Epidemiology of Barrett's Esophagus and Esophageal Adenocarcinoma

Defining precancer: a grand challenge for the cancer community

The term 'precancer' typically refers to an early stage of neoplastic development that is distinguishable from normal tissue owing to molecular and phenotypic alterations, resulting in abnormal cells that are at least partially self-sustaining and function outside of normal cellular cues that constrain cell proliferation and survival. Although such cells are often histologically distinct from both the corresponding normal and invasive cancer cells of the same tissue origin, defining precancer remains a challenge for both the research and clinical communities. Once sufficient molecular and phenotypic changes have occurred in the precancer, the tissue is identified as a 'cancer' by a histopathologist. While even diagnosing cancer can at times be challenging, the determination of invasive cancer is generally less ambiguous and suggests a high likelihood of and potential for metastatic disease. The 'hallmarks of cancer' set out the fundamental organizing principles of malignant transformation but exactly how many of these hallmarks and in what configuration they define precancer has not been clearly and consistently determined. In this Expert Recommendation, we provide a starting point for a conceptual framework for defining precancer, which is based on molecular, pathological, clinical and epidemiological criteria, with the goal of advancing our understanding of the initial changes that occur and opportunities to intervene at the earliest possible time point.

Regulation of pro-apoptotic and anti-apoptotic factors in obesity-related esophageal adenocarcinoma

BACKGROUND

Obesity is a risk factor for esophageal adenocarcinoma (EAC). It was reported that obesity -associated inflammation correlates with insulin resistance and increased risk of EAC. The objective of the study is to investigate the role of obesity associated inflammatory mediators in the development of EAC.

METHODS

We included 23 obese and nonobese patients with EAC or with or without Barrett's esophagus (BE) after IRB approval. We collected 23 normal, 10 BE, and 19 EAC tissue samples from endoscopy or esophagectomy. The samples were analyzed for the expression levels of pro-apoptotic and anti-apoptotic factors, PKC-δ, cIAP2, FLIP, IGF-1, Akt, NF-kB and Ki67 by immunofluorescence and RT-PCR. We compared the expression levels between normal, BE, and EAC tissue using Students' t-test between two groups.

RESULTS

Our results showed decreased gene and protein expression of pro-apoptotic factors (bad, bak and bax) and increased expression of anti-apoptotic factors (bcl-2, Bcl-xL) in BE and EAC compared to normal tissues. There was increased gene and protein expression of PKC-δ, cIAP2, FLIP, NF-kB, IGF-1, Akt, and Ki67 in BE and EAC samples compared to normal esophagus. Further, an increased folds changes in mRNA expression of proapoptotic factors, antiapoptotic factors, PKC-δ, IGF-1, Akt, and Ki-67 was associated with obesity.

CONCLUSION

Patients with EAC had increased expression of cIAP2 and FLIP, and PKC-δ which is associated with inhibition of apoptosis and possible progression of esophageal adenocarcinoma.

Predicting the potential deterioration of Barrett's esophagus based on gut microbiota: a Mendelian randomization analysis

Esophageal adenocarcinoma (EAC) is one of the most malignant tumors in the digestive system. To make thing worse, the scarcity of treatment options is disheartening. However, if detected early, there is a possibility of reversing the condition. Unfortunately, there is still a lack of relevant early screening methods. Considering that Barrett's esophagus (BE), a precursor lesion of EAC, has been confirmed as the only known precursor of EAC. Analyzing which BE cases will progress to EAC and understanding the processes and mechanisms involved is of great significance for early screening of such patients. Considering the significant alterations in the gut microbiota of patients with BE and its potential role in the progression to EAC, this study aims to analyze the relationship between BE, EAC, and GM to identify potential diagnostic biomarkers and therapeutic targets. This study utilized comprehensive statistical data on gut microbiota from a large-scale genome-wide association meta-analysis conducted by the MiBioGen consortium (n = 18,340). Subsequently, we selected a set of single nucleotide polymorphisms (SNPs) that fell below the genome-wide significance threshold (1 × 10-5) as instrumental variables. To investigate the causal relationship between gut microbiota and BE and EAC, we employed various MR analysis methods, including Inverse Variance Weighting (IVW), MR-Egger regression, weighted median (WM), and weighted mean. Additionally, we assessed the level of pleiotropy, heterogeneity, and stability of genetic variations through MR-Egger intercept test, MR-PRESSO, Cochran's Q test, and "leave-one-out" sensitivity analysis. Furthermore, we conducted reverse MR analysis to identify the causal relationships between gut microbiota and BE and EAC. The results from the Inverse Variance-Weighted (IVW) analysis indicate that Alistipes (P = 4.86 × 10-2), Lactobacillus (P = 2.11 × 10-2), Prevotella 7 (P = 4.28 × 10-2), and RuminococcaceaeUCG004 (P = 4.34 × 10-2) are risk factors for Barrett's esophagus (BE), while Flavonifractor (P = 8.81 × 10-3) and RuminococcaceaeUCG004 (P = 4.99 × 10-2) are risk factors for esophageal adenocarcinoma (EAC). On the other hand, certain gut microbiota genera appear to have a protective effect against both BE and EAC. These include Eubacterium (nodatum group) (P = 4.51 × 10-2), Holdemania (P = 1.22 × 10-2), and Lactococcus (P = 3.39 × 10-2) in the BE cohort, as well as Eubacterium (hallii group) (P = 4.07 × 10-2) and Actinomyces (P = 3.62 × 10-3) in the EAC cohort. According to the results of reverse MR analysis, no significant causal effects of BE and EAC on gut microbiota were observed. Furthermore, no significant heterogeneity or pleiotropy was detected in the instrumental variables. We have established a causal relationship between the gut microbiota and BE and EAC. This study holds profound significance for screening BE patients who may be at risk of deterioration, as it can provide them with timely medical interventions to reverse the condition.

Multifaceted association of overweight and metabolically unhealthy with the risk of Barrett's esophagus in the UK Biobank cohort

The association of overweight/obesity and metabolically unhealthy (MU) with the risk of developing Barrett's esophagus (BE) remains uncertain. We evaluated whether MU and overweight/obesity are associated with increased BE incidence and whether they have a synergistic impact on BE development. We analyzed the body mass index (BMI) and metabolic indicators at baseline of 402,510 individuals from the UK Biobank with no history of BE. Overweight/obesity and MU were defined as BMI ≥ 25.0 kg/m2 and presence of ≥ 1 MU indicators, respectively. Accordingly, the participants were categorized into four groups: (1) metabolically healthy non-overweight/obesity (MHNO), (2) metabolically unhealthy non-overweight/obesity (MUNO), (3) metabolically healthy overweight/obesity (MHO), and (4) metabolically unhealthy overweight/obesity (MUO). During a median follow-up of 13.5 years, 6195 (1.5%) individuals were newly diagnosed with BE. Among them, 39,281 (9.8%), 92,000 (22.9%), 25,297 (6.3%), and 245,932 (61.1%) individuals were classified as MHNO, MUNO, MHO, and MUO, respectively. In Cox regression analyses, both MU and overweight/obesity were independently associated with BE incidence. Moreover, BE incidence was significantly higher in the MUNO, MHO, and MUO groups, compared to the MHNO group. MU and overweight/obesity are independent risk factors for BE and have a synergistic effect on BE development.

Diagnostic yield from symptomatic gastroscopy in the UK: British Society of Gastroenterology analysis using data from the National Endoscopy Database

OBJECTIVE

This national analysis aimed to calculate the diagnostic yield from gastroscopy for common symptoms, guiding improved resource utilisation.

DESIGN

A cross-sectional study was conducted of diagnostic gastroscopies between 1 March 2019 and 29 February 2020 using the UK National Endoscopy Database. Mixed-effect logistic regression models were used, incorporating random (endoscopist) and fixed (symptoms, age and sex) effects on two dependent variables (endoscopic cancer; Barrett's oesophagus (BO) diagnosis). Adjusted positive predictive values (aPPVs) were calculated.

RESULTS

382 370 diagnostic gastroscopies were analysed; 30.4% were performed in patients aged <50 and 57.7% on female patients. The overall unadjusted PPV for cancer was 1.0% (males 1.7%; females 0.6%, p<0.01). Other major pathology was found in 9.1% of procedures, whereas 89.9% reported only normal findings or minor pathology (92.5% in females; 94.6% in patients <50).Highest cancer aPPVs were reached in the over 50s (1.3%), in those with dysphagia (3.0%) or weight loss plus another symptom (1.4%). Cancer aPPVs for all other symptoms were below 1%, and for those under 50, remained below 1% regardless of symptom. Overall, 73.7% of gastroscopies were carried out in patient groups where aPPV cancer was <1%.The overall unadjusted PPV for BO was 4.1% (males 6.1%; females 2.7%, p<0.01). The aPPV for BO for reflux was 5.8% and ranged from 3.2% to 4.0% for other symptoms.

CONCLUSIONS

Cancer yield was highest in elderly male patients, and those over 50 with dysphagia. Three-quarters of all gastroscopies were performed on patients whose cancer risk was <1%, suggesting inefficient resource utilisation.

Regulatory effects of statins on Akt signaling for prevention of cancers

Statins, which are primarily used as lipid-lowering drugs, have been found to exhibit anti-tumor effects through modulating and interfering with various signaling pathways. In observational studies, statin use has been associated with a significant reduction in the progression of various cancers, including colon, lung, prostate, pancreas, and esophagus cancer, as well as melanoma and B and T cell lymphoma. The mevalonate pathway, which is affected by statins, plays a crucial role in activating Rho, Ras, and Rab proteins, thereby impacting the proliferation and apoptosis of tumor cells. Statins block this pathway, leading to the inhibition of isoprenoid units, which are critical for the activation of these key proteins, thereby affecting cancer cell behavior. Additionally, statins affect MAPK and Cdk2, which in turn reduce the expression of p21 and p27 cyclin-dependent kinase inhibitors. Akt signaling plays a crucial role in key cancer cell features like proliferation, invasion, and apoptosis by activating multiple effectors in downstream pathways such as FOXO, PTEN, NF-κB, GSK3β, and mTOR. The PI3K/Akt signaling is necessary for many events in the metastatic pathway and has been implicated in the resistance to cytostatic drugs. The Akt/PTEN axis is currently attracting great interest for its role in carcinogenesis. Statins have been shown to activate the purinergic receptor P2X7 and affect Akt signaling, which may have important anti-cancer effects. Hence, targeting Akt shows promise as an effective approach to cancer prevention and therapy. This review aims to provide a comprehensive discussion on the specific impact of statins through Akt signaling in different types of cancer.

Minimally Invasive Modified McKeown Esophagectomy

McKeown esophagectomy is a transthoracic esophagectomy with a cervical anastomosis that is an established mainstay for the management of benign and malignant esophageal pathology. It has gone through multiple modifications. The most current version utilizes robotic or minimally invasive ports through both the right chest and abdominal portions. There is decreased pain and hospital length of stay compared to the open technique. However, anastomotic leak and recurrent laryngeal nerve injury continue to occur. Advancements in management of complications has decreased mortality, making this surgical approach a relevant option for esophageal pathologies.

Predictors for lymph node metastasis and survival of patients with T1b esophageal adenocarcinoma treated with surgery and endoscopic therapy: an analysis of the Surveillance, Epidemiology, and End Results database

BACKGROUND AND AIMS

Limited data exist regarding the long-term outcomes of endoscopic therapy (ET) with or without chemoradiation therapy (CRT) for T1b esophageal adenocarcinoma (EAC). Our aim was to identify the risk factors for lymph node metastasis (LNM) in T1b EAC and assess how the chosen treatment modality affects overall survival (OS) and cancer-specific survival (CSS).

METHODS

We analyzed patients with histologically confirmed T1b EAC diagnosed between 2004 and 2018 using the Surveillance, Epidemiology, and End Results database. Focusing on T1bN0M0 staging, the patients were divided into 2 groups (ET [n = 174] and surgery [n = 769]), and OS and CSS rates were calculated.

RESULTS

Of 1418 patients with T1b EAC, 228 cases (16.1%) exhibited LNM at diagnosis. Notable risk factors for LNM included poorly differentiated tumor and lesion size ≥20 mm. For T1bN0M0 cases, ET was commonly performed from 2009 to 2018 (odds ratio [OR], 4.3), especially for patients aged ≥65 years (OR, 3.1) with tumor size <20 mm (OR, 2.3). During the median 50 months of follow-up, age ≥65 years (hazard ratio [HR], 1.9), ET (HR, 1.5), and CRT (HR, 1.4) were associated with poorer OS. Factors linked to decreased CSS were age ≥65 years (subhazard ratio [SHR], 1.6), poorly differentiated tumors (SHR, 1.5), and CRT (SHR, 1.5).

CONCLUSIONS

In T1b EAC, tumor size ≥20 mm and poor differentiation are notable risk factors for LNM. ET exhibited comparable CSS outcomes to surgery for carefully selected T1bN0M0 lesions. CRT did not provide additional survival benefit for these lesions; however, large-scale studies are required to validate this finding.

Comparison of interventions for Barrett's esophagus: A network meta-analysis

BACKGROUND AND OBJECTIVE

Barrett's esophagus (BE) is a precancerous condition that has the potential to develop into esophageal cancer (EC). Currently, there is a wide range of management options available for individuals at different pathological stages in Barrett's esophagus (BE). However, there is currently a lack of knowledge regarding their comparative efficacy. To address this gap, we conducted a network meta-analysis of published randomized controlled trials to examine the comparative effectiveness of all regimens.

METHODS

Data extracted from eligible randomized controlled trials were utilized in a Bayesian network meta-analysis to examine the relative effectiveness of BE's treatment regimens and determine their ranking in terms of efficacy. The ranking probability for each regimen was assessed using the surfaces under cumulative ranking values. The outcomes under investigation were complete ablation of BE, neoplastic progression of BE, and complete eradication of dysplasia.

RESULTS

We identified twenty-three RCT studies with a total of 1675 participants, and ten different interventions. Regarding complete ablation of non-dysplastic BE, the comparative effectiveness ranking indicated that argon plasma coagulation (APC) was the most effective regimen, with the highest SUCRA value, while surveillance and PPI/H2RA were found to be the least efficacious regimens. For complete ablation of BE with low-grade dysplasia, high-grade dysplasia, or esophageal cancer, photodynamic therapy (PDT) had the highest SUCRA value of 94.1%, indicating it as the best regimen. Additionally, for complete eradication of dysplasia, SUCRA plots showed a trend in ranking PDT as the highest with a SUCRA value of 91.2%. Finally, for neoplastic progression, radiofrequency ablation (RFA) and surgery were found to perform significantly better than surveillance. The risk of bias assessment revealed that 6 studies had an overall high risk of bias. However, meta-regression with risk of bias as a covariate did not indicate any influence on the model. In terms of the Confidence in Network Meta-Analysis evaluation, a high level of confidence was found for all treatment comparisons.

CONCLUSION

Endoscopic surveillance alone or PPI/H2RA alone may not be sufficient for managing BE, even in cases of non-dysplastic BE. However, APC has shown excellent efficacy in treating non-dysplastic BE. For cases of BE with low-grade dysplasia, high-grade dysplasia, or esophageal cancer, PDT may be the optimal intervention as it can induce regression of BE metaplasia and prevent future progression of BE to dysplasia and EC.

Causal analysis of gastroesophageal reflux disease and esophageal cancer

Patients with gastroesophageal reflux disease (GERD) are more likely to develop esophageal cancer (EC). However, a causal relationship between the 2 has been difficult to determine. Therefore, this study aimed to evaluate the impact of GERD on EC using the Mendelian randomization (MR) method. The causal association between GERD and EC was analyzed based on 2 publicly available genetic summary datasets for the GERD cohort (129,080 cases vs 473,524 controls) and the EC cohort (740 cases vs 372,016 controls). The causal inference was mainly evaluated by the inverse variance weighted MR. The MR-Egger regression, MR Pleiotropy Residual Sum and Outlier test, and leave-one-out test were used to confirm the sensitivity of the MR results. Possible interfering factors were excluded by multivariate MR (MVMR) analysis. We used 73 single nucleotide polymorphisms as instrumental variables. GERD was associated with increasing EC risk (odds ratio [OR], 1.001; 95% confidence interval, 1.001-1.002; P < .001), which was identified using the inverse variance weighted method. The sensitivity analysis also demonstrated similar results with the causal explanation, and major bias in genetic pleiotropy was not identified (intercept, 0.001; standard error, 0.001; P = .418). The multivariate MR analysis demonstrated the effect of GERD on EC even after excluding possible mediating factors (OR, 1.003; 95% confidence interval, 1.001-1.005; P = .012). This study confirmed that GERD has a causal effect on EC. Therefore, interventional measures are recommended to prevent EC.

Prebiotic proanthocyanidins inhibit bile reflux-induced esophageal adenocarcinoma through reshaping the gut microbiome and esophageal metabolome

The gut and local esophageal microbiome progressively shift from healthy commensal bacteria to inflammation-linked pathogenic bacteria in patients with gastroesophageal reflux disease, Barrett's esophagus, and esophageal adenocarcinoma (EAC). However, mechanisms by which microbial communities and metabolites contribute to reflux-driven EAC remain incompletely understood and challenging to target. Herein, we utilized a rat reflux-induced EAC model to investigate targeting the gut microbiome-esophageal metabolome axis with cranberry proanthocyanidins (C-PAC) to inhibit EAC progression. Sprague-Dawley rats, with or without reflux induction, received water or C-PAC ad libitum (700 μg/rat/day) for 25 or 40 weeks. C-PAC exerted prebiotic activity abrogating reflux-induced dysbiosis and mitigating bile acid metabolism and transport, culminating in significant inhibition of EAC through TLR/NF-κB/TP53 signaling cascades. At the species level, C-PAC mitigated reflux-induced pathogenic bacteria (Streptococcus parasanguinis, Escherichia coli, and Proteus mirabilis). C-PAC specifically reversed reflux-induced bacterial, inflammatory, and immune-implicated proteins and genes, including Ccl4, Cd14, Crp, Cxcl1, Il6, Il1b, Lbp, Lcn2, Myd88, Nfkb1, Tlr2, and Tlr4, aligning with changes in human EAC progression, as confirmed through public databases. C-PAC is a safe, promising dietary constituent that may be utilized alone or potentially as an adjuvant to current therapies to prevent EAC progression through ameliorating reflux-induced dysbiosis, inflammation, and cellular damage.

Adherence to prescription proton pump inhibitor therapy amongst individuals diagnosed with Barrett's esophagus

INTRODUCTION

In the United States, clinical guidelines recommend daily use of proton pump inhibitors (PPIs) amongst individuals diagnosed with Barrett's esophagus to decrease the risk of progression to dysplasia and neoplasia. Prior studies documenting adherence to PPIs in this population have not characterized heterogeneity in adherence patterns. Factors that may relate to adherence are incompletely described.

METHODS

We used administrative claims data from the Merative MarketScan Commercial Claims and Encounters database to conduct a retrospective study of adherence to prescription PPIs. A cohort of individuals diagnosed with incident Barrett's esophagus between 2010 and 2019 was identified. Group-based trajectory models were generated to detect longitudinal adherence subgroups.

RESULTS

79 701 individuals with a new diagnosis of Barrett's esophagus were identified. The best fitting model detected five distinct adherence trajectory groups: consistently high (44% of the population), moderate decline (18%), slow decline (12%), rapid decline (10%), and decline-then-increase (16%). Compared to individuals starting PPIs, those already using PPIs were less likely to have a declining adherence pattern. Other factors associated with membership in a declining adherence group included (but were not limited to): female sex, having a past diagnosis of anxiety or depression, and having one or more emergency department visits in the past year.

DISCUSSION

Using an exploratory method, we detected heterogeneity in adherence to prescription PPIs. Less than half of individuals were classified into the consistently high adherence group, suggesting that many individuals with Barrett's esophagus receive inadequate pharmacologic therapy.

Inappropriate Use of Proton Pump Inhibitor Among Elderly Patients in British Columbia: What are the Long-term Adverse Events?

BACKGROUND

Proton pump inhibitors (PPIs) are one of the most used classes of drugs. For most indications, PPIs are only recommended up to 8 weeks duration. However, PPI use continues to expand. Regular and prolonged use of PPIs should be avoided because of the risk of adverse events.

OBJECTIVES

The main objective of this study was to (1) investigate the extent of PPI usage in people aged 65 or older in the province of British Columbia (BC), Canada, (2) provide an overview of the harms associated with the long-term use of PPIs.

METHODS

We examined utilization trends of the PPIs in BC since the year 2009 using PharmaNet, BC's medication dispensing database where the information is accessible to community pharmacists. We performed a comprehensive literature search for relevant reviews reporting harms associated with long-term use of PPIs. A search was conducted from January 2014 to June 2022.

RESULTS

Between 2000 and 2018 BC's population grew by 20%, but the use of PPIs escalated to 257%. Of these older British Columbians, 62% had a cumulative exposure exceeding 2 years and 42% exceeded 5 years. This is alarming because the recommended treatment duration is 4-12 weeks for common indications including reflux esophagitis, and duodenal and gastric ulcers. Only 13.5% were dispensed PPIs for 90 days or less. Patients on long-term PPI therapy should be reassessed. Adverse events of PPI use are common among older adults. We identified over 217 systematic reviews published during the last 8 years of specific harms associated with long-term daily usage of PPIs. These harms include increased risks of death, cardiovascular disease, acute renal injury, chronic kidney disease, dementia, fractures, hypomagnesemia, iron deficiency, vitamin B12 deficiency, enteric infection (including C. difficile), pneumonia, and neoplasia (gastric cancer, carcinoids, and colon cancer), and drug interactions.

CONCLUSION

This study revealed a high prevalence of PPI use among elderly populations in BC, Canada. The overutilization of PPIs is often a result of failure to re-evaluate the need for continuation of therapy. Published studies identified signals of serious harm from long-term PPI exposure. Healthcare providers with patients can reverse the relentless expansion of long-term PPI exposure by discussing the expected benefits and potential harms.

Impact of Diabetes on Pathologic Response to Multimodality Therapy for Esophageal Cancer

BACKGROUND

The incidence of esophageal cancer has increased faster than that of most cancers. Evidence from other malignant neoplasms suggests that diabetic patients have a worse response to multimodality therapy. We hypothesized that diabetic patients with esophageal cancer will have a decreased response to neoadjuvant chemotherapy and radiation therapy compared with nondiabetic patients.

METHODS

A retrospective study of The Society of Thoracic Surgeons General Thoracic Surgery Database identified all patients who had an esophagectomy after neoadjuvant therapy for esophageal cancer between 2012 and 2019. Patients were compared on the basis of the presence of diabetes. A pathologic complete response (pCR) was defined as ypT0 N0. The χ2 and Wilcoxon rank sum tests were used to compare patients' demographic and clinical characteristics between those with and those without diabetes. Multivariable logistic regression was used to evaluate the predictors of response to neoadjuvant therapy.

RESULTS

Of the 9171 patients who met inclusion criteria, 2011 (22%) patients were diabetic and 7160 (78%) patients were nondiabetic. Patients with diabetes were older, more likely to be male, and more likely to have all comorbidities. Univariate analysis revealed that diabetic patients were less likely to have pCR (16% vs 18%; P = .026). Although multivariable analysis showed a trend toward diabetic patients' having lower odds of achieving pCR, diabetes was not independently associated with pCR (odds ratio, 0.89; 95% CI, 0.78-1.01; P = .075).

CONCLUSIONS

Diabetic patients may be less likely than nondiabetic patients to achieve pCR after neoadjuvant treatment of esophageal cancer. This suggests the need for further exploration as diabetic patients with esophageal cancer can potentially benefit from different treatment paradigms compared with their nondiabetic counterparts.

Cranberry Proanthocyanidins Mitigate Reflux-Induced Transporter Dysregulation in an Esophageal Adenocarcinoma Model

We recently reported that cranberry proanthocyanidins (C-PACs) inhibit esophageal adenocarcinoma (EAC) by 83% through reversing reflux-induced bacterial, inflammatory and immune-implicated proteins and genes as well as reducing esophageal bile acids, which drive EAC progression. This study investigated whether C-PACs' mitigation of bile reflux-induced transporter dysregulation mechanistically contributes to EAC prevention. RNA was isolated from water-, C-PAC- and reflux-exposed rat esophagi with and without C-PAC treatment. Differential gene expression was determined by means of RNA sequencing and RT-PCR, followed by protein assessments. The literature, coupled with the publicly available Gene Expression Omnibus dataset GSE26886, was used to assess transporter expression levels in normal and EAC patient biopsies for translational relevance. Significant changes in ATP-binding cassette (ABC) transporters implicated in therapeutic resistance in humans (i.e., Abcb1, Abcb4, Abcc1, Abcc3, Abcc4, Abcc6 and Abcc10) and the transport of drugs, xenobiotics, lipids, and bile were altered in the reflux model with C-PACs' mitigating changes. Additionally, C-PACs restored reflux-induced changes in solute carrier (SLC), aquaporin, proton and cation transporters (i.e., Slc2a1, Slc7a11, Slc9a1, Slco2a1 and Atp6v0c). This research supports the suggestion that transporters merit investigation not only for their roles in metabolism and therapeutic resistance, but as targets for cancer prevention and targeting preventive agents in combination with chemotherapeutics.

Management of Long-Segment Barrett's Esophagus

Background: Gastroesophageal reflux disease is a common gastrointestinal disorder with one of its most feared complications being Barrett's esophagus (BE). Currently, most of the recommendations of BE management are driven by the level of dysplasia. However, the length of BE might also be related to the risk of dysplasia/malignant transformation. We aimed to determine the appropriate management of BE based on its length. Materials and Methods: A systematic literature review was conducted with searches made on PubMed, Embase, and Cochrane databases. Long-segment BE (LSBE) was defined as 3 cm or longer and short-segment BE (SSBE) as under 3 cm. Studies evaluating the behavior and management of SSBE and/or LSBE were included for analysis. Results: LSBE have greater risk of dysplasia or progression to esophageal adenocarcinoma compared to SSBE. Despite this greater risk, LSBE and SSBE are currently managed similarly based on the presence and degree of dysplasia. Endoscopic and ablative techniques may have higher level of success and less complications in SSBE, compared to LSBE. Decreasing time interval between surveillance may be a viable option for managing LSBE. Conclusions: Although many algorithms of monitoring and treatment of BE remain the same regardless of segment length, current evidence suggests that more aggressive management for LSBE might be needed due to its higher risk of malignant progression.

Long-Term Postsurgical Outcomes of Neoadjuvant Chemoradiation (CROSS) Versus Chemotherapy (FLOT) for Multimodal Treatment of Adenocarcinoma of the Esophagus and the Esophagogastric Junction

BACKGROUND

The question of the ideal neoadjuvant therapy for locally advanced esophagogastric adenocarcinoma has not been answered to date. Multimodal treatment has become a standard treatment for these adenocarcinomas. Currently, perioperative chemotherapy (FLOT) or neoadjuvant chemoradiation (CROSS) is recommended.

METHODS

A monocentric retrospective analysis compared long-term survival after CROSS versus FLOT. The study enrolled patients with adenocarcinoma of the esophagus (EAC) or the esophagogastric junction type I or II undergoing oncologic Ivor-Lewis esophagectomy between January 2012 and December 2019. The primary objective was to determine the long-term outcome in terms of overall survival. The secondary objectives were to determine differences regarding the histopathologic categories after neoadjuvant treatment and the histomorphologic regression.

RESULTS

The findings showed no survival advantage for one or the other treatment in this highly standardized cohort. All the patients underwent open (CROSS: 9.4% vs. FLOT: 22%), hybrid (CROSS: 82% vs. FLOT: 72%), or minimally invasive (CROSS: 8.9% vs. FLOT: 5.6%) thoracoabdominal esophagectomy. The median post-surgical follow-up period was 57.6 months (95% confidence interval [CI] 23.2-109.7 months), and the median survival was longer for the CROSS patients (54 months) than for the FLOT patients (37.2 months) (p = 0.053). The overall 5-years survival was 47% for the entire cohort (48% for the CROSS and 43% for the FLOT patients). The CROSS patients showed a better pathologic response and fewer advanced tumor stages.

CONCLUSION

The improved pathologic response after CROSS cannot be translated into longer overall survival. To date, the choice of which neoadjuvant treatment to use can be made only on the basis of clinical parameters and the patient's performance status.

The International Network on Oesophageal Atresia (INoEA) consensus guidelines on the transition of patients with oesophageal atresia-tracheoesophageal fistula

Oesophageal atresia-tracheoesophageal fistula (EA-TEF) is a common congenital digestive disease. Patients with EA-TEF face gastrointestinal, surgical, respiratory, otolaryngological, nutritional, psychological and quality of life issues in childhood, adolescence and adulthood. Although consensus guidelines exist for the management of gastrointestinal, nutritional, surgical and respiratory problems in childhood, a systematic approach to the care of these patients in adolescence, during transition to adulthood and in adulthood is currently lacking. The Transition Working Group of the International Network on Oesophageal Atresia (INoEA) was charged with the task of developing uniform evidence-based guidelines for the management of complications through the transition from adolescence into adulthood. Forty-two questions addressing the diagnosis, treatment and prognosis of gastrointestinal, surgical, respiratory, otolaryngological, nutritional, psychological and quality of life complications that patients with EA-TEF face during adolescence and after the transition to adulthood were formulated. A systematic literature search was performed based on which recommendations were made. All recommendations were discussed and finalized during consensus meetings, and the group members voted on each recommendation. Expert opinion was used when no randomized controlled trials were available to support the recommendation. The list of the 42 statements, all based on expert opinion, was voted on and agreed upon.

Anti-reflux surgery vs. bariatric surgery as anti-GERD and hiatal hernia treatment in obese patient. New surgical proposals

The persistence of obesity favors the failure of the Fundoplication (FP) in the treatment of Gastroesophageal Reflux (GER). However, the weight loss obtained with the performance of a Gastric Bypass (GBP) allows a good resolution of symptoms, without increasing the incidence of postoperative complications. All of this leads us to consider that while FP is the indication in patients with BMI < 30, in those patients with BMI > 35, GBP appears to be the procedure of choice. But there is still no position in the case of patients with a BMI between 30 and 35, although we must take into account that an increase in GER recurrence has been described after FP in patients with a BMI > 30. Although Sleeve Gastrectomy (SG) is one of the most frequently used bariatric procedures in recent years, its association with a high rate of postoperative GER has led several authors to propose its performance associated with an anti-reflux procedure in patients with GER symptoms. Likewise, if the existence of an Hiatal Hernia is verified, it must be treated by hiatoplasty, both during the performance of a GBP and a SG. This simultaneous treatment is not associated with an increase in complications.

Reflux and Barrett's esophagus after sleeve gastrectomy: analysis of a statewide database

BACKGROUND

Recent studies have suggested that sleeve gastrectomy (SG) is associated with the development of Barrett esophagus (BE) even in the absence of gastroesophageal reflux disease (GERD) symptoms.

OBJECTIVE

The aim of this study was to assess the rates of upper endoscopy and incidence of new BE diagnoses in patients undergoing SG.

SETTING

This was a claims-data study of patients who underwent SG between 2012 and 2017 while enrolled in a U.S. statewide database.

METHODS

Diagnostic claims data were used to identify pre- and postoperative rates of upper endoscopy, GERD, reflux esophagitis, and BE. Time-to-event analysis using a Kaplan-Meier approach was performed to estimate the cumulative postoperative incidence of these conditions.

RESULTS

We identified 5562 patients who underwent SG between 2012 and 2017. Of these, 1972 patients (35.5%) had at least 1 diagnostic record of upper endoscopy. The preoperative incidences of a diagnosis of GERD, esophagitis, and BE were 54.9%, 14.6%, and .9%, respectively. The predicted postoperative incidences of GERD, esophagitis, and BE, respectively, were 18%, 25.4%, and 1.6% at 2 years and 32.1%, 85.0%, and 6.4% at 5 years.

CONCLUSIONS

In this large statewide database, rates of esophagogastroduodenoscopy remained low after SG, but the incidence of a new postoperative esophagitis or BE diagnosis in patients who underwent esophagogastroduodenoscopy was higher than in the general population. Patients undergoing SG may have a disproportionately high risk of developing reflux complications including BE after surgery.

Prebiotic proanthocyanidins inhibit bile reflux-induced esophageal adenocarcinoma through reshaping the gut microbiome and esophageal metabolome

The gut and local esophageal microbiome progressively shift from healthy commensal bacteria to inflammatory-linked pathogenic bacteria in patients with gastroesophageal reflux disease, Barrett's esophagus and esophageal adenocarcinoma (EAC). However, mechanisms by which microbial communities and metabolites contribute to reflux-driven EAC remain incompletely understood and challenging to target. Herein, we utilized a rat reflux-induced EAC model to investigate targeting the gut microbiome-esophageal metabolome axis with cranberry proanthocyanidins (C-PAC) to inhibit EAC progression. Sprague Dawley rats, with or without reflux-induction received water or C-PAC ad libitum (700 µg/rat/day) for 25 or 40 weeks. C-PAC exerted prebiotic activity abrogating reflux-induced dysbiosis, and mitigating bile acid metabolism and transport, culminating in significant inhibition of EAC through TLR/NF-κB/P53 signaling cascades. At the species level, C-PAC mitigated reflux-induced pathogenic bacteria (Clostridium perfringens, Escherichia coli, and Proteus mirabilis). C-PAC specifically reversed reflux-induced bacterial, inflammatory and immune-implicated proteins and genes including Ccl4, Cd14, Crp, Cxcl1, Il6, Il1β, Lbp, Lcn2, Myd88, Nfkb1, Tlr2 and Tlr4 aligning with changes in human EAC progression, as confirmed through public databases. C-PAC is a safe promising dietary constituent that may be utilized alone or potentially as an adjuvant to current therapies to prevent EAC progression through ameliorating reflux-induced dysbiosis, inflammation and cellular damage.

Impact of Residing in Below Median Household Income Districts on Outcomes in Patients with Advanced Barrett's Esophagus

Background

Barrett's esophagus (BE) is a premalignant condition to esophageal adenocarcinoma (EAC). Low socioeconomic (SES) status adversely impacts care and outcomes in patients with EAC, but this has not been evaluated in BE. As the treatment of BE is similarly intensive, we aimed to evaluate the effect of SES on achieving complete eradication of intestinal metaplasia (CE-IM), dysplasia (CE-D) and development of invasive EAC.

Methods

Our study was a retrospective cohort study. Consecutive patients between January 1, 2010, to December 31, 2018, referred for BE-associated high-grade dysplasia or intramucosal adenocarcinoma were included. Pre, intra and post-procedural data were collected. Household income data was collected from the 2016 census based on postal code region. Patients were divided into income groups relative to the 2016 median household income in Ontario. Multivariate regression was performed for outcomes of interest.

Results

Four hundred and fifty-nine patients were included. Rate of CE-IM was similar between income groups. Fifty-five per cent (n = 144/264) versus 65% (n = 48/264) in the below and above-income groups achieved CE-D, respectively, P = 0.02. Eighteen per cent (n = 48/264) versus 11% (n = 22/195) were found to have invasive EAC during their treatment course in below and above-income groups, respectively, P = 0.04. Residing in a below-median-income district was associated with developing invasive EAC (Odds Ratio, [OR] 1.84, 95% confidence interval [CI] 1.01 to 3.35) and failure to achieve CE-D (OR 0.64, 95% CI 0.42 to 0.97).

Conclusions

Residing in low-income districts is associated with worse outcomes in patients with advanced BE. Further research is needed to guide future initiatives to address the potential impact of SES barriers in the optimal care of BE.

Magnetic sphincter augmentation: considerations for use in Barrett's esophagus

Barrett's esophagus (BE) occurs in 5-15% of patients with gastroesophageal reflux disease (GERD). While acid suppressive therapy is a critical component of BE management to minimize the risk of progression to esophageal adenocarcinoma, surgical control of mechanical reflux is sometimes necessary. Magnetic sphincter augmentation (MSA) is an increasingly utilized anti-reflux surgical therapy for GERD. While the use of MSA is listed as a precaution by the United States Food and Drug Administration, there are limited data showing effective BE regression with MSA. MSA offers several advantages in BE including effective reflux control, anti-reflux barrier restoration and reduced hiatal hernia recurrence. However, careful patient selection for MSA is necessary.

Categorizing Risks within Barrett's Esophagus To Guide Surveillance and Interception; Suggesting a New Framework

Barrett's esophagus is a precancerous condition that can progress in a stepwise manner to dysplasia and eventually esophageal adenocarcinoma (EAC). Once diagnosed, patients with Barrett's esophagus are kept on surveillance to detect progression so that timely intervention can occur with endoscopic therapy. Several demographic and clinical risk factors are known to increase progression toward EAC, such as longer Barrett's segments, and these patients are kept on tighter surveillance. While p53 IHC has been advocated as an adjunct to histopathologic diagnosis, use of this biomarker is variable, and no other molecular factors are currently applied. Given the new evidence available, it is time to consider whether other risk factors or tools could be applied in clinical practice to decide on closer or attenuated surveillance. In this commentary, we summarize the most relevant risk factors for Barrett's esophagus progression, highlight the most promising novel risk stratification tools-including nonendoscopic triage and commercial biomarker panels, and propose a new framework suggesting how to incorporate risk stratification into clinical practice.

Improving outcomes in patients with oesophageal cancer

The care of patients with oesophageal cancer or of individuals who have an elevated risk of oesophageal cancer has changed dramatically. The epidemiology of squamous cell and adenocarcinoma of the oesophagus has diverged over the past several decades, with a marked increase in incidence only for oesophageal adenocarcinoma. Only in the past decade, however, have molecular features that distinguish these two forms of the disease been identified. This advance has the potential to improve screening for oesophageal cancers through the development of novel minimally invasive diagnostic technologies predicated on cancer-specific genomic or epigenetic alterations. Surgical techniques have also evolved towards less invasive approaches associated with less morbidity, without compromising oncological outcomes. With improvements in multidisciplinary care, advances in radiotherapy and new tools to detect minimal residual disease, certain patients may no longer even require surgical tumour resection. However, perhaps the most anticipated advance in the treatment of patients with oesophageal cancer is the advent of immune-checkpoint inhibitors, which harness and enhance the host immune response against cancer. In this Review, we discuss all these advances in the management of oesophageal cancer, representing only the beginning of a transformation in our quest to improve patient outcomes.

Real-world upper endoscopy utilization patterns among patients with gastroesophageal reflux disease, Barrett esophagus, and Barrett esophagus-related esophageal neoplasia in the United States

This study fills a gap in literature by providing contemporary real-world evidence on the prevalence of patients with gastroesophageal reflux disease (GERD), Barrett esophagus (BE), and Barrett esophagus-related neoplasia (BERN) and their upper endoscopy utilization patterns in the United States. A retrospective cohort study design was used: adults with GERD, nondysplastic Barrett esophagus (NDBE), and BERN (indefinite for dysplasia [IND], low-grade dysplasia [LGD], high-grade dysplasia [HGD], or esophageal adenocarcinoma [EAC]) were identified from the MarketScan databases (January 01, 2015-December 31, 2019). For each disease stage, prevalence of adults in commercial claims by calendar year, annual number of upper endoscopies per patient and time between upper endoscopies were reported. In 2019, in commercial claims (N = 12,363,227), the annual prevalence rate of GERD was 13.7% and 0.70% for BE/BERN, among which, 87.1% had NDBE, 6.8% had IND, 2.3% had LGD, 1.0% had HGD, and 2.8% had EAC. From 2015-2019, the study included 3,310,385 patients with GERD, 172,481 with NDBE, 11,516 with IND, 4332 with LGD, 1549 with HGD, and 11,676 with EAC. Annual mean number of upper endoscopies was 0.20 per patient for GERD, 0.37 per patient for NDBE, 0.43 for IND, 0.58 for LGD, and 0.87 for HGD. Median time (months) to second upper endoscopy was 38.10 for NDBE, 36.63 for IND, 22.63 for LGD, and 11.90 for HGD. Upper endoscopy utilization increased from GERD to BE to BERN, and time between upper endoscopies decreased as the disease stage progressed from BE to BERN, with less frequent utilization in BERN than what would be expected from guideline recommendations for surveillance.

Sex and smoking differences in the association between gastroesophageal reflux and risk of esophageal squamous cell carcinoma in a high-incidence area: Golestan Cohort Study

Prior studies have conflicting findings regarding the association between gastroesophageal reflux disease (GERD) and esophageal squamous cell carcinoma (ESCC). We examined this relationship in a prospective cohort in a region of high ESCC incidence. Baseline exposure data were collected from 50 045 individuals using in-person interviews at the time of cohort entry. Participants were followed until they developed cancer, died, or were lost to follow up. Participants with GERD symptoms were categorized into any GERD (heartburn or regurgitation), mixed symptoms, or heartburn alone. Multivariable Cox regression was used to assess the relationship between GERD symptom group and histologically confirmed ESCC. The model was adjusted for known risk factors for GERD and ESCC. 49 559 individuals were included in this study, of which 9005 had GERD symptoms. Over 13.0 years of median follow up, 290 individuals were diagnosed with ESCC. We found no association between any GERD and risk of ESCC (aHR 0.90, 95% CI: 0.66-1.24, P = .54). Similar findings were observed for the GERD symptom subtypes. Significant interactions between any GERD and sex (P = .013) as well as tobacco smoking (P = .028) were observed. In post-hoc analyses, GERD was associated with a decreased risk of ESCC in men (aHR 0.51, 95% CI: 0.27-0.98 P = .04) and in smokers (aHR 0.26, 95% CI: 0.08-0.83 P = .02). While there was little evidence for an overall association between GERD symptoms and ESCC risk, significant interactions with sex and smoking were observed. Men and smokers with GERD symptoms had a lower risk of ESCC development.

Healthcare Resource Utilization and Costs Among Patients With Gastroesophageal Reflux Disease, Barrett's Esophagus, and Barrett's Esophagus-Related Neoplasia in the United States

Background: Gastroesophageal reflux disease (GERD) is a risk factor for Barrett's esophagus (BE) and BE-related neoplasia (BERN). Objectives: This study aimed to evaluate healthcare resource utilization (HRU) and costs associated with GERD, BE, and BERN in the United States. Methods: Adult patients with GERD, nondysplastic BE (NDBE), and BERN (including indefinite for dysplasia [IND], low-grade dysplasia [LGD], high-grade dysplasia [HGD] or esophageal adenocarcinoma [EAC]), were identified from a large US administrative claims database, the IBM Truven Health MarketScan® databases (Q1/2015-Q4/2019). Patients were categorized into the corresponding mutually exclusive EAC-risk/diagnosis cohorts based on the most advanced stage from GERD to EAC using diagnosis codes in medical claims. Disease-related HRU and costs (2020 USD) were calculated for each cohort. Results: Patients were categorized into the following EAC-risk/diagnosis cohorts: 3 310 385 into GERD, 172 481 into NDBE, 11 516 into IND, 4332 into LGD, 1549 into HGD, and 11 676 into EAC. Disease-related annual mean number of inpatient admissions, office visits, and emergency department visits by cohort were 0.09, 1.45, and 0.19 for GERD; 0.08, 1.55, and 0.10 for NDBE; 0.10, 1.92, and 0.13 for IND; 0.09, 2.05, and 0.10 for LGD; 0.12, 2.16, and 0.14 for HGD; and 1.43, 6.27, and 0.87 for EAC. Disease-related annual mean total healthcare costs by cohort were $6955 for GERD, $8755 for NDBE, $9675 for IND, $12 241 for LGD, $24 239 for HGD, and $146 319 for EAC. Discussion: Patients with GERD, BE, and BERN had important HRU and costs, including inpatient admissions and office visits. As patients progressed to more advanced stages, there was substantially higher disease-related resource utilization, with associated costs being 16 times higher in patients with EAC than those with NDBE. Conclusions: Findings suggest the need for early identification of high-risk individuals prior to progression to EAC to potentially improve clinical and economic outcomes in this population.

A glimpse into the future of esophageal carcinoma in the United States: predicting the future incidence until 2040 based on the current epidemiological data

Background

Esophageal carcinoma is the sixth most common cause of death worldwide. With the changing paradigm of esophageal carcinoma, we sought to estimate the future burden of esophageal carcinoma by histology, age, sex, and race, which could help plan prevention, control, and treatment strategies for this cancer.

Methods

Surveillance, Epidemiology, and End Results (SEER) 14 registries were utilized to obtain incidence data from 2000 to 2016. We applied age-period-cohort models to estimate future esophageal carcinoma incidence rates and the estimated disease burden by multiplying incidence forecasts by corresponding US Census population projections.

Results

Our forecasting study suggests that the incidence (per 100,000 persons) of esophageal adenocarcinoma for the age group 40-65 years will increase from 2.12 in 2021 to 3.86 in 2040, which corresponds to an 82% increase over the course of 19 years (3.2% per year, 95% CI: -2.3% to 9.1%). In addition, we found a considerable decrease in the incidence of esophageal squamous cell carcinoma in the current age groups 40-65 years (-2.7% per year) and >65 years (-4.6% per year).

Conclusions

Preventive efforts of esophageal adenocarcinoma should primarily target males of age up to 65 years and females of current age 40 to 65 years who will make up the older age group (>65 years) in 2040.

Current management of gastro-oesophageal reflux disease-treatment costs, safety profile, and effectiveness: a narrative review

Background

The purpose of this study was to review the current management of gastro-oesophageal reflux disease (GORD), including treatment costs, safety profile and effectiveness.

Methods

A literature review was performed of randomized-controlled trials, systematic reviews, Cochrane reports and National/Societal guidelines of the medical, endoscopic and surgical management of GORD. Proton pump inhibitor (PPI) prescribing patterns and expenditure were reviewed in different countries, including Australia, Canada, New Zealand, UK and USA.

Results

Proton pump inhibitors (PPIs) are primarily indicated for control of GORD, Helicobacter pylori eradication (combined with antibiotics), preventing NSAID-induced gastrointestinal bleeding and treating peptic ulcer disease. There is widespread overprescribing of PPIs in Western and Eastern nations in terms of indication and duration, with substantial expense for national health providers. Despite a favourable short-term safety profile, there are observational associations of adverse effects with long-term PPIs. These include nutrient malabsorption, enteric infections and cardiovascular events. The prevalence of PPI use makes their long-term safety profile clinically relevant. Cost-benefit, symptom control and quality-of-life outcomes favour laparoscopic fundoplication rather than chronic PPI treatment. Laparoscopic fundoplication in long-term management of PPI-responsive GORD is supported by SAGES, NICE and ACG, and PPI-refractory GORD by AGA and SAGES guidelines. The importance of establishing a definitive diagnosis prior to invasive management is emphasized, especially in PPI-refractory heartburn.

Conclusions

We examined evidence-based guidelines for PPI prescribing and deprescribing in primary care and hospital settings and the need for PPI stewardship and education of health professionals. This narrative review presents the advantages and disadvantages of surgical, endoscopic and medical management of GORD, which may assist in shared decision making and treatment choice in individual patients.This paper was presented (GS020) at the 88th RACS Annual Scientific Conference, 6-10 May, 2019.

Patterns of care amongst older adults diagnosed with locally advanced esophageal cancer: A cohort study

INTRODUCTION

Since the early 2010s, neoadjuvant chemoradiation followed by esophagectomy (trimodal therapy) has been a recommended treatment for patients diagnosed with locally advanced esophageal cancer. However, it may also add treatment-related toxicity, particularly for older adults with significant comorbidity and frailty burdens. We examined contemporary patterns of care in older adults, which have not been well characterized.

MATERIALS AND METHODS

We used the Surveillance Epidemiology and End Results-Medicare database to identify a cohort of US adults aged 66 years and older diagnosed with incident locally advanced esophageal cancer between 2004 and 2017. Calendar year age-standardized percentages of treatment receipt were calculated. Joinpoint regression was used to detect temporal trends in treatment receipt. Descriptive associations between patient factors and treatment were assessed. Trend analyses quantified how the percentage of trimodal and definitive chemoradiation (no surgery) patients receiving cisplatin-based, carboplatin-based, and other chemotherapy regimens evolved over time.

RESULTS

In total, 4332 adults aged ≥66 years with locally advanced esophageal cancer were included. The age-standardized percentage of patients receiving trimodal therapy increased from 16.7% in 2004 to 26.1% in 2017 (annual percent change = 3.5%; 95% confidence interval [CI], 0.7%-6.4%) in adenocarcinomas and from 7.3% in 2004 to 9.1% in 2017 (annual percent change = 0.4%; 95% CI, -4.1%-5.1%) in squamous cell carcinomas. By 2017, definitive chemoradiation became the most frequently used treatment modality for adenocarcinomas (49.8%; 95% CI, 43.5-56.0) and squamous cell carcinomas (59.5%; 95% CI, 50.8-68.2). Patients with higher comorbidity and frailty burdens were less likely to be treated with trimodal therapy. Amongst patients receiving chemoradiation as part of their treatment, a large and swift channeling away from cisplatin and towards carboplatin-based regimens was observed.

DISCUSSION

In practice, definitive chemoradiation is the most commonly received treatment by older adults with locally advanced esophageal cancer. Four out of five older adults do not receive trimodal therapy, some of whom are potentially undertreated.

The utility of a genetic progression risk test for Barrett esophagus

This study sought to characterize the utility of a gene methylation-based biomarker test that has been validated to predict progression towards esophageal adenocarcinoma. Barrett esophagus (BE) is a precursor condition for esophageal adenocarcinoma (EAC) with somewhat variable approaches among gastroenterologists toward managing neoplastic progression risk. Capsulomics has developed a validated multigene DNA methylation-based biomarker assay performed on BE biopsies designed to address this variability by classifying BE patients into progression risk groups. In the current study, a survey was administered to practicing gastroenterologists in order to assess the potential impact of this assay on clinical practice. In this context, 89% (95% Cl: 85.4-92.6%) of surveyed physicians felt strongly that the multigene Barrett Esophagus test helped resolve uncertainties and optimize care of patients with BE by impacting their decisions on surveillance intervals and use of active treatments, such as ablation. The assay significantly impacted surveillance intervals for both high-risk (22.0 no assay vs 12.3 months with assay; P = 1.7E-8) and low-risk (7.9 no assay vs 11.4 months with assay, P = 8.8E-4) stratified case results. Finally, the assay also significantly impacted decisions to pursue active ablation treatments in both high-risk (5% recommending ablation without assay vs 42% with assay; P = 3.7E-11) and low-risk (42% recommending ablation without assay vs 29% with assay; P = .049) stratified case results. Results demonstrated a strong effect of the assay on clinical decision making, even in conjunction with established clinical guidelines.

RISK OF PRENEOPLASTIC LESIONS IN MUCOSAL PROJECTIONS OF DIFFERENT SIZES OF THE COLUMNAR EPITHELIUM IN THE LOWER ESOPHAGUS

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.

Endoscopic Management of Esophageal Cancer

Advances in technology and improved understanding of the pathobiology of esophageal cancer have allowed endoscopy to serve a growing role in the management of this disease. Precursor lesions can be detected using enhanced diagnostic modalities and eradicated with ablation therapy. Furthermore, evolution in endoscopic resection has provided larger specimens for improved diagnostic accuracy and offer potential for cure of early esophageal cancer. In patients with advanced esophageal cancer, endoluminal therapy can improve symptom burden and provide therapeutic options for complications such as leaks, perforations, and fistulas. The purpose of this review article is to highlight the role of endoscopy in the diagnosis, treatment, and palliation of esophageal cancer.

The Use of Confocal Laser Endomicroscopy in Diagnosing Barrett’s Esophagus and Esophageal Adenocarcinoma

Confocal laser endomicroscopy (CLE) is a diagnostic technique that enables real-time microscopic imaging during microscopic examination and evaluation of epithelial structures with 1000-fold magnification. CLE can be used in the diagnosis of various pathologies, in pneumology, and in urology, and it is very widely utilized in gastroenterology, most importantly in the diagnosis of Barrett’s esophagus (BE), esophageal adenocarcinoma (EAC), biliary strictures, and cystic pancreatic lesions. A literature search was made in MEDLINE/PubMed and Google Scholar databases while focusing on diagnostics using CLE of BE and EAC. We then examined randomized and observational studies, systematic reviews, and meta-analyses relating to the utilization of CLE in BE and EAC diagnostics. Here, we discuss whether CLE can be a suitable diagnostic method for surveillance of BE. Even though many studies have proven that CLE increases diagnostic accuracy in detecting neoplastic transformation of BE, CLE is still not used as a standard diagnostic tool in BE surveillance due to a deficiency of scientific evidence. More studies and data are needed if CLE is to find a place as a new technique in BE surveillance.

Outcomes of Radiofrequency Ablation Compared to Liquid Nitrogen Spray Cryotherapy for the Eradication of Dysplasia in Barrett's Esophagus

INTRODUCTION

Current guidelines recommend endoscopic eradication therapy (EET) for Barrett's esophagus (BE) with dysplasia and intramucosal adenocarcinoma using either radiofrequency ablation (RFA) or liquid nitrogen spray cryotherapy (LNSC). The aims of this multicenter study are to compare the rate and number of treatment sessions of RFA vs. LNSC to achieve CE-D and CE-IM and assess outcomes for those who switched therapy.

METHODS

This is a retrospective cohort study of patients with BE undergoing EET. Demographics, baseline variables, endoscopy details, and histology information were abstracted.

RESULTS

One hundred and sixty-two patients were included in this study with 100 patients in the RFA group and 62 patients in the LNSC group. The rate of CE-D and CE-IM did not differ between the RFA group and LNSC group (81% vs. 71.0%, p = 0.14) and (64% vs. 66%, p = 0.78), respectively. The number of sessions to achieve CE-D and CE-IM was higher with LNSC compared to RFA (4.2 vs. 3.2, p = 0.05) and (4.8 vs. 3.5, p = 0.04), respectively. The likelihood of developing recurrent dysplasia was higher among patients who did not achieve CE-IM (12%) compared to those who did achieve CE-IM (4%), p = 0.04. Similar findings were found in those who switched treatment modalities.

DISCUSSION

EET is highly effective in eradication of Barrett's associated dysplasia and neoplasia. Both RFA and LNSC achieved similar rates of CE-D and CE-IM although LNSC required more sessions. Also, achievement of CE-IM was associated with less recurrence rates of dysplasia.

Deciphering the Immune Complexity in Esophageal Adenocarcinoma and Pre-Cancerous Lesions With Sequential Multiplex Immunohistochemistry and Sparse Subspace Clustering Approach

Esophageal adenocarcinoma (EAC) develops from a chronic inflammatory environment across four stages: intestinal metaplasia, known as Barrett's esophagus, low- and high-grade dysplasia, and adenocarcinoma. Although the genomic characteristics of this progression have been well defined via large-scale DNA sequencing, the dynamics of various immune cell subsets and their spatial interactions in their tumor microenvironment remain unclear. Here, we applied a sequential multiplex immunohistochemistry (mIHC) platform with computational image analysis pipelines that allow for the detection of 10 biomarkers in one formalin-fixed paraffin-embedded (FFPE) tissue section. Using this platform and quantitative image analytics, we studied changes in the immune landscape during disease progression based on 40 normal and diseased areas from endoscopic mucosal resection specimens of chemotherapy treatment- naïve patients, including normal esophagus, metaplasia, low- and high-grade dysplasia, and adenocarcinoma. The results revealed a steady increase of FOXP3+ T regulatory cells and a CD163+ myelomonocytic cell subset. In parallel to the manual gating strategy applied for cell phenotyping, we also adopted a sparse subspace clustering (SSC) algorithm allowing the automated cell phenotyping of mIHC-based single-cell data. The algorithm successfully identified comparable cell types, along with significantly enriched FOXP3 T regulatory cells and CD163+ myelomonocytic cells as found in manual gating. In addition, SCC identified a new CSF1R+CD1C+ myeloid lineage, which not only was previously unknown in this disease but also increases with advancing disease stages. This study revealed immune dynamics in EAC progression and highlighted the potential application of a new multiplex imaging platform, combined with computational image analysis on routine clinical FFPE sections, to investigate complex immune populations in tumor ecosystems.

Gender differences in Barrett's esophagus and progression of disease: a systematic review and meta-analysis

It is known that Barrett's esophagus (BE) and esophageal adenocarcinoma occur more commonly in men. What is unknown are the prevalence of BE and rates of neoplastic progression in women. Our aim was to determine the prevalence of Barrett's and its progression to esophageal cancer in women through systematic review and meta-analysis. A comprehensive search was conducted using PubMed, Scopus, and Google Scholar. Studies were included that reported prevalence rates of BE or progression rates to neoplastic disease stratified by gender. Barrett's was defined by updated criteria as salmon-colored mucosa ≥1 cm proximal to the gastroesophageal junction. Pooled rates and odds ratios (ORs) at 95% confidence interval (CI) of the prevalence of BE and its progression to neoplastic disease were calculated. Ten studies with 19,337 patients (50.6% women) reported on prevalence and six studies with 5137 patients (24.3% women) reported on neoplastic progression of disease between genders. The rate of BE in women was 1.29% ([95% CI: 0.76-2.19], I2 = 91%) compared to men at 4.66% ([95% CI: 3.31-6.53], I2 = 89%); OR: 0.33 ([95% CI: 0.27-0.42], I2 = 0%). The rate of annual progression of Barrett's to high-grade dysplasia or adenocarcinoma was 0.62% ([95% CI: 0.22-1.75]) in women compared to 1.54% ([95% CI: 0.83-2.81], I2 = 96%) in men; OR: 0.44 ([95% CI: 0.30-0.65], I2 = 22%). This study demonstrates a 70% lower rate of prevalence and a 60% lower rate of neoplastic progression of Barrett's in women. Future BE guidelines should tailor screening and surveillance practices by gender.

Advanced imaging and artificial intelligence for Barrett's esophagus: What we should and soon will do

Barrett’s esophagus (BE) is a well-established risk factor for esophageal adenocarcinoma. It is recommended that patients have regular endoscopic surveillance, with the ultimate goal of detecting early-stage neoplastic lesions before they can progress to invasive carcinoma. Detection of both dysplasia or early adenocarcinoma permits curative endoscopic treatments, and with this aim, thorough endoscopic assessment is crucial and improves outcomes. The burden of missed neoplasia in BE is still far from being negligible, likely due to inappropriate endoscopic surveillance. Over the last two decades, advanced imaging techniques, moving from traditional dye-spray chromoendoscopy to more practical virtual chromoendoscopy technologies, have been introduced with the aim to enhance neoplasia detection in BE. As witnessed in other fields, artificial intelligence (AI) has revolutionized the field of diagnostic endoscopy and is set to cover a pivotal role in BE as well. The aim of this commentary is to comprehensively summarize present evidence, recent research advances, and future perspectives regarding advanced imaging technology and AI in BE; the combination of computer-aided diagnosis to a widespread adoption of advanced imaging technologies is eagerly awaited. It will also provide a useful step-by-step approach for performing high-quality endoscopy in BE, in order to increase the diagnostic yield of endoscopy in clinical practice.

The Use of miRNAs in Predicting Response to Neoadjuvant Therapy in Oesophageal Cancer

Oesophageal cancer (OC) is the ninth most common cancer worldwide. Patients receive neoadjuvant therapy (NAT) as standard of care, but less than 20% of patients with oesophageal adenocarcinoma (OAC) or a third of oesophageal squamous cell carcinoma (OSCC) patients, obtain a clinically meaningful response. Developing a method of determining a patient's response to NAT before treatment will allow rational treatment decisions to be made, thus improving patient outcome and quality of life. (1) Background: To determine the use and accuracy of microRNAs as biomarkers of response to NAT in patients with OAC or OSCC. (2) Methods: MEDLINE, EMBASE, Web of Science and the Cochrane library were searched to identify studies investigating microRNAs in treatment naïve biopsies to predict response to NAT in OC patients. (3) Results: A panel of 20 microRNAs were identified as predictors of good or poor response to NAT, from 15 studies. Specifically, miR-99b, miR-451 and miR-505 showed the strongest ability to predict response in OAC patients along with miR-193b in OSCC patients. (4) Conclusions: MicroRNAs are valuable biomarkers of response to NAT in OC. Research is needed to understand the effects different types of chemotherapy and chemoradiotherapy have on the predictive value of microRNAs; studies also require greater standardization in how response is defined.

Are we Missing Barrett's Esophagus in Our Busy Endoscopy Practice? Improving Detection

Barrett's esophagus (BE) denotes the replacement of stratified squamous epithelium of esophagus by columnar epithelium. It is associated with a significantly increased risk of esophageal adenocarcinoma and hence patients with BE are advised endoscopic surveillance for early detection of dysplastic and neoplastic lesions. Esophageal cancer is the sixth most common cancer in terms of incidence and mortality in India. Around 15 to 25% of esophageal cancers are adenocarcinoma. BE is likely to be an important precursor of esophageal adenocarcinoma and we may be missing patients with BE in our busy endoscopy practice. The detection of BE may be improved by identifying high-risk groups, performing thorough endoscopic examination, and applying newer imaging techniques. The high-risk group includes patients with chronic gastroesophageal reflux disease, obesity, smoking, etc. During endoscopic examination, a careful assessment of the gastroesophageal junction and identification of important landmarks such as gastroesophageal junction and Z line are essential to detect BE. Management of BE depends on the detection of dysplasia and for this four quadrant mucosal biopsy is recommended every 1 to 2 cm. However, random biopsy samples only a small area of mucosa and advanced technologies for real-time detection of dysplasia and neoplasia may overcome this limitation. In this review, we discuss the current scenario of BE in India and ways to improve the detection of BE including dysplastic lesions.

Evolutionary dynamics in Barrett oesophagus: implications for surveillance, risk stratification and therapy

Cancer development is a dynamic evolutionary process characterized by marked intratumoural heterogeneity at the genetic, epigenetic and phenotypic levels. Barrett oesophagus, the pre-malignant condition to oesophageal adenocarcinoma (EAC), is an exemplary system to longitudinally study the evolution of malignancy. Evidence has emerged of Barrett oesophagus lesions pre-programmed for progression to EAC many years before clinical detection, indicating a considerable window for therapeutic intervention. In this Review, we explore the mechanisms underlying clonal expansion and contraction that establish the Barrett oesophagus clonal mosaicism over time and space and discuss intrinsic genotypic and extrinsic environmental drivers that direct the evolutionary trajectory of Barrett oesophagus towards a malignant phenotype. We propose that understanding and exploiting the evolutionary dynamics of Barrett oesophagus will identify novel therapeutic targets, improve prognostic tools and offer the opportunity for personalized surveillance programmes geared to prevent progression to EAC.

CXCR4 peptide-based fluorescence endoscopy in a mouse model of Barrett's esophagus

Background

Near-infrared (NIR) fluorescence imaging has been emerging as a promising strategy to overcome the high number of early esophageal adenocarcinomas missed by white light endoscopy and random biopsy collection. We performed a preclinical assessment of fluorescence imaging and endoscopy using a novel CXCR4-targeted fluorescent peptide ligand in the L2-IL1B mouse model of Barrett’s esophagus.

Methods

Six L2-IL1B mice with advanced stage of disease (12–16 months old) were injected with the CXCR4-targeted, Sulfo-Cy5-labeled peptide (MK007), and ex vivo wide-field imaging of the whole stomach was performed 4 h after injection. Before ex vivo imaging, fluorescence endoscopy was performed in three L2-IL1B mice (12–14 months old)  by a novel imaging system with two L2-IL1B mice used as negative controls.

Results

Ex vivo imaging and endoscopy in L2-IL1B mice showed that the CXCR4-targeted MK007 accumulated mostly in the dysplastic lesions with a mean target-to-background ratio > 2. The detection of the Sulfo-Cy5 signal in dysplastic lesions and its co-localization with CXCR4 stained cells  by confocal microscopy further confirmed the imaging results.

Conclusions

This preliminary preclinical study shows that CXCR4-targeted fluorescence endoscopy using MK007 can detect dysplastic lesions in a mouse model of Barrett’s esophagus. Further investigations are needed to assess its use in the clinical setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13550-021-00875-7.

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.

Carbonic Anhydrases II, IX, and XII in Reflux Esophagitis

BACKGROUND

The pathogenesis of gastroesophageal reflux disease (GERD) has not been resolved in detail. Esophageal epithelial cells provide resistance to acidic reflux via several mechanisms, many of which involve buffering acid with bicarbonate and transporting protons. Carbonic anhydrases (CAs) are enzymes that control the acid-base balance by catalyzing the reversible hydration of carbon dioxide to produce bicarbonate and hydrogen ions.

AIMS

We aimed to determine the immunohistochemical expression patterns of CAII, CAIX, and CAXII in the normal esophageal squamous epithelium and in patients with GERD.

METHODS

We evaluated 82 biopsy samples, including 26 with a histologically normal esophagus, 26 with histologically mild esophagitis, and 30 with severe esophagitis. Expression patterns of CAII, CAIX, and CAXII in the esophageal squamous epithelium were determined by immunohistochemical staining.

RESULTS

Cytoplasmic CAII expression was predominantly detected in the upper luminal part of the squamous epithelium and was significantly (p < 0.01) increased in GERD. Expression of CAIX was essentially membranous. The isozyme was constantly present in the peripapillary cells. In the interpapillary areas, clustered expression was observed to emerge and increase significantly (p < 0.01) in esophagitis. CAXII expression was the most abundant of the isozymes and was mainly membranous. In the normal squamous epithelium, CAXII expression was confined to the basal layer; in severe esophagitis, CAXII expression increased significantly in both basal (p < 0.05) and superficial (p < 0.01) halves of the epithelium.

CONCLUSIONS

We demonstrate upregulated expression of CAII, CAIX, and CAXII in GERD. The increase in expression likely contributes to esophageal epithelial resistance to acidic reflux.

Role of Wide-Area Transepithelial Sampling With 3D Computer-Assisted Analysis in the Diagnosis and Management of Barrett's Esophagus

Barrett's esophagus (BE) is a premalignant condition in which cancer prevention is performed by endoscopic surveillance combined with Seattle protocol mucosal biopsies. The Seattle protocol has significant limitations, including a high rate of sampling error due to the focality of dysplasia/carcinoma, low endoscopist adherence to the protocol, and a high degree of variability in pathologic interpretation. These factors all contribute to a high incidence of cancers missed within 1 year of surveillance endoscopy. Wide-area transepithelial sampling with computer-assisted three-dimensional analysis (WATS3D) is a relatively new technique that minimizes sampling error by using a brush biopsy device that extensively samples "at risk" mucosa and helps pathologists diagnose dysplasia/neoplasia by generating three-dimensional images of whole crypts using a neural network-based software program. Several large prospective trials (involving both academic and community practices) have shown significantly increased rates of detection of dysplasia and intestinal metaplasia in both screening and surveillance in patients with BE when used as an adjunct to Seattle protocol-based forceps biopsies. The WATS3D diagnostic platform was included in the most recent American Society for Gastrointestinal Endoscopy Barrett's guideline as an adjunct to forceps biopsies (conditional recommendation and low quality of evidence). This review summarizes the scientific and pathologic basis of WATS3D technology, its potential impact on BE surveillance and management, and its limitations and future directions.

Heartburn Center Set-Up in a Community Setting: Engineering and Execution

Background: Optimal management of gastroesophageal reflux disease (GERD) requires a concerted team of physicians rather than an individual approach. While an integrated approach to GERD has previously been proposed, the practical execution of such a "center of excellence" (COE) has not been described, particularly in a community setting. Ranging from initial consultation and diagnosis to surgical intervention for complex disease, such an approach is likely to provide optimal care and provide surveillance for patients with a complex disease process of GERD. Methods: We report our approach to implement an integrated heartburn center (HBC) and our experience with the first cohort of patients. Patients treated in the HBC were followed for 2 years from initial consultation to completion of their appropriate treatment plan, including anti-reflux surgery. The performance prior to the HBC set-up was compared to that post-HBC. Performance was measured in terms of volume of patients referred, referral patterns, length of stay (LOS), and patient health-related quality of life (HRQL) pre- and post-surgery. Results: Setting up the HBC resulted in referrals from multiple avenues, including primary care physicians (PCPs), emergency departments (EDs), and gastroenterologists (GIs). There was a 75% increase in referrals compared to pre-center patient volumes. Among the initial cohort of 832 patients presenting to the HBC, <10% had GERD for <1 year, ~60% had GERD for 1-11 years, and ~30% had GERD for ≥12 years. More than one-quarter had atypical GERD symptoms (27.6%). Only 6.4% had been on PPIs for <1 year and >20% had been on PPIs for ≥12 years. Thirty-eight patients were found to have Barrett's esophagus (4.6%) (up to 10 times the general population prevalence). Two patients had dysplasia. Seven patients (0.8%) received radiofrequency ablation (RFA) for Barrett's esophagus and two patients received endoscopic mucosal resection (EMR) for Barrett's esophagus-related dysplasia. The most common comorbidities were chronic pulmonary disease (16.8%) and diabetes without complications (10.6%). Patients received treatment for newly identified comorbid conditions, including early maladaptive schemas (EMS) and generalized anxiety disorder (GAD) (n = 7; 0.8%). Fifty cases required consultation with various specialists (6.0%) and 34 of those (4.1%) resulted in changes in care. Despite the significant increase in patient referrals, conversion rates from diagnosis to anti-reflux surgery remained consistent at ~25%. Overall HRQL improved year-over-year, and LOS was significantly reduced with potential cost savings for the larger institution. Conclusions: While centralization of GERD care is known to improve outcomes, in this case study we demonstrated the clinical success and commercial viability of centralizing GERD care in a community setting. The integrated GERD service line center offered a comprehensive, multi-specialty, and coordinated patient-centered approach. The approach is reproducible and may allow hospitals to set up their own heartburn COEs, strengthening patient-community relationships and establishing scientific and clinical GERD leadership.