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Huang Q, Lew E, Cheng Y, Shinagare S, Deshpande V, Gold JS, Wiener D, Weber HC. Esophageal adenocarcinoma heterogeneity in clinicopathology and prognosis: A single center longitudinal study of 146 cases over a 20-year period. Ann Diagn Pathol 2024; 70:152285. [PMID: 38518703 DOI: 10.1016/j.anndiagpath.2024.152285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/23/2024] [Accepted: 02/25/2024] [Indexed: 03/24/2024]
Abstract
Recent genomic studies suggest that esophageal adenocarcinoma (EAC) is not homogeneous and can be divided into true (tEAC) and probable (pEAC) groups. We compared clinicopathologic and prognostic features between the two groups of EAC. Based on endoscopic, radiologic, surgical, and pathologic reports, tumors with epicenters beyond 2 cm of the gastroesophageal junction (GEJ) were assigned to the tEAC group (N = 63), while epicenters within 2 cm of, but not crossing the GEJ, were allocated to the pEAC group (N = 83). All 146 consecutive patients were male (age: median 70 years, range: 51-88) and White-predominant (98.6 %). There was no significant difference in gastroesophageal reflux disease, obesity, comorbidity, and the prevalence of Barrett's esophagus, and cases diagnosed during endoscopic surveillance. However, compared to the pEAC group, the tEAC group had significantly more cases with hiatal hernia (P = 0.003); their tumors were significantly smaller in size (P = 0.007), more frequently with tubular/papillary adenocarcinoma (P = 0.001), had fewer cases with poorly cohesive carcinoma (P = 0.018), and demonstrated better prognosis in stage I disease (P = 0.012); 5-year overall survival (34.9 months) was significantly longer (versus 16.8 months in pEACs) (P = 0.043). Compared to the patients without resection, the patients treated with endoscopic or surgical resection showed significantly better outcomes, irrespective of stages. We concluded that EACs were heterogeneous with two distinct tEAC and pEAC groups in clinicopathology and prognosis; resection remained the better option for improved outcomes. CONDENSED ABSTRACT: Esophageal adenocarcinoma can be divided into true or probable groups with distinct clinicopathology and better prognosis in the former than in the latter. we showed that resection remained the better option for improved outcomes.
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Affiliation(s)
- Qin Huang
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Edward Lew
- Department of Gastroenterology, Veterans Affairs Boston Healthcare System and Harvard Medical School, West Roxbury, MA, USA
| | - Yuqing Cheng
- Department of Pathology, Changzhou Second People's Hospital and Nanjing Medical University, Changzhou, China
| | - Shweta Shinagare
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Vikram Deshpande
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Jason S Gold
- Department of Surgery, Veterans Affairs Boston Healthcare System and Harvard Medical School, West Roxbury, MA, USA
| | - Daniel Wiener
- Department of Surgery, Veterans Affairs Boston Healthcare System and Harvard Medical School, West Roxbury, MA, USA
| | - H Christian Weber
- Department of Gastroenterology, Veterans Affairs Boston Healthcare System and Boston University Medical School, West Roxbury, MA, USA
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Copetti H, Copetti L, Copetti L, Felin GD, Felin GD, Felin CD, Felin FD, Chiesa V. RISK OF PRENEOPLASTIC LESIONS IN MUCOSAL PROJECTIONS OF DIFFERENT SIZES OF THE COLUMNAR EPITHELIUM IN THE LOWER ESOPHAGUS. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2022; 35:e1674. [PMID: 36102485 PMCID: PMC9462856 DOI: 10.1590/0102-672020220002e1674] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 05/28/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Barrett's esophagus is an acquired condition that predisposes to the development of esophageal adenocarcinoma. AIMS The aim of this study was to establish an association between the endoscopic and the histopathological findings regarding differently sized endoscopic columnar epithelial mucosa projections in the low esophagus, under 3.0 cm in the longitudinal extent. METHODS This is a prospective study, including 1262 patients who were submitted to upper gastrointestinal endoscopy in the period from July 2015 to June 2017. The suspicious projections were measured and subdivided into three groups according to the sizes encountered (Group I: <0.99 cm; Group II: 1.0-1.99 cm; and Group III: 2.0-2.99 cm), and biopsies were then performed. RESULTS There was a general prevalence of suspicious lesions of 6.42% and of confirmed Barrett's lesions of 1.17%, without a general significant statistical difference among groups. However, from Groups I and II to Group III, the differences were significant, showing that the greater the lesion, the higher the probability of Barrett's esophagus diagnosis. The absolute number of Barrett's lesions was 7, 9, and 6 for Groups I, II, and III, respectively. CONCLUSIONS The findings led to the conclusion that even projections under 3.0 cm present a similar possibility of evolution to Barrett's esophagus. If, on the one hand, short segments are more prevalent, on the other hand, the long segments have the higher probability of Barrett's esophagus diagnosis, which is why biopsies are required in all suspicious segments.
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Affiliation(s)
- Hairton Copetti
- Universidade Federal de Santa Maria – Santa Maria (RS), Brazil
| | | | - Laura Copetti
- Universidade Federal de Santa Maria – Santa Maria (RS), Brazil
| | | | | | | | | | - Vitória Chiesa
- Universidade Federal de Ciências da Saúde de Porto Alegre – Porto Alegre (RS), Brazil
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Sawas T, Zamani SA, Killcoyne S, Dullea A, Wang KK, Iyer PG, Fitzgerald RC, Katzka DA. Limitations of Heartburn and Other Societies' Criteria in Barrett's Screening for Detecting De Novo Esophageal Adenocarcinoma. Clin Gastroenterol Hepatol 2022; 20:1709-1718. [PMID: 34757196 DOI: 10.1016/j.cgh.2021.10.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/14/2021] [Accepted: 10/24/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Despite extensive Barrett's esophagus (BE) screening efforts, most patients with esophageal adenocarcinoma (EAC) present de novo. It is unclear how much of this problem is the result of insensitivity or poor applications of current screening guidelines. We aimed to evaluate the sensitivity of guidelines by determining the proportion of prevalent EAC cases that meet the American College of Gastroenterology (ACG) or the British Society of Gastroenterology (BSG) guidelines for BE screening and determine whether changes to criteria would enhance detection. METHODS A retrospective single-center cohort from the United States (n = 663) and a prospective multicenter cohort from the United Kingdom (n = 645) were collected and analyzed independently. Screening eligibility was determined as patients with chronic reflux and at least 2 or more risk factors as defined by the guidelines. We calculated the proportion of screening-eligible patients and then compared BE/EAC risk factors between screening-eligible and screening-ineligible patients using the chi-squared or Student t test as appropriate. RESULTS In the Mayo clinic cohort there were 54.9% EAC cases and in the UK cohort there were 38.9% EAC cases that were not identified by ACG or BSG screening criteria, respectively. Among patients who did not meet the screening criteria, lack of heartburn was observed in 86.5% in the Mayo clinic cohort and in 61.4% in the UK cohort. Other risk factors that were lacking included obesity (defined as a body mass index of ≥30 kg/m2) and family history of EAC. Eliminating chronic reflux from the ACG/BSG criteria improved eligibility for screening from 45.1% to 81.3% (P < .001) in the Mayo Clinic cohort and from 61.1% (n = 394) to 81.5% (n = 526; P < .001) in the UK cohort. However, reflux may be difficult to ascertain from the history, and by including proton pump inhibitor use status in addition to the BSG criteria, screening eligibility improved by 10.0% in the UK cohort (n = 459; P < .001). CONCLUSIONS ACG/BSG BE screening guidelines have limited our ability to detect prevalent EAC. An optimized approach to identifying the individuals most suitable for EAC screening needs to be implemented, particularly one that does not rely on chronic reflux symptoms.
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Affiliation(s)
- Tarek Sawas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Shawn A Zamani
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Sarah Killcoyne
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, United Kingdom; European Molecular Biology Laboratory, European Bioinformatics Institute, Hinxton, United Kingdom
| | - Andrew Dullea
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rebecca C Fitzgerald
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Abstract
Oesophageal adenocarcinoma (OAC) develops from columnar metaplasia of the distal oesophagus, Barrett's oesophagus (BO), secondary to chronic gastro-oesophageal reflux disease (GORD). In the present review, the stepwise development of GORD, BO and OAC is presented and the evidence of OAC prevention, including treatment with proton pump inhibitors (PPIs). PPIs are the main treatment of GORD and BO, with some evidence of prevention of OAC in these patients. However, as about 40% of OAC patient do not report a history of GORD and fewer than 15% of OAC cases are detected in individuals during BO surveillance, prevention of OAC is limited by PPI use in GORD and BO patients.
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Affiliation(s)
- Eivind Ness-Jensen
- HUNT Research Centre, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Levanger, Norway.,Department of Medicine, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway.,Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Prognostic, Diagnostic and Predictive Biomarkers in the Barrett’s Oesophagus-Adenocarcinoma Disease Sequence. Cancers (Basel) 2022; 14:cancers14143427. [PMID: 35884487 PMCID: PMC9315596 DOI: 10.3390/cancers14143427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/16/2022] [Accepted: 07/12/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Oesophageal adenocarcinoma (OAC) is a type of cancer of the oesophagus (food pipe) which is associated with poor patient outcomes. Barrett’s oesophagus (BO) is a precancerous condition of the oesophagus associated with chronic heartburn. Currently, surveillance programs exist which monitor patients with BO to prevent it from developing into OAC. However, these surveillance programs are expensive and unpleasant for patients. Prognostic biomarkers are signs which could be measured to determine the chance of someone with BO developing OAC, allowing more targeted surveillance. Similarly, diagnostic biomarkers are indicators which could be measured to see if someone has OAC. Developing new diagnostic biomarkers could allow wider population testing. Only a small proportion of patients with OAC respond to treatment before surgery. Predictive biomarkers could be measured to predict whether someone would respond to the treatments, allowing more individualized therapy. This review focuses on potential biomarkers which could improve patient outcomes in BO/OAC. Abstract Oesophageal adenocarcinoma (OAC) incidence has increased dramatically in the developed world, yet outcomes remain poor. Extensive endoscopic surveillance programs among patients with Barrett’s oesophagus (BO), the precursor lesion to OAC, have aimed to both prevent the development of OAC via radiofrequency ablation (RFA) and allow earlier detection of disease. However, given the low annual progression rate and the costs of endoscopy/RFA, improvement is needed. Prognostic biomarkers to stratify BO patients based on their likelihood to progress would enable a more targeted approach to surveillance and RFA of high-risk precursor lesions, improving the cost–risk–benefit ratio. Similarly, diagnostic biomarkers for OAC could enable earlier diagnosis of disease by allowing broader population screening. Current standard treatment for locally advanced OAC includes neoadjuvant chemotherapy (+/− radiotherapy) despite only a minority of patients benefiting from neoadjuvant treatment. Accordingly, biomarkers predictive of response to neoadjuvant therapy could improve patient outcomes by reducing time to surgery and unnecessary toxicity for the patients who would have received no benefit from the therapy. In this mini-review, we will discuss the emerging biomarkers which promise to dramatically improve patient outcomes along the BO-OAC disease sequence.
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Sawas T, Majzoub AM, Haddad J, Tielleman T, Nayfeh T, Yadlapati R, Singh S, Kolb J, Vajravelu RK, Katzka DA, Wani S. Magnitude and Time-Trend Analysis of Postendoscopy Esophageal Adenocarcinoma: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2022; 20:e31-e50. [PMID: 33901662 PMCID: PMC9799241 DOI: 10.1016/j.cgh.2021.04.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Identification of postendoscopy esophageal adenocarcinoma (PEEC) among Barrett's esophagus (BE) patients presents an opportunity to improve survival of esophageal adenocarcinoma (EAC). We aimed to estimate the proportion of PEEC within the first year after BE diagnosis. METHODS Multiple databases (Medline, Embase, Scopus, and Cochrane databases) were searched until September 2020 for original studies with at least 1-year follow-up evaluation that reported EAC and/or high-grade dysplasia (HGD) in the first year after index endoscopy in nondysplastic BE, low-grade dysplasia, or indefinite dysplasia. The proportions of PEEC defined using EAC alone and EAC+HGD were calculated by dividing EAC or EAC+HGD in the first year over the total number of EAC or EAC+HGD, respectively. RESULTS We included 52 studies with 145,726 patients and a median follow-up period of 4.8 years. The proportion of PEEC (EAC) was 21% (95% CI, 13-31) and PEEC (EAC+HGD) was 26% (95% CI, 19-34). Among studies with nondysplastic BE only, the PEEC (EAC) proportion was 17% (95% CI, 11-23) and PEEC (EAC+HGD) was 14% (95% CI, 8-19). Among studies with 5 or more years of follow-up evaluation, the PEEC (EAC) proportion was 10% and PEEC (EAC+HGD) was 19%. Meta-regression analysis showed a strong inverse relationship between PEEC and incident EAC (P < .001). The PEEC (EAC) proportion increased from 5% in studies published before 2000 to 30% after 2015. Substantial heterogeneity was observed for most analyses. CONCLUSIONS PEEC accounts for a high proportion of HGD/EACs and is proportional to reduction in incident EAC. Using best endoscopic techniques now and performing future research on improving neoplasia detection through implementation of quality measures and educational tools is needed to reduce PEEC.
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Affiliation(s)
- Tarek Sawas
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - James Haddad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Thomas Tielleman
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Tarek Nayfeh
- Evidence Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, California
| | - Siddharth Singh
- Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, California
| | - Jennifer Kolb
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California
| | - Ravy K. Vajravelu
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David A. Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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7
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Esophageal abnormalities and the risk for gastroesophageal cancers-a histopathology-register-based study in Sweden. Eur J Epidemiol 2022; 37:401-411. [PMID: 34978667 PMCID: PMC9187549 DOI: 10.1007/s10654-021-00833-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/13/2021] [Indexed: 02/07/2023]
Abstract
Background The poor survival of patients with gastroesophageal cancers may improve if additional esophageal precursor lesions to Barrett’s esophagus and squamous dysplasia are identified. We estimated the risk for gastroesophageal cancers among patients with various histopathological abnormalities in the esophagus, including Barrett’s esophagus, subdivided by histopathological types. Methods Histopathology data from esophageal biopsies obtained 1979–2014 were linked with several national population-based registers in Sweden. Patients were followed from 2 years after the first biopsy date until cancer, death, emigration, esophagectomy/gastrectomy or end of follow-up, 31st of December 2016, whichever came first. We estimated standardized incidence ratios (SIRs) as measures of relative risk with the Swedish general population as reference. Results In total 367 esophageal adenocarcinoma (EAC) cases were ascertained during 831,394 person-years of follow-up. The incidence rate (IR) for EAC was 0.1 per 1000 person-years for normal morphology, 0.2–0.5 for inflammatory changes, and 0.8–2.9 for metaplasia. The IR was 1.0 per 1000 person-years (95% confidence interval 0.7–1.3) among patients with non-dysplastic intestinal metaplasia, 0.9 (0.8–1.1) in non-dysplastic gastric/glandular metaplasia and 2.9 (2.0–4.2) among columnar metaplasia patients with low-grade dysplasia. The SIRs were 11.7 (95% confidence interval 8.6–15.5), 12.0 (10.0–14.2) and 30.2 (20.5–42.8), respectively. The SIRs for gastric cardia adenocarcinoma (GCA) were moderately elevated. Conclusions For the first time, we demonstrate that patients with esophageal inflammatory and other metaplastic abnormalities than Barrett’s esophagus have an increased risk of EAC and GCA compared to the general population. Moreover, patients with different histopathologic subtypes of Barrett’s esophagus have a comparable risk for EAC. Supplementary Information The online version contains supplementary material available at 10.1007/s10654-021-00833-6.
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Risk Factor Profiles Can Distinguish Esophageal Adenocarcinoma From Barrett's Esophagus. Am J Gastroenterol 2021; 116:198-201. [PMID: 33065588 DOI: 10.14309/ajg.0000000000001001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/16/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION It is assumed that screening risk factors for Barrett's esophagus (BE) and prevalent esophageal adenocarcinoma (EAC) are the same. METHODS A matched case-control study comparing risk factors between EAC and BE was performed. RESULTS In 1,356 patients (678 with EAC and 678 with BE), heartburn (52.7%), diabetes, hyperlipidemia, hypertension, nonalcoholic steatohepatitis, and metabolic syndrome were less common in EAC (52.7, 29.2, 45.7, 48.2, 12, and 28.5%, resp.) compared with BE (84.5, 37.6, 82.2, 64.6, 18.4, and 44.1%, P < 0.01). Mean alanine aminotransferase and HgA1c levels were also significantly lower in EAC compared with BE. DISCUSSION Optimal strategies for screening for prevalent EAC may be different than that for BE.
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9
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Chang C, Worrell SG. Viruses and esophageal cancer. Dis Esophagus 2020; 33:5847897. [PMID: 32462190 DOI: 10.1093/dote/doaa036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/14/2020] [Accepted: 04/18/2020] [Indexed: 12/11/2022]
Abstract
Esophageal adenocarcinoma (EAC) has had the fastest increasing incidence of any solid tumor in the United States in the last 30 years. Long standing gastroesophageal reflux disease is a well-established risk factor with strong associations with obesity, alcohol and tobacco. However, there are likely additional contributing factors. Viruses such as human papillomavirus, ebstein-barr virus and herpes simplex virus have been implicated in the pathogenesis of esophageal cancer. This review will discuss the known literature linking viruses to esophageal adenocarcinoma and consider future relationships such as identifying prognostic and predictive molecular biomarkers to guide therapies.
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Affiliation(s)
- Carolyn Chang
- Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Case Western Reserve School of Medicine, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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RISK OF ADENOCARCINOMA IN BARRETT'S ESOPHAGUS. WORLD OF MEDICINE AND BIOLOGY 2020. [DOI: 10.26724/2079-8334-2020-1-71-120-124] [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]
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Abstract
PURPOSE OF REVIEW Barrett's esophagus is the premalignant condition for esophageal cancer and the diagnosis of esophageal adenocarcinoma on index endoscopy is increasing. Many advanced endoscopic techniques are available and aim to identify Barrett's esophagus-associated neoplasia earlier, thereby preventing progression into malignancy. RECENT FINDINGS It is well established adherence to Seattle protocol increases dysplasia detection but leaves large portions of mucosa unsampled. Recent attention has been given to wide-area transepithelial sampling as an additional means of biopsy and shows increased dysplasia detection rates. Many endoscopic techniques aim to increase the success of diagnosis of Barrett's esophagus-associated neoplasia, including probe confocal endomicroscopy, volumetric laser endomicroscopy, and virtual chromoendoscopy. Interestingly, volumetric laser endomicroscopy may also be useful in delineating margins during endoscopic mucosal resection, leading to both diagnostic and therapeutic applications. SUMMARY Advanced endoscopic techniques are available to increase detection of Barrett's esophagus-associated neoplasia; however, these remain localized to academic centers of excellence. With recent advancements in both sampling techniques and the potential application of imaging to therapeutics, these techniques are becoming more accessible to community endoscopists.
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12
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Holmberg D, Ness-Jensen E, Mattsson F, Lagergren J. Adherence to clinical guidelines for Barrett's esophagus. Scand J Gastroenterol 2019; 54:945-952. [PMID: 31314608 DOI: 10.1080/00365521.2019.1641740] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background and aim: Clinical guidelines recommend endoscopy surveillance at given intervals or endoscopic therapy for Barrett's esophagus with low-grade dysplasia (LGD) and high-grade dysplasia (HGD). Whether these guidelines are followed in clinical practice is unknown and was assessed in this study. Methods: This nationwide Swedish cohort study included patients with Barrett's esophagus with histologically verified LGD or HGD from 50 centers in 2006-2013. These patients were followed up using nationwide registers. Adherence to clinical guidelines was explored. Eight potential risk factors for deviation from guidelines were assessed using multivariable logistic regression, providing adjusted odds ratios (OR) with 95% confidence intervals (95%CI). Results: Among 211 patients with Barrett's esophagus (mean age 67.0 years, standard deviation 9.7 years, 81% male), 71% had LGD and 29% had HGD. During median 3.9 years of follow-up, 84% underwent a follow-up endoscopy, 17% received endoscopic therapy and 8% underwent esophagectomy. The clinical management deviated from guidelines in 60% of all patients (69% in LGD and 39% in HGD), which was mainly due to under-surveillance (86%). Risk factors for deviation from guidelines were LGD compared to HGD (OR 3.4, 95%CI 1.7-6.8), longer Barrett's segment length (OR 2.0, 95%CI 1.0-3.9, comparing ≥3 cm with <3 cm), and treatment at gastroenterology compared to surgery departments (OR 2.3, 95%CI 1.2-4.4). Age, sex, calendar period and university hospital status were not associated with deviation from surveillance guidelines. Conclusions: Adherence to guidelines for dysplastic Barrett's esophagus is poor, particularly for LGD. Efforts to implement clinical guideline recommendations are needed.
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Affiliation(s)
- Dag Holmberg
- Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
| | - Eivind Ness-Jensen
- Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden.,Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology , Levanger , Norway.,Department of Medicine, Levanger Hospital, Nord-Trøndelag Hospital Trust , Levanger , Norway
| | - Fredrik Mattsson
- Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
| | - Jesper Lagergren
- Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden.,School of Cancer and Pharmaceutical Sciences, King's College London , London , UK
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Sawas T, Killcoyne S, Iyer PG, Wang KK, Smyrk TC, Kisiel JB, Qin Y, Ahlquist DA, Rustgi AK, Costa RJ, Gerstung M, Fitzgerald RC, Katzka DA. Identification of Prognostic Phenotypes of Esophageal Adenocarcinoma in 2 Independent Cohorts. Gastroenterology 2018; 155:1720-1728.e4. [PMID: 30165050 PMCID: PMC6298575 DOI: 10.1053/j.gastro.2018.08.036] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/06/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Most patients with esophageal adenocarcinoma (EAC) present with de novo tumors. Although this could be due to inadequate screening strategies, the precise reason for this observation is not clear. We compared survival of patients with prevalent EAC with and without synchronous Barrett esophagus (BE) with intestinal metaplasia (IM) at the time of EAC diagnosis. METHODS Clinical data were studied using Cox proportional hazards regression to evaluate the effect of synchronous BE-IM on EAC survival independent of age, sex, TNM stage, and tumor location. We analyzed data from a cohort of patients with EAC from the Mayo Clinic (n=411; 203 with BE and IM) and a multicenter cohort from the United Kingdom (n=1417; 638 with BE and IM). RESULTS In the Mayo cohort, BE with IM had a reduced risk of death compared to patients without BE and IM (hazard ratio [HR] 0.44; 95% CI, 0.34-0.57; P<.001). In a multivariable analysis, BE with IM was associated with longer survival independent of patient age or sex, tumor stage or location, and BE length (adjusted HR, 0.66; 95% CI, 0.5-0.88; P=.005). In the United Kingdom cohort, patients BE and IM had a reduced risk of death compared with those without (HR, 0.59; 95% CI, 0.5-0.69; P<.001), with continued significance in multivariable analysis that included patient age and sex and tumor stage and tumor location (adjusted HR, 0.77; 95% CI, 0.64-0.93; P=.006). CONCLUSION Two types of EAC can be characterized based on the presence or absence of BE. These findings could increase our understanding the etiology of EAC, and be used in management and prognosis of patients.
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Affiliation(s)
- Tarek Sawas
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Sarah Killcoyne
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, United Kingdom; European Molecular Biology Laboratory, European Bioinformatics Institute (EMBL-EBI), Hinxton, United Kingdom
| | - Prasad G Iyer
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Thomas C Smyrk
- Division of Pathology, Mayo Clinic, Rochester, Minnesota
| | - John B Kisiel
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yi Qin
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - David A Ahlquist
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Anil K Rustgi
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rui J Costa
- European Molecular Biology Laboratory, European Bioinformatics Institute (EMBL-EBI), Hinxton, United Kingdom
| | - Moritz Gerstung
- European Molecular Biology Laboratory, European Bioinformatics Institute (EMBL-EBI), Hinxton, United Kingdom
| | - Rebecca C Fitzgerald
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, United Kingdom; Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom.
| | - David A Katzka
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Clinical prediction model for tumor progression in Barrett's esophagus. Surg Endosc 2018; 33:2901-2908. [PMID: 30456503 PMCID: PMC6684532 DOI: 10.1007/s00464-018-6590-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 11/13/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Individuals with Barrett's esophagus (BE) are at increased risk of high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC), but the cost-effectiveness of general surveillance of BE is low. This study aimed to identify a risk prediction model for tumor progression in individuals with BE based on age, sex, and risk factors found at upper endoscopy, enabling tailored surveillance. METHODS This nested case-control study originated from a cohort of 8171 adults diagnosed with BE in 2006-2013 in the Swedish Patient Registry. Cases had EAC/HGD (n = 279) as identified from the Swedish Cancer Registry, whereas controls had no EAC/HGD (n = 1089). Findings from endoscopy and histopathology reports were extracted from medical records at 71 Swedish hospitals and from the Swedish Patient Registry. Multivariable logistic regression provided odds ratios (OR) with 95% confidence intervals (CIs). RESULTS Older age (OR 1.02 [95% CI 1.01-1.03] per year), male sex (OR 2.8 [95% CI 1.9-4.1]), and increasing maximum BE length (OR 2.3 [95% CI 1.4-3.9] for segments 3-8 cm and OR 4.3 [95% CI 2.5-7.2] for segments ≥ 8 cm) increased the risk of EAC/HGD, while the circumferential extent of the BE, hiatal hernia or reflux esophagitis did not. A model based on age, sex, and maximum BE length predicted 71% of all EAC/HGD cases. CONCLUSIONS A simple combination of the variables age, sex and maximum BE length showed fairly good accuracy for predicting tumor progression in BE. This clinical risk prediction model may help to tailor future surveillance programs.
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Higher Rate of Barrett's Detection in the First Year After Successful Endoscopic Therapy: Meta-analysis. Am J Gastroenterol 2018; 113:959-971. [PMID: 29899439 DOI: 10.1038/s41395-018-0090-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/19/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic eradication therapy (EET) is highly effective in treating dysplastic Barrett's esophagus (BE). Current surveillance intervals after complete remission of intestinal metaplasia (CRIM) are based on expert opinion. We performed a meta-analysis to compare BE detection in the first year to the subsequent ones METHODS: We searched MEDLINE, EMBASE, Scopus and Cochrane Central Register of Controlled Trials through 1 August 2017 for studies reporting IM and neoplasia detection after CRIM. Pooled incidence rate (IR) of IM detection was calculated for each year after CRIM. We compared IM, dysplasia, and high grade dysplasia (HGD)/esophageal adenocarcinoma (EAC) detection in the first year after CRIM to the years after. RESULTS Twenty two studies were included involving 1973 patients with follow-up of 5176 patient-years. IM detection IR per patient-year in the 1st year was 12% (95% CI: 8-17%), in the 2nd year 7% (95% CI: 4-11%), and in the 3rd year 3% (95% CI: 1-7%). IM detection rate in the first year was significantly higher compared to the years after (relative risk (RR) 1.8 (95% CI: 1.29-2.49)). Dysplasia detection IR in the first year after achieving CRIM was 3% per patient-year (95% CI: 2-5%). Dysplasia detection IR after the first year was 1% (95% CI: 1-2%) and significantly higher in the first year compared to the years after (RR: 1.92 (95% CI: 1.32-2.8). HGD/EAC detection was 1 %/patient-year (95% CI: 0-2%) in the first year after CRIM compared to 0%/patient-year (95% CI: 0-1%) in subsequent years. HGD/EAC IR was higher in the first year (RR: 1.58 (95% CI: 0.94-2.65)). CONCLUSION Neoplasia detection after successful treatment of BE appears more common within the first year of surveillance. This appears to be due to incompletely treated prevalent rather than recurrent disease. More intensive surveillance in the first year following CRIM is warranted.
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van Putten M, Johnston BT, Murray LJ, Gavin AT, McManus DT, Bhat S, Turkington RC, Coleman HG. 'Missed' oesophageal adenocarcinoma and high-grade dysplasia in Barrett's oesophagus patients: A large population-based study. United European Gastroenterol J 2017; 6:519-528. [PMID: 29881607 DOI: 10.1177/2050640617737466] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/17/2017] [Indexed: 01/10/2023] Open
Abstract
Background A systematic review suggests that 25% of oesophageal adenocarcinomas (OAC) are 'missed' at index endoscopy for Barrett's oesophagus (BO); however, this included few population-based studies and may be an overestimate. Objective The objective of this article is to quantify the 'missed' rates of high-grade dysplasia (HGD) and OAC at index BO endoscopy. Methods Patients from the Northern Ireland BO register diagnosed between 1993 and 2010 (n = 13,159) were linked to the Northern Ireland Cancer Registry to identify patients who developed OAC or HGD. Logistic regression analysis compared characteristics of 'missed' vs 'incident' HGD/OAC, defined as diagnoses within 3-12 months vs >1 year after incident BO, respectively. Results A total of 267 patients were diagnosed with HGD/OAC ≥3 months after BO diagnosis, of whom 34 (12.7%) were potentially 'missed'. The proportion of 'missed' HGD/OAC was 25% among BO patients with low-grade dysplasia (LGD) and 9% among non-dysplastic BO patients. Older age and BO-LGD carried a higher risk of 'missed' HGD/OAC. Non-dysplastic BO patients were more often diagnosed with a 'missed' OAC (rather than HGD; 89%), compared with BO-LGD patients (40%). Conclusions Approximately one in 10 HGD/OAC cases are 'missed' at incident BO diagnosis, which is significant but lower than previous reports. However, 'missed' HGD/OAC cases represent only 0.26% of all BO patients.
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Affiliation(s)
- Margreet van Putten
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Eindhoven, the Netherlands
| | - Brian T Johnston
- 2Department of Gastroenterology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Liam J Murray
- 3Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Anna T Gavin
- 3Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland.,4Northern Ireland Cancer Registry, Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Damian T McManus
- 5Department of Pathology, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Shivaram Bhat
- Department of Gastroenterology, Craigavon Area Hospital, Southern Health and Social Care Trust, Belfast, Northern Ireland
| | - Richard C Turkington
- 7Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, Northern Ireland
| | - Helen G Coleman
- 3Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
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