The role of endoscopy in the surveillance of premalignant conditions of the upper gastrointestinal tract. American Society for Gastrointestinal Endoscopy

Effectiveness of systematic alphanumeric coded endoscopy for diagnosis of gastric intraepithelial neoplasia in a low socioeconomic population

Background and study aims: In the Western world, gastric cancer (GC) usually presents at an advanced stage, carrying a high mortality rate. Studies have reported that 14 % to 26 % of GCs are missed at endoscopy up to 3 years before diagnosis. Systematic Alphanumeric Coded Endoscopy (SACE) has been proposed to improve quality of esophagogastroduodenoscopy (EGD) by facilitating a complete examination of the upper gastrointestinal tract. This prospective cross-sectional study was designed to determine the frequency of gastric intraepithelial neoplasia (GIN) by using the SACE approach in cohort of patients from low socioeconomic level. It also used non-targeted biopsies to evaluate the frequency of premalignant conditions. Patients and methods: A total of 601 consecutive asymptomatic or dyspeptic patients were enrolled between January 2013 and November 2014 at the Huacho regional hospital in Peru. The SACE method proposed by Emura et al, which divides the stomach into 5 regions and 21 areas, was routinely used for diagnosis. Biopsy samples were obtained from any endoscopically detected focal lesion. To evaluate gastric premalignant conditions, 4 non-targeted biopsies were taken. Results: A total of 573 patients were analyzed. The mean age was 57 years, and the female:male ratio was 1.9 : 1. In all cases, complete photo-documentation of the 21 gastric areas was achieved. The overall rate of detection of GIN was 2.8 %. Low-grade displasia, high-grade dysplasia, and adenocarcinoma were found in 13 (2.3 %), 2 (0.3 %), and 1 (0.2 %) of the patients, respectively. The prevalence of at least 1 premalignant condition was 31 %, and helicobacter pylori infection was found in 57 % of patients. Conclusions: Using the SACE approach and with proper training, we have reported herein a high frequency of GIN in patients from a low socioeconomic status. Gastric cancer detection can be improved in a Western endoscopy setting when SACE, as a screening method, is performed by a trained endoscopist.

Effect of a prior endoscopy on outcomes of esophageal adenocarcinoma among United States veterans

BACKGROUND

The efficacy of screening and surveillance EGD for esophageal adenocarcinoma (EAC) is controversial.

OBJECTIVE

To examine the effect of an EGD before the diagnosis of EAC on survival after the diagnosis of cancer among patients with gastroesophageal reflux (GER).

DESIGN

A retrospective, controlled cohort study.

SUBJECTS

The national administrative databases of the Veterans Affairs were accessed, and patients diagnosed with EAC, from 1995 through 2003, who had a prior diagnosis consistent with GER were identified. Electronic medical records were then abstracted. Cases were subjects who had an EGD performed between 1 and 5 years before the diagnosis of EAC; controls were those subjects without a prior EGD.

RESULTS

A total of 155 subjects with EAC and GER were identified. Cases with a history of an EGD at least 1 year before a diagnosis of EAC (n = 25) were diagnosed at earlier stages than those without a prior EGD (P = .02) but did not experience a significant improvement in survival (adjusted hazard ratio 0.93 [95% CI, 0.58-1.50]). Cases who had been enrolled in surveillance programs that adhered to published guidelines trended toward improved survival, but long-term survival reverted toward the rate found without any surveillance.

CONCLUSIONS

A prior EGD was associated with an improved stage at the diagnosis of EAC but did not alter long-term survival. In the absence of prospective, randomized, controlled trials, the benefit of screening and surveillance to decrease mortality from EAC cannot be confirmed.

Diagnostic accuracy of magnifying chromoendoscopy with detection of intestinal metaplasia and dysplasia using acetic acid in Barrett's esophagus

OBJECTIVES

Endoscopy with systematic randomized biopsies aims to improve the detection of intestinal metaplasia (IM) and dysplasia in Barrett's esophagus (BE). Magnifying chromoendoscopy with alcoholic acetic acid might allow directed biopsies to improve detection of IM and dysplasia.

PATIENTS AND METHODS

Twenty-eight patients were studied with magnifying chromoendoscopy (Optical power zoom x 115, alcoholic acetic acid). Endoscopy biopsies were performed on one or several zones of BE chosen randomly, for which the chromoendoscopic pattern was determined according to Guelrud's classification.

RESULTS

Among seventy-two biopsies, the agreement between magnifying chromoendoscopy and histology and the positive predictive value of the association of patterns III and IV for the diagnosis of IM were 72.4%; sensibility and specificity were respectively 95.5% and 42.9%. The diagnostic accuracy was 75%. Among the six biopsies that showed high-grade dysplasia, three were suspected because of two particular patterns: local loss of ridged cerebriform pattern due to the disorganization of the mucosal folds and hypervascularization of the mucosa.

CONCLUSION

Magnifying chromoendoscopy with acetic acid allows targeted biopsies of the IM in BE and may help to detect high-grade dysplasia.

The changing epidemiology of esophageal cancer in Finland and the impact of the surveillance of Barrett's esophagus in detecting esophageal adenocarcinoma

We examined the epidemiology of esophageal cancer in Finland and the role of the surveillance of Barrett's esophagus (BE) in detecting esophageal adenocarcinoma (EA) in our own hospital referral area. We observed that the incidence of EA in men has increased tenfold from the 1970s and was 1.10/100,000/year in 1998-2002. In women, a 4.5-fold increase was observed (incidence 0.11/100,000/year). In 1998-2002, the mean annual number of new EA cases was 57.4 (79.8% men) in Finland with a population of 5.2 million. In our hospital referral area with a mean population of 261 349, 11 EAs were observed in 1996-2001. Of them, two (18.2%) had BE. One EA was detected during surveillance. EA comprised 0.05% of all causes of deaths in our hospital referral area. We conclude that EA incidence has increased significantly in men in Finland, but still EA is seldom detected on BE surveillance. EA is an uncommon cause of death in our hospital referral area.

Ethnicity, gender, and socioeconomic status as risk factors for esophagitis and Barrett's esophagus

Barrett's esophagus is thought to be a disease occurring predominantly in White Caucasian males of higher socioeconomic status. There are no published studies simultaneously examining risk of Barrett's esophagus according to ethnicity, gender, and socioeconomic status within a single data set. The authors conducted a retrospective case-control analysis within a cross-sectional study to determine risk of Barrett's esophagus in relation to sociodemographic variables in a large United Kingdom population. All patients undergoing upper gastrointestinal endoscopy at two clinical centers between January 2000 and January 2003 were evaluated. Data on ethnicity, age, gender, socioeconomic status, and the presence of Barrett's esophagus and esophagitis at endoscopy were collected. A total of 20,310 patients were analyzed. Barrett's esophagus was more common in White Caucasians (401/14,095 (2.8%)) than in South Asians (16/5,190 (0.3%)) (adjusted odds ratio (OR)=6.03, 95% confidence interval (CI): 3.56, 10.22), as was esophagitis (2,500/14,095 (17.7%) vs. 557/5,190 (10.7%); adjusted OR=1.76, 95% CI: 1.57, 1.97). Patients with Barrett's esophagus were also more likely to be male (adjusted OR=2.70, 95% CI: 2.18, 3.35) and of higher socioeconomic status (adjusted OR=1.58, 95% CI: 1.16, 2.15 (top tertile vs. bottom tertile)). White Caucasian ethnicity, male gender, and higher socioeconomic status are independent risk factors for Barrett's esophagus.

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Endoscopic diagnosis and surveillance of Barrett's esophagus

There are many questions regarding the screening and surveiliance of BE for which there are currently no answers. Despite the use of models and extrapolations by some authors to suggest that screening and surveiliance for a cancer of such low incidence will never be justified, others argue just as vociferously that given the continued epidemic rise in incidence of this cancer, the uniformly fatal outcome of these cancers if dianosed after symptoms occur, and the enormous pool of patients remaining at risk for future cancer development, a focused and prudent screening and surveillance strategy for Barrett's-related esophageal adenocarcinoma is justified. The data also show that a single screening examination is probably as effective as almost all subsequent surveilance examinations in detecting advanced neoplasia, and much of the current resource use and energy for screening and surveillance in BE should be directed toward screening. Whether screening should be offered or recommended to only older patients (> 50-55 years), whites, and men is unknown, but it is premature to adopt this strategy until better evidence exist supporting a restricted screening policy. Regarding the optimal surveilance frequency and technique, examinations more frequent than every 3 to 5 years are not justifiable, and until proven otherwise, biopsy specimens should be obtained with the largest forceps that can be used with the endoscopic instrument and "saturation" biopsies from the Barrett's obtained. It is unlikely that too many biopsy specimens can be taken. Furthermore, the safety of this approach has been, proven. It is quite likely that the inverse is not true; clinicians likely can do much more harm by taking too few biopsy specimens. It is hoped that the current intense interest in Barrett's neoplasia allows clinicians to address these critical issues in the years to come and resolve this clinical conundrum.

Diagnosis and treatment of gastroesophageal reflux disease in Ohio Medicaid patients: practice patterns and temporal trends

PURPOSE

There is a paucity of data about the use of procedures and prescription medications in the treatment of gastroesophageal reflux disease (GERD) in actual clinical practice.

METHODS

Outpatient Ohio Medicaid claims from 1994 to 1998 were searched to identify patients with an initial diagnosis of GERD along with associated prescriptions and gastrointestinal procedures. Complications of GERD and comorbid illnesses were also determined.

RESULTS

A total of 5579 patients were identified. Histamine-2 receptor antagonists (H2RA's) were prescribed in 59%, followed by proton pump inhibitors (PPI's) (30%) and prokinetic drugs (17%). PPI's were more frequently prescribed to patients with GERD-related complications, peptic ulcer disease and major comorbidities, and patients who received PPI's were also more likely to undergo upper gastrointestinal endoscopy. The frequencies of upper endoscopy and barium studies were 20% and 11% respectively, with no change over the study period. There was an increased frequency of PPI therapy (17-43%) and decreased frequency of H2RA therapy (72-47%) from 1994 to 1998 which persisted after adjusting for potential differences in case mix.

CONCLUSIONS

In this population-based study, prescription of PPI's increased over time which likely reflected changes in clinician practice rather than patient mix. Despite a greater awareness of GERD complications, use of upper endoscopy did not increase. Although the cohort consists of predominantly low socioeconomic status, female patients, further studies should be conducted in other populations to confirm these findings.

Association of prediagnosis endoscopy with stage and survival in adenocarcinoma of the esophagus and gastric cardia

BACKGROUND

Barrett esophagus, a consequence of chronic gastroesophageal reflux disease, is a premalignant condition for adenocarcinoma of the esophagus and, possibly, the gastric cardia. However, the actual use and clinical impact of upper gastrointestinal endoscopy in screening and surveillance for Barrett esophagus are unknown.

METHODS

A cohort included 1633 patients with adenocarcinoma (777 esophagus, 856 cardia) who were 70 years or older. They were diagnosed between 1993 and 1996 and were identified from the Surveillance, Epidemiology and End Results program registry. All claims for upper endoscopy and a diagnosis of Barrett esophagus from 1991 through 1 year before diagnosis were identified from linked Medicare files.

RESULTS

One or more upper endoscopies before diagnosis were performed in 9.7% of patients (13.0% esophagus, 6.8% cardia) and a diagnosis of Barrett esophagus was present in only 3.7% of patients. A shift toward earlier stage at diagnosis was observed in patients with previous endoscopy or Barrett diagnosis. For example, 62% of patients with esophageal and 49% of patients with cardia tumors who underwent previous endoscopy presented with in situ or local stage carcinoma, compared with 35% and 27% of other patients, respectively. Receipt of endoscopy was also associated with a reduced risk of death for esophageal adenocarcinoma (relative hazard 0.73, 95% confidence interval 0.57-0.93; P = 0.01), but not for adenocarcinoma of the cardia.

CONCLUSIONS

Receipt of upper endoscopy at least 1 year before diagnosis of adenocarcinoma, which may reflect prediagnosis screening, was associated with an earlier tumor stage and improved survival. These data support the role of endoscopic screening and surveillance for Barrett esophagus and highlight the underdiagnosis of populations at risk.

Classification of Barrett's epithelium by magnifying endoscopy

BACKGROUND

The specialized columnar epithelium of Barrett's esophagus can be detected by obtaining random or 4 quadrant biopsy specimens at conventional endoscopy. However, little is known about the fine mucosal structure of specialized columnar epithelium.

METHODS

Thirty patients with Barrett's esophagus were studied by magnifying endoscopy. The fine mucosal pattern (pit pattern) of 67 regions in Barrett's mucosa was recorded and compared with methylene blue staining. Histologic, mucin immunohistologic, and cell proliferation analyses of biopsy specimens were performed in relation to the pit patterns determined by magnifying endoscopy.

RESULTS

Pit pattern was classified into 5 types. Tubular and villous pit patterns were not only characteristics of both specialized columnar epithelium and methylene blue absorption, but also possessed an intestinal mucin phenotype with a high Ki-labeling index, whereas other pit patterns (dot and straight) did not have specialized columnar epithelium and were categorized as the gastric phenotype. The long oval pit pattern had an intermediate phenotype between gastric and intestinal.

CONCLUSIONS

The classification of the superficial mucosal appearance of Barrett's epithelium by magnifying endoscopy reflects not only histologic features but also mucin phenotypes.

Endoscopy in Barrett's esophagus. Surveillance during reflux management and new advances in the diagnosis and early detection of dysplasia

Given the alarming rise in the incidence of esophageal cancer and the fact that Barrett's esophagus is clearly a precursor to this disease, effective surveillance is desirable. Endoscopic surveillance is recommended by major endoscopic and gastrointestinal societies based on the available data and hypothetic models suggest that the costs of endoscopic surveillance for Barrett's esophagus may be reasonable when compared with other commonly applied cancer screening strategies. Although, however, most implicated physicians agree that surveillance is warranted, recommended guidelines often are not followed. This occurrence may reflect the importance of some of the practical limitations inherent to carrying out intensive endoscopic biopsy protocols in large numbers of eligible patients. In an effort to improve the surveillance process, several new techniques have been tested and are in development. These techniques are aimed at facilitating the histologic sampling of larger areas of metaplastic epithelium, at better targeting sites more likely to harbor dysplasia and cancer, and at replacing endoscopic biopsies with nonhistologic tissue analysis. Although many of these newer techniques are promising, however, none are currently close to widespread clinical application. The current standard for surveillance remains the use of systematic endoscopic biopsies, with the frequency of surveillance endoscopies determined by the severity of any dysplastic changes that are found. Given the large number of patients that are likely to be eligible for screening and the current constraints in terms of physician availability and health-care resources, endoscopic biopsy will remain the cornerstone of Barrett's esophagus surveillance strategies unless newer alternatives are clearly advantageous in terms of accuracy, cost, availability, and ease of application. In the future, however, advances in techniques for minimally invasive ablation of Barrett's epithelium may make endoscopic surveillance obsolete altogether.

An observer-blinded, prospective, randomized comparison of forceps for endoscopic esophageal biopsy

BACKGROUND

The designs of 2 new biopsy forceps attempt to address the difficulty of obtaining esophageal biopsy specimens. The angled design is a modified version of currently used straight forceps. The lateral cup forceps has a straight shaft with a bullet-shaped cuffing head for a tangential approach.

METHODS

Seventy-five patients were enrolled in a prospective study in which 3 different forceps were compared in random order: a reusable straight-shaft spiked forceps, a reusable angled-shaft spiked forceps, and a disposable lateral cup forceps. Two biopsy specimens were obtained with each device per patient. Two pathologists, blinded as to forceps used, graded the tissue samples for size, histologic depth, shear artifact, crush artifact, and adequacy for diagnosis. Data were compared by using multivariate analysis of variance and Scheffé's method.

RESULTS

Analysis of variance showed overall differences in specimen size, histologic depth score, and diagnostic adequacy (p < 0.001). There was no significant difference for crush (p = 0.459) or shear artifacts (p = 0.243). Pair-wise comparisons demonstrated that tissue samples obtained with the straight forceps were larger (p = 0.020) and deeper (p = 0.040) than the angled forceps. These 2 designs were similar in terms of diagnostic adequacy. Biopsy specimens obtained with the straight forceps were larger (p < 0.001) and deeper (p < 0.001) than those obtained with the lateral cup forceps. Both the straight and angled forceps were superior to the lateral cup forceps in terms of diagnostic adequacy (p = 0.020, p = 0.008, respectively).

CONCLUSIONS

The reusable straight-shaft spiked forceps provides larger and deeper esophageal biopsy specimens than either the angled or lateral cup forceps. The angled forceps provides specimens of similar adequacy for diagnosis compared with the straight forceps. The lateral cup forceps should not be used in the esophagus.

Life expectancy and cancer risk in patients with Barrett's esophagus: a prospective controlled investigation

BACKGROUND

It has been suggested that patients with Barrett's esophagus have a substantially increased risk of esophageal and possibly extra-esophageal cancers. We compared the incidence of cancer and the survival rates of patients with Barrett's esophagus with those observed in patients with achalasia, with Schatzki's ring, and in the general population.

PATIENTS AND METHODS

From 1980 through 1994, 60 consecutive patients with newly diagnosed long-segment Barrett's esophagus without dysplasia were seen in a single gastroenterology consultation office and followed until the Fall of 1999. Cancer incidence and survival rates were compared with age- and sex-matched patients with symptomatic Schatzki's ring (n = 60) and achalasia (n = 60). Survival data were also compared with those of the German population.

RESULTS

During a mean (+/-SD) observation period of 10 +/- 5 years, 2 patients with Barrett's esophagus (3%; 95% confidence interval [CI]: 0% to 11%) developed esophageal cancer, and 9 (15%; 95% CI: 7% to 27%) developed extra-esophageal cancers. These data differed only slightly from those of patients with Schatzki's ring (esophageal cancer: n = 1, 2%; 95% CI: 0% to 9%; extra-esophageal cancers: n = 9, 15%; 95% CI: 7%-27%) and achalasia (no esophageal cancers, extra-esophageal cancers: n = 3, 5%; 95% CI: 1% to 4%). Estimated 10-year survival was similar in patients with Barrett's esophagus (83%), patients with symptomatic Schatzki's ring (80%), patients with achalasia (87%), and in the general population (82%).

CONCLUSIONS

The cancer risk in patients with Barrett's esophagus has been overestimated. If patients with nondysplastic epithelium are followed, the risk of esophageal cancer is about 1 per 300 patient-years.

Squamous cell cancer of the oesophagus

Squamous cell cancer is the most common neoplasm of the oesophagus worldwide, with an enormous variation in its global incidence. Several risk factors, such as achalasia, Plummer-Vinson syndrome, coeliac disease and nutritional factors, have been identified. The surveillance of patients, especially those with tylosis or caustic ingestion, has been recommended. Vital staining with iodine may improve the diagnosis of early cancer. The endoscopic management of early cancer and dysplasia by minimal invasive techniques such as photodynamic therapy or mucosal resection has become attractive for many of these patients with co-morbidity.

Practice patterns for surveillance of Barrett's esophagus in the united states

BACKGROUND

Endoscopic surveillance of Barrett's esophagus is recommended to detect dysplasia or cancer at an early and potentially treatable stage. However, little is known about the clinical practice patterns for endoscopic surveillance in the United States.

METHODS

A questionnaire regarding surveillance intervals, techniques and management approaches for patients with Barrett's esophagus was mailed to 1000 randomly selected members of the Clinical Practice Section of the American Gastroenterological Association.

RESULTS

The response rate was 455 of 1000 (45%). Not all respondents answered all questions. Seventy-nine percent of respondents were in community practices, and 21% were in academic practices. Nearly all (96%) performed endoscopic surveillance, but it was practiced more commonly in the community (334 of 341 [98%]) than in the academic setting (83 of 93 [89%], p < 0.001). For patients without dysplasia, endoscopic surveillance was most commonly performed every 2 years (264 of 415 [64%]). Patients with low-grade dysplasia usually had surveillance endoscopy at 6-month intervals (215 of 413 [52%]), whereas those with high-grade dysplasia most commonly had endoscopy every 3 months (201 of 404 [50%]). These surveillance patterns did not differ between the academic and community groups. Random biopsies were performed by 93 of 403 (23%), 4-quadrant biopsies by 310 (77%). Most physicians (83%) used standard capacity forceps. Brush cytology was done uncommonly (69 of 414 [17%]). The most common indications for esophagectomy were high-grade dysplasia by 82% and cancer by 83%. Ablation therapy was performed for Barrett's esophagus without dysplasia by 3.5%, Barrett's with dysplasia by 20%, and cancer by 8%.

CONCLUSIONS

Surveillance for Barrett's esophagus is widely practiced in the United States but there is considerable variation in interval and technique. A clearer consensus on endoscopic surveillance is warranted to optimize care of patients with Barrett's esophagus.