for Barrett's esophagus continues to evolve as the incidence of esophageal adenocarcinoma increases, biomarkers enhance the identification of individuals at highest risk for developing cancer, and endoscopic eradication of Barrett's esophagus improves. Screening to detect Barrett's esophagus may be cost-effective in selected high-risk groups based on age, race, sex and other factors such as symptoms of heartburn. Currently, endoscopic eradication therapy for Barrett's esophagus and high-grade dysplasia is a cost-effective intervention, while endoscopic therapy for non-dysplastic Barrett's esophagus is not a cost-effective strategy. As diagnosis of low-grade dysplasia improves, endoscopic eradication therapy may also prove to be a cost-effective intervention.

Barrett's Esophagus after Bimodality Therapy in Patients with Esophageal Adenocarcinoma

INTRODUCTION

Barrett's esophagus (BE) may be present in patients with esophageal adenocarcinoma (EAC) after bimodality therapy (BMT). There is no specific guidance for follow-up of these patients with regard to the presence of BE or dysplasia. In this study, we assessed the outcomes of patients who, after BMT, had BE and those who did not.

METHOD

Patients with EAC who had BMT were identified and analyzed retrospectively in two groups, with and without BE. We compared patient characteristics and outcome variables (local, distant, and no recurrence).

RESULTS

Of 228 patients with EAC, 68 (29.8%) had BE before BMT. Ninety-eight (42.9%) had BE after BMT, and endoscopic intervention was done in 11 (11.2%). With a median follow-up of 37 months, the presence of post-BMT BE was not significantly associated with overall survival (OS) and local recurrence-free survival (LRFS). Similarly, endoscopic intervention was not significantly associated with OS and LRFS. Fifty (73.5%) patients with BE before BMT had BE after BMT (p < 0.0001).

CONCLUSION

The presence of BE after BMT was not associated with increased risk of local recurrence. The local recurrence rate was not influenced by endoscopic intervention. Prospective studies are warranted to generate guidance for intervention, if necessary, for this group of EAC patients.

Histological assessment & use of immunohistochemical markers for detection of dysplasia in Barrett's esophageal mucosa

BACKGROUND

Histological assessment of dysplasia in Barrett's esophagus (BE) has high inter-observer variability. Hence, use of ancillary markers for early detection of dysplasia in BE is an important clinical question.

METHODS

In this retrospective study consecutive cases of BE (n = 59), over a period of 4 years were included. Hematoxylin and eosin stained sections were reviewed independently by 3 senior qualified pathologists, who graded the dysplasia according to the Vienna Classification system and inter-observer agreement was analysed using the Kappa statistics. Subsequently Alpha-Methyl Acyl-CoA Racemase (AMACR), p53, CyclinD1, β-catenin, H2AX and M30 immunohistochemical (IHC) stains were examined on the following disease categories: BE with no dysplasia [NFD] (45), BE with indefinite for dysplasia (IFD) (4), low grade dysplasia (LGD) (3), high grade dysplasia (HGD) (2) and in adenocarcinomas (5). H score was calculated by adding up products of different grades of stain distribution and stain intensities (range of scores 0-300).

RESULTS

Among the 3 pathologists, overall agreement was poor (k 0.06; 95% CI -0.089 to 0.145), with highest disagreement noted for differentiating the LGD and IFDs (k = 0.21). After revising the histological criteria, the kappa improved to 0.53. Among the IHC stains performed, p53, β-catenin, H2AX and M30 stains were significantly useful to differentiate between IFD and LGD (P values: 0.04, 0.004, 0.05 & 0.04, respectively). AMACR and β-catenin stains though were up-regulated in HGD/adenocarcinomas than in other categories, their expression were not statistically different between the IFD and LGDs.

CONCLUSIONS

A detail histological scoring system may bring uniformity in histological interpretation of dysplasia in BE. Using a combined panel of IHC stains seems helpful in detection of dysplasia in BE, especially to differentiate the IFD and LGD changes in BE.

Accuracy of probe-based confocal laser endomicroscopy (pCLE) compared to random biopsies during endoscopic surveillance of Barrett's esophagus

BACKGROUND

 For surveillance of Barrett's esophagus (BE), the current standard of random 4-quadrant biopsies misses 10 - 50 % of esophageal neoplasms, and does not permit real-time decision-making. Probe-based confocal laser endomicroscopy (pCLE) permits real-time in vivo histologic assessment of esophageal mucosa during upper endoscopy. Prospective studies comparing the accuracy of pCLE to 4-quadrant biopsies in routine clinical practice are lacking.

METHODS

 Consecutive patients with BE underwent high definition white light and narrow-band imaging followed by pCLE and targeted biopsy or mucosal resection. Four-quadrant biopsies were obtained during the same session. Baseline variables, real-time pCLE interpretation, and histology results were prospectively recorded. Blinded expert review of pCLE sequences and histology specimens was performed. A sample size of 64 patients was calculated a priori based on 3 % estimated prevalence of high grade dysplasia (HGD) or cancer.

RESULTS

 In total, 66 patients were included in the study. The prevalence of HGD or cancer was 4.55 %. Both real-time and blinded pCLE correctly identified all cases of cancer. For the primary outcome, real-time pCLE was 98 % specific but only 67 % sensitive for HGD/cancer compared to non-blinded pathologist interpretation. For HGD and cancer, inter-observer agreement was substantial between real-time and blinded endomicroscopists (kappa = 0.6). pCLE identified dysplasia in 75 % of cases where both blinded and unblinded pathology interpretation was low grade dysplasia.

CONCLUSIONS

 pCLE demonstrates high specificity for detecting dysplasia and cancer, but lower sensitivity may limit its utility in routine BE surveillance. pCLE may have a role in confirming LGD in real-time before eradication therapy.

Development and Validation of a Model to Determine Risk of Progression of Barrett's Esophagus to Neoplasia

BACKGROUND & AIMS

A system is needed to determine the risk of patients with Barrett's esophagus for progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). We developed and validated a model to determine of progression to HGD or EAC in patients with BE, based on demographic data and endoscopic and histologic findings at the time of index endoscopy.

METHODS

We performed a longitudinal study of patients with BE at 5 centers in United States and 1 center in Netherlands enrolled in the Barrett's Esophagus Study database from 1985 through 2014. Patients were excluded from the analysis if they had less than 1 year of follow-up, were diagnosed with HGD or EAC within the past year, were missing baseline histologic data, or had no intestinal metaplasia. Seventy percent of the patients were used to derive the model and 30% were used for the validation study. The primary outcome was development of HGD or EAC during the follow-up period (median, 5.9 years). Survival analysis was performed using the Kaplan-Meier method. We assigned a specific number of points to each BE risk factor, and point totals (scores) were used to create categories of low, intermediate, and high risk. We used Cox regression to compute hazard ratios and 95% confidence intervals to determine associations between risk of progression and scores.

RESULTS

Of 4584 patients in the database, 2697 were included in our analysis (84.1% men; 87.6% Caucasian; mean age, 55.4 ± 20.1 years; mean body mass index, 27.9 ± 5.5 kg/m²; mean length of BE, 3.7 ± 3.2 cm). During the follow-up period, 154 patients (5.7%) developed HGD or EAC, with an annual rate of progression of 0.95%. Male sex, smoking, length of BE, and baseline-confirmed low-grade dysplasia were significantly associated with progression. Scores assigned identified patients with BE that progressed to HGD or EAC with a c-statistic of 0.76 (95% confidence interval, 0.72-0.80; P < .001). The calibration slope was 0.9966 (P = .99), determined from the validation cohort.

CONCLUSIONS

We developed a scoring system (Progression in Barrett's Esophagus score) based on male sex, smoking, length of BE, and baseline low-grade dysplasia that identified patients with BE at low, intermediate, and high risk for HGD or EAC. This scoring system might be used in management of patients.

Cancer incidence and mortality risks in a large US Barrett's oesophagus cohort

OBJECTIVE

Barrett's oesophagus (BE) increases the risk of oesophageal adenocarcinoma by 10-55 times that of the general population, but no community-based cancer-specific incidence and cause-specific mortality risk estimates exist for large cohorts in the USA.

DESIGN

Within Kaiser Permanente Northern California (KPNC), we identified patients with BE diagnosed during 1995-2012. KPNC cancer registry and mortality files were used to estimate standardised incidence ratios (SIR), standardised mortality ratios (SMR) and excess absolute risks.

RESULTS

There were 8929 patients with BE providing 50 147 person-years of follow-up. Compared with the greater KPNC population, patients with BE had increased risks of any cancer (SIR=1.40, 95% CI 1.31 to 1.49), which slightly decreased after excluding oesophageal cancer. Oesophageal adenocarcinoma risk was increased 24 times, which translated into an excess absolute risk of 24 cases per 10 000 person-years. Although oesophageal adenocarcinoma risk decreased with time since BE diagnosis, oesophageal cancer mortality did not, indicating that the true risk is stable and persistent with time. Relative risks of cardia and stomach cancers were increased, but excess absolute risks were modest. Risks of colorectal, lung and prostate cancers were unaltered. All-cause mortality was slightly increased after excluding oesophageal cancer (SMR=1.24, 95% CI 1.18 to 1.31), but time-stratified analyses indicated that this was likely attributable to diagnostic bias. Cause-specific SMRs were elevated for ischaemic heart disease (SMR=1.39, 95% CI 1.18 to 1.63), respiratory system diseases (SMR=1.51, 95% CI 1.29 to 1.75) and digestive system diseases (SMR=2.20 95% CI 1.75 to 2.75).

CONCLUSIONS

Patients with BE had a persistent excess risk of oesophageal adenocarcinoma over time, although their absolute excess risks for this cancer, any cancer and overall mortality were modest.

Gastroesophageal Reflux Frequency, Severity, Age of Onset, Family History and Acid Suppressive Therapy Predict Barrett Esophagus in a Large Population

GOALS

To identify risk factors associated with Barrett esophagus (BE) for potential improved surveillance and risk reduction.

BACKGROUND

Gastroesophageal reflux disease (GERD) is a known risk factor for esophageal adenocarcinoma, but the ability of GERD symptom frequency and severity to predict presence of its putative precursor lesion, BE, is less well-defined in large, community-based populations.

STUDY

We conducted a case-control study within the Kaiser Permanente Northern California population. Cases had new diagnoses of BE. To identify risk factors in the general population, we contrasted cases with population controls; to identify risk factors only among patients with GERD, we contrasted cases with GERD patients who lacked BE.

RESULTS

We interviewed 953 patients; 320 patients with BE, 316 patients with GERD who lacked BE and 317 population controls. Compared with population controls, BE risk was highest among patients with the most frequent and severe GERD symptoms [odds ratio (OR), 27.00; 95% confidence interval (CI), 14.52-50.21], nocturnal symptoms (OR, 5.40; 95% CI, 3.81-7.72), and family history of GERD (OR, 2.55; 95% CI, 1.80-3.62) or BE (OR, 10.08; 95% CI, 2.83-35.84). Although at least weekly proton pump inhibitor (PPI) use was a risk factor for BE (OR, 9.85; 95% CI, 6.54-14.84), among PPI users in the general population, GERD symptoms were not strongly associated with the risk of BE. Compared with GERD controls, cases were more likely to have onset of GERD symptoms before 30 years of age (OR, 1.93; 95% CI, 1.15-3.22) and a family history of BE (OR, 3.64; 95% CI, 1.50-8.83).

CONCLUSIONS

Severe and frequent GERD symptoms are strongly associated with increased risk of BE in the general population, especially in the absence of frequent PPI use. Among people with GERD, family history of BE and early age of symptom onset were stronger predictors of BE. These findings may improve identification of patients at highest risk for BE.

Natural History of Barrett's Esophagus

Barrett's esophagus (BE) is a very common condition. We have obtained fairly profound knowledge of the natural history of this condition. This results from many cross-sectional and cohort studies, many describing patients undergoing long-term surveillance. Their consent to use their clinical data has improved our knowledge to the benefit of these same and other patients. The prevalence of BE increases with age both in men and in women. This increase starts at a younger age in men than in women. The incidence of high-grade dysplasia and cancer in BE depends on segment length, gender, and age. The latter two likely indicate the duration of the presence of BE in an individual patient. Other factors that influence the incidence of dysplasia and cancer are smoking behavior and use of certain medications such as PPIs, statins, and NSAIDs. Surveillance of BE and treatment of dysplasia can impact the incidence of and mortality due to esophageal adenocarcinoma. This is of major benefit to a subgroup of BE patients. The epidemiology and burden of disease ask for further efforts to develop targeted screening, surveillance, and intervention techniques in coming years.

Developments in optical imaging for gastrointestinal surgery

To improve outcomes for patients with cancer, in terms of both survival and a reduction in the morbidity and mortality that results from surgical resection and treatment, there are two main areas that require improvement. Accurate early diagnosis of the cancer, at a stage where curative and, ideally, minimally invasive treatment is achievable, is desired as well as identification of tumor margins, lymphatic and distant disease, enabling complete, but not unnecessarily extensive, resection. Optical imaging is making progress in achieving these aims. This review discusses the principles of optical imaging, focusing on fluorescence and spectroscopy, and the current research that is underway in GI tract carcinomas.

Use of immunohistochemical biomarkers as independent predictor of neoplastic progression in Barrett's oesophagus surveillance: A systematic review and meta-analysis

INTRODUCTION

The low incidence of oesophageal adenocarcinoma (EAC) in Barrett's oesophagus (BE) patients reinforces the need for risk stratification tools to make BE surveillance more effective. Therefore, we have undertaken a systematic review and meta-analysis of published studies on immunohistochemical (IHC) biomarkers in BE to determine the value of IHC biomarkers as neoplastic predictors in BE surveillance.

MATERIALS AND METHODS

We searched MEDLINE, EMBASE, Web of Science, CENTRAL, Pubmed publisher, and Google scholar. All studies on IHC biomarkers in BE surveillance were included. ORs were extracted and meta-analyses performed with a random effects model.

RESULTS

16 different IHC biomarkers were studied in 36 studies. These studies included 425 cases and 1835 controls. A meta- analysis was performed for p53, aspergillus oryzae lectin (AOL), Cyclin A, Cyclin D and alpha-methylacyl-CoA racemase. Aberrant p53 expression was significantly associated with an increased risk of neoplastic progression with an OR of 3.18 (95% CI 1.68 to 6.03). This association was confirmed for both non-dysplastic BE and BE with low-grade dysplasia (LGD). Another promising biomarker to predict neoplastic progression was AOL, with an OR of 3.04 (95% CI 2.05 to 4.49).

DISCUSSION

Use of p53 IHC staining may improve risk stratification in BE surveillance. Aberrant p53 expression in BE patients appeared to be associated with a significantly increased risk of neoplastic progression for both non-dysplastic and LGD BE patients.

Care of the Postablation Patient: Surveillance, Acid Suppression, and Treatment of Recurrence

Endoscopic eradication therapy is effective and durable for the treatment of Barrett's esophagus (BE), with low rates of recurrence of dysplasia but significant rates of recurrence of intestinal metaplasia. Identified risk factors for recurrence include age and length of BE before treatment and may also include presence of a large hiatal hernia, higher grade of dysplasia before treatment, and history of smoking. Current guidelines for surveillance following ablation are limited, with recommendations based on low-quality evidence and expert opinion. New modalities including optical coherence tomography and wide-area tissue sampling with computer-assisted analysis show promise as adjunctive surveillance modalities.

The prevalence of viral agents in esophageal adenocarcinoma and Barrett's esophagus: a systematic review

BACKGROUND AND AIMS

Human papilloma virus (HPV), which may reach the esophagus through orogenital transmission, has been postulated to be associated with esophageal adenocarcinoma (EAC). A systematic review of the literature investigating the prevalence of infectious agents in EAC and Barrett's esophagus (BE) was carried out.

METHODS

Using terms for viruses and EAC, the Medline, Embase, and Web of Science databases were systematically searched for studies published, in any language, until June 2016 that assessed the prevalence of viral agents in EAC or BE. Random-effects meta-analyses of proportions were carried out to calculate the pooled prevalence and 95% confidence intervals (CIs) of infections in EAC and BE.

RESULTS

A total of 30 studies were included. The pooled prevalence of HPV in EAC tumor samples was 13% (n=19 studies, 95% CI: 2-29%) and 26% (n=6 studies, 95% CI: 3-59%) in BE samples. HPV prevalence was higher in EAC tissue than in esophageal tissue from healthy controls (n=5 studies, pooled odds ratio=3.31, 95% CI: 1.15-9.50). The prevalence of Epstein-Barr virus (EBV) in EAC was 6% (n=5, 95% CI: 0-27%). Few studies have assessed other infectious agents. For each of the analyses, considerable between-study variation was observed (I=84-96%); however, sensitivity analyses did not show any major sources of heterogeneity.

CONCLUSION

The prevalence of HPV and EBV in EAC is low compared with other viral-associated cancers, but may have been hampered by small sample sizes and detection methods susceptible to fixation processes. Additional research with adequate sample sizes and high-quality detection methods is required.

Effectiveness and Cost-Effectiveness of Endoscopic Screening and Surveillance

Guidelines for the screening and surveillance of Barrett's esophagus continue to evolve as the incidence of esophageal adenocarcinoma increases, identification of individuals at highest risk for cancer improves, and management of dysplasia evolves. This article reviews related studies and economic analyses. Advances in diagnosis offer promising strategies to help focus screening efforts on those individuals who are most likely to develop esophageal adenocarcinoma.

Acceptability of the Cytosponge procedure for detecting Barrett's oesophagus: a qualitative study

OBJECTIVE

To investigate the acceptability of the Cytosponge, a novel sampling device to detect Barrett's oesophagus (BE), a precursor to oesophageal adenocarcinoma (EAC), among people with risk factors for this condition.

DESIGN

A qualitative study using semistructured interviews and focus group discussions. Data were explored by three researchers using thematic analysis.

SETTING

Community setting in London, UK.

PARTICIPANTS

A recruitment company identified 33 adults (17 men, 16 women) aged 50-69 years with gastro-oesophageal reflux disease (GERD), a risk factor for BE. The majority of participants were white British (73%). The focus groups were stratified by gender and education. 10 individuals were interviewed and 23 participated in four focus groups.

RESULTS

3 key themes emerged from the data: the anticipated physical experience, preferences for the content of information materials and comparisons with the current gold-standard test. Overall acceptability was high, but there was initial concern about the physical experience of taking the test, including swallowing and extracting the Cytosponge. These worries were reduced after handling the device and a video demonstration of the procedure. Knowledge of the relationship between GERD, BE and EAC was poor, and some suggested they would prefer not to know about the link when being offered the Cytosponge. Participants perceived the Cytosponge to be more comfortable, practical and economical than endoscopy.

CONCLUSIONS

These qualitative data suggest the Cytosponge was acceptable to the majority of participants with risk factors for BE, and could be used as a first-line test to investigate GERD symptoms. Concerns about the physical experience of the test were alleviated through multimedia resources. The development of patient information materials is an important next step to ensuring patients are adequately informed and reassured about the procedure. Patient stakeholders should be involved in this process to ensure their concerns and preferences are considered.

TRIAL REGISTRATION NUMBER

ISRCTN68382401; pre-results.

Quality of life and fear of cancer recurrence after endoscopic treatment for early Barrett's neoplasia: a prospective study

Endoscopic therapy is the treatment of choice for high grade intraepithelial neoplasia (HGIN) or early cancer (≤T1sm1) in Barrett's esophagus (BE). We prospectively evaluated the effect of endoscopic treatment on quality of life (QOL) and fear of cancer (recurrence) and compared this with the effect of Barrett's surveillance or surgery. Patients treated endoscopically for early Barrett's neoplasia (n = 42, HGIN - T1sm1N0M0) were compared with three groups: patients with non-dysplastic BE undergoing surveillance (n = 44); patients treated surgically for early BE neoplasia (HGIN - T2N0M0, n = 21); patients treated surgically for advanced BE cancer (T1N1M0 - T3N1M0, n = 19). QOL (SF-36; EORTC-QLQ-C30; EORTC-QLQ-OES18) and fear of cancer recurrence (Worry of Cancer Scale [WOCS] and the Hospital Anxiety and Depression Scale [HADS]) were measured at baseline, 2 and 6 months after treatment. The endoscopic treatment group reported significantly better QOL in both physical and mental scales of SF-36 and EORTC-QLQ-C30 and less esophageal cancer related symptoms compared to both surgical groups. The endoscopic treatment group reported significant more worry for cancer recurrence (WOCS) compared to the early surgical group. Their scores on the WOCS were comparable with the scores of the advanced surgical group. Endoscopic treatment of early esophageal cancer has less negative impact on QOL and esophageal cancer symptoms than surgery. However, endoscopically treated patients worry as much about cancer recurrence as patients treated surgically for advanced cancer.

Risk stratification for malignant progression in Barrett’s esophagus: Gender, age, duration and year of surveillance

AIM

To clarify risk based upon segment length, diagnostic histological findings, patient age and year of surveillance, duration of surveillance and gender.

METHODS

Patients registered with the United Kingdom Barrett’s Oesophagus Registry from 9 United Kingdom centers were included. The outcome measures were (1) development of all grades of dysplasia; (2) development of high-grade of dysplasia or adenocarcinoma; and (3) development of adenocarcinoma. Prevalent cases and subjects with < 1 year of follow-up were excluded. The covariates examined were segment length, previous biopsy findings, age at surveillance, duration of surveillance, year of surveillance and gender.

RESULTS

One thousand and one hundred thirty six patients were included (total 6474 patient-years). Fifty-four patients developed adenocarcinoma (0.83% per annum), 70 developed high-grade dysplasia/adenocarcinoma (1.1% per annum) and 190 developed any grade of dysplasia (3.5% per annum). High grade dysplasia and adenocarcinoma increased with age and duration of surveillance. The risk of low-grade dysplasia development was not dependent on age at surveillance. Segment length and previous biopsy findings were also significant factors for development of dysplasia and adenocarcinoma.

CONCLUSION

The risk of development of low-grade dysplasia is independent of age at surveillance, but high-grade dysplasia and adenocarcinoma were more commonly found at older age. Segment length and previous biopsy findings are also markers of risk. This study did not demonstrate stabilisation of the metaplastic segment with prolonged surveillance.

Evolving management of metaplasia and dysplasia in Barrett's epithelium

Oesophageal cancer affects more than 450000 people worldwide and despite continued medical advancements the incidence of oesophageal cancer is increasing. Oesophageal cancer has a 5 year survival of 15%-25% and now globally attempts are made to more aggressively diagnose and treat Barrett's oesophagus the known precursor to invasive disease. Currently diagnosis the of Barrett's oesophagus is predominantly made after endoscopic visualisation and histopathological confirmation. Minimally invasive techniques are being developed to improve the viability of screening programs. The management of Barrett's oesophagus can vary greatly dependent on the presence and severity of dysplasia. There is no consensus between the major international medical societies to determine and agreed surveillance and intervention pathway. In this review we analysed the current literature to demonstrate the evolving management of metaplasia and dysplasia in Barrett's epithelium.

Review: Surveillance of patients with Barrett oesophagus

There has been a rapid increase in the incidence of oesophageal adenocarcinoma in most Western countries over the past thirty years. Barrett's oesophagus (BE) is a common premalignant lesion of oesophageal adenocarcinoma, although the risk of developing cancer in BE remains low. Therefore, screening is not recommended in the general population. Surveillance of BE is recommended to detect high grade dysplasia or carcinoma in an early stage, although there is no clear evidence that surveillance leads to a reduced mortality. This review discusses the several screening and surveillance techniques, including chromoendoscopy, narrow band imaging, autofluorescence imaging and confocal laser endomicroscopy, pointing out the areas that are well established as well as the new techniques that require more research.

Advances in the Endoscopic Diagnosis of Barrett Esophagus

BACKGROUND

Barrett esophagus (BE) continues to be a major risk factor for developing esophageal adenocarcinoma.

METHODS

We review the risk factors, diagnosis, and management of BE, with an emphasis on the most current endoscopic diagnostic modalities for BE.

RESULTS

Novel diagnostic modalities have emerged to address the inadequacies of standard, untargeted biopsies, such as dye-based and virtual chromoendoscopy, endoscopic mucosal resection, molecular biomarkers, optical coherence tomography, confocal laser endomicroscopy, volumetric laser endomicroscopy, and endocytoscopy. Treatment of BE depends on the presence of intramucosal cancer or dysplasia, particularly high-grade dysplasia with or without visible mucosal lesions.

CONCLUSIONS

Recent advances in endoscopic diagnostic tools demonstrate promising results and help to mitigate the shortcomings of the Seattle protocol. Future research as well as refining these tools may help aid them in replacing standard untargeted biopsies.

Pathogenesis and progression of oesophageal adenocarcinoma varies by prior diagnosis of Barrett's oesophagus

Background:

The absolute risk of oesophageal adenocarcinoma (EA) among individuals with Barrett's oesophagus (BE) is low and a majority of EA cases are diagnosed among individuals with no prior BE diagnosis. To ensure that insights from EA case–control studies are transferable to clinical management of BE populations, we conducted a case–case study to compare the clinical presentation, medical history and survival of EA cases with and without a prior BE diagnosis in the Surveillance, Epidemiology and End Results Medicare database.

Methods:

Eligible EA cases were diagnosed at age ⩾68 years during 1994–2009. There were 5271 EA cases in this study, 87% of which did not have a prior diagnosis of BE (EA-no prior BE).

Results:

Multivariable case–case comparisons evidenced adverse associations of GERD, ever cigarette smoking, hypertension, dyslipidemia, weight loss, peptic ulcer and irritable bowel disease each in EA-prior BE compared with EA-no prior BE. Obesity, metabolic syndrome, impaired fasting glucose and diabetes did not differ between groups. EA-prior BE cases were diagnosed with less advanced disease, were more likely to undergo surgery and less likely to receive chemotherapy and radiotherapy, and had better overall mean survival (2.5 vs 1.4 years). This survival advantage persisted in the multivariable Cox model (HR=0.69, 95%CI: 0.60, 0.78), despite adjustment for many factors including stage, grade and clinical interventions.

Conclusions:

This study provides evidence that EA cases occurring among individuals previously diagnosed with BE are different from the large majority of EA cases that occur without a prior BE diagnosis. Regardless of whether these differences emanate from aetiology, biology and/or selection biases, they underscore the importance of a prudent approach in using knowledge from EAC case–control studies in the management of BE populations.

Progression of Barrett's esophagus toward esophageal adenocarcinoma: an overview

In Barrett's esophagus, normal squamous epithelium is replaced by a metaplastic columnar epithelium as a consequence of chronic gastroesophageal reflux disease. There is a strong association with esophageal adenocarcinoma. In view of the increasing incidence of esophageal adenocarcinoma in the western world, it is important that more attention be paid to the progression of Barrett's esophagus toward esophageal adenocarcinoma. Recently, several molecular factors have been identified that contribute to the sequence towards adenocarcinoma. This might help identify patients at risk and detect new targets for the prevention and treatment of esophageal adenocarcinoma in the future.

High Mobility Group A proteins in esophageal carcinomas

We have recently shown that HMGA2 is overexpressed in esophageal squamous cell carcinoma (ESCC) and its detection allows to discriminate between cancer and normal surrounding tissue proposing HMGA2 as a novel diagnostic marker. Interestingly, esophageal adenocarcinoma shows an opposite behavior with the overexpression of HMGA1 but not HMGA2. Moreover, we show that the suppression of HMGA2 in 2 ESCC cell lines reduces the malignant phenotype. Then, this paper highlights a differential induction of the HMGA proteins, depending on the cancer histological type, and reinforces the perspective of an innovative esophageal cancer therapy based on the suppression of the HMGA protein function and/or expression.

Epidemiology of Barrett's esophagus and esophageal adenocarcinoma in Spain. A unicentric study

INTRODUCTION

Barrett's esophagus (BE) is an acquired disease defined by the presence of intestinal metaplasia with goblet cells in the distal esophagus. The prevalence of BE has increased dramatically over the last years.

AIMS

The primary aims of the study were to analyze the characteristics of BE and esophageal adenocarcinoma (EAC) in a Spanish health district during a follow-up period.

METHODOLOGY

Sociodemographic factors, alcohol consumption and cigarette smoking were analyzed. We also studied the histological behavior and cause of death in each group.

RESULTS

In the present study 430 patients were included, 338 with BE and 92 with EAC. Incidence rates have risen from 2.25 and 1.25 per 100,000 inhabitants in 1996 to 6.5 and 4.75 per 100,000 in 2011, respectively. In the EAC group, male gender, age and alcohol consumption were higher in comparison to the BE group, and the overall survival was 23 months. In the BE group, the main causes of death were non-esophageal cancer and cardiovascular disease.

CONCLUSIONS

The incidence and prevalence rates of AEC and BE have risen over the past years. Risk factors for these conditions were male gender, age and alcohol consumption. Long BE (> 3 cm) is involved in dysplasia progression. AEC diagnosis mainly occurs after neoplasia is detected and, in a few cases, due to a previous BE. Cardiovascular diseases and non-esophageal cancers have been found to be the main cause of death in BE patients.