1
|
Choi KKH, Sanagapalli S. Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies. World J Gastrointest Oncol 2022; 14:568-586. [PMID: 35321279 PMCID: PMC8919017 DOI: 10.4251/wjgo.v14.i3.568] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 11/12/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Kevin Kyung Ho Choi
- AW Morrow Gastroenterology Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, NSW, Australia
| | - Santosh Sanagapalli
- Department of Gastroenterology, St Vincent’s Hospital, Darlinghurst 2010, NSW, Australia
| |
Collapse
|
2
|
Pratap A, McCarter MD, Watson TJ. Surgical Management of Barrett's-Related Neoplasia. Gastrointest Endosc Clin N Am 2021; 31:205-218. [PMID: 33213796 DOI: 10.1016/j.giec.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The management of Barrett's-related neoplasia has benefited from advances in endoscopic assessment, resection, and ablation, along with improved pathologic and radiographic staging. The development of specialized, high-volume esophageal multidisciplinary teams, with improvements in patient selection, preparation, perioperative care, minimally invasive operative approaches, and enhanced recovery after surgery programs, has contributed to improved outcomes for patients undergoing esophagectomy for Barrett's-related neoplasia.
Collapse
Affiliation(s)
- Akshay Pratap
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Martin D McCarter
- Department of Surgery, Division of Surgical Oncology, University of Colorado Denver, Academic Office One, L15-6106, 12631 East 17th Avenue, MS C325, Aurora, CO 80045, USA.
| | - Thomas J Watson
- Department of Surgery, MedStar Georgetown University Hospital, Georgetown University School of Medicine, 3900 Reservoir Road Northwest, Washington, DC 20007, USA
| |
Collapse
|
3
|
Mohan BP, Krishnamoorthi R, Ponnada S, Shakhatreh M, Jayaraj M, Garg R, Law J, Larsen M, Irani S, Ross A, Adler DG. Liquid Nitrogen Spray Cryotherapy in Treatment of Barrett's Esophagus, where do we stand? A Systematic Review and Meta-Analysis. Dis Esophagus 2019; 32:5304729. [PMID: 30715267 DOI: 10.1093/dote/doy130] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/06/2018] [Indexed: 12/11/2022]
Abstract
Radiofrequency ablation (RFA) is the preferred treatment option for Barrett's esophagus (BE) to achieve complete eradication (CE) of dysplasia (D), and intestinal metaplasia (IM). Cryotherapy, using liquid nitrogen (LNC), is a cold-induced tissue-injury technique option for the ablation of BE. We conducted a systematic review and meta-analysis to assess the overall efficacy and safety of LNC in the treatment of BE. We conducted a search of multiple electronic databases and conference proceedings from inception through June 2018. The primary outcome was to estimate the pooled rates of CE-IM, CE-D, and CE-HGD. The secondary outcome was to estimate the risk of adverse events and recurrence of disease after LNC. Nine studies reported 386 patients who were treated with LNC. The pooled rate of CE-IM was 56.5% (95% CI 48.5-64.2, I2 = 47), pooled rate of CE-D was 83.5% (95% CI 78.3-87.7, I2 = 22.8), and pooled rate of CE-HGD was 86.5% (95% CI 64.4-95.8, I2 = 88.1). Rate of adverse events was 4.7%, and the risk of BE recurrence was 12.7%. On subgroup analysis, the pooled rate of CE-IM with LNC in patients who failed RFA was 58.4% (95% CI 47.2-68.8, I2 = 32.5), and the pooled rate of CE-D in the same population was 81.9% (95% CI 72.5-88.6, I2 = 5.9). CE-D rates with LNC are comparable to RFA while CE-IM rates appear to be lower than the rates achievable with RFA. CE-IM rate in RFA failed patients is 58.4% and thus LNC is a rescue option to consider in this population.
Collapse
Affiliation(s)
- B P Mohan
- DCH Medical Center, University of Alabama, Tuscaloosa, Alabama
| | - R Krishnamoorthi
- Digestive Diseases Institute, Virginia Mason Medical Center, Seattle, Washington
| | - S Ponnada
- Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - M Shakhatreh
- Rapides Regional Medical Center, Alexandria, Louisiana
| | - M Jayaraj
- University of Nevada, Las Vegas, Nevada
| | - R Garg
- Cleveland Clinic Foundation, Cleveland, Ohio
| | - J Law
- Digestive Diseases Institute, Virginia Mason Medical Center, Seattle, Washington
| | - M Larsen
- Digestive Diseases Institute, Virginia Mason Medical Center, Seattle, Washington
| | - S Irani
- Digestive Diseases Institute, Virginia Mason Medical Center, Seattle, Washington
| | - A Ross
- Digestive Diseases Institute, Virginia Mason Medical Center, Seattle, Washington
| | - D G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| |
Collapse
|
4
|
Plum PS, Hölscher AH, Pacheco Godoy K, Schmidt H, Berlth F, Chon SH, Alakus H, Bollschweiler E. Prognosis of patients with superficial T1 esophageal cancer who underwent endoscopic resection before esophagectomy—A propensity score-matched comparison. Surg Endosc 2018. [DOI: 10.1007/s00464-018-6139-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
5
|
Belghazi K, Bergman JJGHM, Pouw RE. Management of Nodular Neoplasia in Barrett's Esophagus: Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection. Gastrointest Endosc Clin N Am 2017; 27:461-470. [PMID: 28577767 DOI: 10.1016/j.giec.2017.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic resection has proven highly effective and safe in the removal of focal early neoplastic lesions in Barrett's esophagus and is considered the cornerstone of endoscopic treatment. Several techniques are available for endoscopic resection in Barrett's esophagus. The most widely used technique for piecemeal resection of early Barrett's neoplasia is the ligate-and-cut technique. Newer techniques such as endoscopic submucosal dissection may also play a role in the treatment of neoplastic Barrett's esophagus. Treatment of early Barrett's neoplasia should be centralized and limited to expert centers with a high-volume load and sufficient expertise in the detection and treatment of esophageal neoplasia.
Collapse
Affiliation(s)
- Kamar Belghazi
- Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands.
| |
Collapse
|
6
|
Abstract
Endoscopic therapies have become the standard of care for most cases of Barrett's esophagus with high-grade dysplasia or intramucosal adenocarcinoma. Despite a rapid and dramatic evolution in treatment paradigms, esophagectomy continues to occupy a place in the therapeutic armamentarium for superficial esophageal neoplasia. The managing physician must remain cognizant of the limitations of endoscopic approaches and consider surgical resection when they are exceeded. Esophagectomy, performed at experienced centers for appropriately selected patients with early-stage disease can be undertaken with the expectation of cure as well as low mortality, acceptable morbidity, and good long-term quality of life.
Collapse
Affiliation(s)
- Thomas J Watson
- Division of Thoracic and Esophageal Surgery, Department of Surgery, MedStar Washington, Georgetown University School of Medicine, 3800 Reservoir Road Northwest, 4PHC, Washington, DC 20007, USA.
| |
Collapse
|
7
|
Armijo PR, Herbella FAM, Patti MG. Gastric Tube Motility Patterns in Patients After Esophageal Resection with Gastric Pull-up. J Neurogastroenterol Motil 2016; 22:157-8. [PMID: 26459460 PMCID: PMC4699734 DOI: 10.5056/jnm15121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/18/2015] [Accepted: 08/18/2015] [Indexed: 11/20/2022] Open
Affiliation(s)
- Priscila R Armijo
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco G Patti
- Department of Surgery, University of Chicago, Il, Chicago, USA
| |
Collapse
|
8
|
Schmidt HM, Mohiuddin K, Bodnar AM, El Lakis M, Kaplan S, Irani S, Gan I, Ross A, Low DE. Multidisciplinary treatment of T1a adenocarcinoma in Barrett's esophagus: contemporary comparison of endoscopic and surgical treatment in physiologically fit patients. Surg Endosc 2015; 30:3391-401. [PMID: 26541725 DOI: 10.1007/s00464-015-4621-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 10/09/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Previous reports comparing endoscopic therapy (ET) and surgical therapy (ST) have predominantly assessed patients with high-grade dysplasia. The study aim was to compare ET to ST in physiologically fit patients with cT1a adenocarcinoma (EAC). METHODS Review of two prospective databases yielded 100 patients presenting with clinical cT1a EAC between 2000 and 2013. Only physiologically fit patients who were candidates for either treatment were analyzed. RESULTS Presenting patient characteristics were similar between ET (n = 36) and ST groups (n = 49). Surgical patients were less likely to be staged with EMR (43 vs 100 %) and were associated with mass lesions >1 cm at EGD (p = 0.01), multifocal EAC (p = 0.03), and positive margins for EAC on EMR (p < 0.05). On multivariate analysis, only multifocal HGD was an independent factor for surgery. Following esophagectomy, R0 resection rates for Barrett's esophagus and cancer were 100 %. Incidence of surgery decreased over the study period from 85 to 25 %. All ET patients had EMR, and 28 patients underwent additional ablative therapies for Barrett's esophagus. Following ET, eradication rates of EAC, dysplasia, and BE were 92, 81, and 53 %, respectively. Morbidity rates were comparable between groups (ST 51 % vs ET 39 %, p = 0.31). In-hospital mortality rate was zero in each group. Recurrence rates in ST and ET group were 2 and 11 % (p = 0.08). In the ET group, two patients with endoluminal cancer recurrence after complete eradication underwent esophagectomy. Age-adjusted overall survival was comparable. CONCLUSION In high-volume esophageal centers, ST and ET provide equally safe and effective treatment for cT1a EAC in medically fit patients. While the results of this study provide a historical perspective and clearly demonstrate an evolution toward ET over time, the appropriate treatment modality is best selected in a multidisciplinary fashion with EMR providing the most accurate staging. In endoscopically treated patients, indefinite endoscopic follow-up required, however, standardized long-term follow-up protocols are needed.
Collapse
Affiliation(s)
- Henner M Schmidt
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Kamran Mohiuddin
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Artur M Bodnar
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Mustapha El Lakis
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Stephen Kaplan
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA
| | - Shayan Irani
- Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Ian Gan
- Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andrew Ross
- Department of Hepatology and Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Donald E Low
- Section of General Thoracic Surgery, Department for General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA.
| |
Collapse
|
9
|
Abstract
Although there are many unanswered questions with Barrett esophagus, we can safely say that the incidence is increasing, chemoprevention strategies for the prevention of Barrett metaplasia and its progression to adenocarcinoma may be in the offing, surveillance should be considered for all patients who are discovered to have Barrett esophagus, RFA is the treatment of choice for those with HGD and strongly considered in those with LGD, EMR should be the treatment of choice for patients with nodular high-grade Barrett esophagus, and, finally, vagal-sparing esophagectomy reserved for patients with persistent HGD or a strong suspicion of carcinoma, with consideration of a concomitant fundoplication.
Collapse
Affiliation(s)
- Mark Splittgerber
- Division of General Surgery, University of South Florida, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, FL, USA.
| |
Collapse
|
10
|
Abstract
Patients with gastroesophageal reflux disease and Barrett's esophagus can be a management challenge for the treating physician or surgeon. The goals of therapy include relief of reflux symptoms, induction of histologic regression, and prevention of progression of intestinal metaplasia to dysplasia or invasive carcinoma. Antireflux surgery is effective at achieving these end points, although ongoing follow-up and endoscopic surveillance are essential. In cases of dysplasia or early esophageal neoplasia associated with Barrett's esophagus, endoscopic resection and ablation have supplanted esophagectomy as the standard of care in most cases. Esophageal resection continues to have a role, however, in a minority of appropriately selected candidates.
Collapse
Affiliation(s)
- Christian G Peyre
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Avenue, Box Surgery, Rochester, NY 14642, USA
| | - Thomas J Watson
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Avenue, Box Surgery, Rochester, NY 14642, USA.
| |
Collapse
|
11
|
Dubecz A, Kern M, Solymosi N, Schweigert M, Stein HJ. Predictors of Lymph Node Metastasis in Surgically Resected T1 Esophageal Cancer. Ann Thorac Surg 2015; 99:1879-85; discussion 1886. [PMID: 25929888 DOI: 10.1016/j.athoracsur.2015.02.112] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/21/2015] [Accepted: 02/06/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The application of endoscopic therapies for early cancers of the esophagus is limited by the possible presence of regional lymph node metastases. Our objective was to determine the prevalence and predictors of lymph node metastases in patients with pT1 carcinoma of the esophagus and the gastric cardia. METHODS The National Cancer Institute's Surveillance Epidemiology and End Results Database (2004 to 2010) was used to identify all patients with pT1 carcinomas who underwent primary surgical resection for squamous cell carcinoma (SCC) or adenocarcinoma (EAC) of the esophagus and of the esophagogastric junction (AEG). Prevalence of lymph node metastases was assessed, and survival in all types of cancer was calculated. Multivariate logistic regression was used to identify factors predicting positive lymph node status. RESULTS There were 1,225 patients (84% male), with a mean age of 64 ± 10 years, and 90% were white. Intramucosal disease was present in 44% of patients, and submucosal invasion (T1b) was present in 692 (56%). Prevalence of lymph node metastases in EAC, SCC, and AEG was 6.4%, 6.9%, and 9.5% for pT1a tumors and 19.6%, 20%, and 22.9% for pT1b tumors, respectively. In patients with more than 23 lymph nodes removed during resection, prevalence of lymph node metastases in EAC, SCC, and AEG was 8.1%, 25%, and 7.4% for pT1a tumors and 27.8%, 33.3%, and 22% for pT1b tumors, respectively. Positive lymph node status was associated with worse overall 5-year survival in EAC (N0 vs N+: 78% vs 52%) and AEG (N0 vs N+: 83% vs 44%) but did not have a significant effect on the long-term survival of patients with SCC. Infiltration of the submucosa, tumor size exceeding 10 mm, and poor tumor differentiation were independently associated with the risk of nodal disease. Prevalence of lymph node metastasis negative for these three risk factors was only 4.8%. CONCLUSIONS Prevalence of lymph node metastasis in early esophageal cancer is high in patients with T1 cancer. Inadequate lymphadenectomy underestimates lymph node status. Endoscopic treatment can be considered only in a select group of patients with early esophageal cancer.
Collapse
Affiliation(s)
- Attila Dubecz
- Department of Surgery, Private Medical University Nürnberg, Nuremberg, Germany.
| | - Marcus Kern
- Department of Surgery, Private Medical University Nürnberg, Nuremberg, Germany
| | - Norbert Solymosi
- Faculty of Veterinary Science, Szent István University Budapest, Hungary
| | - Michael Schweigert
- Department of Thoracic Surgery, Klinikum Dresden-Friedrichstadt, Dresden, Germany
| | - Hubert J Stein
- Department of Surgery, Private Medical University Nürnberg, Nuremberg, Germany
| |
Collapse
|
12
|
Lam YH, Bright T, Leong M, Thompson SK, Mayne G, Watson DI. Oesophagectomy is a safe option for early adenocarcinoma arising from Barrett's oesophagus. ANZ J Surg 2015; 86:905-909. [DOI: 10.1111/ans.13023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Yick Ho Lam
- Department of Surgery; Flinders University; Adelaide South Australia Australia
| | - Tim Bright
- Department of Surgery; Flinders University; Adelaide South Australia Australia
| | - Matthew Leong
- Department of Surgery; Flinders University; Adelaide South Australia Australia
| | - Sarah K. Thompson
- Department of Surgery; University of Adelaide; Adelaide South Australia Australia
| | - George Mayne
- Department of Surgery; Flinders University; Adelaide South Australia Australia
| | - David I Watson
- Department of Surgery; Flinders University; Adelaide South Australia Australia
| |
Collapse
|
13
|
Lada MJ, Watson TJ, Shakoor A, Nieman DR, Han M, Tschoner A, Peyre CG, Jones CE, Peters JH. Eliminating a need for esophagectomy: endoscopic treatment of Barrett esophagus with early esophageal neoplasia. Semin Thorac Cardiovasc Surg 2014; 26:274-84. [PMID: 25837538 DOI: 10.1053/j.semtcvs.2014.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2014] [Indexed: 12/19/2022]
Abstract
Over the past several years, endoscopic ablation and resection have become a new standard of care in the management of Barrett esophagus (BE) with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC). Risk factors for failure of endoscopic therapy and the need for subsequent esophagectomy have not been well elucidated. The aims of this study were to determine the efficacy of radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) in the management of BE with HGD or IMC, to discern factors predictive of endoscopic treatment failure, and to assess the effect of endoscopic therapies on esophagectomy volume at our institution. Data were obtained retrospectively for all patients who underwent endoscopic therapies or esophagectomy for a diagnosis of BE with HGD or IMC in our department between January 1, 2004, and December 31, 2012. Complete remission (CR) of BE or HGD or IMC was defined as 2 consecutive biopsy sessions without BE or HGD or IMC and no subsequent recurrence. Recurrence was defined by the return of BE or HGD or IMC after initial remission. Progression was defined as worsening of HGD to IMC or worsening of IMC to submucosal neoplasia or beyond. Overall, 57 patients underwent RFA with or without EMR for BE with HGD (n = 45) or IMC (n = 12) between 2007 and 2012, with a median follow-up duration of 35.4 months (range: 18.5-52.0 months). The 57 patients underwent 181 ablation sessions and more than half (61%) of patients underwent EMR as a component of treatment. There were no major procedural complications or deaths, with only 2 minor complications including 1 symptomatic stricture requiring dilation. Multifocal HGD or IMC was present in 43% (25/57) of patients. CR of IMC was achieved in 100% (12/12) at a median of 6.1 months, CR of dysplasia was achieved in 79% (45/57) at a median of 11.5 months, and CR of BE was achieved in 49% (28/57) at a median of 18.4 months. Following initial remission, 28% of patients (16/57) had recurrence of dysplasia (n = 12) or BE (n = 4). Progression to IMC occurred in 7% (4/57). All patients without CR continue endoscopic treatment. No patient required esophagectomy or developed metastatic disease. Overall, 6 patients died during the follow-up interval, none from esophageal cancer. Factors associated with failure to achieve CR of BE included increasing length of BE (6.0 ± 0.6 vs 4.0 ± 0.6cm, P = 0.03) and shorter duration of follow-up (28.5 ± 3.8 months vs 49.0 ± 5.8 months, P = 0.004). Shorter surveillance duration (17.8 ± 7.6 months vs 63.9 ± 14.4 months, P = 0.009) and shorter follow-up (21.1 ± 6.1 months vs 43.2 ± 4.1 months) were the only significant factors associated with failure to eradicate dysplasia. Our use of esophagectomy as primary therapy for BE with HGD or IMC has diminished since we began using endoscopic therapies in 2007. From a maximum of 16 esophagectomies per year for early Barrett neoplasia in 2006, we performed only 3 esophageal resections for such early disease in 2012, all for IMC, and we have not performed an esophagectomy for HGD since 2008. Although recurrence of BE or dysplasia/IMC was not uncommon, RFA with or without EMR ultimately resulted in CR of IMC in all patients, CR of HGD in the majority (79%), and CR of BE in nearly half (49%). No patient treated endoscopically for HGD or IMC subsequently required esophagectomy. In patients with BE with HGD or IMC, RFA and EMR are safe and highly effective. The use of endoscopic therapies appears justified as the new standard of care in most cases of BE with early esophageal neoplasia.
Collapse
Affiliation(s)
- Michal J Lada
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Thomas J Watson
- Department of Surgery, University of Rochester Medical Center, Rochester, New York..
| | - Aqsa Shakoor
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Dylan R Nieman
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Michelle Han
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Andreas Tschoner
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Christian G Peyre
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Carolyn E Jones
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Jeffrey H Peters
- Chief Operating Officer, University Hospitals, Cleveland, Case Western Reserve University
| |
Collapse
|
14
|
Abstract
A substantial portion of patients diagnosed preoperatively with high grade dysplasia (HGD) alone will have occult esophageal adenocarcinoma on analysis of the surgical specimen. Therefore, because of an increased risk of disease progression and malignancy, patients with HGD should be referred for esophagectomy promptly when endoscopic therapy has failed. The required extent of lymphadenectomy in this cohort of patients is unknown because of the variable incidence of submucosal cancer observed. Improvements in perioperative care, adoption of a minimally invasive surgical approach, and centralization of esophageal cancer services have substantially reduced the rates of mortality and morbidity associated with esophagectomy in recent years. Minimally invasive esophagectomy should be considered the treatment of choice in patients with dysplastic Barrett's esophagus that is refractory to endoscopic therapy or those at high risk of invasive cancer.
Collapse
|
15
|
Watson TJ. Endoscopic therapies for Barrett's neoplasia. J Thorac Dis 2014; 6 Suppl 3:S298-308. [PMID: 24876934 DOI: 10.3978/j.issn.2072-1439.2014.03.35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 03/27/2014] [Indexed: 01/14/2023]
Abstract
The standard of care for treatment of Barrett's esophagus (BE) with early esophageal neoplasia, including high-grade dysplasia (HGD) and intramucosal adenocarcinoma (IMC), has undergone a revolution over the past several years. With the introduction and popularization of endoscopic ablative technologies, along with the refinement of endoscopic mucosal resection (EMR) techniques, the majority of cases of early neoplasia in the setting of BE now are managed by endoscopic approaches. As a result, many patients who previously would have been referred for esophagectomy now may be spared from this major surgical procedure with its inherent morbidity, potential for mortality, and negative impact on long-term gastrointestinal function. The esophageal surgeon must be knowledgeable about the indications for such endoscopic therapies, as well as their limitations and potential pitfalls, so as to apply them in the appropriate clinical scenarios.
Collapse
Affiliation(s)
- Thomas J Watson
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| |
Collapse
|
16
|
Abstract
OBJECTIVE To define prognostic risk factors in patients with early adenocarcinomas of the esophagus (eACEs) who were treated by esophagectomy. BACKGROUND Although endoscopic resection (ER) is more accepted for eACEs limited to the mucosa, the reported prevalence of lymph node metastases once the tumor infiltrates the submucosa seems to necessitate surgery in these cases. METHODS We analyzed the results of 168 patients who had an esophageal resection because of an eACE. On the basis of specimen histologies and clinical follow-up (median, 64 months), we investigated the influence of lymph node metastases (N+), tumor infiltration depth, tumor differentiation (G1-3), and lymphatic or venous infiltration (L+ or V+) on overall and tumor-specific survival and recurrence rates. RESULTS The 5-year survival rate was 79%. Lymph node infiltration was the only prognostic factor for the overall survival [hazard ratio (HR), 2.856; 1.314-6.207; P = 0.008], tumor-specific survival (HR, 8.336; 2.734-25.418; P < 0.001), and tumor recurrence (HR, 8.031; 3.041-21.206; P < 0.001) that was consistently present in all multivariate hazard Cox regression analyses. A total of 47% of the patients who had an N+ status developed tumor recurrences compared with 5.2% of those who had no lymph node involvement (P = <0.001). We found a significant correlation between N+ status and increasing depth of tumor infiltration (P = 0.004), lymphatic vessel infiltration (P = 0.002), tumor differentiation (G1 + G2 vs G3; P = 0.014) and vascular infiltration (P = 0.01). CONCLUSIONS Lymph node status is the only independent risk factor for survival and recurrence rates. Tumor infiltration depth correlates with the rate of the lymph node metastases, but a clear watershed between deep mucosal and submucosal infiltration does not exist. As a consequence, careful staging procedures, including diagnostic ER, are mandatory to determine which patients can be treated by ER and which require an esophagectomy.
Collapse
|
17
|
Cowie A, Noble F, Underwood T. Strategies to improve outcomes in esophageal adenocarcinoma. Expert Rev Anticancer Ther 2014; 14:677-87. [PMID: 24621143 DOI: 10.1586/14737140.2014.895668] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Esophageal adenocarcinoma is one of the fastest rising cancers in Western society. Incidence has increased by 600% within the last 30 years. Rates of diagnosis and death run parallel due to the poor prognosis and a lack of effective treatments. Potentially curative treatments are followed by high rates of disease recurrence. For the majority of patients, who present with advanced disease, we have no effective treatment. We discuss the key areas of progress in this demanding field and offer our views on the direction of future research and treatment.
Collapse
Affiliation(s)
- Andrew Cowie
- Cancer Sciences Unit, Somers Cancer Research Building, Faculty of Medicine, University of Southampton, SO16 6YD, UK
| | | | | |
Collapse
|
18
|
Fitzgerald RC, di Pietro M, Ragunath K, Ang Y, Kang JY, Watson P, Trudgill N, Patel P, Kaye PV, Sanders S, O'Donovan M, Bird-Lieberman E, Bhandari P, Jankowski JA, Attwood S, Parsons SL, Loft D, Lagergren J, Moayyedi P, Lyratzopoulos G, de Caestecker J. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut 2014; 63:7-42. [PMID: 24165758 DOI: 10.1136/gutjnl-2013-305372] [Citation(s) in RCA: 828] [Impact Index Per Article: 82.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
These guidelines provide a practical and evidence-based resource for the management of patients with Barrett's oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was followed to provide a methodological strategy for the guideline development. A systematic review of the literature was performed for English language articles published up until December 2012 in order to address controversial issues in Barrett's oesophagus including definition, screening and diagnosis, surveillance, pathological grading for dysplasia, management of dysplasia, and early cancer including training requirements. The rigour and quality of the studies was evaluated using the SIGN checklist system. Recommendations on each topic were scored by each author using a five-tier system (A+, strong agreement, to D+, strongly disagree). Statements that failed to reach substantial agreement among authors, defined as >80% agreement (A or A+), were revisited and modified until substantial agreement (>80%) was reached. In formulating these guidelines, we took into consideration benefits and risks for the population and national health system, as well as patient perspectives. For the first time, we have suggested stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria. In order to improve communication between clinicians, we recommend the use of minimum datasets for reporting endoscopic and pathological findings. We advocate endoscopic therapy for high-grade dysplasia and early cancer, which should be performed in high-volume centres. We hope that these guidelines will standardise and improve management for patients with Barrett's oesophagus and related neoplasia.
Collapse
|
19
|
Ertan A, Zaheer I, Correa AM, Thosani N, Blackmon SH. Photodynamic therapy vs radiofrequency ablation for Barrett's dysplasia: efficacy, safety and cost-comparison. World J Gastroenterol 2013; 19:7106-13. [PMID: 24222954 PMCID: PMC3819546 DOI: 10.3748/wjg.v19.i41.7106] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 07/21/2013] [Accepted: 08/17/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To compare effectiveness, safety, and cost of photodynamic therapy (PDT) and radiofrequency ablation (RFA) in treatment of Barrett's dysplasia (BD). METHODS Consecutive case series of patients undergoing either PDT or RFA treatment at single center by a single investigator were compared. Thirty-three patients with high-grade dysplasia (HGD) had treatment with porfimer sodium photosensitzer and 630 nm laser (130 J/cm), with maximum of 3 treatment sessions. Fifty-three patients with BD (47 with low-grade dysplasia -LGD, 6 with HGD) had step-wise circumferential and focal ablation using the HALO system with maximum of 4 treatment sessions. Both groups received proton pump inhibitors twice daily. Endoscopic biopsies were acquired at 2 and 12 mo after enrollment, with 4-quadrant biopsies every 1 cm of the original BE extent. A complete histological resolution response of BD (CR-D) was defined as all biopsies at the last endoscopy session negative for BD. Fisher's exact test was used to assess differences between the two study groups for primary outcomes. For all outcomes, a two-sided P value of less than 0.05 was considered to indicate statistical significance. RESULTS Thirty (91%) PDT patients and 39 (74%) RFA were men (P = 0.05). The mean age was 70.7 ± 12.2 and 65.4 ± 12.7 (P = 0.10) year and mean length of BE was 5.4 ± 3.2 cm and 5.7 ± 3.2 cm (P = 0.53) for PDT and RFA patients, respectively. The CR-D was (18/33) 54.5% with PDT vs (47/53) 88.7% with RFA (P = 0.001). One patient with PDT had an esophageal perforation and was managed with non-surgical measures and no perforation was seen with RFA. PDT was five times more costly than RFA at our institution. The two groups were not randomized and had different BD grading are the limitations of the study. CONCLUSION In our experience, RFA had higher rate of CR-D without any serious adverse events and was less costly than PDT for endoscopic treatment of BD.
Collapse
|
20
|
Estores D, Velanovich V. Barrett esophagus: epidemiology, pathogenesis, diagnosis, and management. Curr Probl Surg 2013; 50:192-226. [PMID: 23601575 DOI: 10.1067/j.cpsurg.2013.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
21
|
Chan FKL. Endoscopic therapy as an alternative to radical surgery for early stage esophageal adenocarcinoma with submucosal invasion? Clin Gastroenterol Hepatol 2013; 11:587-8. [PMID: 23602739 DOI: 10.1016/j.cgh.2013.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
22
|
Manner H, Pech O, Heldmann Y, May A, Pohl J, Behrens A, Gossner L, Stolte M, Vieth M, Ell C. Efficacy, safety, and long-term results of endoscopic treatment for early stage adenocarcinoma of the esophagus with low-risk sm1 invasion. Clin Gastroenterol Hepatol 2013; 11:630-5; quiz e45. [PMID: 23357492 DOI: 10.1016/j.cgh.2012.12.040] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 12/06/2012] [Accepted: 12/21/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Patients with early-stage mucosal (T1a) esophageal adenocarcinoma (EAC) are increasingly treated by endoscopic resection. EACs limited to the upper third of the submucosa (pT1b sm1) could also be treated by endoscopy. We assessed the efficacy, safety, and long-term effects of endoscopic therapy for these patients. METHODS We analyzed data from 66 patients with sm1 low-risk lesions (macroscopically polypoid or flat, with a histologic pattern of sm1 invasion, good-to-moderate differentiation [G1/2], and no invasion into lymph vessels or veins) treated by endoscopic therapy at the HSK Hospital Wiesbaden from 1996 through 2010. The efficacy of endoscopic therapy was assessed on the basis of rates of complete endoluminal remission (CER), metachronous neoplasia, lymph node events, and long-term remission (LTR). Safety was assessed on the basis of rate of complications. RESULTS Remissions were assessed in 61 of the 66 patients; 53 of the 61 achieved CER (87%). Of patients with small focal neoplasias ≤2 cm, 97% achieved CER (for those with tumors ≥2 cm, 77%; P = .026). Metachronous neoplasias were observed in 10 of 53 patients (19%; 9 of the 10 underwent repeat endoscopic resection). One patient developed a lymph node metastasis (1.9%). Fifty-one patients achieved LTR (84%); 90% of those with focal lesions ≤2 cm achieved LTR after a mean follow-up period of 47 ± 29.1 months (range, 8-120 months). No tumor-associated deaths were observed, and the estimated 5-year survival rate was 84%. The rate of major complications from endoscopic resection was 1.5%, and no patients died. CONCLUSIONS Endoscopic therapy appears to be a good alternative to esophagectomy for patients with pT1b sm1 EAC, on the basis of macroscopic and histologic analyses. The risk of developing lymph node metastases after endoscopic resection for sm1 EAC is lower than the risk of surgery.
Collapse
Affiliation(s)
- Hendrik Manner
- Department of Internal Medicine II, HSK Hospital (Teaching Hospital of the University Medicine of Mainz), Wiesbaden, Germany.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Advanced esophageal cancer in patients who underwent radiofrequency ablation for barrett esophagus with high-grade dysplasia. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013; 8:17-22. [PMID: 23571789 DOI: 10.1097/imi.0b013e31828db550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE We sought to evaluate clinicopathologic features of patients who underwent esophageal surgery after radiofrequency ablation (RFA) treatment using the HALO system for Barrett esophagus (BE) with high-grade dysplasia (HGD). METHODS We evaluated patients from our hospital database who underwent esophagectomy from August 2006 to January 2012 after previously receiving RFA for BE. Information on demographics, time between RFA and surgery, indications for surgery, and final esophageal pathology was collected. RESULTS In our study, we selected 102 patients who underwent esophagectomy. Five patients had a history of RFA for BE with HGD. Three patients were referred because of persistent HGD despite RFA, and all three patients had HGD in the esophagectomy specimen. Two patients presented with a benign diagnosis (esophageal perforation and leiomyoma), and both of these patients had pathologic stage T3N2M0 adenocarcinoma of the esophagus in the resected specimen. One of these patients had normal mucosa overlying carcinoma in the muscularis propria and adventitia. The patients with stage T3N2M0 cancer did not have pre-RFA endoscopic ultrasound, first treatment of RFA with HALO, or surveillance endoscopic biopsy every 3 months. CONCLUSIONS Radiofrequency ablation for BE with HGD may mask underlying esophageal cancer. Patients who are counseled to undergo RFA for HGD should be aware that RFA could lead to delayed diagnosis and delayed treatment of invasive esophageal cancer without careful patient selection, appropriate RFA use, and close surveillance.
Collapse
|
24
|
|
25
|
Grant KS, DeMeester SR, Kreger V, Oh D, Hagen JA, Chandrasoma P, DeMeester TR. Effect of Barrett's esophagus surveillance on esophageal preservation, tumor stage, and survival with esophageal adenocarcinoma. J Thorac Cardiovasc Surg 2013; 146:31-7. [PMID: 23312980 DOI: 10.1016/j.jtcvs.2012.12.058] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Revised: 11/29/2012] [Accepted: 12/12/2012] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Surveillance endoscopy has been recommended for patients with Barrett's esophagus; however, recent studies have questioned the importance owing to the new, lower, estimates of the rate of progression of Barrett's esophagus to cancer. The aim of the present study was to compare the tumor stage, survival, and frequency of esophageal preservation in patients who presented with progression of Barrett's esophagus within a surveillance program versus those who presented with prevalent disease. METHODS A retrospective chart review was performed of all patients treated for high-grade dysplasia or esophageal adenocarcinoma from 2005 to 2010. The surveillance group included patients who had had at least 1 endoscopy and biopsy confirming intestinal metaplasia (with or without low-grade dysplasia) 6 months or more before the endoscopy showing progression. RESULTS A total of 224 patients were included in the present study, 36 in the surveillance group and 188 in the prevalence group. The surveillance patients had significantly earlier stage tumors (P < .0001) and were more likely to undergo endoscopic therapy and to keep their esophagus (44% vs 11%, P < .0001) than were patients with prevalent disease. Furthermore, the patients in the surveillance group were less likely to have lymph node metastases and had better overall and disease-free survival. No patient with high-grade dysplasia or an intramucosal tumor died of cancer. CONCLUSIONS Patients within a surveillance program for Barrett's esophagus had better survival and were less likely to have an esophagectomy than those who presented with prevalent disease. Treatment of intramucosal cancer was curative, and improved survival with surveillance was not secondary to lead time bias. Surveillance endoscopy remains important in patients with Barrett's esophagus.
Collapse
Affiliation(s)
- Kimberly S Grant
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, Calif 90033, USA
| | | | | | | | | | | | | |
Collapse
|
26
|
Kim MP, Brown KN, Schwartz MR, Blackmon SH. Advanced Esophageal Cancer in Patients who Underwent Radiofrequency Ablation for Barrett Esophagus with High-Grade Dysplasia. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013. [DOI: 10.1177/155698451300800104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Min P. Kim
- Department of Surgery, Weill Cornell Medical College, New York, NY USA
- Department of Surgery, The Methodist Hospital, Houston, TX USA
| | - Kendra N. Brown
- Department of Surgery, The Methodist Hospital, Houston, TX USA
| | - Mary R. Schwartz
- Department of Pathology and Genomic Medicine, The Methodist Hospital, Houston, TX USA
| | - Shanda H. Blackmon
- Department of Surgery, Weill Cornell Medical College, New York, NY USA
- Department of Surgery, The Methodist Hospital, Houston, TX USA
| |
Collapse
|
27
|
Villaflor VM, Allaix ME, Minsky B, Herbella FA, Patti MG. Multidisciplinary approach for patients with esophageal cancer. World J Gastroenterol 2012; 18:6737-46. [PMID: 23239911 PMCID: PMC3520162 DOI: 10.3748/wjg.v18.i46.6737] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 11/19/2012] [Accepted: 11/24/2012] [Indexed: 02/06/2023] Open
Abstract
Patients with esophageal cancer have a poor prognosis because they often have no symptoms until their disease is advanced. There are no screening recommendations for patients unless they have Barrett's esophagitis or a significant family history of this disease. Often, esophageal cancer is not diagnosed until patients present with dysphagia, odynophagia, anemia or weight loss. When symptoms occur, the stage is often stage III or greater. Treatment of patients with very early stage disease is fairly straight forward using only local treatment with surgical resection or endoscopic mucosal resection. The treatment of patients who have locally advanced esophageal cancer is more complex and controversial. Despite multiple trials, treatment recommendations are still unclear due to conflicting data. Sadly, much of our data is difficult to interpret due to many of the trials done have included very heterogeneous groups of patients both histologically as well as anatomically. Additionally, studies have been underpowered or stopped early due to poor accrual. In the United States, concurrent chemoradiotherapy prior to surgical resection has been accepted by many as standard of care in the locally advanced patient. Patients who have metastatic disease are treated palliatively. The aim of this article is to describe the multidisciplinary approach used by an established team at a single high volume center for esophageal cancer, and to review the literature which guides our treatment recommendations.
Collapse
|
28
|
Abstract
Barrett's esophagus is a pathologic change of the normal squamous epithelium of the esophagus to specialized columnar metaplasia. Barrett's esophagus is a result of prolonged exposure of the esophagus to gastroduodenal refluxate. Although Barrett's itself is not symptomatic, and, in fact, patients with Barrett's esophagus may be completely asymptomatic, it does identify patients at higher risk of developing esophageal adenocarcinoma. Traditionally, antireflux surgery was reserved for patients with symptoms, because it was believed that antireflux surgery did not eliminate Barrett's esophagus and reduce cancer risk. Rationale for the treatment of Barrett's esophagus beyond treating symptoms of gastroesophageal reflux disease stems from the hope to decrease, if not eliminate, the risk of adenocarcinoma. Treatment options ranged from medical acid suppression without surveillance to resection. Ablation, particularly endoscopic radio-frequency ablation, has become the standard of care for Barrett's esophagus with high-grade dysplasia. It role in nondysplastic or low-grade dysplastic Barrett's is less clear. Combined endoscopic mucosal resection with ablation is effective in nodular high-grade Barrett's esophagus. Resection should be reserved for patients with persistent high-grade dysplasia despite multiple attempts at endoscopic ablation or resection or for patients with evidence of carcinoma.
Collapse
Affiliation(s)
- Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, Florida
| |
Collapse
|
29
|
BENNETT CATHY, VAKIL NIMISH, BERGMAN JACQUES, HARRISON REBECCA, ODZE ROBERT, VIETH MICHAEL, SANDERS SCOTT, GAY LAURA, PECH OLIVER, LONGCROFT–WHEATON GAIUS, ROMERO YVONNE, INADOMI JOHN, TACK JAN, CORLEY DOUGLASA, MANNER HENDRIK, GREEN SUSI, DULAIMI DAVIDAL, ALI HAYTHEM, ALLUM BILL, ANDERSON MARK, CURTIS HOWARD, FALK GARY, FENNERTY MBRIAN, FULLARTON GRANT, KRISHNADATH KAUSILIA, MELTZER STEPHENJ, ARMSTRONG DAVID, GANZ ROBERT, CENGIA GIANPAOLO, GOING JAMESJ, GOLDBLUM JOHN, GORDON CHARLES, GRABSCH HEIKE, HAIGH CHRIS, HONGO MICHIO, JOHNSTON DAVID, FORBES–YOUNG RICKY, KAY ELAINE, KAYE PHILIP, LERUT TONI, LOVAT LAURENCEB, LUNDELL LARS, MAIRS PHILIP, SHIMODA TADAKUZA, SPECHLER STUART, SONTAG STEPHEN, MALFERTHEINER PETER, MURRAY IAIN, NANJI MANOJ, POLLER DAVID, RAGUNATH KRISH, REGULA JAROSLAW, CESTARI RENZO, SHEPHERD NEIL, SINGH RAJVINDER, STEIN HUBERTJ, TALLEY NICHOLASJ, GALMICHE JEAN, THAM TONYCK, WATSON PETER, YERIAN LISA, RUGGE MASSIMO, RICE THOMASW, HART JOHN, GITTENS STUART, HEWIN DAVID, HOCHBERGER JUERGEN, KAHRILAS PETER, PRESTON SEAN, SAMPLINER RICHARD, SHARMA PRATEEK, STUART ROBERT, WANG KENNETH, WAXMAN IRVING, ABLEY CHRIS, LOFT DUNCAN, PENMAN IAN, SHAHEEN NICHOLASJ, CHAK AMITABH, DAVIES GARETH, DUNN LORNA, FALCK–YTTER YNGVE, DECAESTECKER JOHN, BHANDARI PRADEEP, ELL CHRISTIAN, GRIFFIN SMICHAEL, ATTWOOD STEPHEN, BARR HUGH, ALLEN JOHN, FERGUSON MARKK, MOAYYEDI PAUL, JANKOWSKI JANUSZAZ. Consensus statements for management of Barrett's dysplasia and early-stage esophageal adenocarcinoma, based on a Delphi process. Gastroenterology 2012; 143:336-46. [PMID: 22537613 PMCID: PMC5538857 DOI: 10.1053/j.gastro.2012.04.032] [Citation(s) in RCA: 271] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 03/26/2012] [Accepted: 04/06/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophageal adenocarcinoma (EA) is increasingly common among patients with Barrett's esophagus (BE). We aimed to provide consensus recommendations based on the medical literature that clinicians could use to manage patients with BE and low-grade dysplasia, high-grade dysplasia (HGD), or early-stage EA. METHODS We performed an international, multidisciplinary, systematic, evidence-based review of different management strategies for patients with BE and dysplasia or early-stage EA. We used a Delphi process to develop consensus statements. The results of literature searches were screened using a unique, interactive, Web-based data-sifting platform; we used 11,904 papers to inform the choice of statements selected. An a priori threshold of 80% agreement was used to establish consensus for each statement. RESULTS Eighty-one of the 91 statements achieved consensus despite generally low quality of evidence, including 8 clinical statements: (1) specimens from endoscopic resection are better than biopsies for staging lesions, (2) it is important to carefully map the size of the dysplastic areas, (3) patients that receive ablative or surgical therapy require endoscopic follow-up, (4) high-resolution endoscopy is necessary for accurate diagnosis, (5) endoscopic therapy for HGD is preferred to surveillance, (6) endoscopic therapy for HGD is preferred to surgery, (7) the combination of endoscopic resection and radiofrequency ablation is the most effective therapy, and (8) after endoscopic removal of lesions from patients with HGD, all areas of BE should be ablated. CONCLUSIONS We developed a data-sifting platform and used the Delphi process to create evidence-based consensus statements for the management of patients with BE and early-stage EA. This approach identified important clinical features of the diseases and areas for future studies.
Collapse
Affiliation(s)
| | - NIMISH VAKIL
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | | | - ROBERT ODZE
- Harvard Medical School, Boston, Massachusetts
| | | | | | - LAURA GAY
- Queen Mary University London, London, UK
| | | | | | | | | | - JAN TACK
- Leuven University, Leuven, Belgium
| | | | | | - SUSI GREEN
- Queen Alexandra Hospital, Portsmouth, UK
| | | | - HAYTHEM ALI
- Maidstone and Tunbridge Wells NHS trust, Maidstone, UK
| | | | - MARK ANDERSON
- City Hospital, Birmingham, UK and Sandwell Hospital, West Midlands, UK
| | | | - GARY FALK
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | | | - ROBERT GANZ
- Bloomington Medical Centre, Bloomington, Minnesota
| | | | | | - JOHN GOLDBLUM
- Anatomic Pathology, The Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | | | | | | | - PHILIP KAYE
- Digestive Diseases Centre, Nottingham University Hospital, Nottingham, UK
| | | | | | - LARS LUNDELL
- Karolinska Institutet, CLINTEC, Stockholm, Sweden
| | | | | | | | | | | | | | | | | | - KRISH RAGUNATH
- Digestive Diseases Centre, Nottingham University Hospital, Nottingham, UK
| | | | | | - NEIL SHEPHERD
- Gloucestershire Royal Hospitals, Gloucestershire, UK
| | - RAJVINDER SINGH
- Lyell McEwin Hosptial, University of Adelaide, Adelaide, Australia
| | | | | | - JEAN–PAUL GALMICHE
- Department of Gastroenterology, CHU and University of Nantes, Nantes, France
| | | | | | - LISA YERIAN
- Anatomic Pathology, The Cleveland Clinic, Cleveland, Ohio
| | | | - THOMAS W. RICE
- Anatomic Pathology, The Cleveland Clinic, Cleveland, Ohio
| | - JOHN HART
- University of Chicago, Chicago, Illinois
| | - STUART GITTENS
- ECD Solutions, PO Box 862, Bridgetown, St. Michael, Barbados
| | - DAVID HEWIN
- Gloucestershire Royal Hospitals, Gloucestershire, UK
| | | | | | | | | | - PRATEEK SHARMA
- Veterans Affairs Medical Center and University of Kansas
| | | | | | | | - CHRIS ABLEY
- University Hospitals of Leicester, Leicester, UK
| | | | | | - NICHOLAS J. SHAHEEN
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - AMITABH CHAK
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - LORNA DUNN
- Northern Oesophagogastric Cancer Unit Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | | | | | | | - S. MICHAEL GRIFFIN
- Northern Oesophagogastric Cancer Unit Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | - HUGH BARR
- Gloucestershire Royal Hospitals, Gloucestershire, UK
| | - JOHN ALLEN
- University of Minnesota School of Medicine, Minneapolis, Minnesota
| | | | | | - JANUSZ A. Z. JANKOWSKI
- University Hospitals of Leicester, Leicester, UK,Queen Mary University London, London, UK,University of Oxford, Oxford, UK
| |
Collapse
|
30
|
Milind R, Attwood SE. Natural history of Barrett's esophagus. World J Gastroenterol 2012; 18:3483-91. [PMID: 22826612 PMCID: PMC3400849 DOI: 10.3748/wjg.v18.i27.3483] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 03/27/2012] [Accepted: 05/12/2012] [Indexed: 02/06/2023] Open
Abstract
The natural history of Barrett’s esophagus (BE) is difficult to quantify because, by definition, it should describe the course of the condition if left untreated. Pragmatically, we assume that patients with BE will receive symptomatic treatment with acid suppression, usually a proton pump inhibitor, to treat their heartburn. This paper describes the development of complications of stricture, ulcer, dysplasia and adenocarcinoma from this standpoint. Controversies over the definition of BE and its implications in clinical practice are presented. The presence of intestinal metaplasia and its relevance to cancer risk is discussed, and the need to measure the extent of the Barrett’s epithelium (long and short segments) using the Prague guidelines is emphasized. Guidelines and international consensus over the diagnosis and management of BE are being regularly updated. The need for expert consensus is important due to the lack of randomized trials in this area. After searching the literature, we have tried to collate the important studies regarding progression of Barrett’s to dysplasia and adenocarcinoma. No therapeutic studies yet reported show a clear reduction in the development of cancer in BE. The effect of pharmacological and surgical intervention on the natural history of Barrett’s is a subject of ongoing research, including the Barrett’s Oesophagus Surveillance Study and the aspirin and esomeprazole cancer chemoprevention trial with interesting results. The geographical variation and the wide range of outcomes highlight the difficulty of providing an individualized risk profile to patients with BE. Future studies on the interaction of genome wide abnormalities in Barrett’s and their interaction with environmental factors may allow individualization of the risk of cancer developing in BE.
Collapse
|
31
|
Dunn JM, Mackenzie GD, Banks MR, Mosse CA, Haidry R, Green S, Thorpe S, Rodriguez-Justo M, Winstanley A, Novelli MR, Bown SG, Lovat LB. A randomised controlled trial of ALA vs. Photofrin photodynamic therapy for high-grade dysplasia arising in Barrett's oesophagus. Lasers Med Sci 2012; 28:707-15. [PMID: 22699800 DOI: 10.1007/s10103-012-1132-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 05/31/2012] [Indexed: 02/06/2023]
Abstract
Photofrin photodynamic therapy (PDT) is a licenced treatment for Barrett's oesophagus (BE) with high-grade dysplasia (HGD) but causes strictures and photosensitivity and complete reversal of dysplasia (CR-HGD) by 50 % at 5 years. 5-Aminolaevulinic acid (ALA) is an alternative treatment with non-randomised data suggesting 85 % CR-HGD and a low risk of side effects. We aimed to compare efficacy and side effect profile between the drugs. A single-centre randomised controlled trial was conducted. Presence of HGD was confirmed on three occasions by two specialist GI pathologists. Stratification was by length of BE and extent of dysplasia. Standard protocols for ALA and Photofrin-PDT were followed. Endoscopic follow-up with 2-cm four-quadrant biopsy was at 6 weeks, 4 months, and then annually. All adverse event data were collected. Sixty four patients were randomised, 34 ALA and 30 Photofrin-PDT. Median follow-up is 24 months. On intention-to-treat analysis, CR-HGD was 16/34 (47 %) with ALA-PDT and 12/30 (40 %) with Photofrin-PDT. The overall cancer incidence was 14 % (9/64). On sub-group log-rank analysis, for BE ≤ 6 cm, CR-HGD was significantly higher with ALA-PDT than Photofrin-PDT (χ(2) =5.39, p=0.02). Strictures and skin photosensitivity were significantly more common after treatment with Photofrin-PDT than ALA-PDT (33 vs. 9 % and 43 vs. 6 %, respectively, p<0.05). The rate of buried glands with either drug was significantly higher post-PDT (48 % of patients) than pre-PDT (20 %). ALA-PDT has a better risk profile than Photofrin-PDT. In patients with BE length ≤ 6 cm, preliminary results show ALA-PDT is associated with significantly higher CR-HGD. In longer segments of BE, neither PDT drug is sufficiently efficacious to warrant routine use.
Collapse
Affiliation(s)
- J M Dunn
- National Medical Laser Centre, Division of Surgery and Interventional Science, University College London, 67-73 Riding House Street, London, W1W 7EJ, UK
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Dunbar KB, Spechler SJ. The risk of lymph-node metastases in patients with high-grade dysplasia or intramucosal carcinoma in Barrett's esophagus: a systematic review. Am J Gastroenterol 2012; 107:850-62; quiz 863. [PMID: 22488081 PMCID: PMC3578695 DOI: 10.1038/ajg.2012.78] [Citation(s) in RCA: 168] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Endoscopic eradication therapy is used to treat mucosal neoplasms in Barrett's esophagus, but cannot cure cancers that have metastasized to lymph nodes. The risk of such metastases has been proposed as a reason to consider esophagectomy rather than endoscopic therapy for esophageal mucosal neoplasia. The objective of our study was to determine the frequency of lymph-node metastases in patients with high-grade dysplasia (HGD) and intramucosal carcinoma in Barrett's esophagus. METHODS We performed a systematic review using the PRISMA guidelines to identify studies that included patients who had esophagectomy for HGD or intramucosal carcinoma in Barrett's esophagus, and that reported final pathology results after examination of esophagectomy specimens. RESULTS We identified 70 relevant reports that included 1,874 patients who had esophagectomy performed for HGD or intramucosal carcinoma in Barrett's esophagus. Lymph-node metastases were found in 26 patients (1.39 % , 95 % CI 0.86 – 1.92). No metastases were found in the 524 patients who had a final pathology diagnosis of HGD, whereas 26 (1.93 % , 95 % CI 1.19 – 2.66 %) of the 1,350 patients with a final pathology diagnosis of intramucosal carcinoma had positive lymph nodes. CONCLUSIONS The risk of unexpected lymph-node metastases for patients with mucosal neoplasms in Barrett's esophagus is in the range of 1 – 2 %. Esophagectomy has a mortality rate that often exceeds 2 %, with substantial morbidity and no guarantee of curing metastatic disease. Therefore, the risk of lymph node metastases alone does not warrant the choice of esophagectomy over endoscopic therapy for HGD and intramucosal carcinoma in Barrett's esophagus.
Collapse
|
33
|
Krishnan K, Komanduri S, Cluley J, Dirisina R, Sinh P, Ko JZ, Li L, Katzman RB, Barrett TA. Radiofrequency ablation for dysplasia in Barrett's esophagus restores β-catenin activation within esophageal progenitor cells. Dig Dis Sci 2012; 57:294-302. [PMID: 21948356 DOI: 10.1007/s10620-011-1899-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 08/26/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Endoscopic therapies for Barrett's esophagus (BE) associated dysplasia, particularly radiofrequency ablation (RFA), are popular alternatives to surgery. The effect of such therapies on dysplastic stem/progenitor cells (SPC) is unknown. Recent studies suggest that AKT phosphorylation of β-Catenin occurs in SPCs and may be a marker of activated SPCs. We evaluate the effect of RFA in restoring AKT-mediated β-Catenin signaling in regenerative epithelium. METHODS Biopsies were taken from squamous, non-dysplastic BE, dysplastic BE and esophageal adenocarcinoma (EAC). Also, post-RFA, biopsies of endoscopically normal appearing neosquamous epithelium were taken at 3, 6, and 12 months after successful RFA. Immunohistochemistry and Western blot analysis was performed for Pβ-Catenin(552) (Akt-mediated phosphorylation of β-Catenin), Ki-67 and p53. RESULTS There was no difference in Pβ-Catenin552 in squamous, GERD, small bowel and non-dysplastic BE. There was a fivefold increase in Pβ-Catenin(552) in dysplasia and EAC compared to non-dysplastic BE (P < 0.05). Also, there was a persistent threefold increase in Pβ-Catenin(552) in neosquamous epithelium 3 months after RFA compared to native squamous epithelium (P < 0.05) that correlated with increased Ki-67. Six months after RFA, Pβ-Catenin(552) and Ki-67 are similar to native squamous epithelium. CONCLUSIONS Enhanced AKT-mediated β-Catenin activation is seen in BE-associated carcinogenesis. Three months after RFA, squamous epithelial growth from SPC populations exhibited increased levels of Pβ-Catenin(552). This epithelial response becomes quiescent at 6 months after RFA. These data suggest that elevated Pβ-Catenin(552) after RFA denotes a repair response in the neosquamous epithelium 3 months post-RFA.
Collapse
Affiliation(s)
- K Krishnan
- Department of Internal Medicine, Division of Gastroenterology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair, Suite 1400, Chicago, IL 60611, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Rice TW, Goldblum JR. Management of Barrett esophagus with high-grade dysplasia. Thorac Surg Clin 2011; 22:101-7, vii. [PMID: 22108694 DOI: 10.1016/j.thorsurg.2011.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
High-grade dysplasia in Barrett esophagus is a marker for future development of cancer and for the existence of synchronous cancer. A significant problem in management is intraobserver and interobserver variation in the diagnosis of high-grade dysplasia in Barrett esophagus, the natural history of which is poorly understood; thus, treatment decisions are problematic. The ability to preserve the esophagus with endoscopic mucosal ablation or resection and reduce morbidity of treatment has made endoscopic treatment the mainstay of therapy. Esophagectomy is reserved for treatment failures and for high-grade dysplasia not amenable to less aggressive therapies. This article outlines the data supporting current management strategies.
Collapse
Affiliation(s)
- Thomas W Rice
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue/Desk J4-1, Cleveland, OH 44195, USA.
| | | |
Collapse
|
35
|
Abstract
Endoscopic methods are increasingly propagated as oncologically adequate and less invasive treatment modalities for early esophageal cancer compared to surgery. The superiority or equality of endoscopic treatment has, however, so far not been proven by controlled trials. Current guidelines and an analysis of recently published data support surgical resection and lymphadenectomy as the standard of care for early esophageal cancer. This is based on the following arguments: 1) a reliable complete tumor resection with clear margins in all directions (R0 resection) including removal of all precancerous and precursor lesions can currently only be achieved by surgical resection, 2) none of the currently available staging tools allows definitive exclusion of lymphatic spread. A potentially curative surgical lymphadenectomy should thus only be omitted in well-defined subgroups. 3) In experienced hands surgical resection and lymphadenectomy can be performed with low mortality and morbidity, 4) reproducible and reliable data on long-term recurrence-free survival and quality of life are currently only available for surgical series. Thus, endoscopic therapy for early esophageal cancer is an alternative to surgical resection with lymphadenectomy only in patients unfit for surgery and in strictly defined low-risk situations.
Collapse
Affiliation(s)
- H J Stein
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Nürnberg, Deutschland.
| | | | | |
Collapse
|
36
|
Galey KM, Wilshire CL, Watson TJ, Schneider MD, Kaul V, Jones CE, Litle VR, Ullah A, Peters JH. Endoscopic management of early esophageal neoplasia: an emerging standard. J Gastrointest Surg 2011; 15:1728-35. [PMID: 21811883 DOI: 10.1007/s11605-011-1618-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 07/12/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Endoscopic mucosal resection (EMR) and ablation technologies have markedly changed the treatment of early esophageal neoplasia. We analyzed treatment and outcomes of patients undergoing multimodal endoscopic treatment of early esophageal neoplasia at our institution. METHODS Records of patients undergoing endoscopic treatment for esophageal low-grade intraepithelial neoplasia (LGIN, n = 11), high-grade intraepithelial neoplasia (HGIN, n = 24), or T1N0M0 neoplasia (n = 10), presenting between 2007 and 2009, were reviewed. Outcomes included eradication of neoplasia/intestinal metaplasia, development of metachronous neoplasia, and progression to surgical resection. RESULTS There were 45 patients, 96% male, with a mean age 67 years. The degree of neoplasia prior to intervention was intramucosal (8) or submucosal (2) carcinoma in 10, HGIN in 24, and LGIN in 11. Patients underwent a total of 166 procedures (median 3/patient, range 1-9). These included 120 radiofrequency ablation sessions, 38 EMRs, and 8 cryoablations. Mean follow-up was 21.3 months. Neoplasia and intestinal metaplasia were eradicated in 87.2% and 56.4% of patients, respectively, while 15.4% developed metachronous neoplasia. Three patients underwent esophagectomy. No patient developed unresectable disease or died. CONCLUSION Endoscopic treatment of early esophageal neoplasia is safe and effective in the short term. A minority of treated patients developed recurrent neoplasia, which is usually amenable to further endoscopic therapy. Complications are relatively minor and uncommon. Endoscopic therapy as the initial treatment for early esophageal neoplasia is an emerging standard of care.
Collapse
Affiliation(s)
- Kelly M Galey
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Shields HM, Nardone G, Zhao J, Wang W, Xing Z, Fang D, Jacobson BC, Romero Y, Dvorak K, Goldman A, Pellegrini CA, Wiley EL, Peura DA, Tatum RP, Schnell TG. Barrett's esophagus: prevalence and incidence of adenocarcinomas. Ann N Y Acad Sci 2011; 1232:230-47. [DOI: 10.1111/j.1749-6632.2011.06054.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
38
|
Bozio G, Baulieux J, Mabrut JY. The role of surgery in the management of Barrett's esophagus (from dysplasia to cancer). J Visc Surg 2011; 148:19-26. [PMID: 21310681 DOI: 10.1016/j.jviscsurg.2010.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The goal of this review is to evaluate, through a review of the surgical literature, the role of esophagectomy in the management of Barrett's esophagus as it evolves histologically from intestinal metaplasia through increasing grades of dysplasia to adenocarcinoma. We precisely define the indications and therapeutic modalities of esophagectomy for high-grade dysplasia, superficial adenocarcinoma, and invasive adenocarcinoma.
Collapse
Affiliation(s)
- G Bozio
- Service de chirurgie générale, digestive et de la transplantation hépatique, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | | | | |
Collapse
|
39
|
Abstract
INTRODUCTION Esophageal cancer remains a challenging clinical problem, with overall long-term survivorship consistently at a level of approximately 30%. The incidence of esophageal cancer is increasing worldwide, with the most dramatic increase being seen with respect to esophageal adenocarcinoma. DISCUSSION Pretreatment staging accuracy has improved with the utilization of CT and PET scans, as well as endoscopic ultrasound and endoscopic mucosal resection. In an increasing percentage of patients, endoscopic techniques are being utilized in selected patients for the treatment of high-grade dysplasia in Barrett's and intramucosal cancer. Surgery remains the treatment of choice in all appropriate patients with invasive and locoregional esophageal cancer, although multimodality therapy is now used in most patients with stage II or stage III disease. CONCLUSION Outcomes for esophagectomy have been dominated by concerns regarding high mortality and morbidity; however, mortality rates associated with esophageal resection have dramatically decreased, especially in high-volume specialty centers. This manuscript highlights some of the evolutionary issues associated with staging and endoscopic and surgical treatments of Barrett's and esophageal cancer.
Collapse
|
40
|
SPECHLER STUARTJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ. American Gastroenterological Association technical review on the management of Barrett's esophagus. Gastroenterology 2011; 140:e18-52; quiz e13. [PMID: 21376939 PMCID: PMC3258495 DOI: 10.1053/j.gastro.2011.01.031] [Citation(s) in RCA: 783] [Impact Index Per Article: 60.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
41
|
Hirst NG, Gordon LG, Whiteman DC, Watson DI, Barendregt JJ. Is endoscopic surveillance for non-dysplastic Barrett's esophagus cost-effective? Review of economic evaluations. J Gastroenterol Hepatol 2011; 26:247-54. [PMID: 21261712 DOI: 10.1111/j.1440-1746.2010.06506.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Several health economic evaluations have explored the cost-effectiveness of endoscopic surveillance for patients with non-dysplastic Barrett's esophagus, with conflicting results. By comparing results across studies and highlighting key methodological and data limitations a platform for future, more rigorous analyses, can be developed. METHODS A systematic literature review was undertaken of studies evaluating cost-effectiveness of surveillance for non-dysplastic Barrett's esophagus. Articles were included if they assessed both cost and health outcomes for surveillance versus no surveillance. A descriptive review was undertaken and the quality of the studies appraised against best-practice recommendations for economic evaluations and modeling studies. RESULTS Seven publications met the inclusion criteria. All used decision-analytic Markov models. Half of the evaluations found surveillance was not cost-effective. At best, surveillance produced improved outcomes at a cost of US$16 640 per quality-adjusted life-year, and at worst it did more harm than good and at a greater cost. The quality of the evaluations and generalizability to the Asia-Pacific region was diminished as a result of inadequate or inconsistent evidence supporting parameter estimates, such as quality of life, endoscopic sensitivity and specificity and cancer recurrence rates. CONCLUSIONS Unless newly emerging technologies improve the quality-adjusted survival benefit conferred by endoscopic surveillance, this strategy is unlikely to be cost-effective. Obsolete assumptions and incomplete analyses reduce the quality of published evaluations. For these reasons new evaluations are required that encompass the growing evidence base for new technologies, such as new endoscopic therapies for high-grade dysplasia and intramucosal cancer.
Collapse
Affiliation(s)
- Nicholas G Hirst
- Genetics and Population Health Division, Queensland Institute of Medical Research, PO Royal Brisbane Hospital, Brisbane, Australia
| | | | | | | | | |
Collapse
|
42
|
Bulsiewicz WJ, Shaheen NJ. The role of radiofrequency ablation in the management of Barrett's esophagus. Gastrointest Endosc Clin N Am 2011; 21:95-109. [PMID: 21112500 DOI: 10.1016/j.giec.2010.09.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Studies in the last several years have consistently shown radiofrequency ablation (RFA) to be effective, safe, and well tolerated in the treatment of nondysplastic and dysplastic Barrett's esophagus (BE). The results found at academic medical centers have been reproduced in the community setting. RFA provides a safe and cost-effective alternative to surgery or surveillance in the management of high-grade dysplasia (HGD). RFA should be given serious consideration as first-line therapy for HGD. This article reviews the evidence behind RFA to differentiate it from other management strategies in terms of efficacy, durability, safety, tolerability, and cost-effectiveness. The role of RFA in the management of BE is described, including endoscopic resection. Future directions are identified for research that will help to better define the role of RFA in the management of BE.
Collapse
Affiliation(s)
- William J Bulsiewicz
- GI Outcomes Training Program, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | |
Collapse
|
43
|
Boger PC, Turner D, Roderick P, Patel P. A UK-based cost-utility analysis of radiofrequency ablation or oesophagectomy for the management of high-grade dysplasia in Barrett's oesophagus. Aliment Pharmacol Ther 2010; 32:1332-42. [PMID: 21050235 DOI: 10.1111/j.1365-2036.2010.04450.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In the UK, oesophagectomy is the current recommendation for patients with persistent high-grade dysplasia in Barrett's oesophagus. Radiofrequency ablation is an alternative new technology with promising early trial results. AIM To undertake a cost-utility analysis comparing these two strategies. METHODS We constructed a Markov model to simulate the natural history of a cohort of patients with high-grade dysplasia in Barrett's oesophagus undergoing one of two treatment options: (i) oesophagectomy or (ii) radiofrequency ablation followed by endoscopic surveillance with oesophagectomy for high-grade dysplasia recurrence or persistence. RESULTS In the base case analysis, radiofrequency ablation dominated as it generated 0.4 extra quality of life years at a cost saving of £1902. For oesophagectomy to be the most cost-effective option, it required a radiofrequency ablation treatment failure rate (high-grade dysplasia persistence or progression to cancer) of >44%, or an annual risk of high-grade dysplasia recurrence or progression to cancer in the ablated oesophagus of >15% per annum. There was an 85% probability that radiofrequency ablation remained cost-effective at the NICE willingness to pay threshold range of £20 000-30 000. CONCLUSION Radiofrequency ablation is likely to be a cost-effective option for high-grade dysplasia in Barrett's oesophagus in the UK.
Collapse
Affiliation(s)
- P C Boger
- Department of Luminal Gastroenterology, Southampton General Hospital, UK.
| | | | | | | |
Collapse
|
44
|
Affiliation(s)
- Matthew J Schuchert
- Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | |
Collapse
|
45
|
Are endoscopic therapies appropriate for superficial submucosal esophageal adenocarcinoma? An analysis of esophagectomy specimens. J Am Coll Surg 2010; 210:418-27. [PMID: 20347733 DOI: 10.1016/j.jamcollsurg.2010.01.003] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Revised: 01/04/2010] [Accepted: 01/04/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND Endoscopic resection and ablation have advanced the treatment of intramucosal esophageal adenocarcinoma and have been promoted as definitive therapy for selected superficial submucosal tumors. Controversy exists regarding the prevalence of nodal metastases at various depths of mucosal and submucosal invasion. Our aim was to clarify this prevalence and identify predictors of nodal spread. STUDY DESIGN An expert gastrointestinal pathologist retrospectively reviewed 54 T1 adenocarcinomas from 258 esophagectomy specimens (2000 to 2008). Tumors were classified as intramucosal or submucosal, the latter being subclassified as SM1 (upper third), SM2 (middle third), or SM3 (lower third) based on the depth of tumor invasion. The depth of invasion was correlated with the prevalence of positive nodes. Fisher's exact test and univariate and multivariate logistic regression were used to identify variables predicting nodal disease. RESULTS Nodal metastases were present in 0% (0 of 25) of intramucosal, 21% (3 of 14) of SM1, 36% (4 of 11) of SM2, and 50% (2 of 4) of SM3 tumors. The differences were significant between intramucosal and submucosal tumors (p < 0.0001), although not between the various subclassifications of submucosal tumors (p = 0.503). Univariate logistic regression identified poor differentiation (p = 0.024), lymphovascular invasion (p = 0.049), and number of harvested lymph nodes (p = 0.037) as significantly correlated with nodal disease. Multivariate logistic regression did not identify any of the tested variables as independent predictors of the prevalence of positive lymph nodes. CONCLUSIONS All depths of submucosal invasion of esophageal adenocarcinoma were associated with an unacceptably high prevalence of nodal metastases and a marked increase relative to intramucosal cancer. Accurate predictors of nodal spread, independent of tumor depth, are currently lacking and will be necessary before recommending endoscopic resection with or without concomitant ablation as curative treatment for even superficial submucosal neoplasia.
Collapse
|
46
|
Frantz DJ, Dellon ES, Shaheen NJ. Radiofrequency ablation of Barrett's esophagus. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2010. [DOI: 10.1016/j.tgie.2010.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
47
|
Evaluation and treatment of superficial esophageal cancer. J Gastrointest Surg 2010; 14 Suppl 1:S94-100. [PMID: 19760303 DOI: 10.1007/s11605-009-1025-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 08/25/2009] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Adenocarcinoma of the esophagus is the fastest increasing cancer in the USA, and an increasing number of patients are identified with early-stage disease. The evaluation and treatment of these superficial cancers differs from local and regionally advanced lesions. METHODS This paper is a review of the current methods to diagnose, stage, and treat superficial esophageal adenocarcinoma. RESULTS Intramucosal adenocarcinoma can be effectively treated with endoscopic resection techniques and with less morbid surgical options including a vagal-sparing esophagectomy. However, submucosal lesions are associated with a significant risk for lymph node metastases and are best treated with esophagectomy and lymphadenectomy. DISCUSSION There has been a major shift in the treatment for Barrett's high-grade dysplasia and superficial esophageal adenocarcinoma in the past 10 years. New therapies minimize the morbidity and mortality of traditional forms of esophagectomy and in some cases allow esophageal preservation. Individualization of therapy will allow maximization of successful outcome and quality of life with minimization of complications and recurrence of Barrett's or cancer.
Collapse
|
48
|
Abstract
INTRODUCTION Minimally invasive esophagectomy has gained popularity over the past two decades. The procedural goal is to decrease the high overall morbidity of a traditional open esophageal resection. The entire spectrum of open esophagectomy techniques has been successfully replicated in a minimally invasive fashion. DISCUSSION Esophagectomy remains one of the most technically challenging operations, and developing the skills necessary for minimal invasive esophagectomy is associated with a steep learning curve. Minimally invasive approaches show most promise for benign disease and select early esophageal cancers, but their role in more advanced cancer remains controversial due to lack of long-term results. CONCLUSION As minimally invasive esophagectomy matures, its true value in both benign and malignant disorders will become better defined.
Collapse
|
49
|
Dubecz A, Stein HJ. Endoscopic versus surgical therapy for early cancer in Barrett's esophagus. Gastrointest Endosc 2009; 70:632-4. [PMID: 19788980 DOI: 10.1016/j.gie.2009.04.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Accepted: 04/12/2009] [Indexed: 02/08/2023]
|
50
|
Sharma RR, London MJ, Magenta LL, Posner MC, Roggin KK. Preemptive surgery for premalignant foregut lesions. J Gastrointest Surg 2009; 13:1874-87. [PMID: 19513795 DOI: 10.1007/s11605-009-0935-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Accepted: 05/20/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Preemptive surgery is the prophylactic removal of an organ at high risk for malignant transformation or the resection of a precancerous or "early" malignant neoplasm in an individual with a hereditary predisposition to cancer. Recent advances in molecular diagnostic techniques have improved our understanding of the biologic behavior of these conditions. Predictive testing is an emerging field that attempts to assess the potential risk of cancer development in predisposed individuals. Despite substantial improvement in these forms of testing, all results are imperfect. This information often becomes an important tool that is used by healthcare providers to evaluate the risk-benefit ratio of various risk modifying strategies (i.e., intensive surveillance or preemptive surgery). METHODS A systematic literature review was performed using Medline and the bibliographies of all referenced publications to identify articles relating to preemptive surgery for premalignant foregut lesions. RESULTS AND DISCUSSION In this review, we outline the controversies surrounding predictive risk assessment, surveillance strategies, and preemptive surgery in the management of high-grade dysplasia (HGD) in Barrett's esophagus (BE), hereditary diffuse gastric cancer (HDGC), bile duct cysts, primary sclerosing cholangitis (PSC), and pancreatic cystic neoplasms. Resection of BE is supported by the progressive nature of the disease, the risk of occult carcinoma, and the lethality of esophageal cancer. Prophylactic total gastrectomy for HDGC appears reasonable in the absence of accurate screening tests but must be balanced by the impact of surgical complications and altered quality of life. Surgical resection of biliary cysts theoretically eliminates the exposed epithelium to decrease the lifetime risk of cholangiocarcinoma. Liver transplantation for PSC remains controversial given the scarcity of donor organs and inability to accurately identify high-risk individuals. Given the uncertain natural history of pancreatic cystic neoplasms, the merits of selective versus obligatory resection will continue to be debated. CONCLUSIONS Preemptive operations require optimal judgment and surgical precision to maximize function and enhance survival. Ultimately, balancing the risk of surgical intervention with less invasive interventions or observation must be individualized on a case-by-case basis.
Collapse
Affiliation(s)
- Rohit R Sharma
- Department of Surgery, Section of General Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | | | | | | | | |
Collapse
|