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Nieponice A, Gilbert TW, Johnson SA, Turner NJ, Badylak SF. Bone marrow-derived cells participate in the long-term remodeling in a mouse model of esophageal reconstruction. J Surg Res 2012; 182:e1-7. [PMID: 23069684 DOI: 10.1016/j.jss.2012.09.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 08/14/2012] [Accepted: 09/19/2012] [Indexed: 01/01/2023]
Abstract
BACKGROUND The default response of the esophagus to injury includes inflammation and scar tissue formation often leading to stricture. Biologic scaffolds composed of extracellular matrix (ECM) have been associated with the reconstitution of functional esophageal tissue in preclinical studies and clinical case reports of esophageal mucosal resection, anastomotic reinforcement, and full circumferential replacement. However, the mechanisms responsible for this change in the default response to esophageal injury are not fully understood. METHODS The objective of the present study was to determine whether bone marrow-derived cells (BMCs) participate in the long-term remodeling of ECM scaffolds in the esophageal location in a mouse model. RESULTS BMCs were present in low numbers in remodeling ECM scaffolds. Compared with the untreated control mice, the ECM-implanted animals showed better remodeling of the epithelial layer. CONCLUSIONS BMCs are involved in ECM remodeling process during tissue repair after esophageal injury, but the low numbers argue against any significant involvement in the constructive remodeling process.
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Affiliation(s)
- Alejandro Nieponice
- Departments of Surgery and Bioengineering, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
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2
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Wang KK, Tian JM, Gorospe E, Penfield J, Prasad G, Goddard T, Wongkeesong M, Buttar NS, Lutzke L, Krishnadath S. Medical and endoscopic management of high-grade dysplasia in Barrett's esophagus. Dis Esophagus 2012; 25:349-55. [PMID: 22409514 PMCID: PMC4134126 DOI: 10.1111/j.1442-2050.2012.01342.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The management of high-grade dysplasia in Barrett's esophagus has clearly changed over recent years. The risk of cancer development is still substantial, with about one in three patients developing cancer, but a number of patients do not develop cancer. The nature of high-grade dysplasia has also been genetically elucidated with more evidence of chromosomal instability being present at this stage than previously thought. Therapy of the condition has evolved more toward endoscopic therapy, given the good results of radio-frequency ablation and photodynamic therapy in eliminating dysplasia and decreasing cancer development in randomized controlled trial. The best candidates for treatment include compliant patients that have relatively short segments of Barrett's esophagus, an anatomically straight segment, lack of nodularity, and an intact p16. However, even with excellent long-term results similar to surgical resection, the risk of recurrence is present in over 14% of patients, which indicates that there will be a need to continue surveillance endoscopy in these patients.
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Affiliation(s)
- K K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55934, USA.
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3
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Deb SJ, Shen KR, Deschamps C. An analysis of esophagectomy and other techniques in the management of high-grade dysplasia of Barrett's esophagus. Dis Esophagus 2012; 25:356-66. [PMID: 21518102 DOI: 10.1111/j.1442-2050.2011.01186.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Barrett's esophageal (BE) metaplasia is a premalignant condition of the distal esophagus that develops as a consequence of gastroesophageal reflux disease. The progression to carcinogenesis results from progressive dysplastic changes of the metaplastic epithelium through low-grade and then high-grade dysplasia (HGD) to eventually adenocarcinoma of the esophagus. The management of HGD is controversial with proponents for each of the three major management strategies: endoscopic surveillance, endoscopic ablative therapies, and esophagectomy. The aim of the study was to define and discuss the various management strategies of HGD arising from BE metaplasia. There is a paucity of randomized controlled data from which to draw definitive conclusions. All strategies for the management of HGD are reasonable options and are complimentary. BE with HGD is a malignant lesion. A multidisciplinary approach individualizing therapy should be undertaken when possible. Esophageal resection should be reserved for otherwise healthy patients. Endoscopic techniques are viable alternatives to surgery.
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Affiliation(s)
- S J Deb
- Division of General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, MN 50501, USA
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4
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Sharma RR, London MJ, Magenta LL, Posner MC, Roggin KK. Preemptive surgery for premalignant foregut lesions. J Gastrointest Surg 2009; 13:1874-87. [PMID: 19513795 DOI: 10.1007/s11605-009-0935-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Accepted: 05/20/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Preemptive surgery is the prophylactic removal of an organ at high risk for malignant transformation or the resection of a precancerous or "early" malignant neoplasm in an individual with a hereditary predisposition to cancer. Recent advances in molecular diagnostic techniques have improved our understanding of the biologic behavior of these conditions. Predictive testing is an emerging field that attempts to assess the potential risk of cancer development in predisposed individuals. Despite substantial improvement in these forms of testing, all results are imperfect. This information often becomes an important tool that is used by healthcare providers to evaluate the risk-benefit ratio of various risk modifying strategies (i.e., intensive surveillance or preemptive surgery). METHODS A systematic literature review was performed using Medline and the bibliographies of all referenced publications to identify articles relating to preemptive surgery for premalignant foregut lesions. RESULTS AND DISCUSSION In this review, we outline the controversies surrounding predictive risk assessment, surveillance strategies, and preemptive surgery in the management of high-grade dysplasia (HGD) in Barrett's esophagus (BE), hereditary diffuse gastric cancer (HDGC), bile duct cysts, primary sclerosing cholangitis (PSC), and pancreatic cystic neoplasms. Resection of BE is supported by the progressive nature of the disease, the risk of occult carcinoma, and the lethality of esophageal cancer. Prophylactic total gastrectomy for HDGC appears reasonable in the absence of accurate screening tests but must be balanced by the impact of surgical complications and altered quality of life. Surgical resection of biliary cysts theoretically eliminates the exposed epithelium to decrease the lifetime risk of cholangiocarcinoma. Liver transplantation for PSC remains controversial given the scarcity of donor organs and inability to accurately identify high-risk individuals. Given the uncertain natural history of pancreatic cystic neoplasms, the merits of selective versus obligatory resection will continue to be debated. CONCLUSIONS Preemptive operations require optimal judgment and surgical precision to maximize function and enhance survival. Ultimately, balancing the risk of surgical intervention with less invasive interventions or observation must be individualized on a case-by-case basis.
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Affiliation(s)
- Rohit R Sharma
- Department of Surgery, Section of General Surgery, University of Chicago Medical Center, Chicago, IL, USA
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5
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Abela JE, Going JJ, Mackenzie JF, McKernan M, O'Mahoney S, Stuart RC. Systematic four-quadrant biopsy detects Barrett's dysplasia in more patients than nonsystematic biopsy. Am J Gastroenterol 2008; 103:850-5. [PMID: 18371135 DOI: 10.1111/j.1572-0241.2007.01746.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIMS To compare detection of Barrett's dysplasia and adenocarcinoma by systematic versus nonsystematic surveillance biopsy protocols. METHODS Upper GI consultation and open-access endoscopy are provided jointly at Glasgow Royal Infirmary by medical and surgical teams. The surgical team adopted annual systematic four-quadrant biopsy Barrett's surveillance in 1995. The medical team continued annual Barrett's surveillance with nonsystematic biopsy until 2004. We compare detection of Barrett's dysplasia and esophageal adenocarcinoma in unselected patients by these two biopsy strategies over 10 yr. All patients had > or = 3 cm Barrett's esophagus and histological proof of intestinal metaplasia. Patients referred for dysplasia management or with prevalent adenocarcinoma were excluded. Cohort A (N = 180) had four-quadrant biopsy every 2 cm while cohort B (N = 182) had nonsystematic biopsies. RESULTS Cohort A versus cohort B: Median number of biopsies per endoscopy: 16 versus 4. Prevalence of low-grade dysplasia (per patient): 18.9% versus 1.6% (P << 0.001). Prevalence of high-grade dysplasia: 2.8% versus 0% (P = 0.03). Incidence of low-grade dysplasia: 2.2% versus 6.6% (NS). Incidence of high-grade dysplasia: 2.8% versus 0% (P = 0.03). Nine cohort A patients (total 5%, 1.4% per patient-year) were treated for HGD (eight endoscopically, one by esophagectomy). Two had intramucosal adenocarcinoma. No cohort A patient developed advanced cancer but three cohort B patients developed and died of invasive Barrett's adenocarcinoma (0.6% per patient-year). CONCLUSIONS Patient age, gender, Barrett's segment length, and follow-up were similar (though not identical) in both cohorts, but confounding seems unlikely to account for a 13-fold difference in detection of prevalent dysplasia between the two groups. Our data support the hypothesis that systematic four-quadrant biopsy is considerably more effective than nonsystematic biopsy sampling in detecting Barrett's dysplasia and early adenocarcinoma. Greater biopsy numbers and the systematic pattern of biopsy taking may both contribute to this greater effectiveness.
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Affiliation(s)
- Jo-Etienne Abela
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
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6
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Savoy AD, Wolfsen HC, Raimondo M, Woodward TA, Noh K, Pungpapong S, Hemminger LL, Wallace MB. The role of surveillance endoscopy and endosonography after endoscopic ablation of high-grade dysplasia and carcinoma of the esophagus. Dis Esophagus 2008; 21:108-13. [PMID: 18269644 DOI: 10.1111/j.1442-2050.2007.00763.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Barrett's esophagus (BE) with high-grade dysplasia (HGD) or early carcinoma treated with surgery or photodynamic therapy (PDT) is at risk of recurrence. The efficacy of endoscopic ultrasound (EUS) for surveillance after PDT is unknown. Our objective was to determine if EUS is superior to esophagogastroduodenoscopy (EGD) and/or CT scan for surveillance of BE neoplasia after PDT. The study was designed as a retrospective review with the setting as a tertiary referral center. Consecutive patients with BE with HGD or carcinoma in situ treated with PDT were followed with EUS, CT scan and EGD with jumbo biopsies every 1 cm at 3, 4, or 6-month intervals. Exclusion criteria was < 6 months of follow up and/or < 2 EUS procedures. Main outcome measurements were residual or recurrent disease discovered by any method. Results showed that 67/97 patients met the inclusion criteria (56 men and 11 women). Median follow-up was 16 months. Recurrent or residual adenocarcinoma (ACA) was detected in four patients during follow-up. EGD with random biopsies or targeted nodule biopsies detected three patients. EUS with endoscopic mucosal resection of the nodule confirmed T1 recurrence in one of these three. In the fourth patient, CT scan revealed perigastric lymphadenopathy and EUS-FNA (fine needle aspiration) confirmed adenocarcinoma. There were two deaths, one related to disease progression and one unrelated. The rate of recurrent/persistent ACA after PDT was 4/67 = 6%. EUS did not detect disease when EGD and CT were normal. Limitations of this study include non-blinding of results and preferential status of non-invasive imaging (CT) over EUS. Our experience suggests that EUS has little role in the surveillance of these patients, unless discrete abnormalities are found on EGD or cross-sectional imaging.
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Affiliation(s)
- A D Savoy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida 32224, USA
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7
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Sumiyama K, Gostout CJ. Novel techniques and instrumentation for EMR, ESD, and full-thickness endoscopic luminal resection. Gastrointest Endosc Clin N Am 2007; 17:471-85, v-vi. [PMID: 17640577 DOI: 10.1016/j.giec.2007.05.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic intervention is evolving into an established therapeutic alternative for small superficial lesions, and an eventual application for en bloc resection of large lesions, deeper layers, and a reliable access to lesions outside of the gastrointestinal wall. Although further developmental and clinical evaluation is necessary, we believe endoscopic resection by the submucosal route and by full-thickness approaches will replace standard surgical procedures in the next several years.
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Affiliation(s)
- Kazuki Sumiyama
- Mayo Clinic, Developmental Endoscopy Unit, Charlton 8-A, 200 First Street, SW, Rochester, MN 55905, USA
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8
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Wolfsen HC. Endoprevention of esophageal cancer: endoscopic ablation of Barrett's metaplasia and dysplasia. Expert Rev Med Devices 2006; 2:713-23. [PMID: 16293098 DOI: 10.1586/17434440.2.6.713] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This review describes the use of endoscopic therapy for the treatment of Barrett's disease and the prevention of esophageal carcinoma, predominantly a disease of older white men. While the term endoprevention may be novel, gastroenterologists have been using endoscopic techniques to prevent colon cancer for decades. For the endoprevention of Barrett's carcinoma, the regulatory approval for the use of porfimer sodium photodynamic therapy was an important milestone, as this treatment has been proven to safely ablate Barrett's glandular epithelium, including high-grade dysplasia, and significantly decrease the risk for the development of invasive cancer in several single-center studies, a prospective multicenter randomized controlled study using expert centralized histopathology analysis and long-term single-center results. Newer methods of mucosal ablation, such as the radiofrequency balloon, have been developed for the treatment of patients with Barrett's metaplasia or dysplasia. These newly developed techniques are able to treat large fields of glandular epithelium in a short treatment procedure using safe, effective, durable methods for the complete ablation of Barrett's metaplasia and low-grade dysplasia. These techniques may finally allow the interventional gastrointestinal endoscopist to prevent the development of esophageal carcinoma, just as colonoscopy with polypectomy has prevented colon cancer. However, it will be critically important to document the safety, durability and efficacy of these devices. Ultimately, the impact of successful Barrett's ablation on the incidence of Barrett's carcinoma, and the need for postablation surveillance endoscopy must be determined.
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Affiliation(s)
- Herbert C Wolfsen
- Mayo Clinic, Division of Gastroenterology and Hepatology, 6A Davis Building, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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9
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Wolfsen HC. Photodynamic therapy for Barrett's esophagus with high-grade dysplasia. ACTA ACUST UNITED AC 2005; 31:137-44. [PMID: 15901944 DOI: 10.1007/s12019-005-0010-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2004] [Accepted: 01/27/2005] [Indexed: 12/31/2022]
Abstract
This article describes advances in photodynamic therapy for patients with Barrett's esophagus and high-grade dysplasia-an important, minimally invasive treatment option proven to safely and durably ablate Barrett's dysplasia and prevent carcinoma while preserving the gastroesophageal junction.
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10
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Abbas G, Pennathur A, Keeley SB, Landreneau RJ, Luketich JD. Laser Ablation Therapies for Barrett’s Esophagus. Semin Thorac Cardiovasc Surg 2005; 17:313-9. [PMID: 16428037 DOI: 10.1053/j.semtcvs.2005.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2005] [Indexed: 11/11/2022]
Abstract
The metaplastic change of the normal squamous epithelium of the distal esophagus into a specialized columnar epithelium is known as Barrett's esophagus (BE) and is associated with an increased risk of adenocarcinoma of the esophagus. It is a frequent complication of gastroesophageal reflux disease (GERD) and up to 10% of patients with GERD suffer from BE. The progression to dysplasia increases the risk of cancer development and the annual risk of developing cancer in Barrett's esophagus is estimated to be 0.5% per year. The management of BE with high grade dysplasia (HGD) is controversial. Recent innovations in endoscopic therapy have allowed for the development of multiple endoscopic techniques, such as photodynamic therapy (PDT), argon plasma coagulation (APC), and endoscopic mucosal resection. In this article, we will discuss primarily photodynamic therapy, and other ablative technologies such as argon plasma coagulation in the treatment of BE.
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Affiliation(s)
- Ghulam Abbas
- Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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11
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Badylak SF, Vorp DA, Spievack AR, Simmons-Byrd A, Hanke J, Freytes DO, Thapa A, Gilbert TW, Nieponice A. Esophageal reconstruction with ECM and muscle tissue in a dog model. J Surg Res 2005; 128:87-97. [PMID: 15922361 DOI: 10.1016/j.jss.2005.03.002] [Citation(s) in RCA: 191] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2004] [Revised: 03/02/2005] [Accepted: 03/04/2005] [Indexed: 10/25/2022]
Abstract
An in vivo study was conducted to determine if an extracellular matrix (ECM) scaffold co-localized with autologous muscle tissue could achieve constructive remodeling of esophageal tissue without stricture. ECM derived from the porcine urinary bladder was processed, decellularized, configured into a tube shape, and terminally sterilized for use as a bioscaffold for esophageal reconstruction in a dog model. Twenty-two dogs were divided into four groups, three groups of five and one group of seven. Groups 1 and 2 were repaired with either ECM alone or muscle tissue alone, respectively. Groups 3 and 4 were repaired with ECM plus either a partial (30%) covering with muscle tissue or a complete (100%) covering with muscle tissue, respectively. Animals in groups 1 and 2 were sacrificed within approximately 3 weeks because of the formation of intractable esophageal stricture. Four of five dogs in group 3 and six of seven dogs in group 4 were survived for 26 days to 230 days and showed constructive remodeling of esophageal tissue with the formation of well organized esophageal tissue layers, minimal stricture, esophageal motility, and a normal clinical outcome. Mechanical testing of a subset of the remodeled esophageal tissue from animals in groups 3 and 4 showed progressive remodeling from a relatively stiff, non-compliant ECM tube structure toward a tissue with near normal biomechanical properties. We conclude that ECM bioscaffolds plus autologous muscle tissue, but not ECM scaffolds or muscle tissue alone, can facilitate the in situ reconstitution of structurally and functionally acceptable esophageal tissue.
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Affiliation(s)
- Stephen F Badylak
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15219, USA.
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12
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Wolfsen HC. Carpe luz--seize the light: endoprevention of esophageal adenocarcinoma when using photodynamic therapy with porfimer sodium. Gastrointest Endosc 2005; 62:499-503. [PMID: 16185960 DOI: 10.1016/j.gie.2005.07.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Accepted: 07/11/2005] [Indexed: 12/10/2022]
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13
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Wong Kee Song LM, Wilson BC. Optical Detection of High-Grade Dysplasia in Barrett’s Esophagus. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2005. [DOI: 10.1016/j.tgie.2005.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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14
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Abstract
In the UK and across the Western world there has been a rapid increase in oesophageal adenocarcinoma, such that this cancer is now more common than squamous cell carcinoma. The 5-year mortality from oesophageal adenocarcinoma is >80% and therefore there has been increasing interest in the pre-malignant condition Barrett's oesophagus. Barrett's oesophagus is defined by a visible columnar-lined segment with histopathological evidence of a glandular epithelium, which typically contains intestinal metaplasia. Once Barrett's oesophagus is diagnosed, most centres in the UK offer endoscopic surveillance with the aim to detect early, curable lesions. Surveillance in its current form is cumbersome and expensive, and new endoscopic and molecular developments are hoped to improve the yield of such procedures. The current treatments are symptomatic control of reflux symptoms, with more definitive treatments usually reserved for patients with at least high-grade dysplasia. There is interest in chemoprevention strategies, including proton-pump inhibitors, cyclo-oxygenase-2 inhibitors and aspirin, but to date none of these have proven effective. Treatment options for high-grade dysplasia include surgery, endoscopic mucosal resection (in the context of a visible lesion) and photodynamic therapy. Comparative studies between various geographical regions, as the predominant histopathological subtypes of oesophageal cancer change, may give us some clues about the pathogenesis of Barrett's adenocarcinoma.
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Affiliation(s)
- R C Fitzgerald
- Cancer Cell Unit, Hutchison/MRC Research Centre, Hills Road, Cambridge CB2 2XZ, UK.
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15
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Wolfsen HC, Hemminger LL, Raimondo M, Woodward TA. Photodynamic therapy and endoscopic mucosal resection for Barrett's dysplasia and early esophageal adenocarcinoma. South Med J 2004; 97:827-30. [PMID: 15455964 DOI: 10.1097/01.smj.0000136265.34296.62] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) and endoscopic ablation with porfimer sodium photodynamic therapy (PDT) have recently been combined to improve the accuracy of histologic staging and remove superficial carcinomas. MATERIALS AND METHODS All patients with Barrett's esophagus and high-grade dysplasia were evaluated with computed tomography and endosonography. Patients with nodular or irregular folds underwent EMR followed by PDT. RESULTS In three patients, endoscopic mucosal resection upstaged the diagnosis to mucosal adenocarcinoma (T1N0M0). PDT successfully ablated the remaining glandular mucosa. Complications were limited to transient chest discomfort and odynophagia. CONCLUSIONS The use of EMR resection in Barrett's high-grade dysplasia patients with mucosal irregularities resulted in histologic upstaging to mucosal adenocarcinoma, requiring higher laser light doses for PDT. PDT after EMR appears to be safe and effective for the complete elimination of Barrett's mucosal adenocarcinoma. EMR should be strongly considered for Barrett's dysplasia patients being evaluated for endoscopic ablation therapy.
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Affiliation(s)
- H C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL 32224, USA.
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16
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Rajan E, Gostout CJ, Feitoza AB, Leontovich ON, Herman LJ, Burgart LJ, Chung S, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Pasricha PJ. Widespread EMR: a new technique for removal of large areas of mucosa. Gastrointest Endosc 2004; 60:623-7. [PMID: 15472695 DOI: 10.1016/s0016-5107(04)01929-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Widespread EMR is a novel technique for resection of large areas of mucosa as a single bloc. Large lesion size (>2 cm) is a recognized limitation of current EMR techniques. This study assessed the technical feasibility, efficacy, and safety of widespread EMR in a porcine model. METHODS Widespread EMR was performed in 6 pigs. A submucosal fluid cushion was created in the distal esophagus by using a 0.83% solution of hydroxypropyl methylcellulose. A mucosal strip 5 cm in length and including at least 50% of the luminal circumference was marginated by using a prototype cutting device. The proximal end of the mucosa was stripped from the submucosa by using a grasping forceps. The distal end was snare resected. Resected tissue was assessed histologically. Endoscopy was repeated at weeks 1 and 6. At week 6, a second widespread EMR of the mucosa on the wall opposite the initial resection was attempted to create a full circumferential resection. RESULTS Widespread EMR was completed in all animals. The esophagus was denuded of mucosa in 5-cm lengths that included 50% of the circumference of the lumen. No procedure-related complication was observed. Histologic assessment demonstrated that the resection specimen included mucosa and submucosa but not muscularis propria. Endoscopy at 1 week revealed mucosal regrowth in two animals and ulceration in 4. At week 6, regrowth of mucosa was noted in all animals. The second wide EMR proved to be technically difficult and was associated with perforation, peri-esophageal abscess, and stricture formation. CONCLUSIONS Wide EMR appears to be technically feasible for removal of large areas of mucosa. Mucosal strips 5 cm long that included over 50% of the luminal circumference were resected safely. Resection was followed by complete regrowth of the mucosa. However, a second wide EMR to create a circumferential resection proved to be technically difficult and unsafe.
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Affiliation(s)
- Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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17
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Affiliation(s)
- Thomas G Paulson
- Divisions of Human Biology and Public Health Sciences, University of Washington, Seattle 98109, USA
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18
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Caygill CPJ, Watson A, Lao-Sirieix P, Fitzgerald RC. Barrett's oesophagus and adenocarcinoma. World J Surg Oncol 2004; 2:12. [PMID: 15132744 PMCID: PMC420492 DOI: 10.1186/1477-7819-2-12] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2004] [Accepted: 05/07/2004] [Indexed: 12/23/2022] Open
Affiliation(s)
- Christine PJ Caygill
- Registrar UK National Barrett's Oesophagus Registry (UKBOR), and Honorary Senior Lecturer, University Department of Surgery, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK
| | - Anthony Watson
- Joint director UK National Barrett's Oesophagus Registry (UKBOR), and visiting Professor, University Department of Surgery, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK
| | | | - Rebecca C Fitzgerald
- Joint director UK National Barrett's Oesophagus Registry (UKBOR) and Group Leader MRC Cancer cell Unit, Hutchison Research Centre, Cambridge, CB2 2XZ, UK
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19
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Abstract
The rising incidence and poor prognosis of esophageal adenocarcinoma in the Western world have intensified research efforts into earlier methods of detection of this disease and its relationship to Barrett's esophagus. The progression of Barrett's esophagus to adenocarcinoma has been the focus of particular scrutiny, and a number of potential tissue and serum-based disease biomarkers have emerged. The epidemiology and pathogenesis of esophageal adenocarcinoma are outlined. Tissue biomarkers allowing risk stratification of Barrett's are reviewed as well as strategies currently being used to discover novel biomarkers that will facilitate the early detection of esophageal adenocarcinoma. Finally, the uses of biomarkers as predictive tests for targeted treatments and as surrogate endpoints in chemoprevention trials are considered.
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Affiliation(s)
- Damian T McManus
- Histopathology/Cytopathologist, Belfast City Hospital Trust, Belfast, Northern Ireland
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20
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Song LMWK, Wang KK. Optical detection and eradication of dysplastic Barrett's esophagus. Technol Cancer Res Treat 2003; 2:289-302. [PMID: 12892511 DOI: 10.1177/153303460300200403] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Dysplastic Barrett's esophagus is a condition that offers multiple diagnostic and therapeutic challenges. The diagnosis of dysplasia within Barrett's esophagus currently relies on periodic endoscopic surveillance with multiple biopsies, a methodology limited by random sampling error, inconsistent histopathologic interpretation and delay in diagnosis. Optical spectroscopic and imaging techniques have the potential to identify dysplastic or early neoplastic lesions in real-time. These diagnostic modalities are needed to enhance the endoscopic surveillance of Barrett's esophagus in the future as well as help to define lesions for endoscopic therapy. Esophagectomy has been the standard of care for Barrett's esophagus with high-grade dysplasia although it is a procedure associated with significant morbidity and mortality. Minimally invasive endoscopic ablative therapies are attractive and less morbid alternatives to esophagectomy, with promising results obtained from the use of light-activated drugs (i.e., photodynamic therapy). The combination of novel optical diagnostic techniques and therapies will provide the endoscopist with much needed tools that can considerably enhance the management of patients with Barrett's esophagus. This article reviews the current status and future prospects of optical-based modalities for diagnosis and therapy of dysplastic Barrett's esophagus.
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Abstract
The alarming rise in the incidence of esophageal adenocarcinomas in the Western world has focused interest on so-called Barrett's esophagus. Barrett's esophagus is characterized by specialized intestinal epithelium replacing the normal squamous epithelium in the distal esophagus and is considered a consequence of long-lasting and severe gastroesophageal reflux disease. A metaplasia-dysplasia-carcinoma sequence links Barrett's esophagus with adenocarcinoma of the distal esophagus (Barrett's cancer). Despite intensive research, many questions concerning the pathogenesis, diagnosis, and treatment of Barrett's esophagus and associated adenocarcinoma are still unanswered. Based on current data, the malignant progression of Barrett's esophagus cannot be substantially prevented by medical or surgical therapy for reflux. Although no firm data are available to show that surveillance strategies can reduce overall mortality from Barrett's cancer, early detection and cure are possible. Management of Barrett's esophagus and carcinoma is reviewed with reference to the sequence of disease from metaplasia to carcinoma.
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Affiliation(s)
- Burkhard H A von Rahden
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar der TU München, Ismaningerstr 22, 81675 München, Germany
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