Survival in esophageal high-grade dysplasia/adenocarcinoma post endoscopic resection

Barrett's esophagus: The pathomorphological and molecular genetic keystones of neoplastic progression

Barrett's esophagus is a widespread chronically progressing disease of heterogeneous nature. A life threatening complication of this condition is neoplastic transformation, which is often overlooked due to lack of standardized approaches in diagnosis, preventative measures and treatment. In this essay, we aim to stratify existing data to show specific associations between neoplastic transformation and the underlying processes which predate cancerous transition. We discuss pathomorphological, genetic, epigenetic, molecular and immunohistochemical methods related to neoplasia detection on the basis of Barrett's esophagus. Our review sheds light on pathways of such neoplastic progression in the distal esophagus, providing valuable insight into progression assessment, preventative targets and treatment modalities. Our results suggest that molecular, genetic and epigenetic alterations in the esophagus arise earlier than cancerous transformation, meaning the discussed targets can help form preventative strategies in at-risk patient groups.

Systematic review with meta-analysis: prevalence of prior and concurrent Barrett's oesophagus in oesophageal adenocarcinoma patients

BACKGROUND

The proportions of patients with oesophageal adenocarcinoma (OAC) diagnosed by Barrett's oesophagus surveillance or with pre-existing Barrett's oesophagus are unclear.

AIM

To estimate the prevalence of prior and concurrent Barrett's oesophagus diagnosis among patients with OAC or oesophagogastric junction adenocarcinomas (OGJAC).

METHODS

We searched PubMed and Embase to identify studies published 1966-1/8/2020 that examined the prevalence of prior (≥6 months) or concurrent Barrett's diagnosis (at cancer diagnosis) among OAC and OGJAC patients. Random effects models estimated overall and stratified pooled prevalence rates.

RESULTS

A total of 69 studies, including 33 002 OAC patients (53 studies) and 2712 patients with OGJAC (28 studies) were included. The pooled prevalence of prior Barrett's oesophagus diagnosis in OAC was 11.8% (95% confidence interval [CI] 8.4%-15.6%). The prevalence of prior Barrett's oesophagus diagnosis was higher in single-centre resection studies (16.0%, 95% CI 8.7%-24.9%) than population-based cancer registry studies (8.4%, 95% CI 5.5%-11.9%). The prevalence of concurrent Barrett's oesophagus in OAC was 56.6% (95% CI 48.5%-64.6%). Studies with 100% early stage OAC had higher prevalence of concurrent Barrett's oesophagus (91.3%, 95% CI 82.4%-97.6%) than studies with <50% early OAC (39.7%, 95% CI 33.7%-45.9%). In OGJAC, the prevalence of prior and concurrent Barrett's oesophagus was 23.2% (95% CI 7.5%-44.0%) and 26.3% (95% CI 17.8%-35.7%), respectively.

CONCLUSIONS

Most patients with OAC have Barrett's oesophagus. Our meta-analysis found ~12% of OAC patients had prior Barrett's diagnosis, but concurrent Barrett's oesophagus was found in ~57% at the time of OAC diagnosis. This represents a considerable missed opportunity for Barrett's oesophagus screening.

Circulating miRNAs in patients with Barrett's esophagus, high-grade dysplasia and esophageal adenocarcinoma

Background

Diagnostic screening of premalignant esophageal lesions is hampered by the absence of biomarkers indicative of metaplastic and/or malignant transformation. The aim of this exploratory study was to investigate the potential use of miRNAs as biomarkers capable of identifying patients with (pre)malignant lesions: Barrett's esophagus (BE) metaplasia, high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC).

Methods

A total of 69 patients were included in the study. Six serum samples from each of four study groups, i.e., patients with normal squamous epithelium (SE), BE, HGD and EAC, were profiled using the Nanostring miRNA analysis platform. Differential miRNA expression patterns then were validated in 69 patient samples using qRT-PCR.

Results

miRNA expression profiling revealed seven miRNAs with a 2-fold change in expression level. Validation by qRT-PCR confirmed that serum miR-320e levels were significantly decreased in the BE group compared to the SE (P≤0.001, AUC 0.790) and HGD groups (P≤0.005, AUC 0.786). Serum miR-199a-3p levels were significantly decreased in the BE group compared to the SE group (P≤0.001), area under the curve (AUC) of 0.813.

Conclusions

The results of this study suggest that decreased serum miRNA levels of miR-199a-3p and miR-320e could help to identify patients with BE and HGD.

A guide to multimodal endoscopy imaging for gastrointestinal malignancy - an early indicator

Multimodality imaging is an essential aspect of endoscopic surveillance for the detection of neoplastic lesions, such as dysplasia or intramucosal cancer, because it improves the efficacy of endoscopic surveillance and therapeutic procedures in the gastrointestinal tract. This approach reveals mucosal abnormalities that cannot be detected by standard endoscopy. Currently, these imaging techniques are divided into those for primary detection and those for targeted imaging and characterization, the latter being used to visualize areas of interest in detail and permit histological evaluation. This Review outlines the use of virtual chromoendoscopy, narrow-band imaging, autofluorescence imaging, optical coherence tomography, confocal endomicroscopy and volumetric laser endomicroscopy as new imaging techniques for diagnostic investigation of the gastrointestinal tract. Insights into use of multimodal endoscopic imaging for early disease detection, in particular for pre-malignant lesions, in the oesophagus, stomach and colon are described.

Esophageal neoplasia arising from subsquamous buried glands after an apparently successful photodynamic therapy or radiofrequency ablation for Barrett's associated neoplasia

OBJECTIVE

Photodynamic therapy (PDT) and radiofrequency ablation (RFA) are effective non-surgical options for the treatment of Barrett's esophagus (BE) associated neoplasia. Development of subsquamous intestinal metaplasia after successful PDT and/or RFA is a recognized phenomenon; however, the occurrence of neoplasia arising from buried glands is a rare complication.

METHODS

This is a prospective case series of patients treated with PDT and/or RFA from 1999 to 2014 at University College London Hospital for neoplasia associated with BE, whose outcomes were analyzed retrospectively. Prior to any ablative therapy any visible nodularity was removed with endoscopic mucosal resection (EMR). After successful PDT and/or HALO RFA treatment, defined as a complete reversal of dysplasia and metaplasia, patients underwent endoscopic follow up using the Seattle protocol.

RESULTS

A total of 288 patients were treated, 91 with PDT between 1999 and 2010, 173 with RFA between 2007 and 2014, and 24 with both PDT and RFA for neoplasia associated with BE. Subsquamous neoplasia occurred in seven patients (7/288, 2%). The first patient developed subsquamous invasive adenocarcinoma and underwent curative surgery. Another five patients with subsquamous neoplasia (either high-grade dysplasia or intramucosal cancer) were treated successfully with EMR. The final patient developed subsquamous invasive esophagogastric junctional adenocarcinoma with liver metastases.

CONCLUSION

Development of subsquamous neoplasia after an apparently successful PDT and/or RFA is a rare but recognized complication. Clinicians should be aware of this phenomenon and have a low threshold for performing an EMR. Thorough surveillance following successful PDT and/or RFA ensuring high-quality endoscopy is required.

Comparison of endoscopic treatment modalities for Barrett's neoplasia

BACKGROUND

There are few data comparing endoscopic treatment outcomes for Barrett's esophagus (BE).

OBJECTIVE

To compare treatment outcomes in BE patients treated with radiofrequency ablation (RFA), RFA after EMR, and porfimer sodium photodynamic therapy (Ps-PDT).

DESIGN

Retrospective, observational study.

SETTING

Single tertiary center between 2001 and 2013.

PATIENTS

A total of 342 BE patients treated with RFA (n = 119), EMR+RFA (n = 98), and Ps-PDT (n = 125).

MAIN OUTCOME MEASUREMENTS

Rates of complete remission of intestinal metaplasia (CRIM), BE recurrence, and adverse events.

RESULTS

Baseline BE high-grade dysplasia (HGD) and adenocarcinoma were more common in the Ps-PDT group (89%) compared with the EMR-RFA (70%) and RFA (37%) groups. At a median follow-up of 14.2 months, 173 patients (50.6%) achieved CRIM. CRIM was significantly more common in Ps-PDT patients compared with RFA (P < .001) and EMR-RFA (P < .001) patients on multivariable analysis. In patients who achieved CRIM, the rates of subsequent BE recurrence were relatively similar among the 3 groups. Although the rates of bleeding were similar, strictures were less common in RFA patients (2.4%) compared with EMR-RFA (13.3%, P = .001) and Ps-PDT (10.4%, P =.043) patients.

CONCLUSION

This study of endoscopic treatment for Barrett's dysplasia and neoplasia found that complete remission was achieved more often and more rapidly after Ps-PDT with similar disease recurrence rates compared with EMR or RFA. Adverse events were more common after EMR and Ps-PDT. Further studies are required to determine which ablation and resection techniques are ideally suited for each BE patient.

Management of high grade dysplasia in Barrett's oesophagus with underlying oesophageal varices: A retrospective study

BACKGROUND

Endoscopic treatment of Barrett's oesophagus leading to high grade dysplasia with oesophageal varices may lead to bleeding complications.

AIMS

Estimate effectiveness of endoscopic band-ligation in oesophageal varices patients treated for high grade dysplasia, and compare to endoscopically treated non-oesophageal varices high grade dysplasia patients.

METHODS

Retrospective comparative study. All 8 high grade dysplasia patients with varices who were treated initially with band-ligation at Mayo Clinic between 8/1/1999 and 2/28/2014 were compared with reference group of 52 high grade dysplasia patients treated endoscopically.

RESULTS

One high grade dysplasia patients patient with oesophageal varices (12.5%) achieved complete remission of intestinal metaplasia defined by at least one followup endoscopy with normal biopsies, and 3 (37.5%) achieved complete remission of dysplasia defined by at least one followup endoscopy with non-dysplastic biopsies. 39 (75.0%) endomucosal resection/radiofrequency ablation patients experienced at least one followup endoscopy with normal biopsies, and 49 (94.2%) experienced non-dysplastic biopsies. Both of these endpoints occurred significantly more often in the endomucosal resection/radiofrequency ablation group compared to the high grade dysplasia with oesophageal varices group (p=0.016 and p=0.025, respectively).

CONCLUSIONS

High grade dysplastic Barrett's can be safely managed with band-ligation. However, resolution of Barrett's epithelium is rarely achieved with banding alone.

Comparative risk of recurrence of dysplasia and carcinoma after endoluminal eradication therapy of high-grade dysplasia versus intramucosal carcinoma in Barrett's esophagus

BACKGROUND

Endoscopic therapy is the preferred approach for the management of Barrett's esophagus (BE) patients with high-grade dysplasia (HGD) and intramucosal carcinoma (IMC). Little is known about outcome differences in patients with HGD versus IMC.

OBJECTIVE

To determine and compare the rate of recurrent dysplasia or neoplasia in patients with HGD or IMC undergoing endoscopic therapy.

DESIGN

Retrospective cohort study.

PATIENTS

A total of 246 BE patients with either HGD or IMC referred for endoscopic therapy.

INTERVENTION

Patients underwent EMR and/or ablation therapy with the goal of complete eradication of all dysplasia/neoplasia and intestinal metaplasia (CE-IM). Patients were assigned to either the HGD or IMC group based on highest pathology grade at the start of therapy.

MAIN OUTCOME MEASUREMENTS

Complete eradication and recurrence of IM and/or HGD/neoplasia were assessed among patients with HGD versus IMC. Only patients with CE-IM (documented eradication of all dysplasia/neoplasia and IM on a single endoscopy) were included for analysis of recurrence rates and risk factors.

RESULTS

CE-IM was achieved in 113 of 135 patients (83.7%) with HGD and in 84 of 111 patients (75.7%) with IMC (P = .16). Overall recurrence rates of dysplasia or neoplasia after CE-IM were similar in both groups (HGD, 8.0% vs IMC, 9.5%; P = .44; relative risk, 1.2; 95% confidence interval, 0.5-3.0) and remained similar in patients with 5 years of surveillance after CE-IM (HGD, 13.5% vs IMC, 11.4%; P = .53; relative risk, 0.85; 95% confidence interval, 0.3-2.7).

LIMITATIONS

Retrospective, observational study and evolution of endoscopic modalities and experience.

CONCLUSION

Endoluminal therapy can successfully achieve eradication of IM and dysplasia or neoplasia in BE patients with HGD and IMC at comparable rates. There were no differences in the rates of recurrent HGD/IMC in the 2 groups.

Safety of esophageal EMR in elderly patients

BACKGROUND

EMR is commonly used to remove suspicious esophageal lesions among patients with Barrett's esophagus (BE). BE primarily affects older patients. Yet, the safety profile of EMR in elderly patients has not been well-described.

OBJECTIVE

We aimed to study the safety profile of EMR in elderly patients compared with younger patients.

DESIGN

Retrospective, observational, descriptive study that used a prospective database.

SETTING

Tertiary-care referral center.

PATIENTS

A total of 136 patients who underwent esophageal EMR for BE.

INTERVENTIONS

EMR with/without ablative therapy.

MAIN OUTCOME MEASUREMENTS

The rate of adverse events, including bleeding, stricture formation, and perforation between elderly (aged ≥75 years) and younger (aged <75 years) patients.

RESULTS

We identified 136 patients who underwent esophageal EMR who were followed-up in our clinic. Of those, 40% (n = 55) were aged ≥75 years (elderly group) and 60% (n = 81) were aged <75 years (younger group). There was no difference in rate of stricture formation or early or delayed bleeding when we compared elderly patients to younger patients. None of the patients had esophageal perforation. On multivariable logistic regression analysis, controlling for patient sex, EMR technique, and underlying pathology, older age was not associated with increased odds of adverse events (OR 0.88; 95% confidence interval, 0.42-1.9; P = .75).

LIMITATIONS

Single-center experience.

CONCLUSION

Rates of adverse events from EMR appear to be similar in elderly patients compared with younger patients. Overall, esophageal EMR seems to offer an acceptable safety profile in elderly patients.

Outcomes in the management of esophageal cancer

Esophageal cancer rates have continued to rise in the Western World. Esophageal cancer will be responsible for an estimated 15,450 deaths in the United States in 2014 alone. Esophageal resection with or without preoperative therapy remains the mainstay of treatment. Advances in surgical technique and perioperative care have improved short-term outcomes considerably by decreasing operative mortality. Despite these advances though, esophagectomy remains a procedure associated with considerable morbidity from a wide range of complications. Prompt recognition and treatment of complications can lower overall morbidity and mortality. Unfortunately, long-term outcomes remain poor as the vast majority of patients present with loco-regionally advanced or metastatic disease. Surgery by itself provides poor loco-regional control and fails to address micrometastatic disease. Neoadjuvant chemotherapy or chemoradiation provides a modest survival advantage compared to surgical resection alone. Future gains in understanding the molecular biology of esophageal cancer will hopefully lead to improved therapeutics and resultant outcomes.

Gender differences in remission of esophageal intestinal metaplasia after radiofrequency ablation

OBJECTIVES

Few studies have assessed the effect of gender on remission rates after radiofrequency ablation (RFA) of Barrett's esophagus (BE). We aim to assess the effect of gender on the time to achieve complete remission of intestinal metaplasia (CRIM) among patients with BE, who underwent RFA.

METHODS

This was a retrospective, observational study using a large RFA database in a tertiary referral center. The primary outcome was time to CRIM compared between males and females. Covariates included age, race, smoking history, use of endoscopic mucosal resection (EMR), histology before RFA, and the number of RFA sessions. Time to CRIM (in months) was calculated using the Kaplan-Meier method and compared using the log-rank test. Multivariable Cox-proportional hazard models were used to assess for any association between time to CRIM and gender.

RESULTS

Two hundred and fifty-seven patients, 11% (n=23) female, underwent RFA for BE between May 2005 and June 2012. Males and females were similar in mean age, race, smoking history, median BE length, history of EMR, and baseline histology. Median time to CRIM for females was longer than males (24 months (95% confidence interval (CI): 10.3-60.2) vs. 11.7 months (95% CI: 10-15), P=0.03). Using Cox-regression analysis, controlling for age, use of EMR, BE segment length, and the number of RFA sessions, female gender was associated with a 55% decrease in the rate of CRIM compared with that in males (hazard ratio=0.45 (95% CI: 0.25-0.82), P=0.009).

CONCLUSIONS

Females take longer time to achieve CRIM when treated with RFA when compared with males of similar age and BE length.